**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, Medical Director and Nurse Practitioner interviews, the facility failed to ensure the necessary supervision was provided to a severely cognitively impaired resident to prevent an avoidable accident. Resident #1 was prescribed a puree diet and had a history of choking. On 3/19/25 Resident #1, who was known to have poor safety awareness, had a choking episode in the main lobby. Staff performed a back blow that produced a piece of bread from his mouth. He was assessed by the Nurse Practitioner (NP) and determined to return to his baseline. Following the 3/19/25 choking incident, all facility staff were educated on the importance of providing residents with diets per the physician order. On 4/22/25, while dinner trays were being picked up by the staff, Resident #1 took a hot dog off an unattended meal cart, put part of it in his mouth, and began to choke. Staff provided abdominal thrusts and were unable to dispel the food. Cardiopulmonary Resuscitation (CPR) was started when the resident became unresponsive and was pulseless. Emergency Medical Services (EMS) was called and were unable to revive Resident #1 who was pronounced deceased at 8:01 PM. The deficient practice affected 1 of 2 residents reviewed for supervision to prevent accidents (Resident #1). The findings included: A hospital Discharge summary dated [DATE] ordered a level 1 dysphagia diet (all food are pureed smooth to a pudding consistency to ensure easy swallowing) and honey thick liquid with close supervision and assistance with feeding. Resident #1 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), cerebrovascular accident (stroke), weakness to both legs, and aphasia (difficulty or inability to express with language). Review of the facility physician orders for 1/25/ 2025 revealed a diet of honey thickened fluids and pureed texture. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was severely cognitively impaired with no refusal of care. He had a therapeutic diet due to difficulty with swallowing and was independent with eating after setting up meal tray. He used a wheelchair for mobility and required supervision to stand. A care plan was initiated on 2/20/2025. It focused on Resident #1's swallowing problem related to coughing or choking during meals. The goal was for no aspiration (when something you swallow goes down the wrong way and enters your airway [trachea or windpipe] or lungs) injury, maintain weight and nutrition and no choking episodes with eating. Interventions included all staff to be informed of Resident #1's special dietary and safety needs. There were no interventions related to supervision during meals. An interview conducted on 6/5/25 at 5:22 PM with the MDS Coordinator revealed Resident #1's safety needs in the care plan were about supervising him and preventing him from accessing food he should not eat. He propelled in his wheelchair and looked for food, he exhibited behaviors of hunger by gestures. Information was on the electronic Kardex (care guide) for the nursing staff. The MDS Coordinator explained that the Kardex was deleted after the resident was discharged so the information on the Kardex was no longer available. The discharge speech therapy note revealed dated 3/14/2025 revealed Resident #1 refused treatment. Discharge recommendations from speech therapy was a nectar thick liquid with swallowing strategies implemented. Mechanical soft/ground textures (with strategies implemented). Strategies were alternate liquids and solids. Small bites, tuck the chin during swallowing. Upright posture thirty (30) minutes after meals. His goal was not met, and he remained on a honey-thick liquids and a pureed diet. An interview with the Speech Therapist (ST) on 6/4/2025 at 2:04 PM revealed Resident #1 was able to eat a mechanical soft/ground diet if he used strategies. His diet was honey thick liquids and pureed diet and he was not upgraded because of noncompliance with the exercises to strengthen the muscles in his throat. The ST indicated Resident #1 was able to feed himself and propelled himself in a wheelchair. Resident #1 comprehended directions and he understood his diet and not eating foods that were not pureed. The ST stated Resident #1 He was discharged from speech therapy because he refused treatment. She stated she was not aware of his seeking food outside his prescribed diet. On 6/4/2025 at 6:10 PM the Rehab (Rehabilitation) Manager indicated Resident #1 was able to walk short distances. He refused to do the swallowing exercises during meals and tore up the strategies the speech therapist had given him. The Rehab Manager stated Resident #1 He had awareness and was able to follow cues and instructions. His diet was not advanced, and he remained on his original ordered diet. The Activities Assistant was interviewed on 6/5/2025 at 11:56 AM. She revealed she had been sitting in the dining room watching television with Resident #1 on 3/19/2025 and did not recall the time. Resident #1 was taken out by an unidentified nurse aide. The Activities Assistant stated she did not provide Resident #1 with any food on 3/19/25 because she was not allowed to give residents food. The interview further revealed the Activities Assistant had no idea how or when Resident #1 had gotten food on 3/19/25. Interview on 6/5/25 at 11:40 AM with Unit Manager #2 revealed on 3/19/25 she came off the elevator and entered the lobby and Resident #1 was on the floor and had a blank look on his face. She was not familiar with this resident. She did not recall what time it was or who was present except Nurse #50. Resident #1 was on his left side when Nurse #50 reached into his mouth and pulled out bread. Resident #1 was no longer in distress. An interview with Nurse #50 on 6/5/2025 at 11:12 AM revealed on 3/19/25 he was working on the hall on first floor, and he saw a commotion in the lobby. He walked to the lobby and Resident #1 was lying on the floor. Nurse #50 did not recall which staff were present. He stated Resident #1 looked scared and he did a quick assessment, turned Resident #1 to his left side and did a back blow, and a piece of bread fell out of his mouth. The Nurse Practitioner assessed Resident # 1, then the EMS paramedics did an assessment. Resident #1 was back to his baseline and Nurse #50 helped Resident #1 back to his chair and returned to his hall. A Nurse Practitioner note dated 3/19/25 with no time, revealed Resident #1 had choked on food in the lobby. Food was removed by finger sweep and Resident #1 returned to baseline. A telephone interview on 6/9/2025 at 3:39 PM revealed the Nurse Practitioner indicated she responded to the choking episode on 3/19/2025. Resident #1's lungs were clear, and he was at his baseline. A nursing note documented by Unit Manager (UM) #1 dated 3/19/2025 at 11:50 AM revealed Resident #1 had an episode where he was sliding out of the wheelchair with seizure like symptoms in the main lobby. He was lowered to the floor by a nurse aide and assessed by a nurse (not identified) and observed to have food in his mouth. The food was removed from his mouth, Emergency Medical Services responded. The Nurse Practitioner was in the building and was notified. Resident #1 returned to his baseline Record review of the report dated 3/19/2025 identified as Incident Description, Nursing Description Resident pushed by CNA (unidentified Nurse Aide) from dining room to hallway and noted he was sliding from wheelchair. CNA was assisting residents to the floor and noted resident having seizure-like activity. Immediate Action Taken: Assessment completed resident actively coughing piece of bread noted in his mouth. Resident turned to his side, a slight strike on back and resident spit out a piece of bread. No loss of consciousness, respiratory status remains stable. NP (Nurse Practitioner) notified and evaluated, lungs clear and resident is no (sic) distress. EMS arrived and evaluated with same findings. Resident refused to transfer to the hospital. This document was completed by the Director of Nursing (DON). An interview on 6/5/2025 at 11:05 AM with UM #1 indicated she could not recall which Nurse Aide (NA) wheeled Resident #1 out of the dining room on 3/19/25. UM #1 stated she saw Nurse #50 turn Resident #1 on his side and struck him on the back which produced the piece of bread out of his throat. Resident #1 returned to baseline and the Nurse Practitioner assessed him. Resident #1 refused to go to the hospital. The facility provided education to all staff, to provide the correct diet after the 3/19/25 choking incident. An interview on 6/5/2025 11:05 AM Unit Manager #1 revealed she saw Resident #1 was returning from activities into the main lobby and he was coughing. An NA (could not remember who) was pushing the wheelchair, and Resident #1 was sliding down. Unit Manager #2 and Nurse #50 observed this, and they put him on the floor and turned him to the left side. Nurse #50 struck Resident #1 on the back and a piece of bread fell out of his mouth. He never lost consciousness, and he fully recovered to his baseline. He was assisted back to his wheelchair. Emergency Medical Services arrived, Nurse Practitioner listened to his lung sounds and she asked him to go to the hospital, and he refused. An interview on 6/5/2025 at 12:40 PM with the Administrator revealed that activity staff had been educated by the Staff Development Coordinator (SDC) on the importance of providing the correct diet and the Activity Director was given the changes to residents' diets during the morning stand-up meeting after Resident #1's 3/19/25 choking incident. A record of training titled, Resident Diets conducted on 3/18/25 (sic) was conducted by the SDC. The training enforced the importance of providing residents with special diets as prescribed by the physician or other delegated provider. The provided signature sheet dated 3/19/2025 had the activity department personnel signatures and two nursing assistants. The facility produced further sign off sheets and identified them as training that occurred for all staff for the 3/19/2025 event. An interview with the Activity Director by phone on 6/5/25 at 12:24 PM revealed the Activity Assistant was not permitted to give food to residents. The activity department had been educated on the diets of residents. The Activity Director stated she was not present when the episode occurred on 3/19/25. The SDC conducted education with the Activity Department on the importance of providing the correct diet. The Activity Director explained she was responsible for knowing each resident's diet order and the Activities Assistant was allowed to distribute food and fluids to residents once the Activity Director determined what was appropriate. An Incident Description report dated 4/22/2025 revealed Nursing Description CNA (unidentified nurse aide) noted resident with a hot dog bun in his hand with a bite out of it. Resident actively coughing and a piece of hot dog bun coughed out. Immediate Action Taken: Resident assessed, (staff not identified) actively coughing with strong cough and noted to cough out a piece of hot dog bun. Resident noted to become distressed and unable to produce a strong cough and face became red. Heimlich (abdominal thrusts) initiated and 911 called. Mouth sweeps unable to produce the remainder of bun. Resident became weak and placed on floor and Heimlich continued. Resident became unresponsive and breathless and cardiopulmonary resuscitation initiated until EMS arrived. Predisposing factors were impaired safety awareness and impaired memory. Injuries Report Post Incident, No injuries observed post incident. This was documented by the DON. The dinner menu on 4/22/2025 included chili dogs. A telephone interview was conducted on 6/4/2025 at 4:48 PM with NA #1. She stated Resident #1 comprehended what he was told and followed directions. NA #1 stated Resident #1 was supervised because he was impulsive and stood up without warning. She stated on 4/22/2025 she had taken some bread from Resident #1 while she was picking up trays and she told him to go to his room. NA #1 indicated she went into room [ROOM NUMBER] and was held up. NA #1 recalled she came out of room [ROOM NUMBER] and observed NA #4 doing abdominal thrusts on Resident #1 while he was seated in his wheelchair. Then NA #4 got on the phone with 911 and she (NA #1) took over the abdominal thrusts then NA #5 did the abdominal thrusts. NA #1 said they passed Resident #1 from person to person and Resident #1 was not responding to the thrusts and was put onto the floor. NA #1 explained she did abdominal thrusts while she straddled Resident #1. Nurse #1 had NA #1 stop and checked for his pulse and Nurse #1 had NA #1 start chest compressions. Nurse #1 took over from NA #1 and did the chest compressions and then she (NA #1) took over chest compressions until EMS arrived. NA #1 stated she had never observed Resident #1 take food from a meal cart. During a follow up interview on 6/5/2025 at 2:20 PM NA #1 stated she never saw a hot dog in Resident #1's hand, only bread. An interview was conducted with NA #2 on 6/4/2025 at 5:13 PM. NA #2 stated on 4/22/25, she was assigned to monitor another resident on a one-to-one basis and was seated in the hall outside of room [ROOM NUMBER]. NA #2 stated Resident #1 was monitored because he was impulsive and stood up from his wheelchair. He usually stayed by his door or in the lobby and he liked to watch TV. On 4/22/25 dinner was late, and Resident #1 was pointing at the kitchen indicating he was hungry. NA #2 indicated Resident #1 received and ate his meal on 4/22/25 and did not ask for other food. NA #2 recalled she and NA #3 were picking up meal trays and the meal cart was close to Resident #1's room (which was behind her). NA #2 observed Resident #1 propelling himself to room [ROOM NUMBER] and looked like he was choking. His eyes were wide, and his face was purple. Resident #1 handed her a piece of hot dog then he coughed up a piece of hot dog and he was choking. NA #2 indicated she yelled up to the nurses' station for help. NA #4 came down the hall from the nurse's station and NA #4 did abdominal thrusts. NA #1 came out of room [ROOM NUMBER] to the hallway outside of room [ROOM NUMBER], stood up Resident #1, and took over the abdominal thrusts while NA #4 called 911 on her cell phone. Then NA# 5 took over abdominal thrusts. The Director of Nursing checked his mouth for food and stated she didn't see anything else. During an interview on 6/6/2025 at 10:24 AM NA #3 indicated that Resident #1 was supervised during his meals. In the past he had grabbed his roommate's food. She indicated that all staff were aware to watch Resident #1 when the meal carts were on the floor because he got food off the cart. On 4/22/2025 Resident #1 had his dinner in the dining room. NA #3 recalled she and NA #1 had gone into room [ROOM NUMBER] and when they came out of the room with the meal trays Resident #1 was in the hallway near NA #2 and Resident #1's face was purple. NA #3 and NA #2 yelled to Nurse #1 who was at the nursing station that Resident #1 was choking, and his face was purple. NA #5 tried abdominal thrusts and then NA #4 did abdominal thrusts. NA #5 took over abdominal thrusts and NA #4 called 911. The 911 dispatch was on the phone and NA #4 relayed what they said. NA #3 stated Resident #1 went limp, and the dispatch said to put him on the floor and do abdominal thrusts. NA #3 indicated NA #1 continued to do abdominal thrusts. NA #3 said she sat at Resident #1's head. The DON got the oxygen and put a nasal cannula on him. Then EMS arrived and took over. A telephone interview was conducted on 6/5/2025 at 3:47 PM. NA #4 indicated that she had clocked in at 6:50 PM on 4/22/2025 and was at the nurse's station. NA #2 yelled something was wrong with Resident #1. She stated that NA #1 and NA #3 said they had told Resident #1 to get out of the meal cart on 4/22/25. NA #4 stated we all knew Resident #1 took food off meal carts. NA #4 stated that she called 911 on her cell phone and NA #7 had also called 911 from the nursing station. Record review of the timecard punches on 4/22/25 confirmed NA # 4 had clocked in for work at 6:53 PM. An interview with NA #5 was conducted on 6/4/2025 at 4:00 PM. NA #5 revealed while the trays were being picked up from dinner on 4/22/25, Resident #1 was standing, and NA #1 did abdominal thrusts. NA #5 stated she tried abdominal thrusts and Resident #1 became unresponsive and was laid down on the floor. Nurse #1 started cardiac pulmonary resuscitation, and NA #4 called 911. NA #5 indicated she had never observed Resident #1 taking food from another resident and she did not know how Resident #1 got food on 4/22/25. A telephone interview with Nurse #1 was conducted on 6/4/2025 at 4:28 PM. Nurse #1 stated she was at the nurses' station when NA #2 told her that something was wrong with Resident #1 on 4/22/25. Nurse #1 indicated she went down the hallway to Resident #1 and he pointed to his chest, was not able to speak, and was choking. NA #1 was administering abdominal thrusts. Then NA #5 took over and administered the abdominal thrusts. Resident #1 went limp and was lowered to the floor and NA #1 continued to administer abdominal thrusts. Nurse #1 stated she had NA #1 stop the abdominal thrusts and the pulse was checked. She felt no pulse and they switched to doing chest compressions until Emergency Medical Services took over. Nurse #1 indicated she had not ever seen Resident #1 take food off the meal cart or a resident's tray. Record review of the late entry nursing note dated 4/22/25 authored by the Director of Nursing (DON) indicated at about 6:40 PM staff were observed in the hallway assisting the resident (Resident #1) who was in a standing position while abdominal thrusts were being performed. The staff informed the DON that while the staff were going room to room collecting trays Resident #1 had reached into the closed food cart and had taken a hot dog and bit a piece of it. A nurse aide coming out of a room realized he needed help and asked him to cough and spit out the food, but a piece of food was still lodged in his throat. Heimlich was immediately begun and 911 was called. While waiting, abdominal thrusts continued until the resident became unresponsive and chest compressions were started. EMS arrived and took over; the resident regained pulse and respirations on two separate occasions but vital signs were unable to be sustained. Resident #1 was pronounced dead at 8:08 PM. An interview on 6/5/2025 at 9:02 AM revealed the Director of Nursing indicated that initially Resident #1 stayed in his room and after he had completed his occupational and physical therapy, he propelled his wheelchair. She had never observed him at the meal cart, and he had never asked her for food. The nursing staff have a Kardex (care guide) that included the type of diet for each resident. They were accessible by computer and a paper copy was at the nursing station. The Kardex was updated as the care plan was updated or after a change of the resident. The DON stated she was in the office with the SDC on 4/22/2025 (unable to recall time) and heard commotion on the hall. She observed NA #1 doing abdominal thrusts and Nurse Aide #4 was on the phone with 911. Nurse #1 did the mouth sweep and got a small piece of food. The DON recalled 911 had them put Resident #1 on the floor and continue abdominal thrusts. Nurse #1 started chest compressions and EMS arrived. Training was completed with nursing staff again after the 4/22/25 choking incident and currently no food carts were left unattended while meals were passed or trays picked up. Meal carts were brought up to the nursing station and the doors faced the wall until the carts were returned to the kitchen. On 6/5/2025 at 1:42 PM during a follow up interview, the DON stated on 4/22/25 the doors of the food carts were closed to keep the heat on the food. She stated her investigation, determined he opened the door of the meal cart and took the hot dog, and it was a fluke. He had never tried to open the meal cart doors to her knowledge. A telephone interview on 6/9/2025 at 3:39PM revealed the Nurse Practitioner indicated Resident #1 was very social. The NP stated the facility was aware of the possibility that he may choke. The facility educated the staff and had put interventions in place after the choking event in March to follow the residents' diets. The NP further stated Resident #1 understood directions and followed direction, but he did not realize the consequences of his actions. The Emergency Medical Services (EMS) report dated 4/22/2025 revealed a call was received at 7:00 PM for a cardiac arrest from choking. EMS resuscitation services began at 7:08 PM. Initial assessment at 7:10 PM revealed Resident #1 was on his left side with no pulse or respirations. Suctioning at 7:13 PM and removal of foreign body air obstruction revealed no solid obstruction in the airway. Resident #1 had liquidized bread in the airway. Suction removed the material and intubation was successful at 7:16 PM. Resuscitation efforts continued until 8:01 PM when Resident #1 was pronounced deceased . The Medical Examiner death certificate dated 4/27/2025 revealed the cause of death was accidental and caused by an occlusion by a bolus (a blockage caused by a ball like mixture of food and saliva) of food. An interview by telephone on 6/5/2025 at 4:11 PM Medical Director revealed speech therapy assessed Resident #1 and this was the diet that was followed. The Medical Director indicated Resident #1 was able to comprehend and follow direction and it was the facility's responsibility that Resident #1 did not have access to food that caused him to choke. The interview further revealed Resident #1 was compliant with his diet and the Medical Director was not aware of Resident #1 looking for foods he should not eat. The Medical Director stated Resident #1 was at high risk to choke. The Administrator was notified of immediate jeopardy at 6/5/2025 at 7:13 PM. The facility provided the corrective action plan with a completion date of 4/26/25. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice. Resident #1 was admitted on [DATE] with diagnoses of, but not limited to, cerebral infarction (stroke), acute cerebral vascular insufficiency, hemiplegia (weakness of one side of the body) and hemiparesis (paralysis of one side of the body), altered mental status, depression, hypertension, congestive heart failure, and cardiomyopathy. The resident had a diagnosis of dysphagia (difficulty swallowing) and had a diet order of puree texture and honey thickened liquids consistency. The resident's score on the Brief Interview for Mental status indicated severe cognitive impairment. The resident was able to self-propel in the wheelchair. The resident had aphasia, but the speech therapist was unable to evaluate the degree of aphasia. In addition, the speech therapist notes increased impulsivity. On 3/19/25 while NA began to push Resident #1 from the dining room into the hallway where Nurse #50 was walking down the hall and noted the resident sliding out of his wheelchair. NA informed Nurse #50 that the resident was having a seizure. NA #1 and Nurse #50 lowered the resident to the floor and turned him on his side. Nurse #50 assessed the resident and noted a piece of bread in his mouth. Nurse #50 called out to Unit Manager #1. When Unit Manager #1 arrived, the resident was lying on the floor on his side and no seizure activity was noted; however, noted Resident #1 was actively coughing. Unit Manager #1 noted Nurse #50 slightly hit the resident on his back and the resident spit out a piece of bread. The resident did not lose consciousness and respiratory status remained intact. The Nurse Practitioner was paged to the lobby to assess the resident. EMS arrived at the facility stating they were called for seizure activity. NP and EMS assessed resident noting lungs remained clear and resident was in no distress. Resident declined to go to the hospital. Resident's responsible party notified. Education was provided by the Director of Nursing and Staff Development Coordinator to the activities department regarding activities involving food to ensure that they provide food textures as ordered. In addition, activities were educated on ensuring that a thorough clean-up is completed post a food activity either by themselves or the environmental services department. On 4/22/25 at approximately 5:00 pm dinner carts were delivered to the first floor, where Resident #1 resided. The food served for dinner that evening was a chili cheese dog on a bun. Resident #1 was in his room sitting on his bed in preparation for eating. Nurse Aide (NA) #1 provided his tray. The tray delivered was a pureed meal with honey-thick liquids per physician's order. At approximately 6:00 pm NAs began to collect the trays of residents who were finished eating. At approximately 6:15 pm NA #1 picked up Resident #1's tray. The resident was noted to have eaten 75-100% of his meal. NA #1 placed the tray on the meal cart and closed the cart door with the latch in place to secure the door in the closed position. This was the only cart on the hall near the resident's room. At approximately 6:40 pm NA #2 noticed Resident #1, who was in his wheelchair, was actively coughing and trying to expel something. NA #3 noted Resident #1 had a hot dog with a bun with a bite out of it in his hand. When Resident #1 saw NA #3 approaching, he immediately dropped the hotdog on the floor. NA #3 went to Resident #1 and stayed with him, while encouraging him to actively cough. The resident did spit out some pieces of bun. Several staff members (NAs) observed Resident #1 coughing and went to the aid of Resident #1. Resident #1 then became distressed unable to produce a strong cough and red faced. NA #4 stood him up and begun the Heimlich maneuver in an attempt to dispel what the resident was choking on. NA #1 took over the Heimlich and NA #4 called 911 from her personal cell phone exact time is unknown. Nurse #1 and #2 arrived to assist Resident #1 and Nurse #2 attempted to sweep the mouth, to remove what the resident was choking on, without success. Resident #1 became weak; staff placed him on the floor and continued the Heimlich. A small piece of bun/hotdog was expelled. However, Resident #1 continued to be in distress as evidenced by his limp body and facial color change to a blue-gray. Resident #1 then became unresponsive and breathless. A code blue, indicating a resident requiring immediate resuscitation, was yelled and then called over the intercom system. Nurse #1, NA #1, and NA #5 initiated cardiopulmonary resuscitation (CPR) with chest compressions and breaths an ambu bag (a device used to force air into a person's lungs). There was no pulse or respirations noted at this time. Staff continued CPR, chest compressions and breaths for two minutes. They were able to get air into the resident's lungs as evidenced by the rise of the chest during breaths provided with the ambu bag. At 7:08pm Emergency Medical Services (EMS) arrived and relieved the staff by taking over CPR. EMS began attempts to resuscitate with the use of the LUCAS compression system, a device that provides mechanical chest compression to residents in cardiac arrest. EMS attempted suction to remove the obstruction without success. EMS was able to intubate the resident. EMS continued with attempts of resuscitation for approximately 8 cycles of CPR. All efforts of resuscitation ceased at approximately 8:15pm. Resident #1 was announced dead at this time. The cause of death on the death certificate was cardiac arrest. Address how the facility will identify other residents having the potential to be affected by the same deficient practice. Residents with altered diets, including pureed, mechanically altered, and thickened liquids, have the potential to be affected by the deficient practice. On 4/22/25 the Director of Nursing initiated an audit of resident diets to determine what residents were on altered diets, are ambulatory or can self-propel in a wheelchair, and potential food seekers. One resident was identified as a potential food seeker. This resident was placed on supervision during mealtimes until the meal trays were removed from the unit and during activities with food involvement. The resident has a roommate with a regular textured diet. The roommate does not have snacks stored in her room nor does she have the ability to purchase snacks. The supervision will be provided by the NA assigned to the resident during the presence of food for either the resident or the roommate, in the event there is more than one resident needing supervision for an NA, department heads will be assigned to supervise residents. The NA receives an assignment for supervision from the charge nurse at the beginning of the shift. This supervision was put into place on 4/23/25. Tray cart doors are to remain closed during tray pass and pick up except for when the staff member is taking or putting the tray away. When the tray cart is not in direct contact with a staff member, the tray cart door will be pushed up against the wall. This education was provided to staff by the Staff Development Coordinator and Director of Nursing, which was initiated on 4/22/25. Food availability is from meals, food activities or the vending machines. Snacks are kept in the nourishment rooms behind the nurses' station. Residents would need to have money to access food from the vending machines. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur. On 4/22/25 the Staff Development Coordinator and the Director of Nursing initiated education with facility staff to include nursing, dietary, environmental services and therapy department staff regarding monitoring of tray carts when they were out on the units to ensure the doors remain closed, cart against the wall, and monitoring residents who received alternate diets/thickened liquids and were ambulatory or were able to self-propel in a wheelchair to ensure they are not attempting to get in the tray cart or showing food seeking behaviors. The education included making sure residents who were on alternate/thickened liquids diet were not consuming inappropriate foods. Snacks are kept in the nourishment room accessible by staff. Staff who do not receive the education by 4/25/25 will not be allowed to work until the education is completed. Newly hired staff will receive the education during orientation from the Staff Development Coordinator. The Director of Nursing will be responsible for ensuring the education is complete for current staff and new hires. If a staff member identifies a resident with a food consistency they do not have ordered, the staff member will go to the resident and encourage them to spit it out while simultaneously calling for assistance. The IDT review diet orders during morning stand up and determines the residents that need monitoring. The Unit Managers deliver any new information to the charge nurse, who assigns the NA that will be responsible for monitoring the resident at risk. The Director of Nursing and Administrator are the second check to ensure the monitoring has been put in place. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. On 4/25/25 the facility had an ad hoc Quality Assurance Performance Improvement (QAPI) meeting, including the Interdisciplinary Team consisting of the Administrator, Director of Therapy, Unit Manager First Floor, Unit Manager Second Floor, Staff Development Coordinator, Environmental Services Director, Dietary Manager, MDS nurse, Director of Nursing, Regional Nurse Consultant. The Medical Director was notified via telephone. During the meeting it was determined the Director of Nursing, or the Administrator will conduct audits of residents who receive altered diets and are able to ambulate or self-propel in the wheelchair for monitoring during mea[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interviews with staff and the Medical Director, the facility failed to provide care in a safe manner for 1 of 3 residents reviewed for supervision to prevent accidents (Resident #1). On [DATE] Resident #1 requested incontinence care and Nurse Aide (NA) #1 gathered supplies and raised the level of the bed to provide care. NA #1 asked Resident #1 to turn on her side away from NA #1. NA #1 stated she had her right-hand touching Resident #1 and while the resident was turning the brief fell on the floor. NA #1 took her hand off Resident #1 when she bent down to pick up the brief and Resident #1 rolled off the bed onto floor hitting her head. Nurse #1 was called to the room and assessed Resident #1 and noted she was incoherent and unable to answer questions. When Nurse #1 palpated Resident #1's head she yelled out in pain her head and neck hurt. Resident #1 yelled out in pain when Nurse #1 assessed her upper extremities. Resident #1 was sent to the emergency room (ED) on [DATE] and results of x-rays completed on [DATE] revealed fractured left 6th and 7th ribs and the CT scan (computed tomography scan is a medical imaging procedure that uses x-rays to create detailed images) of the head noted an acute on chronic bilateral subdural hematomas (collection of blood on the surface of the brain) that had increased in size from compared with prior imaging on [DATE] and a possible trace acute subarachnoid hemorrhage (bleeding in the space below one of the thin layers that cover and protect the brain). On [DATE] Resident #1 had a neurological change (a change in the function of the brain, spinal cord, or nerves) to include expressive aphasia (condition that makes it difficult to speak or write) with right-sided weakness, seizure activity, and admission to Intensive Care Unit (ICU). On [DATE] Resident #1's neurological status worsened due to an increase in subdural hematoma. On [DATE] Resident #1 was made comfort care and died on [DATE] at 5:00 pm. The Death Certificate indicated the immediate cause of death for Resident #1 was complications of blunt force injury to the head. Immediate jeopardy began on [DATE] when Resident #1 rolled out of bed to the floor while incontinence care was provided. The immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective. Findings included: Resident #1 was admitted to the facility on [DATE], with a diagnosis that included dialysis dependent end stage renal disease (ESRD), metabolic encephalopathy, hypertension, congestive heart failure, diabetes, history of seizures, venous sinus thrombosis 12/2024 (rare form of a stroke), and history of pulmonary embolism. Physician orders dated [DATE] included Eliquis (blood thinner used to prevent blood clots and stroke) 5 mg (milligrams) one tablet by mouth two times a day related to thrombosis and remained current until the resident was discharged to hospital on [DATE]. Resident #1's admission Minimum Data Set (MDS) assessment dated [DATE] revealed she was cognitively intact, with no behaviors, with a height of 65 inches and weighed 213 pounds Resident #1 required partial/moderate assistance (helper does less than half the effort, Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with roll left and right (the ability to roll from lying back to left and right side, and return to lying on back on the bed.) The facility did not provide a care plan that focused on Resident #1's functional abilities (self-care and mobility). Review of ED provider notes dated [DATE] revealed Resident #1 was transferred to the hospital for evaluation due to an episode of hypotension (abnormally low blood pressure) and altered mental status after being found unresponsive at the facility. The resident was awake and at her baseline and had normal blood pressure by the time she got to the ED. She did not remember passing out. The initial CT scan completed on [DATE] showed bilateral subdural calvarial convexities (subdural hematomas) which were likely subacute to chronic with some acute component not excluded. Laboratory tests were unremarkable. It was noted she had not had any falls and had no subdural hematomas on her scans last month. Neurosurgery recommended a repeat CT scan in 8 hours. The resident was admitted given her episode of syncope, hypotension and new onset subdural hematomas. The hospital discharge summary note dated [DATE] indicated that resident was discharged in stable condition with active problems, end stage renal disease on hemodialysis, hypotension and subdural hematoma. It was noted the follow up CT head scan was done with no acute changes and per neurology department and Resident #1 should have a neurological outpatient follow up to determine duration of anticoagulation and follow-up CT scan. Eliquis 5 mg twice daily was listed as a medication to be continued. Physical Therapy (PT) evaluation for start of care dated [DATE], indicated that Resident #1 was worried about falling. The functional mobility assessment on the PT evaluation report revealed that Resident #1 required partial/moderate assistance to roll left and right during bed mobility. It also showed that the mobility function score (ranges from 0-12; 12 being the highest function) was a 3. The self-care performance assessment indicated on the PT evaluation revealed that Resident #1's self-care function score (score 0-12; 12 being the highest function) was a 0. The musculoskeletal system assessment on the PT evaluation indicated that Resident #1 had impaired right and left lower extremity strength. Occupational Therapy (OT) evaluation for start of care [DATE], indicated that Resident #1 required substantial/maximal assistance with toileting hygiene, and bed mobility. The mobility function score (ranges form 0-12;12 being the highest function) was a 1. The musculoskeletal system assessment on the OT evaluation revealed that Resident #1 had impaired right and left upper extremity strength, and impaired right upper extremity shoulder, elbow, forearm and wrist. An interview with the Rehabilitation Director was conducted on [DATE] at 11:58 am. The Rehabilitation Director confirmed that Resident #1 required minimum to moderate staff assistance with bed mobility to include rolling left and right. Rehab Director indicated that Resident #1 was never independent with bed mobility but required assistance with bed mobility to include rolling left and right while in bed. The facility Transfer/Mobility Evaluation Assessment completed by Unit Manager #1, on [DATE] was reviewed. The resident evaluation/functional ability section indicated that Resident #1 was non-ambulatory, had unsteady gait, with difficulty standing and required partial support to sit on bedside. The assessment further indicated that resident was able to sit on bedside with partial support (rail or person). Interview was conducted with Unit Manager #1 on [DATE] at 2:54 pm. Unit Manager #1 confirmed that she completed the transfer/mobility evaluation assessment. Unit Manager #1 indicated that Resident #1 required assistance with bed mobility and could not turn side to side in bed without assistance. Daily skill assessment completed on [DATE] by Nurse #3 was reviewed. Assessment indicated that Resident #1 required total assistance of one person with bed mobility. Multiple attempts were made to reach Nurse #3 for an interview were unsuccessful. Facility Incident report dated [DATE] completed by Nurse #1 at 1:28 am indicated under the nursing description; nurse aide [NA #1] states the resident [Resident #1] fell from bed when she rolled resident over to clean her bottom. The report revealed that Resident #1 had an injury to the back of head, left shoulder and top of scalp with occasional moaning or groaning, low level of speech with a negative quality and facial grimacing. The report also mentioned that upon the initial assessment immediately after the fall, Resident #1 could not answer questions and staff had to say Resident #1's name and physically stimulate Resident #1 to get a response. As time passed while waiting for emergency medical services (EMS), Resident #1 became more coherent but seemed to become more lethargic. The level of consciousness reflected on the incident report indicated Resident #1 was responsive only to vigorous stimulation after fall. NA #1's signed statement dated [DATE] indicated the incident occurred on Sunday [DATE] and NA #1 had seen Resident #1 about 6:00 pm when picking up the dinner tray from and Resident #1 was watching TV (television). NA #1 was doing rounds between 7:30 pm and 7:45 pm and Resident #1 requested to be changed. NA #1 gathered her supplies, raised the bed up and the brief fell on the floor. NA #1 she bent down to pick up the brief, and [Resident #1] rolled over to the window and rolled off the bed. A chair was by the air conditioner and NA #1 was unsure whether Resident #1 hit the chair. NA #1 indicated was screaming and she called for a nurse and called NA #2 on her cell phone. NA #1 requested NA #2 to send a nurse to Resident #1's room. Nurse #2 entered the room and immediately asked about how high the bed was but did not evaluate Resident #1. Nurse #1 came in and helped and assessed Resident #1. NA #1 Nurse #1 and NA #2 remained with Resident #1 and did not move the resident until EMS arrived. Resident #1 was talking and knew the day and time. Initially Resident #1 refused to go to the hospital, and her family was called and helped convince her to go. EMS transferred Resident #1 to the hospital. An interview with NA #1 was conducted on [DATE] at 4:06 pm. NA #1 revealed that Resident #1 was under her care from 7:00am, until she finished her shift at about 8:56 pm, on [DATE]. NA #1 confirmed that Resident #1 was able to make her needs known. NA #1 indicated that at around 7:15 pm, she went to check on Resident #1 and Resident #1 requested assistance with incontinence care. NA #1 indicated that she gathered her supplies which included a brief, wash clothes and towels to assist Resident #1 with incontinence care. NA #1 explained that once she entered the room, she got a basin of water, washcloths, brief and soap to provide care. NA #1 then confirmed that she raised the height of the bed to where she did not have to bend at all. NA #1 indicated that the height of bed was approximately at her chest level. NA #1 emphasized that she did not think the bed was too high, because she always brought it up that high. NA #1 revealed that after she completed washing Resident #1's perineal area, she told Resident #1 could you turn over there. NA #1 stated she was pointing Resident #1 towards the window, which was away from NA #1. NA #1 confirmed that she was standing to the left of Resident #1, facing the window. NA #1 further explained that prior to asking Resident #1 to turn from her back towards her right side, NA #1 did not move Resident #1 towards Resident #1 left side first, to ensure that Resident #1 was not close to the to the edge of the bed when she turned. NA #1 stated she did not recall how Resident #1 was positioned on the bed prior to requesting her to turn. NA #1 indicated the brief fell just when she had completed telling Resident #1 to turn towards the window, away from NA #1. NA #1 indicated that Resident #1 turned over, and then NA #1 turned from Resident #1 to bend down and pick up the fallen brief off the floor. NA #1 stated that Resident #1 fell off the bed onto the floor. NA #1 stated that she thought Resident #1 fell because, when the brief fell to the floor next to the bed, and she (NA #1) went to get it, she (NA #1) let go of Resident #1 and Resident #1 fell. NA #1 indicated that she did not touch Resident #1 while she turned /rolled over and Resident #1 turned herself to the side. NA #1 explained that she had her right-hand touching Resident #1 after Resident #1 was on her side. NA #1 continued to explain that when she went bent down to get the brief from the floor, she took her right hand off the resident. NA #1 stated when she picked up the brief off the floor, and stood up, it was too late for her to stop Resident #1 from falling because she was already falling off the bed, and she (NA #1) could not reach her at that point. NA #1 stated that Resident #1 fell, hit her head on the floor with a loud thud. NA #1 stated that she (NA #1) started screaming asking for assistance. NA #1 repeatedly stated that Resident #1 rolled too far and fell. NA #1 further stated that she did not leave Resident #1 alone, but sat with her on the floor, while screaming for help. NA #1 continued to state that NA #2 was at the nursing station and notified Nurse #1 and Nurse #2 about the incident. NA #1 indicated that both Nurse #1 and Nurse #2 came into Resident #1's room. NA #1 revealed that Nurse #1 asked her what happened. NA #1 explained to Nurse #1 that she was changing Resident #1 and Resident #1 fell. NA #1 revealed that while Resident #1 was on the floor, she was trying to talk to Nurse #1. NA #1 explained that when EMS arrived at the facility, Resident #1 has initially refused to go to the hospital, because she did not want anyone to take her television. NA #1 indicated that EMS convinced Resident #1 to go to the hospital. Nurse #1 contacted Resident #1's family member, who stated that Resident #1 was not in her right mind at the moment due to the fall. NA #1 indicated that Resident #1 was then lifted off the floor, onto the stretcher by EMS, Nurse #1 and NA #1. NA #1 indicated that the facility Administrator typed out a statement about the incident and told her to sign. NA #1 explained she was trying to write a statement on the day of the incident, but was told that the facility did not have any paper for her to use. NA #1 indicated that she never wrote a statement. Progress note written by Nurse #1 on [DATE] at 12:48 am which referenced Resident #1 stated at approximately 7:35 pm, while receiving shift report from off-going nurse, writer responded to nursing assistant [NA#1] calling out for help in Resident #1's room. Upon entering the room, the resident observed lying on the floor on her left side with the back of her head on the ac/heating unit. The NA stated the resident fell off bed when being rolled over to have her bottom cleaned. Nurse #1 noted the bed was significantly elevated. Upon assessment, resident was somewhat incoherent and unable to answer questions appropriately. Resident noted to have dazed look in her eyes and tremoring of lips. While palpating the resident's head and attempting to move head off ac/heating unit, the resident yelled out in pain stating her head and neck hurt. No further attempts were made to move neck or head but placed pillow for comfort. While assessing upper extremities, resident also yelled out in pain, especially during manipulation of left extremity. Neurological checks (assessment to check change in the function of the brain, spinal cord, or nerves) revealed change of LOC (level of consciousness), movement of upper extremities. Lower extremities were not assessed due to the resident's increasing pain. While writer was assessing resident, off-going nurse notified the on-call provider of fall and resident's use of Eliquis. An order given to send resident to ER. EMS was called and family was notified of events. When EMS arrived, resident initially refused to be transported to hospital. EMS called the resident's family and explained that they could not take resident if she did not want to be transported. Eventually, EMS and staff were able to encourage resident to go to hospital to be evaluated. At 8:15 pm, EMS left the facility and transported the resident to the ED. Family was notified of transport to the ED. The Director of Nursing was notified of fall and transport to hospital. A phone interview with Nurse #1 was conducted on [DATE] at 4:40pm. Nurse #1 indicated that she worked from 7:00 pm on [DATE] to 7:00 am on [DATE]. Nurse #1 stated that she was at the nursing station, having completed taking report from the outgoing Nurse #2 when NA #1 called out for help. Nurse #1 indicated that NA #1 came out to the hallway outside Resident #1's room and shouted, [Resident #1] is not responding. Nurse #1 indicated she immediately ran to Resident #1's room and upon entering Resident #1's room, Nurse #1 observed the bed was raised to the highest level. Nurse #1 further stated NA #1 explained to her that she raised the bed up to give Resident #1 care and when she rolled Resident #1 over to wipe her back side, she realized she did not have the diaper and wipes. NA #1 indicated she turned around to get the supplies and when she let go of Resident #1, she fell over. Nurse #1 added that NA #1 also stated that she rolled over Resident #1 too far. Nurse #1 indicated she observed Resident #1 on the floor with the back of her head against the air conditioning unit. Nurse #1 further revealed that Resident #1 was lying on the floor on her left side and her left arm was over her head. Nurse #1 indicated she rubbed Resident #1's head and Resident #1 made a groaning noise like it hurt. Nurse #1 informed NA #1 and Nurse #2 that they could not move Resident #1, but they had to notify provider and EMS as Resident #1 required immediate medical attention. Nurse #1 revealed that when she attempted to talk to Resident #1, resident was super dazed as if she was knocked out and not focused. Nurse #1 emphasized that if NA #1 did not let go of Resident #1, Resident #1 would not have fallen out of the bed. Nurse #1 stated Resident #1 could make her needs known but could not turn to her side without assistance. Nurse #1 repeated this statement NA #1 did it. She let her go. She did not hold onto to her, and she did not have the stuff next to the bed. Nurse #1 indicated that the bed was high to its maximum height, a height that she had never seen before. Nurse #1 further stated that NA #1 kept saying I had to raise the bed high. Nurse #1 indicated that she notified Resident #1's family member of the incident and also stayed with Resident #1 until EMS arrived. Statement provided by facility with no date or signature was reviewed. The Administrator indicated in the document that she typed out, that she (Administrator) told Nurse #2 to sign it, and Nurse #2 refused. The statement documented indicated Fell [Resident #1] about 7:30pm. Aide yelled down hall for the nurse. 'She's not responding.' Me [Nurse #2] and Nurse #1 were sitting at the nurses' station getting report. [NA #1] ran screaming '[Resident #1] is not responding.' We got to the room. [NA #1] said she was changing her, turned back to get something off the nightstand. Grabbed brief or wipe or 'something.' Resident #1 was between heater and bed on her left side. I left the room and printed the paperwork to go to ED for Nurse #1. She was responsive. She was not talking. I did not assess Resident #1. The other nurse was in the room. 'Resident #1 eyes were fixed. Looked like she was having a seizure. 'I told aide 'why is the bed so high?' The aide explained she was giving patient care and turned around to get something. I left the room about 7:32 pm. A phone interview was conducted with Nurse #2 on [DATE] at 10:00am. Nurse #2 indicated that she worked from 7:00 am to 7:00 pm on [DATE]. Nurse #2 explained that after she had completed giving report to oncoming Nurse #1, NA #1 came out of a room into the hallway and said [Resident #1] was not responding. Nurse #2 indicated that she thought Resident #1 had become unresponsive and required cardiopulmonary resuscitation (CPR). Nurse #2 stated she ran into Resident #1's room and the first thing she noted was the bed was at its highest level. Nurse #2 indicated that she was 5 feet 3 inches tall, and the bed was all the way up to her chest. Nurse #2 indicated that the bed was raised to its highest position. Nurse #2 indicated that she asked NA #1 what happened, and NA #1 stated she was changing Resident #1, turned around to grab something off the dresser, and Resident #1 fell on the floor. Nurse #2 indicated that Nurse #1 was in the room as well. Nurse #2 stated that Nurse #1 requested that EMS and the provider be notified. Nurse #2 then left the room, notified the provider, called EMS and prepared the discharge paperwork. Nurse #2 revealed that she had cared for Resident #1 multiple times and indicated that Resident #1 was able to make her needs known and required extensive assistance from staff with turning in bed. Nurse #2 indicated she explained the incident to the Administrator but was not allowed to write a statement. Nurse #2 indicated the Administrator typed a statement and asked Nurse #2 to sign it. Nurse #2 confirmed that she refused to sign the statement the Administrator typed because she did not agree with what was written on the form about the incident. Nurse #2 indicated the Administrator had changed her words to imply something else had happened and that is why she refused to sign it. Resident #1's emergency department (ED) provider note dated [DATE] indicated she had a history of ESRD with hemodialysis, recent venous sinus thrombosis on Eliquis, recent seizures on Keppra, and diabetes mellitus. Resident #1 reported she was being changed when she rolled about 3 feet off the bed, landing on the floor on her right side. She was not sure if she lost consciousness. The ED physician noted per chart review Resident #1 was admitted [DATE] through [DATE] following a syncopal episode and was found to have a new subdural hematoma and was restarted in Eliquis prior to discharge. Results of x-rays completed on [DATE] revealed fractured left 6th and 7th ribs and the CT scan of the head noted an acute on chronic bilateral subdural hematomas that had increased in size from compared with prior imaging and a possible trace acute subarachnoid hemorrhage. Neurosurgery was consulted due to worsening of the prior subdural hematomas and possible new acute subarachnoid hemorrhage. The Neurosurgeon recommended a follow-up CT scan in 6 hours and to hold Eliquis. Hospital progress notes dated [DATE] through [DATE] revealed on [DATE] while boarding in the ED neurological changes were noted including expressive aphasia with right-sided weakness. The repeat head CT scan revealed an increase in the left subdural hematoma without a midline shift (shift of the brain past its center line due to bleeding or swelling). Neurology was consulted and recommended admission to the intensive care unit for frequent neurological checks and Eliquis reversal. An Internal Medicine consultation note dated [DATE] indicated serial CT scans were now showing increase in the size of the subdural hematomas with a new midline shift measuring 3 mm (milliliters). The consulting Physician also noted that during the exam that morning Resident #1 appeared to be actively seizing. Neurology was paged urgently and intravenous Keppra (antiepileptic drug) was given. On [DATE] hospital progress notes indicated that Resident #1 had a worsened neurological status due to increase in subdural hematoma. On [DATE] Resident #1 was made comfort care and died on [DATE] at 5:00 pm. Certificate of Death, dated [DATE], from North Carolina vital records, indicated that the immediate cause of death for Resident #1 as complications of blunt force injury to the head. An interview with the Director of Nursing (DON) was conducted on [DATE] at 3:35 pm. DON indicated that she was notified by Unit Manager #1 on [DATE] at 7:45 pm that Resident #1 fell out of the bed while receiving care from NA #1. DON indicated that she then contacted the Administrator about the incident. DON indicated that Resident #1 was receiving care from NA #1, who did not use the proper positioning technique to assist the resident onto her side, and thus Resident #1 fell out of the bed. DON indicated that Resident #1 needed assistance to be turned to her side. An interview was conducted with the facility Administrator on [DATE] at 3:35 pm. The Administrator indicated she interviewed NA #1 on [DATE]. The Administrator explained that NA #1 was able to show a return demonstration of what happened during care with Resident #1, while in the Administrator's office. The Administrator stated that NA #1 demonstrated that she (NA #1) had her right hand on Resident #1 and her left hand was not touching Resident #1. The Administrator continued to state that NA #1 indicated that the brief fell to the floor, and NA #1 demonstrated that she turned to pick up the brief from the floor and her right hand moved away from Resident #1. The Administrator added that NA #1 confirmed that once she moved her right hand away from Resident #1 and went to pick up the brief form the floor, Resident #1 fell out of the bed onto the floor. The Administrator stated that NA #1 was not able to indicated how high the bed was raised. A phone interview with the Medical Director was conducted on [DATE] at 4:39pm. The Medical Director confirmed that he did not examine or see Resident #1 upon readmission on [DATE]. The Medical Director indicated that he was scheduled to assess Resident #1 on [DATE], but the resident was out of facility. The Medical Director stated that he had reviewed the discharge summary from the acute care hospital dated [DATE]. The Medical Director stated that with the combination of the fact that Resident #1 was on Eliquis the fall did contribute to the increase in the subdural hematoma. The Medical Director revealed the head injury sustained from the fall off the bed, contributed to increased hemorrhage in combination with the use of Eliquis. The Administrator was notified of immediate jeopardy on [DATE] at 4:30 pm. The facility provided the following plan for IJ removal. * Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 was admitted to the facility on [DATE] with diagnoses that included a recent venous sinus thrombosis, and a chronic bilateral hematoma. She was ordered anticoagulation prior to admission to the facility for the venous sinus thrombosis. The Resident was discharged to the hospital on [DATE]. She was readmitted on [DATE]. On [DATE] at 7:20 p.m. Resident #1 requested incontinent care. Nursing Assistant (NA) #1 prepared supplies, that included a brief, and began by raising the bed to hip height, per recommended care safety guidelines for staff. The brief fell to the floor and NA #1 bent over to pick up the brief. NA #1 did not have her hands on Resident #1 when she picked up the brief and Resident #1 rolled over to face the window, on the right side of the bed, and rolled off the bed. NA #1 immediately responded to the Resident by walking to that side of the bed and called for assistance from NA #2. NA #2 notified Nurse #1 that there was a fall. Nurse #1 responded to the fall immediately, observed Resident #1 on the floor on the right side of the bed. Nurse #1 called for assistance from Nurse #2. Nurse #2 finished the assessment while Nurse #1 contacted Emergency Medical Services (EMS) to transport Resident #1 to an acute care hospital. While EMS was in route to the facility, Nurse #2 continued to conduct assessments that included neurological examinations, vital signs, and a skin assessment. Nurse #2 reported there were no visible signs of broken skin. Resident #1 was admitted to the hospital on [DATE]. * 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. On [DATE] Nurse #2 notified the unit manager that Resident #1 had a fall from the bed during care. The Unit Manager (UM) notified the Director of Nursing (DON) and the Administrator. The intervention included Resident was to be seen at the acute care hospital and for the fall to be discussed in the morning clinical risk meeting on [DATE]. On [DATE] Resident #1's care plan was updated to indicate she would require two staff assistance during care related to most recent fall. Following interview with CNA #1, it was determined that CNA #1 removed her hand from Resident #1 in order to pick up the brief from the floor and resident rolled away from CNA #1. On [DATE] an audit was conducted by the DON, Regional Nurse Consultant (RNC), and the Minimum Data Set (MDS) nurse, to identify any residents at risk for falls utilizing fall risk analysis report and Morse Scale report. The Activities of Daily Living (ADL) care plans of the residents who are at risk for falls and/or have had falls in the past 30 days were reviewed to ensure they included if the resident required a level of assistance of minimum, moderate, or maximum assistance with bed mobility. This audit included residents who currently have devices care planned to ensure the device is in place. Kardex updates automatically in Point Click Care (PCC) when the intervention is updated in the care plan, which CNAs can review under their documentation system of Point of Care (POC). The DON identified 2 items related to Dycem and a weighted blanket. These two items were corrected immediately by DON and/or SDC. This audit was completed on [DATE]. On [DATE] the Staff Development Coordinator (SDC) began education on turning and repositioning during care, utilizing the appropriate level of care required, maintaining resident safety during care by maintaining physical contact, and utilizing any assistive devices are according to resident's care plan/Kardex. Education was conducted in person with staff with an observed return demonstration completed to SDC. The education included an emphasis on the procedure for turning and repositioning resident when providing care, obtaining assistance when needed, maintaining resident's safety during care by maintaining physical contact, and repositioning a resident to the center of the bed when care is completed. SDC observed return demonstration included answering any questions, and/or re-educating 1:1. The education will be completed by [DATE] for clinical staff currently working and will continue with staff who provide care to residents including nurses, nurse aides, therapy. Those who were not educated by [DATE] will be educated and provide return demonstration prior to beginning their next scheduled shift. Newly hired staff including nurses, nurse aides, and therapy will receive the education from the SDC or designee and provide return demonstration to SDC, DON, or UMs during orientation and this will be conducted by the SDC or DON. On [DATE] the Activities Director conducted interviews with residents that had a Brief Interview for Mental Status (BIMS) > 12, to identify any resident concerns related to turning and repositioning during care. Interviews were completed by [DATE]. No concerns were identified. On [DATE] the DON conducted observations of residents and resident rooms identified to be at risk for falls to ensure the fall interventions placed on the plan of care were in place. Effective [DATE] the Administrator will be responsible for ensuring implementation of this immediate jeopardy removal for this alleged non-compliance. Date of immediate jeopardy removal: [DATE] Validation of the immediate jeopardy removal plan was conducted in the facility on [DATE]. The facility's initial plan audit was verified and signature sheet for education reviewed with no concerns. Facility nurses and nursing assistants were interviewed and were aware of turning and repositioning during care, utilizing the appropriate level of care required, maintaining resident safety during care by maintaining physical contact, obtaining assistance when needed, repositioning a resident to the center of the bed when care is completed and utilizing any assistive devices are according to resident's care plan/Kardex. The facility's immediate jeopardy removal da[TRUNCATED]

Based on observations, record review, Nurse Practitioner and staff interviews, the facility failed to verify competency for cleaning and disinfecting glucometers according to the manufacturer's instructions. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same shared glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. MA #1 was interviewed and reported she worked at the facility for approximately 2 years and her competencies for cleaning and disinfecting glucometers per the manufacturer's instructions had never been verified. She stated she never cleaned and disinfected the glucometer between residents. This was for 1 of 1 Medication Aide reviewed. The Immediate Jeopardy began on 7/10/24 when the failure to verify the competency of MA #1 on the cleaning and disinfecting of a glucometer resulted in the MA's failure to clean and disinfect a shared glucometer between residents when conducting FSBS checks. Immediate Jeopardy was removed on 7/12/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems is put in place and to complete employee in-service training. Findings included: Cross refer to tag F-880: Based on record reviews, observations, and staff and Nurse Practitioner (NP) interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. This occurred while there were no residents with known bloodborne pathogens, such as Hepatitis and Human Immunodeficiency Virus (HIV), in the facility. Failure to clean and disinfect the shared glucometer per manufacturer's instructions after use on each resident has the high likelihood of exposing residents to the spread of bloodborne pathogens. The deficient practice occurred for 4 of 4 residents observed for finger stick blood sugar monitoring. During an interview on 7/10/24 at 4:55 pm, MA #1 revealed she was not trained on cleaning and disinfecting glucometers per the manufacturer's instructions in the facility. She stated she had always wiped down her cart and the glucometer with 2 wipes. One wipe was used to clean and the other wipe to disinfect. She indicated nobody watched her perform the process of cleaning and disinfecting glucometers while she worked in the facility. During an interview on 7/11/24 at 9:15 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) revealed she just started her job three months ago and she was not sure what had been taught to the medication aides regarding cleaning and disinfecting the glucometers. She could not find orientation checklists for the MAs including MA #1 and was having to come up with her own orientation checklists which included cleaning and disinfecting glucometers. She said she did an in-service about infection control and disinfecting glucometers in April 2024 based on the facility's policy. She had staff sign rosters when doing an in service. She stated she was not sure if MA #1 attended the in-service. She was not able to provide a roster for the in-service in April 2024. The SDC/IP stated she was not sure if the medication aides' competencies were verified or how they were verified. She revealed she could not find the training folders. The SDC/IP stated in the future, she would ask the nurse and MA's to demonstrate the cleaning and disinfecting of glucometers per manufacturer's instruction to make sure they understood when she trained them. After the interview on 7/11/24 with the SDC/IP, evidence of training and verification of competencies for cleaning and disinfecting glucometers for MA #1, MA #2, MA #3, MA #4 and MA #5 was requested from the SDC/IP. As of the survey's exit, no evidence was provided. During an interview on 7/11/24 at 9:27 am, the Director of Nursing (DON) revealed she started her job in April 2024. The DON explained the MA not cleaning and disinfecting the glucometer between resident use was an example of not having a strong training and a good orientation program which she observed in the facility when she first got the job in April 2024. She could not find training folders, or the staff folders did not have records regarding training, such as infection control, in them. The DON stated they had an in service on checking blood glucose and the cleaning and disinfection of glucometers in April of 2024. She did not know if MA #1 was at the April in service. She could not find any evidence the nurses and the MAs' competencies were verified. She stated she hired the SDC/IP and trained her. She also hired two Unit Managers to help with training and educating staff. The DON was hoping to structure the orientation program and streamline the education. The constraint to the effective training program was the staffing shortage. She stated the SDC/IP and the Unit Managers who she was hoping to help train were getting pulled to work the carts. The DON stated she was trying to create processes and improve their training program and had made strides since she started. On 7/11/24 at 10:03 am, an interview was conducted with the Administrator, in the presence of the DON. The Administrator revealed she just started at the facility in January 2024 as the administrator. She revealed there were a lot of improvements that needed to be made at the facility and she was working closely with the DON to ensure improvements were made. During an interview on 7/11/24 at 2:05 pm, the Regional Nurse Consultant stated the Chief Nursing Officer sent an email to the DON regarding the use of glucometers in April and the staff had the in-service on checking blood sugars and cleaning and disinfecting the glucometers. She revealed MA #1 told her on 7/11/24 that nobody in the facility trained her on the cleaning and disinfecting of glucometers in between residents per manufacturer's instructions. The Administrator was notified of Immediate Jeopardy on 7/11/24 at 1:50 pm. The facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 7/10/2024 at 4:45 p.m., Medication Aide (MA) #1 performed a fingerstick blood glucose check on Resident #1, #2, #3, and #4. MA #1 failed to perform glucometer fingersticks on 4 residents utilizing each resident's personal glucometer and instead used one (1) glucometer for the 4 residents. MA #1 failed to cleanse and disinfect the glucometer according to glucometer manufacturer and EPA-registered disinfectant germicidal wipes recommendations. MA #1 did not follow the facility process and manufacturer and disinfected product guidelines despite having received proper training 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. On 7/10/2024 at 5:10 p.m., The Medical Director was notified of the incident by the interdisciplinary team (IDT). The IDT discussed education and systems to put into place to prevent future staff competency issues related to blood glucose monitoring. These systems included education to MA #1, all nurses, and medication aides. On 7/10/2024, SDC #2 was notified by Nurse Consultant #1 of her responsibility to conduct education with nurses and medication aides regarding residents' personal glucometers for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The education will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation process for newly hired nurses and medication aides. On 7/10/2024 at 5:10 p.m. the IDT team reviewed the manufacturer instructions to obtain the manufacturer recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included germicidal disposable wipes (EPA 9480-4). The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow the surface to remain wet for two minutes. Let air dry. On 7/10/2024 at 5:15 p.m., SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacture guidelines for the glucometer and the germicidal wipe recommendations to clean and then disinfect with two minutes of wet contact time. The SDC then in-serviced all nurses and medication aides working. SDC then began in-servicing all nurses and medication aides not currently working at the facility. All staff were instructed to see the Director of Nursing (DON) and/or SDC before their next shift for a return demonstration. The SDC will educate all newly hired nurses, medication aides and agency staff before receiving an assignment. The SDC will be responsible for keeping up with the newly hired staff and new agency staff. The new staff will be in-serviced on glucometer disinfection prior to working on a medication cart and will be required to perform a return demonstration for the DON or SDC before the next assignment. The glucometer policy was placed on every medication cart and reads: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. 2. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. [NAME] gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) disinfectant wipes from container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, according to the glucometer manufacturer's instructions. Follow the germicidal directions for the dry time. Allow the glucometer to air dry. 11. Discard disinfectant wipes in waste receptacle. 12. Perform hand hygiene. On 7/11/2024 the IDT made the decision to move all resident glucometers into the corresponding resident's room to be stored at the bedside. The glucometers were moved by the Unit Managers on 7/11/2024 and education on the location of the glucometers was provided to all nurses and Medication Aides working on this shift. Any nurse, medication aide, or agency staff that were not working on 7/11/2024 will receive education prior to starting the next scheduled shift. This education will be conducted by SDC #2. Alleged date of Immediate Jeopardy removal is 7/12/24. The credible allegation for immediate jeopardy removal was validated on 07/17/24. Education for nurses and medication aides was confirmed as completed. The education included obtaining capillary blood glucose sampling and cleaning/disinfecting glucometers per the manufacturer's instructions before and after each resident or to use individual glucometers. Review of the facility audits revealed nurses and medication aides had been observed by Director of Nursing (DON), and Staff Development Coordinator (SDC) performing blood checks and cleaning/disinfecting the glucometers. The audits documented there were no issues. During this survey both licensed nurses and medication aides were interviewed and revealed knowledge of education and training to show competency to provide care and disinfect residents' glucometers and knowledge that all residents have their personal glucometers in their rooms. Education for licensed nurses and unlicensed staff was confirmed with observations of staff providing glucose blood checks on each hall and the glucometers were cleaned/disinfected with no issues identified during this survey. The immediate jeopardy removal date of 07/12/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff and Nurse Practitioner (NP) interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents whose blood glucose levels required monitoring. Medication Aide (MA) #1 was observed to conduct a finger stick blood sugar (FSBS) check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. This occurred while there were no residents with known bloodborne pathogens, such as Hepatitis and Human Immunodeficiency Virus (HIV), in the facility. Failure to clean and disinfect the shared glucometer per manufacturer's instructions after use on each resident has the high likelihood of exposing residents to the spread of bloodborne pathogens. The deficient practice occurred for 4 of 4 residents observed for finger stick blood sugar monitoring. Immediate Jeopardy began on 7/10/24 when MA #1 failed to clean and disinfect the shared glucometer in between residents when conducting FSBS checks. Immediate Jeopardy was removed on 7/12/24 when the facility implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level of E (no actual harm with a potential for minimal harm that is not Immediate Jeopardy) to ensure monitoring of systems are put in place and to complete employee in-service training. The findings included: A review of the facility's policy entitled Glucometer Disinfection last revised 12/1/23 read in part as follows: 1. The facility will ensure glucometers will be cleaned and disinfected according to manufacturer's instruction for multi-resident use . 3. The glucometers will be disinfected with a wipe pre-saturated with an Environmental Protection Agency (EPA) registered healthcare disinfectant that is effective against HIV, Hepatitis C, and Hepatitis B virus. 4. Glucometers will be cleaned and disinfected according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. The manufacturer's User Guide for cleaning and disinfecting the glucometer read in part, Blood glucose meters are at high risk for becoming contaminated with bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV). Transmission of these viruses has been documented due to a contaminated blood glucose device. According to the Centers for Disease Control and Prevention, cleaning and disinfecting of meters between resident use can prevent the transmission of these viruses through indirect contact .Blood glucose meters need to be cleaned and disinfected after each use for individual resident care . Disinfecting can be accomplished with an EPA registered disinfectant detergent or germicide that is approved for healthcare settings . On 7/10/24 from 4:45 pm through 4:55 pm, a continuous observation of MA #1 performing FSBS on the 1 North unit was conducted. At 4:45 pm, MA #1 put on gloves and obtained the glucometer from a compartment in the top drawer of her medication cart. She completed a FSBS check on Resident #1 and using the same glucometer proceeded to check blood sugar levels on Resident #2, Resident #3, and Resident #4 without disinfecting the glucometer between any of the residents. In between each resident, the MA returned to the cart to change gloves and use hand sanitizer. At 4:55 pm, the MA was observed to place the glucometer back in the compartment of the top drawer after checking Resident #4's blood sugar without cleaning and disinfecting the glucometer. During an interview on 7/10/24 at 4:55 pm, MA #1 revealed she cleaned the glucometer with disinfectant wipes when she started her shift (MA #1 worked 7:00 am to 7:00 pm according to the schedule on 7/10/24). The MA explained she wiped down her cart and the glucometer when she came in with two disinfecting wipes each time, one was to clean, and the other was to disinfect. The MA said she then wiped down the cart again including the glucometer before the end of her shift. The MA said she had worked at the current facility for about 2 years but, she was trained by another medication aide at another facility years ago to wipe down the cart and the glucometer at the start and end of each shift. She stated not every resident had their own glucometer. MA #1 explained she did not clean and disinfect glucometer in between residents; she just cleaned and disinfected the glucometer before and after her shift with disinfectant wipes. MA #1 stated the glucometer was not technically touching the resident and she made sure she did not put the glucometer down in the resident's room. The MA said there was a 5th resident who she would have completed a FSBS check on, but the resident was at dialysis. An observation of 1 North medication cart and interview of MA #1 was conducted on 7/11/24 at 10:00 am. There were five individual bags containing glucometers labeled with residents' names, including Resident #1, Resident #2, Resident #3, Resident #4, and the dialysis resident that were seen at the bottom drawer of the medication cart. There was a plastic container with a purple top containing disinfectant wipes inside another bottom drawer. Medication Aide #1 stated she did not see the residents' individual glucometers on 7/10/24. She further stated she used the disinfecting wipes in the purple top container to wipe down the glucometer and her cart at the start and end of her shift. The observed disinfectant wipes brand was listed as one of the accepted disinfectant wipes from the glucometer manufacturer. Review of the purple top container containing the disinfectant wipes label indicated it contained germicidal disposable wipes effective against bacteria, viruses, fungi, and blood borne pathogens when used as directed. The label specified blood borne pathogens such as Hepatitis B Virus, Hepatitis C Virus, and HIV among others. Attempts to interview the Unit Manager, who was supervising MA #1, for 1 North during the survey were unsuccessful. During an interview on 7/11/24 at 9:15 AM, the Staff Development Coordinator/Infection Preventionist (SDC/IP) revealed the facility used disinfecting wipes in a purple top plastic container. The staff used the first wipe to clean the glucometer and used the second wipe to disinfect. The staff had to wait for the disinfectant to dry for about 5 to 6 minutes and then the glucometer could be used on another resident or put them back in the individual bags if they were done checking blood sugars. During an interview on 7/16/24 at 10:55 am, NP #1 revealed she was made aware on 7/11/24 by the facility about the glucometer not being cleaned and disinfected in between residents on 7/10/24. The NP said the cleaning and disinfecting of the glucometer was to prevent the transmission of blood borne pathogens to the residents. She stated that was the standard and staff had to follow it. During an interview on 7/11/24 at 9:27 am, the Director of Nursing (DON) revealed the facility had individual glucometers for residents needing to have their blood glucose monitored. She stated MA #1 was not familiar with the 1 North medication cart. She revealed she spoke with MA #1 this morning and informed her the glucometers for individual residents were at the bottom of the cart. The DON said the MAs and the nursing staff should be cleaning and disinfecting the glucometers before and after each use on each resident using the disinfectant wipes as per their policy for disinfecting glucometers. On 7/11/24 at 10:03 am, an interview was conducted with the Administrator, in the presence of DON. The Administrator revealed she just started at the facility in January as the administrator. The MA should have cleaned and disinfected the glucometer in between the residents. MA #1 should have used the resident's individual glucometer. She stated they expected staff to follow their policies and procedures. During a discussion on 7/11/24 at 2:05 pm, the Regional Nurse Consultant stated MA #1 should have cleaned and disinfected the glucometer in between residents according to the facility's policy and manufacturer's instructions. The Administrator was informed of the Immediate Jeopardy on 7/11/24 at 12:34 pm. The facility provided the following credible allegation of Immediate Jeopardy removal. Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. On 7/10/2024 at 4:45 p.m., Medication Aide (MA) #1 performed a fingerstick blood glucose check on Resident #1, #2, #3, and #4. The MA removed a glucometer for a recently discharged resident (Resident #5) from the medication cart. The MA did not cleanse or disinfect the glucometer, according to glucometer's manufacturer's instructions and germicidal wipe manufacturer's instructions, prior to testing, between each resident, or upon completion. All residents that required blood glucose monitoring were identified on the 7/10/2024 census and added to the potentially affected resident list. No residents that receive glucometer blood glucose monitoring were identified to have blood borne pathogens. 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. On 7/10/2024 at 5:10 p.m., The Medical Director was notified of the incident by the interdisciplinary team (IDT). The IDT discussed education and systems to put into place to prevent future staff competency issues related to blood glucose monitoring. These systems included education to MA #1, all nurses, and medication aides. The education will be monitored by Staff Development Coordinator (SDC) #2 and included in all orientation to newly hired nurses and medication aides. On 7/10/2024 at 5:10 p.m. the IDT team reviewed the manufacturer's recommendations for glucose cleansing and disinfecting. The manual under section B read; Testing confirmed the following wipes will not damage the functionality or performance of the meter, this included suggested manufacturer germicidal disposable wipes. The germicidal disposable wipes directions for use read: To disinfect nonporous surfaces use a wipe to remove visible soil prior to disinfecting. Unfold a clean wipe and thoroughly wet surface. Allow the surface to remain wet for two minutes. Let it air dry. On 7/10/2024 at 5:15 p.m., SDC #2 in-serviced Medication Aide (MA) #1 on the policy and procedure of cleaning and disinfecting glucometers, observed a return demonstration, and educated on potential consequences of not properly cleaning and disinfecting glucometers. The education included the manufacture guidelines for the glucometer and the germicidal wipe recommendations to clean and then disinfect with two minutes of wet contact time. SDC then in-serviced all nurses and medication aides working. SDC then began in-servicing all nurses and medication aides not currently working at the facility on the telephone. All nursing staff and medication aides were instructed to see the Director of Nursing (DON) and/or SDC before their next shift for a return demonstration of blood glucose monitoring cleansing and disinfection process. The SDC will educate all newly hired nurses, medication aides and agency staff regarding cleaning and disinfection of glucometers, before receiving an assignment. On 7/10/2024, SDC #2 was notified by Nurse Consultant #1 of her responsibility to conduct education with nurses and medications aides regarding resident's personal glucometer for individual use, the proper steps to clean and disinfect a glucometer, storage of a glucometer, and where to locate a glucometer when needed. The SDC will be responsible for keeping up with the newly hired staff and new agency staff. The new staff will be in-serviced on glucometer disinfection prior to working on a medication cart and will be required to perform a return demonstration for the DON or SDC before the next assignment. On 7/10/2024 at 5:15 p.m. the Unit Manager removed the glucometer of the discharged Resident (Resident #5) and discarded the glucometer. On 7/10/2024 the Director of Nursing and Unit Manager assessed, cleansed, and disinfected all glucometers according to the manufacturer recommendations for glucose disinfection and the germicidal disposable wipes directions. On 7/10/2024, an audit was conducted by Nurse Consultant #1 and Unit Manager to verify that residents had personal glucometers on the medication carts, bagged, and labeled. The audit revealed 100% of residents that required glucose monitoring had individualized glucometers available. The Administrator notified [NAME] County Department of Health of the incident on 7/11/2024. The Health Department had no initial recommendations but requested a summary of the event. The Health Department responded to the summary with recommendations to conduct laboratory blood work on all diabetics that receive blood glucose monitoring to screen for blood borne pathogens. Medical Director was notified on 7/11/2024 of [NAME] County Department of Health recommendations. On 7/11/2024, the physician orders were entered into the laboratory system by the DON or designee. The DON will be responsible for ensuring orders are implemented, the laboratory order is completed, and communicate results to the health department and Medical Director. The glucometer policy was placed on every medication cart by the Assistant Nursing Home Administrator on 7/10/2024 and reads: 1. Obtain needed equipment and supplies: Gloves, glucometer, alcohol pads, gauze pads, single-use lancet, blood glucose testing strips, disinfecting wipes. 2. Perform Hand Hygiene. 3. Explain the procedure to the resident. 4. Provide privacy. 5. [NAME] gloves. 6. Obtain capillary blood glucose sampling. 7. Remove and discard gloves, perform hand hygiene prior to exiting the room. 8. Retrieve (2) disinfectant wipes from container. 9. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. 10. After cleaning, use the second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, according to the glucometer manufacturer's instructions. Follow the germicidal directions for the dry time. Allow the glucometer to air dry. 11. Discard disinfectant wipes in waste receptacle. 12. Perform hand hygiene. On 7/11/2024 the IDT team made the decision to move the glucometers off the medication carts and into each resident's room. Education was provided by the Unit Managers to all Nurses and Medication Aides working on 7/11/2024 regarding the location of the glucometers in the rooms and this education will be provided to all nursing and MA staff prior to working the next shift, by the SDC. Any nurse or medication aide found to be sharing glucometers will be subject to disciplinary action. The alleged date of Immediate Jeopardy removal was 7/12//24. The facility's credible allegation of immediate jeopardy removal was validated on 7/17/24. Documentation of the County Health Department, physician, and residents' Responsible Party notification was provided and reviewed. Evidenced by observations of nurses and medication aides and interviews conducted on each hallway with regards to the required infection control practices for the use of glucometers. All nurses and medication aides who were interviewed reported they had received the required in-service training. This training included the importance of using an approved disinfectant wipe and disinfecting a glucometer with the procedures in accordance with the manufacturer's instructions for the disinfectant. Observations were conducted on each hallway as blood glucose checks were conducted and glucometers were disinfected. All residents observed had their own personal glucometers. Multiple observations also confirmed EPA-approved disinfectant wipes were stored on each medication cart. The immediate jeopardy removal date of 07/12/24 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, resident interview, staff interviews, Nurse Practitioner (NP) interview and Medical Director interview, the facility staff failed to implement a pain management program that included pharmacological and non-pharmacological approaches for Resident #518 who was admitted with chronic pain syndrome. Resident #518 was not thoroughly assessed for pain, a plan for pain management was not initiated, pain medication was not ordered, care continued to be delivered to Resident #518 in the presence of pain described at 9 out of 10. Pain interfered with sleep, mobility, and provision of activities of daily living. Resident #518 exhibited verbal and nonverbal cues of pain that included facial grimacing, groaning, and holding tightly onto the grab bars during incontinence care and bed mobility. A diagnostic x-ray was not implemented stat (rush) as ordered. Resident #518 was diagnosed with osteoarthritis following the results of the x-ray. This deficient practice occurred for 1 of 1 resident reviewed for pain management (Resident #518). Immediate jeopardy began on 11/20/2023 when Resident #518 experienced pain at a 10 out of 10 level according to the occupational therapy treatment encounter notes, indicated to the Nurse Practitioner (NP) she was not sleeping well due to the pain and had no orders for pain management. The immediate jeopardy was removed on 12/1/23 when the facility implemented an acceptable credible allegation of immediate jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (isolated with no actual harm with potential for more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to pain management. Findings included: Resident #518's Medication Administration Record (MAR) from the Hospital, indicated the resident was hospitalized on [DATE]. Resident #518's hospital MAR indicated she received Cymbalta DR (antidepressant) 30 milligram (mg) capsule two times a day by mouth starting 11/6/23 to 11/13/23, Lamictal 200mg 1 tablet by mouth a day starting 11/6/23 to end 11/6/23 and Lamictal 25mg 1 tablet by mouth daily starting 11/13/23 to 11/17/23. Resident #518 was admitted to the facility on [DATE], with diagnosis that included chronic pain syndrome, disorder of thyroid, adult failure to thrive, bipolar disorder, constipation, anorexia, hypothyroidism, and spondylosis. Resident #518 physician order dated 11/18/23 revealed resident was to receive Lamictal (mood stabilizer) 25 milligram (mg) one tablet, by mouth one time a day. Occupational therapy treatment encounter notes for Resident #518 dated 11/20/23 indicated that resident reported 10/10 global pain affecting function. NP progress notes dated 11/20/23, revealed that resident underwent psychiatry evaluation, and it was determined that resident's decreased appetite is due to hypothyroidism and not a psychiatric issue. Resident states today that she is in the rehabilitation facility because she is unable to move secondary to bilateral arm and leg pain and numbness. Resident states she is not sleeping well due to the pain. On 11/30/23 at 1:07 pm, a telephone interview was conducted with the NP. The NP progress notes for 11/20/23 were reviewed with NP where she indicated Resident #518 had chronic pain and had undergone psychiatric evaluation. A continued review of the NP progress notes further indicated Resident #518 had bilateral arm and leg pain and numbness, and complained she could not sleep because of pain. The NP indicated, after reviewing her notes, that she did not address Resident #518's pain on 11/20/23 because Resident #518 had a diagnosis of bipolar disorder and she wanted Resident #518 to take her medication (Lamictal) first, before the NP would be able to do anything about the resident's pain. The NP further indicated the medication needed time to kick in before she could address the pain. Resident #518's care plan initiated 11/21/23 did not address resident's pain and did not have any care plan in reference to behaviors or refusal of medication. Medical Director's progress notes for Resident #518 dated 11/22/23 indicated that resident has pain and numbness in bilateral arms and legs. An in-person interview was conducted on 11/30/23 at 4:04 pm with the Medical Director (MD). The MD indicated Resident #518 did not complain of pain. The MD indicated the review of systems in his progress notes was from the history and physical and Resident #518 did not have anything acute. The MD indicated the resident was on Lamictal (a medication used to treat epilepsy and bipolar disorder.) which would usually take at least 4 to 6 weeks to be therapeutic, but he would not expect for a medical provider to wait 4 to 6 weeks or to wait until a medication was therapeutic to address any resident's pain and he would have initiated a pain medication such as Tylenol, or an anti-inflammatory medication such as aspirin. The MD further indicated pain was not dependent on a resident's psychiatric status, especially when dealing with a resident who did not have any dependency concerns with pain medication. Physical therapy treatment encounter notes for Resident #518 dated 11/22/23 indicated that resident reported pain all over body and limiting resident's ability to scoot. Occupational therapy treatment encounter notes for Resident #518 dated 11/22/23 indicated that resident reporting ongoing pain and discomfort all over. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #518 was cognitively intact with no behaviors or rejection of care and no pain and required moderate assistance with bed mobility and was dependent on toileting hygiene. Physical therapy treatment encounter notes dated 11/27/23 indicated that resident with reports of pain all over, facial grimacing and groaning. An interview was conducted with NA #5 on 11/29/23 at 3:12 pm. NA #5 indicated that she worked with Resident #518 on 11/27/23 during the day shift (7:00 am to 3:00 pm shift). NA #5 indicated that Resident #518 did complain of shoulder pain (could not validate which shoulder) during care on 11/27/23, and she notified Nurse #3 and Medication Aide (MA) #2. On 11/29/23 at 3:19 pm, an interview was conducted with Nurse #3. Nurse #3 indicated that the NA #5 did not notify her on 11/27/23 that Resident #518 was complaining of pain. Interview with Medication Aide (MA)#2 was conducted on 11/30/23 at 10:04 am. MA#2 indicated that on 11/28/23 she was working day shift (7:00 am to 3:00 pm) and was in training. MA #2 stated she went to provide Resident #518 her medication in her room, and during medication administration, Resident #518 made groaning noises while she was moving in bed. MA #2 indicated she did not ask Resident #518 about her pain and stated Resident #518 did not state she was in pain. MA #2 indicated she did not report this to the nurse. Physical therapy treatment encounter notes dated 11/28/23 indicated that physical therapy assistant requested patient to be provided pain medication prior to session to prevent pain limiting progression. Resident refused her medication and pain pills and reported pain all over her body. Physical therapist assistant talked with Director of rehabilitation about patients increase pain levels and limitation. Resident #518 Medication Administration Record starting 11/17/23 through 11/29/23, revealed that resident had not refused to take any medication. Physician orders starting 11/17/23 through 11/29/23, revealed that resident had no pain medications ordered. Resident #518 MAR starting 11/17/23 through 11/29/23, revealed that resident had no pain medication order. Resident #518 did not have any standing orders. An interview with the Director of Nursing on 11/30/23 at 4:15 pm revealed Resident #518 did not have any standing orders. DON further indicated that standing orders are usually on a case-to-case basis. Review of Resident #518 occupational therapy treatment encounter notes dated 11/28/23 indicated that resident with increase pain today. Resident #518's Medication Administration Record (MAR) revealed no pain medication physician orders from 11/17/2023. There was also no refusal of medication by Resident #518. On 11/30/23 at 10:54 am, an interview was conducted with Certified Occupational Therapist Assistant (COTA). The COTA indicated that Resident #518 had limited mobility due to pain that was getting worse. The COTA indicated she had communicated multiple times to nursing staff about Resident #518's pain for more than a week. The COTA indicated the resident had complained about her shoulder pain for about a week. The COTA indicated Resident #518 could not lift her arm during shoulder flexion due to shoulder pain. The COTA indicated she had asked nursing to administer pain medications to Resident #518 prior to rehabilitation treatment on 11/27/23 and 11/28/23. At 11:17 am, on 11/30/23 the COTA further indicated Resident #518 was clearly in pain and Resident #518 had been indicating her shoulder hurts. The COTA indicated she was seeing more signs of pain with Resident #518 that progressed. The COTA indicated Resident #518 had received therapy on 11/28/23, during which time, the nurse (unknown) was asked to medicate Resident #518 with pain medication after lunch, prior to her rehabilitation therapy treatment. The nurse (unknown) indicated to therapy the resident had refused to take her medication and refused to take her pain medication on 11/28/23. The COTA indicated the facility did have a diathermy machine (a medical device that uses high-frequency electric current to produce heat deep inside a targeted tissue through the skin to the area that is causing pain) that was used as a non-medication pain regime, but it was not used on the resident, because she did not go to the therapy room for treatment. On 11/29/23 at 5:13 am, an observation of incontinence care was made with Resident #518 and NA #3. As NA #3 was moving resident, Resident #518 complained of right shoulder pain. NA #3 continued to proceed with providing incontinence care. Resident #518 was observed holding onto both her grab bars, making nonverbal signs of pain (facial grimacing, groaning) while NA #3 was providing incontinence care. Resident #518 also verbalized pain while NA #3 was providing incontinence by saying that hurts and NA #3 continued to provide incontinence care. NA #3 stated to Resident #518 that her perineal area was red and appeared to be irritated and infected. The observation revealed that the resident's perineal area was reddened. NA #3 turned the resident over to her right side to continue incontinence care. Resident #518 verbally complained of pain and indicated her right shoulder was in pain. NA #3 continued to provide incontinence care.NA # 3 completed incontinence care and indicated to Resident #518 that she was going to get another aide to assist her with moving Resident #518 up in her bed. NA #3 returned to the room a few minutes later with NA #4 to assist resident with bed mobility. NA #3 asked Resident #518 to cross both her arms on her chest. Resident #518 indicated to both NA #3 and NA #4 that her right shoulder was hurting. NA #3 and NA #4 continued to assist Resident #518 with bed mobility by moving her up in the bed even after Resident #518 indicated that she was having right shoulder pain. NA #3 and NA #4 used the draw pad/linen protector to move the resident up in the bed with their hands positioned in the mid chest area of the resident. An interview was conducted with NA #3 on 11/29/23 at 5:40 am. NA #3 indicated her shift started on 11/28/23 at 3:00 pm, and she was doing a double shift(3:00 pm to 7:00 am), which would end on 11/29/23 at 7:00 am. NA #3 indicated she notified Nurse #1 at about 3:30 pm on 11/28/23 , after she had completed her first round of incontinence care on Resident #518, that the resident was complaining of pain in her perineal area and all over. NA #3 indicated that she did not stop providing perineal care, because she wanted to clean the area first. Resident #518 was interviewed on 11/29/23 at 5:49 am. Resident #518 indicated that she notified a nurse (Unknown) a couple of days prior, about her perineal area pain and irritation, and her right shoulder pain upon moving. Resident #518 indicated that the Nurse (unknown) came back to her room and applied A and D ointment (skin protectant) to her perineal area and did not offer anything to relieve her right shoulder pain. Resident #518 indicated that she would take Tylenol (analgesic) medication when she was home and did not use any opioid medication. On 11/29/23 at 3:34 pm, an interview was conducted with Nurse #1. Nurse #1 confirmed that she worked with Resident #518 on 11/27/23 and 11/28/23. Nurse #1 indicated she did not work with the resident often and stated that the resident never reported pain to her. Nurse #1 indicated that she did not recall NA #3 reporting Resident #518 having right shoulder pain. At 5:57 am on 11/29/23, an interview was done with Nurse #2. Nurse #2 confirmed that she was the regular night shift nurse for Resident #518 and stated the resident did not report pain to her. Nurse #2 indicated NA # 3 and NA #4 never notified her about Resident #518's pain and that she would go and assess Resident #518. A follow up interview was done with Nurse #2 at 6:15 am on 11/29/23, and she indicated upon assessment of Resident #518, the resident complained of right shoulder pain. Nurse #2 indicated that she would notify the medical provider of Resident #518's right shoulder pain. On 11/29/23 at 3:19 pm, an interview was conducted with Nurse #3. Nurse #3 indicated that the outgoing nurse on 11/29/23 (11:00 pm to 7:00 am), Nurse #2 reported to her during shift report, that Resident #518 was assessed to have right shoulder pain. Nurse #3 further indicated that she notified the NP who was in the facility. Nurse #3 indicated the NP did not initiate anything for Resident #518's pain. An observation of incontinence care was made on 11/30/23 at 10:07 am with NA #5 and Resident #518. Resident #518 complained of right shoulder pain and was observed holding tightly on her grab bars and having facial grimacing while NA #5 continued to provide incontinence care. NA #5 asked Resident #518 to turn to her right side, and Resident #518 informed NA #5 that her right shoulder and perineal area were in pain. An interview with Resident #518 was conducted on 11/30/2023 at 10:09 am while she received perineal care from NA #5. Resident #518 was asked to rate her pain related to her right should and perineal area, on a scale of 1 to 10 and the resident indicated that her pain was 9 out of 10 during perineal care and moving. An interview with NA #5 was conducted on 11/30/23 at 10:10 am. NA #5 indicated she could not stop providing care but would notify the nurse of Resident #518's right shoulder pain, after she had completed incontinence care. On 11/30/23 at 10:11 am an interview was conducted with Nurse #1. The Surveyor informed Nurse #1 that Resident #518 complained of right shoulder pain during observation of incontinence care, and Resident #518 held tightly to her grab bars, with facial grimacing during perineal care and bed mobility. Nurse #1 indicated she would assess the resident. At 10:15 am on 11/30/23, Nurse #1 indicated that she would notify the medical provider about Resident #518's right shoulder pain of 9 out of 10 and she would recommend an X-ray to rule out fracture. Nurse #1 indicated that Resident #518 had a history of falls prior to admission to the facility, and the pain could be related to that. Nurse #1 indicated that Resident #518 did not have any medication for pain. An interview was conducted on 11/30/23 at 10:47 am. Nurse #1 indicated that she had received a new physician order for Resident #518 to start Tylenol (non-opioid analgesic) 500milligrams two tablets by mouth twice a day and Voltaren gel (dermatological anti-inflammatory analgesic) 2 grams for right shoulder. She also indicated the medical provider ordered for a right shoulder X ray to rule out fracture. The physician order dated 11/30/23 revealed a STAT order for a right shoulder X ray to rule out fracture. The physician's order dated 11/30/23 revealed an order for Tylenol 500mg two tablets by mouth twice a day for right shoulder pain. On 11/30/23 at 1:07 pm, a telephone interview was conducted with the NP. The NP indicated she assessed Resident #518 on 11/29/23 while in the facility. The NP indicated Resident #518 did not complain of pain upon her assessment on 11/29/23. The NP indicated that nursing staff did notify her on 11/29/23 of Resident #518's right shoulder pain but she had not addressed the pain due to Resident #518's psychiatric issues and she wanted to make sure the pain was real. Interview was conducted with Nurse #1 on 11/30/23 at 3:52 pm. Nurse #1 indicated that the STAT Xray ordered for Resident #518 at 10:30 am on 11/30/23 had not been initiated. Nurse #1 did not know why the Xray had not been initiated. At 4:15 pm on 11/30/23 an interview was conducted with the Director of Nursing (DON). DON indicated STAT x-rays had not been implemented because the company that was contracted to provide diagnostic testing, did not consider STAT physician orders to be within 4 hours, but could be done in a day or two or later. DON indicated that if a resident verbalized pain or had any nonverbal signs of pain during peri care, she would require the nursing assistants to complete providing peri care first, and tell the residents Sorry it hurts, but they would need to complete care and after completion of care, the nurse aide would notify the nurse. DON further indicated that if resident verbalizes pain or has any nonverbal signs of pain noted before or during bed mobility, she would require the nursing assistants to stop moving the resident and notify the nurse. Resident #518's Xray to right shoulder was completed after the surveyor's intervention 11/30/23. The result of Xray revealed no fracture but showed mild osteoarthritis. The administrator was notified in person of the immediate jeopardy on 11/30/23 at 5:40 pm. On 12/2/23 on the facility provided the following IJ removal plan: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident was admitted to facility on 11-17-23 status post hospitalization with chronic pain syndrome. Resident was witnessed experiencing pain on 11-30-23 in the presence of staff. Interviews identified the resident had been experiencing pain for greater than one week with facility staff aware of the situation. During these periods of pain, the facility failed to identify the pain, properly assess for location and severity, and put proper interventions in to place to manage the pain. The CNA that was providing care was educated on 11/30/23 by the Regional Nurse Consultant regarding identifying pain and immediately ceasing care being provided to notify nurse of the pain. The Regional Clinical Nurses and the Director of Nursing conducted a full-house pain interview and assessment by using verbal and non-verbal signs. This was completed on 11-30-23. The total of in-house residents is 108. Notification was given to the hall nurse for any resident who reported pain at that time and an intervention was put into place. o 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. Resident was assessed for pain immediately after the surveyor issued the template on 11/30/23 by the Director of Nursing. Resident reported her pain was a 7/10 and that the Tylenol she received earlier was helping. The nurse offered to call for more pain medication and the resident voiced that she would only take Tylenol. The nurse administered 2-500mg tablets of Tylenol as ordered. Also, Voltaren was applied to the right shoulder. Resident expressed some relief. The X-ray company was notified and completed the order at 7:00 pm. The x-ray results showed no fracture but did show mild osteoarthritis acromioclavicular and glenohumeral joints. Pain assessment has been added to Resident MAR for monitoring every shift. Tylenol has been scheduled three times a day, Voltaren gel has been scheduled three times a day and Meloxicam has been scheduled to assist with controlling resident's pain. Pain will continue to be assessed by the nurse and documented on the MAR. Tylenol has been scheduled three times a day to help with pain management and relief during therapy sessions. Care plan updated to reflect a goal of normal activities will not be interrupted secondary to pain. Interventions include anticipating the resident's need for pain relief and respond immediately to any complaint of pain. Care plan was reviewed and updated by the Regional Nurse Consultant on 11/30/23. The non-pharmaceutical intervention of repositioning was added for pain relief and comfort. The direct care staff were informed on 11/30/23 by the Unit Managers and Staff Development Coordinator to respond to the resident's complaint of pain timely and encourage the use of her ordered pain medications. Education on identifying and reporting pain to staff (to include licensed nurses, certified nursing assistants, medication aides, all department heads, housekeeping, dietary, laundry and therapy) was initiated on 11-30-23 and conducted by the Unit Managers, wound nurse, and Staff Development Coordinator. The education included identifying pain through verbal and nonverbal cues (grimacing, screaming, guarding, etc.) then reporting to the resident's nurse or Director of Nursing. The nurse is to then complete an assessment of the resident's pain and put the proper intervention in to place. Nurses were educated on completing a pain assessment and documenting on the medical record. Any staff who did not receive this in service by 11-30-23 were not allowed to work until this was completed. The Director of Nursing and Staff Development Coordinator are responsible for maintaining records of staff who need the in-service prior to their next shift. All licensed nurses were educated in following up on x-ray orders. This education was initiated on 11-30-23 by the Unit Managers, wound nurse, and Staff Development Coordinator. Any licensed nurse who did not receive this education by 11-30-23 was not allowed to work until completed. The Director of Nursing and Staff Development Coordinator are responsible for maintaining records of all licensed staff who need the in-service prior to their next shift. This education was added to the new hire orientation by the Director of Nursing on 11-30-23. Facility alleges removal of the immediate Jeopardy as 12-1-23. Validation of the immediate jeopardy removal plan was conducted in the facility on 12/4/23. The facility's initial plan audit was verified and signature sheet for education reviewed with no concerns. Facility nurses were interviewed and were aware of the pain management protocol, how and when to assess pain, and how to appropriately respond to a resident's request or nonverbal signs of pain. Facility medication aides, nurse aides, dietary staff, housekeeping staff and rehabilitation staff were also aware of the pain protocol and how to observe for nonverbal signs of pain and how to respond to resident's request or nonverbal signs of pain. The facility's immediate jeopardy removal date of 12/1/23 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews and record reviews, the facility failed to transfer a resident safely from her bed to a wheelchair while using a total mechanical lift for 1 of 3 residents reviewed for accidents (Resident #1). Resident #1 experienced a fall when two staff members failed to securely attach the sling to the lift which resulted in the sling jarring loose as the lift was moved and with the resident falling to the floor. Resident #1 was sent out to the hospital for evaluation / treatment with severe pain and was found to have a comminuted (a bone that is broken in at least two places) and displaced (where the bones are not in alignment) scapular body (shoulder blade) fracture, rib fractures involving the second through fifth right ribs. Immediate Jeopardy began on 11/13/22 when Resident #1 was being transferred with a total mechanical lift and one of the four loops from the resident's sling detached from the lift, resulting in the resident falling to the floor and sustaining multiple fractures. Immediate Jeopardy was removed as of 11/23/22 when the facility implemented an acceptable allegation of Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level D (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the facility to continue staff education and ensure monitoring systems put into place are effective. The findings included: A review of the manufacturer's instructional video for the facility's total mechanical lift included directions for staff members using the lift. As the video demonstrated a lift being used to transfer a resident from a bed to a wheelchair, the narrator stated, As the resident is being raised (slightly off of the bed), confirm the secure attachment of the sling to the cradle. A review of the Food and Drug Administration (FDA) Patient Lifts Safety Guide included a compilation of best practices and general safety recommendations that when followed, can help mitigate the risks associated with patient lifts. The safety recommendations included the following sections, in part: -- Place Patient in Sling. A cautionary note read, ! Using the wrong sling or attaching the sling incorrectly may cause serious injury to the caregiver or patient. The steps included, Ensure all clips or loops are secure and will stay attached as patient is lifted. --Perform Safety Check. This section provided the following instructions: Before lifting the patient, perform safety check: Examine all hooks and fasteners to ensure they will not unhook during use. Double-check position and stability of straps and other equipment before lifting patient. Ensure clips, latches and bars are securely fastened and structurally sound. -- Lift the Patient. The recommendations included: Lift patient two inches off the surface to make sure patient is secure. Check the following: Sling straps are confined by guard on sling bar and will not disengage. Weight is spread evenly between straps. Patient will not slide out of sling or tip backward or forward. Resident #1 was admitted to the facility on [DATE]. Her cumulative diagnoses included multiple sclerosis (MS) and paraplegia (paralysis of the legs and lower body). The resident's most recent Minimum Data Set (MDS) was a quarterly assessment dated [DATE]. The MDS reported Resident #1 had intact cognition. She required extensive assistance with two plus (2+) persons physical assist for transfers. The resident was 65 inches tall and weighed 191 pounds (#). The resident's Care Plan included the following area of focus, in part: --Resident has an Activities of Daily Living (ADL) self-care performance deficit related to activity intolerance, paraplegia, impaired balance, MS (Date Initiated: 12/6/20; Revision on: 8/16/22). The care plan interventions indicated the resident was totally dependent on and was transferred by a total mechanical lift with 2 staff members. (Date Initiated: 12/6/20). The resident's electronic medical record (EMR) included a Situation-Background-Assessment-Recommendation (SBAR) Summary dated 11/13/22 at 10:45 AM and authored by Nurse #1. The Summary indicated Resident #1 had a fall. Her Primary Care Provider was notified and an order received to send the resident to the hospital for evaluation. An interview was conducted with Resident #1 on 11/21/22 at 12:28 PM. The resident was awake, alert, and oriented as she was lying on her bed. When asked about the fall she sustained while being transferred with a total mechanical lift, the resident reported two veteran nurse aides (NAs) came in to transfer her from the bed to her wheelchair using a total mechanical lift. She was able to identify the two NAs who transferred her (NA #1 and NA #2). Resident #1 reported she had been transferred with the total mechanical lift for several years and thought all would be well because these two aides had worked with her several times in the past. She stated there was a problem with the pad (the lift's sling) not being hooked up right. Upon further inquiry, she stated she was raised above the bed just fine. However, when the lift moved towards the wheelchair, she was flipped out off of the sling and dropped onto the floor. At the time of her fall, she reported she thought both of the NAs were standing behind the lift (not within reach of her). The resident stated, It all happened very quickly. She reported she thought she hit her back on the base of the lift when she landed on the floor. Immediately after the fall, Resident #1 reported she was in a great deal of pain and could hardly breathe. The hall nurse (Nurse #1) came in, assessed her, and the facility called 911. The paramedics transferred her from the floor to the stretcher, then took her to the hospital. The resident reported she has been in a considerable amount of pain since sustaining the fall on 11/13/22. She stated the NAs told her they were sorry about the incident. A telephone interview was conducted on 11/22/22 at 6:48 PM with NA #1. NA #1 was identified as one of the nurse aides who was transferring Resident #1 with the total mechanical lift when she fell on [DATE]. During the interview, the NA recalled she was working on obtaining weights for the residents on that date. The NA stated she already had the total mechanical lift with her when a coworker wanted to borrow it to get Resident #1 up in her wheelchair. I told her we would get her in the chair and get the weight at the same time. NA #1 stated the resident was already laying on the sling on her bed and was ready for the transfer. NA #2 assisted her and was on the resident's left side with NA #1 on the right side. She recalled both sides of the bottom part of the sling were hooked up to the lift using the blue loops while both sides of the top part of sling were hooked up to the lift using the orange loops. The NA reported, I had the controls. I proceeded to move the (brand name of mechanical lift). She stated the lift's legs were open and when the lift was moved, it jerked a little because it got caught on a wire under the bed. She stated, So we proceeded to move her and when we moved her, the lift's pad (sling) on the top right hand side gave way and she (Resident #1) yelled. She reported that Resident #1 fell in such a way that she was lying on the legs of the total mechanical lift. NA #2 ran and got Nurse #1 while she stayed with the resident. The telephone interview continued on 11/22/22 at 6:48 PM with NA #1. During the interview, the NA was asked if she looked at the resident's sling after the fall. She stated, No, I didn't. When asked if she had any reason to believe there was a problem with the sling, the NA only stated that she threw the sling away in the garbage after the fall just in case there had been a problem with it. NA #1 reported she recalled hearing a pop during the lift transfer but stated she did not know where the noise came from. The NA was also asked if either of the NAs had a hand on the resident to provide guidance to her body during the transfer. She reported they did not. NA #1 stated she had the control and was turning the lift while NA #2 had come around the foot of the bed as she was getting the wheelchair ready for transfer. An interview was conducted with NA #2 on 11/22/22 at 3:54 PM. NA #2 was identified as one of the nurse aides who was transferring Resident #1 with the total mechanical lift when she fell on [DATE]. As the NA recalled the incident, she reported NA #1 was planning to weigh the resident prior to transferring her to the wheelchair and NA #2 was going to assist her. The NA recalled Resident #1 had her own sling and she remembered examining the sling (straps and loops) to make sure everything was in order before using it. NA #2 stated she started out on the resident's left side with the other NA on the right side of the bed with the control for the lift. She recalled each of the NAs hooked the orange color-coded loop on the top of the sling to the lift; and each hooked the blue color-coded loop at the bottom of the sling to the lift. She noted these were the loops typically used to for Resident #1. NA #2 stated after the loops were hooked to the lift, she came around to the right side of the bed to help straighten the resident onto the middle of both the bed and the sling. NA #1 started to lift the resident up with the mechanical lift, then pulled the lift backwards. As she came backwards with the lift, NA #2 turned and grabbed the wheelchair to position it for the transfer. NA #1 turned the lift towards the wheelchair while NA #2 was grabbing the wheelchair. NA #2 stated, That's when the resident started to lean backwards in the sling. She reported at the time when the resident was leaning backwards, there was no one touching her. The resident continued to go backwards and fell directly on the base (legs) of the lift. The NA recalled it all happened very quickly. After Resident #1 fell, the NA recalled she went outside, called the nurse, and the nurse called 911. The interview continued with NA #2 on 11/22/22 at 3:54 PM. During the interview, the NA was asked if there was a problem with the sling. She stated, I don't think there was. I didn't understand how the fall happened. NA #2 reported she looked at the sling after the fall and did not see a problem with it. She stated NA #1 told her the loop came off and she actually said it broke. Upon further inquiry, NA #2 stated she looked at the loop on the sling and did not see a break in the loop. When asked, the NA reported she did not hear anything unusual (any noises) from the lift or sling during Resident #1's transfer to indicate there may be a problem. The NA was also asked if at least one person would have typically had a hand on the resident to provide guidance to her body during the transfer. The NA responded by saying, Sometimes we do .both of us normally have a hand on her right side because she tends to lean in that direction. A telephone interview was conducted on 11/23/22 at 8:19 AM with Nurse #1. Nurse #1 was identified as the nurse who was assigned to care for Resident #1 on 11/13/22 (the date of her fall). As the nurse recalled the incident, she stated she was at the medication cart in the hall close to Resident #1's room. Immediately after hearing a loud noise and scream, she went to the room. Resident #1 was crying and moaning from pain. The nurse noticed her head was laying on the leg of the lift and said right away she needed to go to the hospital due to the resident hitting her head. The nurse reported the resident's vital signs were obtained and her physician was called. An order was received to send the resident out to the hospital. The nurse reported the resident continued to be alert and oriented. She did not complain of head pain but did have some shortness of breath. Nurse #1 administered a dose of the resident's tramadol (an opioid pain medication ordered to be given to Resident #1 on an as needed basis). When asked, the nurse reported she did not have any additional conversations with the NAs regarding the fall. She was also asked if she examined the resident's sling after the fall. The nurse stated she did not. A Nursing Note dated 11/13/22 at 11:08 AM and authored by Nurse #1 reported the resident was transferred to the hospital for evaluation after the fall due to right shoulder pain. Resident #1's hospital record indicated the resident arrived in the Emergency Department (ED) on 11/13/22 at 11:25 AM. The ED Triage Notes read in part: Per EMS patient was in (brand name of mechanical lift) at a height of 4 - 5 ft (feet) in the air and fell out of the sling. Patient fell on R (right) shoulder and hit head. Patient denies loss of consciousness. The resident's history reported, they were moving her when they dropped her onto her right side onto the floor. The resident reported having severe sharp [NAME] pain 9 out of 10 in her right shoulder which does not radiate is worse anytime she tries to move it and she reports she did hit her head and has a mild right-sided headache and some neck pain .She does not take any anticoagulation. They gave her tramadol at the facility with minimal improvement in the pain. The history is provided by the patient and the EMS personnel. Findings from the 11/13/22 hospital x-ray and computerized tomography (CT) radiology indicated the resident had a comminuted and displaced scapular body fracture, a nondisplaced fracture of the right anterior (located towards the front of the body) second rib, a nondisplaced fracture of the right lateral (located towards the side of the body) third rib, and minimally displaced right lateral fourth and fifth rib fractures. Orthopedics was consulted. The physician noted, .She has advanced MS, is wheelchair-bound, and unfortunately this is her primary functional upper extremity. She can use her fingers wrist and hand, and can even use her shoulder if she can tolerate, but I doubt she will be able to do much. Plan for nonsurgical management and follow-up in the office in 1 to 2 weeks. Additional pain control was provided and a sling recommended for comfort. The resident was transferred back to the facility on [DATE]. A Nursing Note dated 11/13/22 at 6:00 PM (authored by Nurse #1) reported Resident #1 returned from the hospital and was reported to be pain free at that time. The resident continued to receive the following pain medications as previously ordered: 50 milligrams (mg) tramadol to be given as two tablets by mouth every 6 hours as needed for pain (Start Date 8/21/21); and 325 mg acetaminophen to be given as two tablets by mouth every 8 hours as needed for mild to moderate pain (Start Date 9/16/21). The resident's level of pain was reported to range from 0 to 8 on a scale of 0 - 10 (with zero indicative of no pain) on 11/13/22 and 11/14/22. A physician's order was received on 11/15/22 for 5 mg / 325 mg oxycodone / acetaminophen (a combination opioid pain medication) to be given as one tablet by mouth every 6 hours as needed for moderate to severe pain. An Ad Hoc Quality Assurance and Performance Improvement (QAPI) Meeting/Four Point Plan of Correction Agenda and Summary dated 11/14/22 was provided by the facility for review. This Summary identified an opportunity for improvement with the following description: On 11/13/22, a resident fell during a 2-person (brand name of mechanical lift) transfer and sustained a closed rib fracture and a scapula fracture. After a thorough investigation, incident reenactment and staff interviews the facility determined the root cause of resident fall was related to staff failure to properly secure sling loops which allowed resident to fall during transfer. 1) The Corrective Action in the Action Plan reported the total mechanical lift was verified as properly functioning and sling size and condition was good. The results of the root cause analysis determined that while nurse aide (NA) was knowledgeable on performing a proper lift transfer, they did not ensure proper loop securement. 2) Residents who require use of a total mechanical lift were identified as being at risk. 3) The Systemic Changes made based on results of the root cause analysis noted the facility would ensure nursing staff were knowledgeable and competent of the proper use of total mechanical lifts and the facility would monitor compliance of total mechanical lift transfers by making rounding observations of identified residents and staff during transfers. All licensed nurses and nurse aides were to be educated on the proper use of total mechanical lifts during transfers. This education would also be included in orientation and at least annually. 4) Monitoring of the Plan of Correction would be done by completing audits of staff observations during care to ensure proper technique with total mechanical lift transfers and reporting results of the audits to during QAPI monthly meetings. The Four Point Plan of Correction did not specify a date as to when the plan would be fully implemented. A review of the facility's In-Service education records on (Brand name of mechanical lift) Lift Safety provided for nurses and nurse aides was completed. This review revealed the following: --On 11/15/22, 19 nursing staff members (nurses, medication aides or MAs, and nurse aides) worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/16/22, 13 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/17/22, 21 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/18/22, 20 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/19/22, 25 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. --On 11/20/22, 21 nursing staff members worked without being documented as having received the (Brand name of mechanical lift) Lift Safety in-service education. An interview was conducted on 11/21/22 at 2:35 PM with NA #3. NA #3 was assigned to care for Resident #1 during 1st shift on 11/21/22. During the interview, the NA reported she was new to the facility. She stated she was an Agency NA (temporary staff) who started at the facility 2-3 days ago. When asked how she would know if a mechanical lift was required to safely transfer a resident, the NA stated she primarily relied on colleagues to tell her about the residents' needs for assistance and care when she received report at the change of shift. If no one was available for additional questions she may have, the NA stated she could look in the resident's [NAME] (an electronic overview of the individual resident's care needs). When asked if she received any orientation to the facility when she first started, she reported orientation was primarily provided by her Agency. Upon inquiry regarding Resident #1, NA #3 reported the resident preferred not to get out of bed today. An interview was conducted on 11/21/22 at 4:55 PM with the facility's DON. During this interview, the DON discussed Resident #1's fall from the total mechanical lift. She reported two NAs were transferring the resident from her bed to the wheelchair when the fall occurred. From her investigation, she believed the NAs were using the correct lift sling for the resident. The facility ultimately concluded the NAs did not properly hook the sling onto the total mechanical lift. The DON reported the facility took additional measures to ensure the safety of transfers using a total mechanical lift. Resident #1's sling was discarded and an audit was done to assess the condition of all lift slings in the facility. She reported a total of three slings were discarded as a result of the audit and new slings were ordered. As the interview continued on 11/21/22 at 4:55 PM, the DON provided two in-service sign-in sheets from a (Brand name of mechanical lift) Lift Safety In-Service. The signature list included NAs, MAs, and nurses. At that time, the DON was told the 1st shift NA assigned to care for Resident #1 on this date (11/21/22) had been interviewed. Review of the documentation of the (Brand name of mechanical lift) Lift Safety in-services did not indicate NA #3 had received this education. The DON reported the in-services on (Brand name of mechanical lift) Lift Safety were initiated on 11/13/22 (the day Resident #1 experienced her fall). When asked, the DON stated all nursing staff should have received the (Brand name of mechanical lift) Lift Safety in-service before the start of their shift. Upon their request, an interview was conducted on 11/22/22 at 9:49 AM with the facility's Administrator and DON. During the interview, the Administrator and DON reported the facility had two total mechanical lifts currently in use. New slings were ordered last week (specifically for their brand of total mechanical lift) to replace all of the older slings in the facility. The new slings were delivered on 11/21/22 and distributed on this date (11/22/22) along with staff educated on the proper use of the slings. An interview was conducted on 11/22/22 at 11:00 AM with the facility's Staff Development Coordinator (SDC). During the interview, the SDC reported she was working at the facility on 11/13/22 (the day Resident #1 had a fall). She recalled interviewing and reenacting the total mechanical lift transfer with NA #1 and NA #2 on that date. The SDC reported concerns were identified at that time regarding the need to make sure the loops of the sling were properly clamped (secured) into place. The SDC reported she started education with the nursing staff on 11/13/22 and it was on-going since then. When asked about the content of the education, she stated the in-service placed an emphasis on making sure two staff members were always used for total mechanical lifts so one person would be available to guide the resident's feet, ensuring either the DON or Administrator were notified of any holes or fraying on a sling so it could be promptly replaced, and making sure the color-coded loops on the sling were hooked up properly to the lift. The SDC explained staff were educated to make sure the color-coded loops on the sling matched on each side so the two loops at the top would be the same color and the two loops at the bottom of the sling would be the same color. She reported it was concluded that either the color-coded loops of the sling were not matched up on each side or they weren't clamped down all the way and secured on the lift when Resident #1 fell on [DATE]. She reported if the loop to the sling was not hooked all the way under black locking piece on each side of the lift's cradle, the loop could dislodge. The SDC stated, Something dislodged. As the interview continued on 11/22/22 at 11:00 AM, The SDC further described the in-service education provided on (Brand name of mechanical lift) Lift Safety consisted of verbal information, printed material, and the manufacturer's instruction video for the lift (viewed by some of the staff). She noted that some nursing staff members also performed a return demonstration. When asked, the SDC reported she had in-serviced nurses, NAs, and management staff who worked directly with the residents. She stated the goal was to provide this education to the nursing staff before the start of his/her shift. The SDC reported although the in-service documentation did not indicate NA #3 received the in-service education, she recalled the NA actually had been in-serviced (but was unsure of the date). When asked if she had been able to in-service all nursing staff members before the start of their shift, the SDC stated, Yes .for the most part. On 11/22/22 at 11:43 AM, the SDC used a total mechanical lift and sling to demonstrate the key points emphasized in the (Brand name of mechanical lift) Lift Safety in-service. The SDC reported each resident had his/her own sling kept in their room with extra slings stored in the laundry department. A follow-up interview was conducted with the SDC on 11/22/22 at 12:15 PM. At that time, a partial review of the (Brand name of mechanical lift) Lift Safety in-service documentation was compared to the nursing staff schedule for 11/15/22 to 11/20/22. The SDC acknowledged there were several nursing staff members who worked a shift on these dates prior to receiving the in-service education. The Administrator was notified of immediate jeopardy on 11/22/22 at 2:00 PM. The facility provided an acceptable credible allegation on 11/23/22 at 8:03 AM. Identify those residents who have suffered, or likely to suffer, a serious adverse outcome as a result of the noncompliance: The facility failed to transfer Resident #1 safely from surface to surface while using a total mechanical lift. While transferring a resident with a total mechanical lift, two Nurse Aides did not hook the sling to the lift according to manufacturer's instruction resulting in the sling jarring loose when moving the resident in the lift and Resident #1 falling to the floor. Root Cause Analysis was conducted as a result of the investigation. The factors that were identified were as follows; Certified Nursing Aide #1 did not ensure the right shoulder strap was secured to the cradle before operating mechanical lift. Certified Nursing Aide #1 proceeded to operate mechanical lift while Certified Nursing Aid #2 was located at the foot of the bed. Certified Nursing Aid #2 was not located in the proper position to help guide the resident. On 11/14/2022, the Director of Nursing assessed current residents using the mechanical lift to ensure residents were safely transferred without incident by interviewing the alert and oriented residents with a BIMs score of > 12. Residents with BIMs score < 12 the residents received a range of motion assessment to ensure no new onset of pain. On 11/14/2022, there were no other residents involved in any other incidents that were transferred with the mechanical lift. Currently the 18 other residents are being transferred using the total mechanical lift. 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 Staff Development Coordinator, Director of Nursing, and Unit Managers educated the Licensed Nurses and the Certified Nursing Aides on the process of how to properly transfer using the mechanical lift using a video provided by the mechanical lift company and written information in a classroom setting. Education included ensuring the sling is the appropriate size for the resident. Staff are to ensure the colors of the straps match at the shoulder and at the head. They are to check the straps in the cradle to ensure they are seated properly and secure before the certified nursing aide operates the mechanical lift. Once this is completed the second certified nursing aide will position themselves on the same side of the bed as the mechanical lift to guide the resident in the completion of the transfer. The Director of Nursing will ensure no Licensed Nurse and Certified Nursing Aide will work without receiving this education. Any new hires, including agency staff, will receive education prior to providing resident care. Education will be completed by 11/22/2022 by the Staff Development Coordinator, Director of Nursing, and Unit Managers. The staff members will document the date and time on the education form to show education was provided prior to providing resident care. The Director of Nursing and/or designee will observed 2 residents that are transferred using the mechanical lift on random shifts 3 times weekly (including weekends) x 4 weeks to ensure proper usage for safely transferring residents. Effective 11/22/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance Alleged Date of IJ Removal: 11/23/2022 The facility's credible allegation of Immediate Jeopardy removal was validated on 11/23/22. The validation was evidenced by observations of lift transfers using a total mechanical lift and an interview with the Staff Development Coordinator regarding the system put into place to ensure nursing staff were provided the necessary in-service education prior to working their shift. Multiple interviews with both licensed nursing staff and non-licensed nursing staff (NAs) currently working at the facility were conducted. The nursing staff consistently reported they received in-service education on (Brand name of mechanical lift) Lift Safety and were able to verbalize key measures necessary to ensure a resident's safety during the lift transfers, including ensuring the sling's color-coded loops were securely attached to the total mechanical lift. Immediate Jeopardy was removed on 11/23/22 at 12:00 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Physician Assistant and the Medical Director, the facility failed to implement an order from the hospital discharge summary to test blood sugar twice daily for Resident #72. The facility administered injectable and oral diabetes medication to Resident #72 who was diagnosed with diabetes without monitoring the resident's blood sugar from admission to the facility until admission to the hospital. On 8/13/22, Resident #72's blood sugar registered HI on the glucometer. Resident #72 was sent to the emergency department (ED) due to being lethargic and staff were unable to obtain vital signs. At the hospital, Resident #72 ' s blood sugar was recorded as 764 milligrams per deciliter (mg/dl) and the Resident received insulin via intravenous method to lower blood sugar levels. Resident #72 was diagnosed with Diabetic Ketoacidosis (a buildup of acids in your blood that can lead to diabetic coma or even death) /Hyperosmolar hyperglycemia (an extremely high blood sugar level). This deficient practice occurred for 1 of 3 sampled residents reviewed for diabetes care (Resident #72). Immediate jeopardy began on 4/21/22 when the facility failed to monitor blood sugars for Resident #72 who had diabetes and received injectable and oral diabetes medications. The hospital discharge summary included orders to monitor the resident ' s blood sugars twice a day. The facility admission orders did not include blood sugar monitoring twice daily. The immediate jeopardy was removed on 8/18/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: A review of Resident #72 ' s hospital discharge (d/c) summary dated 4/17/2022 revealed orders to test blood sugar twice daily. Resident #72 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, Parkinson ' s disease, and dementia. Physician orders dated 4/21/22 included Trulicity (an antihyperglycemic injectable medication used to control high blood sugar) 1.5 milligrams (mg)/0.5 milliliters (ml) subcutaneously in the morning every Monday and Metformin HCl (an oral diabetes medication) 1000 mg give 1 tablet by mouth one time a day. Nurse # 1 documented the admission orders. A review of Physician orders from 4/21/2022 through 8/13/2022 revealed no order documented for blood sugar monitoring. During an interview on 8/17/22 at 2:08 pm with Nurse #1 it was indicated she was not completely sure if she had put the orders in the computer from the hospital d/c summary on admission, however she indicated she was the nurse that day. She indicated if it was documented on the discharge summary for Resident #72 to have blood sugar checks done that then there should have been an order to do so. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had cognitive impairment received insulin during the assessment period. A review of Physician progress notes dated 4/27/22, 5/26/22, 6/23/22 read, in part, recent A1c (A blood test that measures your average blood sugar levels over the past three months.) was 6.6% (A level of 6.5% indicates diabetes.) and will check blood sugars before meals and at bedtime. A review of medical record revealed blood sugar was obtained after a fall on 4/29/22 and was 88 mg/dl. A review of the Basic Metabolic Panel dated 5/16/22 revealed the sugar result was high at 220 mg/dl, reference range is 70-99 mg/dl. A review of medical record revealed a blood sugar was obtained on 6/23/22 and was 155 mg/dl. A review of a Progress notes by Nurse #2 dated 8/13/22 read, in part, Resident #72 was found to be severely lethargic, skin cool to touch and staff were unable to obtain vital signs. Blood sugar registered HI, which per the glucometer manufacture information indicates a result of HI is over 600 mg/dl. Spouse was present & agreed with nurse to transfer Resident to hospital ED for evaluation and treatment. Call was placed to on-call Nurse Practitioner and was made aware. A call was placed to 911 to transfer Resident to hospital and emergency medical service arrived and transferred resident to hospital. An interview with Director of Nursing (DON) 8/17/22 at 3:05 pm was conducted and she indicated she was not aware Resident #72 had orders on admission for blood sugar checks. She stated the facility should have verified the orders for the blood sugar checks On 8/17/22 at 3:19 pm an interview with Physician Assistant who indicated an order for blood sugar checks was missed by her and the Physician. She indicated if blood sugar checking was on the orders from the hospital, then the blood sugar should have been checked as ordered. During an interview with the Medical Director (MD) on 8/18/22 at 4:49 pm it was indicated the facility had issues with orders that were not being transcribed as ordered. He indicated for Resident #72 the blood sugar checks were missed and the facility should have been doing the checks as they were ordered. He indicated if the facility had been doing the blood sugar checks, then staff could ' ve seen his blood sugar was rising ahead of time and modified his medications. A review of the EMS report dated 8/13/22 at 7:48 pm revealed upon arrival to facility Resident #72 was responsive to verbal stimuli by name only and blood sugar was obtained, and results read HI. According to the hospital ED documentation dated 8/13/22, Resident #72 had a blood sugar of 764 mg/dl in the ED and was diagnosed with Diabetic Ketoacidosis/Hyperosmolar hyperglycemia and remained in the hospital at the time of the survey. The Resident presented to the ED with altered mental status and was admitted for further management. He was started on an insulin drip for severe hyperglycemia. The Administrator was notified of immediate jeopardy on 8/17/22 at 5:06 pm. On 8/18/2022 the facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to complete an evaluation of residents #72 medication regimen that identified the need to monitor insulin administration and anti-diabetic medications. Resident #72 medication regimen review did not identify the inadequate monitoring of insulin administration and anti-diabetic medication. Resident #72 received weekly insulin and daily anti-diabetic medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. A review of the pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 revealed no identification of inadequate monitoring of insulin administration and anti-diabetic medication. On 8/17/2022 the Regional Director of Clinical Services (RDCS), reviewed residents with diabetic medication to ensure residents are receiving blood sugar checks. On 8/17/22 the RDCS notified the Nurse Managers of any opportunities identified during this audit and explained their responsibility to correct by 8/17/2022. On 8/17/2022 the Regional Director of Clinical Service (RDCS), reviewed 30 days of admissions to ensure accuracy of orders. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers educated the Licensed Nurses regarding the process for verifying new admission orders for residents admitted to the facility. The nurse is to call the medical doctor and/or nurse practitioner to verify orders on the discharge summary prior to entering the orders into the residents ' electronic medical record. When the admission orders are entered into the electronic medical record, a second nurse is to verify orders for accuracy when confirming. The Director of Nursing will ensure no licensed nurse will work without receiving this education. Any new hires, including agency staff will receive education prior to the start of their shift. Education will be completed by 8/17/2022 by the Staff Development Coordinator, Regional Director of Clinical Services, and Unit Managers. The Regional Director of Clinical Services educated the Director of Nursing and Nurse Managers regarding the validation of new admission orders during the morning clinical meeting for admissions from the prior day. This education was completed on 8/17/2022. Effective 8/17/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance Alleged Date of Immediate Jeopardy Removal: 8/18/2022 On 8/19/22 the credible allegation of immediate jeopardy was validated by onsite verification. Record reviews and interviews were conducted which verified the audits were completed. Interview with the Regional Clinical Nurse Consultant revealed when a new admission was admitted to the facility, the nurse needed to call the Medical Director or Nurse Practitioner to verify discharge summary orders prior to entering the orders into the resident ' s medical record. She also indicated when admission orders were placed in the medical record, a second nurse was to verify orders when confirming for accuracy, and when the resident entered the facility, they were to take the discharge summary from the resident and verify the orders that were in the system for accuracy. A review of the audits revealed all residents ' orders were reviewed and any discrepancies were corrected. A review of the education training revealed education was provided to staff as stated in the credible allegation. Interview was conducted with staff on 8/19/2022 at 10:52 am who indicated knowledge of what to do for new admission residents and entering the new orders. Interview was conducted with staff on 8/19/2022 at 11:00 am who indicated knowledge of what to do for new admission residents and entering the new orders from the hospital. Interview was conducted with Unit Manager on 8/19/2022 at 11:45 am who indicated knowledge of the process implemented to verify orders from the d/c summary from the hospital for all new patients. Interview was conducted with Staff Development Coordinator on 8/19/2022 at 11:58 am and it was indicated she had the knowledge of how to complete the medication reconciliation for new admissions, and she also indicated a new checklist that was implemented for the completion of new admissions. Interview with the DON on 8/19/2022 at 12:00 pm revealed the new admission audit will help the nurses complete a full assessment of residents ' needs. All medications and treatments will be reviewed for the residents during the admission process. Interviews with staff revealed that education was provided. The immediate jeopardy removal date of 8/18/2022 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Consultant Pharmacist, Medical Director and staff interviews, the facility failed to complete an evaluation of Resident #72's medication regimen that identified the need to monitor injectable and oral diabetes medications for 4 of 4 medication regimen reviews. Resident #72 received weekly injectable and daily oral diabetes medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. This deficient practice occurred for 1 of 6 sampled residents reviewed for medication regimen review (Resident #72). Immediate Jeopardy began on 4/27/22 when the facility failed to complete an evaluation of Resident #72 ' s medication regimen that identified the need to monitor injectable and oral diabetes medications and failed to identify the inadequate monitoring of injectable and oral diabetes medication as ordered to test blood sugar tests twice daily. The Immediate Jeopardy was removed on 8/19/22 when the facility provided an acceptable credible allegation of immediate jeopardy removal. The facility will remain out of compliance at a scope and severity E (not actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring and all staff have been in-serviced. The findings included: A review of Resident #72 ' s hospital discharge (d/c) summary dated 4/17/2022 revealed orders to test blood sugar twice daily. Resident #72 was admitted to the facility on [DATE] and had diagnoses including diabetes mellitus type 2, Parkinson ' s disease, and dementia. The Quarterly Minimum Data Set (MDS) dated [DATE] revealed resident had cognitive impairment received insulin during the assessment period. Review of physician orders revealed orders dated 4/21/22 included Trulicity (an antihyperglycemic injectable medication used to control high blood sugar) 1.5 milligrams (mg)/0.5 milliliters (ml) subcutaneously in the morning every Monday and Metformin HCl (an oral diabetes medication) 1000 mg give 1 tablet by mouth one time a day. Nurse # 1 documented the admission orders. No order documented for blood sugar monitoring. Manufacturer precautions for Trulicity and Metformin indicate Check blood glucose levels regularly. A review of pharmacy medication regimen review for the month of April dated 4/27/2022 by Pharmacist #1 revealed a review of Resident #72 ' s medical record which included discharge summary, vital signs, weight, labs, progress notes, Physician/Nurse Practitioner notes were done, and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of May dated 5/27/22 by Pharmacist #1 revealed a review of Resident #72 ' s blood sugar dated 4/29/22 was 88 mg/dl and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of June dated 6/28/22 by Pharmacist #2 revealed a review was completed of Resident #72 ' s medical record including: orders, available labs, progress notes and no recommendations were made related to blood sugar monitoring. A review of pharmacy medication regimen review for the month of July dated 7/18/22 by Pharmacist #2 revealed a review was completed for Resident # 72 ' s medical record including: orders, available labs, progress notes and no recommendation were made related to blood sugar monitoring. A review of Progress note dated 8/13/22 read, in part, Resident #72 was found to be severely lethargic, skin cool to touch and staff were unable to obtain vital signs. Blood sugar registered HI. (The glucometer manufacturer ' s information indicates HI displays if the result is over 600 mg/dl.) Spouse was present and agreed with nurse to transfer Resident to hospital emergency department (ED) for evaluation & treatment Call placed to 911 and Resident transferred to ED by emergency medical services. According to the review of hospital ED documentation dated 8/13/22, Resident #72 had a blood sugar of 764 milligrams per deciliter (mg/dl) in the ED and was diagnosed with Diabetic Ketoacidosis (a buildup of acids in your blood that can lead to diabetic coma or even death) /Hyperosmolar hyperglycemia (an extremely high blood sugar level) and remained in the hospital at the time of the survey. The Resident presented to the ED with altered mental status and was admitted for further management. He was started on an insulin drip for severe hyperglycemia. On 8/18/2022 at 9:35 am an interview was conducted with Pharmacist #1, and she indicated she was no longer the Pharmacy consultant for the facility, however, was for the months of April and May 2022. She stated she was not able to see any documentation for Resident #72 due to no longer having access to the facility records, however she stated in general she would look at the d/c summary and the orders in the computer that the Nurse entered in the computer. She indicated it was usually the facility ' s protocol to verify orders with the Physician and then enter the orders in the computer. She stated it was her understanding that the orders in the system were accurate. She indicated residents that have the diagnosis of diabetes would not necessarily have blood sugars monitored daily, but she would rather review their A1c because it was a more accurate marker of how residents ' diabetes are controlled verses a blood sugar check that can fluctuate. She indicated if the resident would have had an incident that would warrant her to recommend blood sugar checks, then she would have recommended it to be done. During an interview on 8/18/2022 at 11:50 am with Pharmacist #2, it was indicated she noted from the Physicians June progress note that Resident #72 had a recent A1c of 6.6%, and June fingerstick blood sugar was 155, which indicated to her a stable blood sugar. She indicated Resident #72 had no issues whatsoever and was a stable diabetic from what she reviewed starting in June 2022. She also indicated Resident had no previous concerns by the other Pharmacist. She indicated she wasn ' t concerned and had in her notes to follow-up with another A1c in September 2022, which she indicated was 3 months from the June Physician progress note with the 6.6 % A1c result. She stated when she last reviewed Resident #72 ' s medications he was a stable diabetic with no signs of diabetic issues. She indicated she reviewed Resident #72 ' s medications on 8/18/2022 and noted Resident had started Megace (ordered for an appetite stimulant) on 8/8/22 and it could have possibly been the cause of his blood sugar to have increased. She stated Trulicity and Metformin are not medications that need blood sugar monitoring, and she would not have known the Resident had orders on admission for blood sugar monitoring as she was not the Pharmacist for the facility at the time of his admission. During an interview with the Medical Director (MD) on 8/18/22 at 4:49 pm it was indicated the facility had issues with orders that were not being transcribed as ordered. He indicated for Resident #72 the blood sugar checks were missed and the facility should have been doing the checks as they were ordered. He indicated if the facility had been doing the blood sugar checks, then staff could ' ve seen his blood sugar was rising ahead of time and modified his medications. The Administrator was notified of immediate jeopardy on 8/18/2022 at 1:22 pm. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome because of the noncompliance. The facility failed to complete an evaluation of residents #72 medication regimen that identified the need to monitor insulin administration and anti-diabetic medications. Resident #72 medication regimen review did not identify the inadequate monitoring of insulin administration and anti-diabetic medication. Resident #72 received weekly insulin and daily anti-diabetic medication without blood sugar testing as ordered and experienced critically high blood sugars identified at the hospital. A review of the pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 revealed no identification of inadequate monitoring of insulin administration and anti-diabetic medication. On 8/18/2022 the Regional Director of Clinical Services (RDCS), reviewed residents with diabetic medication pharmacy medication regimen reviews for the months of April, May, June, and July of 2022 to ensure residents have been reviewed for orders that were not transcribed from the discharge summary to the resident ' s medical record, to ensure residents that are receiving diabetic medication has blood sugar checks and address any concerns. Pharmacy medication regimen reviews did not include the discharge summaries. On 8/18/2022, nurse management reviewed 30 days of admissions to ensure accuracy of transcribing medications from the discharge summary to the residents ' medical records. Actions taken by the facility to alter to alter the process or system failure to prevent a serious adverse outcome from reoccurring and when the action will be completed. The Regional Director of Clinical Services educated the facility pharmacist on reviewing the resident ' s admission orders to ensure orders from the discharge summaries are implemented as ordered, as well as diabetics that are reviewed monthly to identify any monitoring of blood glucose checks for resident insulin and/or anti-diabetic medications. This education was completed on 8/18/2022. Education will be provided to the new pharmacist if the facility has a change by the Regional Director of Clinical Services (RDCS). Effective 8/18/2022 the Regional Director of Clinical Services will review the pharmacy monthly medication regimen on new admissions for 3 months to ensure accuracy from the discharge summary to include medications and interventions. Effective 8/18/2022 the Administrator will be ultimately responsible to ensure implementation of this immediate jeopardy removal for this alleged non-compliance. Alleged Date of Immediate Jeopardy Removal: 8/19/2022 On 8/19/22 the credible allegation of immediate jeopardy was validated by onsite verification which included record reviews and interviews which verified the audits and education were completed. An interview with the Regional Clinical Nurse Consultant revealed they will review the pharmacy monthly medication regimens on new admissions for 3 months to ensure accuracy of orders from the discharge summary to include medications and interventions. The facility's immediate jeopardy removal date of 8/19/2022 was validated on 8/19/2022.