**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews with staff, resident, and the Medical Director, the facility failed to ensure safe securement per manufacturer recommendations of a resident during a van transport. On 2/21/25, Resident #8 was being transferred to dialysis in the facility's transportation van. When Transportation Driver #1 made a left turn, Resident #8 and the wheelchair she was seated in tipped over onto the floor of the van. The Transportation Driver called 911. Resident #8 complained of pain to the right side of her neck and face and was transported to the hospital via Emergency Medical Services (EMS). Resident #8 was receiving a blood thinner which increased her risk of bleeding. While at the hospital, Resident #8 was found to not have sustained any injuries but was admitted for one day to receive her missed dialysis treatment before returning to the facility. This practice had a high likelihood of causing a serious adverse outcome, including death or serious injury. This deficient practice was for 1 of 7 residents reviewed for accidents (Resident #8).Findings included: Review of the manufacturer's operating instructions dated 2014 for the facility's securement system used in the transportation van showed the following instructions for the use of the 4-Point Wheelchair Securement System: 1. Center wheelchair facing forward in Securement Zone and lock wheelchair brakes (or power off electric chair). 2. Attach four retractors into Floor Anchorage points and lock them in place, with an approximate distance of 48 to 54 between the front and rear retractors. 3. Completely pull out each webbing and attach J-hooks to compliant WC19 (a WC19 is a term used to describe a standard wheelchair designed to be used in vehicles) Chair Securement Points near seat level (or solid frame members) at an approximate 45-degree side angle. 4. Move wheelchair forward and back to remove webbing slack or manually tension webbing with retractor knobs. Resident #8 was admitted to the facility on [DATE] with diagnoses which included End-Stage Renal Disease (ESRD), congestive heart failure and atrial fibrillation. The physician's order dated 12/8/23 and the current medication administration records revealed Resident #8 received 2.5mg (milligrams) apixaban two times per day. Apixaban is an anticoagulant medication (blood thinner). The quarterly minimum Data Set (MDS) assessment dated [DATE] indicated Resident #8 was cognitively intact, received anticoagulant medication, had no falls, and received dialysis therapy. The review of the Incident Report prepared by Unit Manager #1 and the Interdisciplinary Team Review completed by Nurse #6, both dated 2/21/25 documented that as Resident #8 was transported to the dialysis center in the facility's transportation van, the resident's wheelchair turned over, onto its side. The Resident was assessed and transported to the Emergency Department for further evaluation. The Resident was unable to give a description of what had happened. There were no witnesses. There were no injuries observed at the time of the incident. Review of the Emergency Medical Services (EMS) Report dated 2/21/25 documented that upon EMS arrival on the scene, Resident #8 was observed on the floor of the transport van with a wheelchair turned on its' side and underneath the resident. The Resident was alert, speaking full sentences. Transportation Driver #1 informed EMS that he was transporting the Resident in her wheelchair in the van to the dialysis center and when the van turned a corner the Resident and her wheelchair overturned. The Resident complained of pain to the right side of her face and the right side of her neck. EMS freed the wheelchair from the safety straps and removed the wheelchair from under the resident. A cervical collar was placed on the Resident, and she was transferred to a stretcher and in the EMS unit where assessment and interview were completed. The Resident denied loss of consciousness, chest pain, shortness of breath, nausea and vomiting. The Resident revealed she was enroute to the dialysis center and her last dialysis treatment was on Wednesday, 2/19/25. The Resident denied any other injuries and was able to move lower extremities with no pain to pelvis/hips and had equal hand grip. The duration of head and neck pain was ten minutes. The Resident was transferred to the Emergency Department of the hospital, answering questions appropriately. Transportation Driver #1 was not available for interview during the survey. Review of the hospital Emergency Department assessment and plan dated 2/21/25 revealed Resident #8 was evaluated for right-sided head/neck pain due to resident stating her head and neck were injured by striking something inside the transport van on her way to the dialysis center. The result of the computed tomography (CT) scan of the resident's head and neck showed no acute intracranial pathology or cervical spine pathology. The Emergency Department physician contacted the resident's outpatient nephrologist and it was decided that it was too late in the day for the Resident to go to the dialysis center this day. Also, there was no indication that the Resident would be able to be transported from the nursing home to the dialysis center on 2/22/25 (Saturday). Because the Resident's next scheduled dialysis appointment would not be until 2/24/25 (Monday), the recommendation was for Resident #8 to be evaluated for admission to the hospital and receive her dialysis treatment on this night of 2/21/25. The hospital Discharge summary dated [DATE] revealed Resident #8 also reported right hip pain and the right hip x-ray showed no acute fracture or abnormality. The pain was mild and managed conservatively. The resident received her normal treatment of dialysis on Friday night (2/21/25) and would continue on her Mondays, Wednesdays, and Fridays schedule. There were no new physician orders made during this hospitalization. The summary indicated the Resident's condition was good at discharge and that she returned to the facility. During an interview on 8/12/2025 at 10:21 a.m., Resident #8 revealed that in February 2025 she had a fall in the facility's transportation van enroute to the dialysis center. She recalled that as the transportation van driver was making a left turn, her wheelchair fell sideways to the right in the van causing her to hit her neck and face. The resident did not recall what she hit her neck and face on. She stated she was hospitalized overnight. The Resident indicated the accident did not result in any fractures, but she had constant back pain since the accident. A second interview was conducted with Resident #8 while awaiting transport to the dialysis center on 8/13/25 at 10:23 a.m. The Resident was observed sitting upright in a wheelchair The Resident recalled that the February accident occurred at approximately 12:30 p.m. when Transportation Driver #1 made a left turn onto another street. She revealed she was the only passenger in the van. She stated that Transportation Driver #1 did not attempt to move or reposition her after the fall. The Resident stated EMS arrived and applied a neck brace and transported her to the hospital. She stated she believed Transportation Driver #1 must have turned the van too fast causing her wheelchair to turn over on its side. A telephone interview was conducted with the facility's Medical Director on 8/13/25 at 3:10 p.m. The Medical Director recalled being notified by the Administrator and the Director of Nursing of Resident #8's accident in the van the same day. She stated she reviewed the incident records, the hospital reports, including the x-rays which showed the Resident had no injuries as a result of the accident. The Medical Director indicated Resident #8 receiving blood thinner medication did not place her at risk of serious injury or death as a result of the minor accident. The Medical Director concluded the resident was sent to the hospital as a precaution following the accident. An interview was conducted with the Administrator on 8/12/25 at 3:45 p.m. He stated Transportation Driver #1 notified him of the accident and his call for EMS on 2/21/25 via telephone. The Administrator stated when he arrived on the scene of the accident, EMS was on-site. He revealed he observed Resident #8 in the facility's van, in her wheelchair, alert and verbal. He stated he interviewed Transportation Driver #1 at the scene of the accident and on return to the facility and Transportation Driver #1's account of the accident remained the same. The Transportation Driver #1 informed him (Administrator) that he was transporting Resident #8 to the dialysis center in the van and when he made a left turn onto another street, the Resident's wheelchair tilted over. Transportation Driver #1 reported he stopped the van and telephoned EMS then the facility. The Administrator stated Transportation Driver #1 insisted he had double checked the immobility of the Resident's wheelchair in the van to ensure no movement. The Administrator revealed Transportation Driver #1 was originally hired in June 2024 as the Maintenance Assistant but in January 2025 became one of two facility transportation drivers. The Administrator added Transportation Driver #1 was trained by the former Maintenance Director. The Administrator provided documentation of Transportation Driver #1's facility transportation training dated 1/13/25 and signed by Transportation Driver #1. This signed training documentation included: Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs; Authorized Driver Checklist; Vehicle Safety Competency; The Wheelchair tie down and Occupant Restraint System; Mobile Device Use Agreement for Drivers of Company Vehicles; and Procedures to Follow after a Vehicle Accident. The former Maintenance Director was interviewed on 8/15/25 at 11:03 a.m. and explained he was the Maintenance Director at the facility during the time of the accident involving the wheelchair turning over in the facility's van during transport. He revealed the van was purchased by the facility in January 2025 and after a complete inspection, he replaced the ratchets and straps before the van was used by the facility because they were old and loose. He stated that he inspected the facility's two transportation vans including the wheelchair securement systems, yearly. He stated that within twenty-four hours of the accident in February 2025, he inspected the van including having Transportation Driver #1 re-enact the securing method of the Resident's wheelchair in the van, as he did on the day of the accident. He stated that the demonstration concluded Transportation Driver #1 securely strapped Resident #8's wheelchair to the floor of the van; and inspection of the van identified no defective equipment. On 8/13//25 at 5:13 p.m., the Administrator was notified of immediate jeopardy. The facility implemented the following corrective action plan: 1. Address how corrective action will be accomplished for those residents found to havebeen affected by the deficient practice;Root cause analysis has revealed that on 02/21/2025 at approximately 11:57am, resident #8 sustained a fall while being transported to dialysis in the facility van. The facility Van driver stated as he was turning onto Meadow Pl at 6 miles per hour the wheelchair tipped over due to the ratchet system used to secure residents in place not properly adjusted to ensure that Resident #8 wheelchair was secured inside the facility van. Resident #8 (BIMS - 15) did not provide details regarding the incident as she only stated that she was having current back and neck pain. At the time of the incident, the van driver called Emergency Services. EMS and Fire Department arrived at the scene of the incident at 12:11pm. The incident occurred at the intersection of Ferndale Boulevard and Meadow Place. The resident was safely transported to the hospital by Emergency Medical Services at 12:25pm. Administrator, Resource Operator and Registered Nurse arrived at the scene of the incident at 12:11pm. It was observed by the facility's Administrator and Registered Nurse that resident #8 was strapped in her wheelchair via a facility van lapbelt. Resident #8's wheelchair was latched via the floor track ratcheting system x1 strap from the rear of the wheelchair to the left sided frame and x1 strap from the rear of the wheelchair to the right sided frame. Additionally, the wheelchair was latched by utilizing the floor ratcheting system x1 strap to the front frame of the right side of the wheelchair and x1 strap to the front frame of the left side of the wheelchair. Resident #8 was transported to hospital for evaluation on 02/21/2025 by Emergency Medical Services. The resident was assessed at the hospital. According to the hospital records, a CT of Resident #8's head and C-Spine. CT scan from hospital dated 02/21/2025 at 2:30 pm revealed no fractures to head or spine. Resident #8 was discharged from the hospital on [DATE] back to the facility. Upon her return, the Licensed Nurse assessed resident #8. A new order from the hospital for zofran 4MG was prescribed every 6 hours for nausea and vomiting. The facility van driver was interviewed by the facility Administrator at the facility. The van driver's statement revealed, Resident #8 was loaded into the van at 11:55am by the van driver. The facility van driver secured the wheelchair via 4 straps on the floor track ratcheting system and placed and secured the van's lapbelt on the resident. The van driver checked to ensure the wheelchair was secure prior to departing from the facility. The van driver departed from the facility heading to Kidney Center. Facility Van driver stated as he was turning onto Meadow Pl at 6 miles per hour the wheelchair tipped over. The facility Van driver stated he immediately called Emergency Services. The van driver stated that he was unaware of what caused the incident as he believed that he secured the resident's chair per the manufacturer's recommendation for the ratcheting system. The van driver stated that as he was making a left turn he heard the wheelchair tilt and immediately stopped the facility van. The facility van driver was placed on administrative leave pending investigation on 02/21/2025. A formal investigation was initiated by the Administrator on 02/21/2025. As a result of the investigation, it was determined that the ratchet system used to secure residents in the facility van was not properly used by the van driver per manufacturers recommendations on 2/21/25. On 02/21/2025, the Administrator reviewed the restraint manufacturer's instructions for how to secure a wheelchair and person to the facility van. The Administrator re-educated the Maintenance Director to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to the beginning of his next scheduled shift. From 02/22/2025 - 02/24/2025, an outsource transportation company was utilized to transport residents to medical appointments. The Maintenance Director re-educated to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to beginning their next scheduled shifts. The Medical Director and the Resident #8 responsible party were notified of the incident by the Administrator. The wheelchair for Resident #8 was inspected by the Maintenance and Therapy department to ensure proper functioning. No issues identified during either inspection. Following Resident #8 readmission from the hospital, Resident #8 was transported via facility van to medical appointments in a standard wheelchair. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; On 2/21/25, the Administrator reviewed a list of residents who have been transported by facility staff and all outsourced transportation companies in the last 30 days to ensure no other residents sustained an injury during transportation. No additional incidents were identified as a result of the audit. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; On 02/21/2025, an audit was conducted by the Administrator to ensure all facility van drivers were current on van safety education and skills competencies were up to date. No negative findings as a result of the audit. Education consisted of the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs. On 02/21/2025, the Administrator and Maintenance Director inspected the ratcheting system and all seat belts in the facility van. All ratchet straps and seatbelts were in proper working order. The Administrator re-educated the Maintenance Director to include competency checks on 2 facility van drivers who transport facility residents on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs prior to the beginning of his next scheduled shift. Beginning 02/25/2025, the Administrator and Maintenance Director re-educated 2 facility van drivers on the center's Authorized Driver Checklist, Vehicle Safety Competency, Vehicle Safety Policy (SH413), Vehicle Safety: Tips for Safely Transporting Patients in Wheelchairs. The safety tips are comparable to the restraint manufacturer's instructions. Return demonstration was conducted by 2 van drivers to ensure proper methods are used while securing residents / wheelchairs in the van via the ratcheting system. Any van driver that was not educated will receive education prior to their next scheduled shift. Newly hired drivers will be trained upon hire in orientation by the Maintenance Director. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. Effective 02/21/2025, the Administrator will audit resident transportations on 10 residents 2 times per week for 4 weeks, then 1 time per week for 8 weeks utilizing a monitoring tool to ensure residents are transported without incident regardless of the transportation organization and that all facility van drivers remain educated on facility van safety policies to include restraint manufacturer's instructions. On 02/21/2025, an ADHOC Quality Assurance Performance Improvement meeting was conducted by the Administrator with the interdisciplinary team members to review the root cause of the incident, discuss immediate measures to ensure all other residents are safe, education required for facility licensed van drives and how the center will ensure quality monitoring going forward to ensure no other residents are not safely transported regardless of the transportation organization. The Administrator will report the results of the monitoring to the QAPI committee to review audits and make recommendations to ensure compliance is maintained ongoing. The QAPI Committee will determine the need for further intervention and auditing beyond three months to assure compliance is sustained ongoing. Alleged date of Immediate Jeopardy Removal: 02/26/25The deficiency correction date is alleged to be 02/26/25. The facility's corrective action plan was validated by the following on 8/15/25: The facility provided audits of residents in wheelchairs who were interviewed if they felt safe with the wheelchair securing methods used in the transportation vans and if they felt safe with the driving of the transportation van drivers. Only 1 of the 2 facility van drivers were currently working at the facility. Transportation Driver #1 was currently on leave. The Maintenance Director also worked as a transportation van driver, documentation specified Transportation Driver #1, Transportation Driver #2, and the Maintenance Director received the training on the restraint system's manufacturer's instructions. The facility provided documentation of the restraint system's manufacturer's video of correct application of the use of the 4-Point Wheelchair Securement System in transport vans. This training included checklists, observations and audits that included return demonstration on securing a resident in their wheelchair inside the transportation van, and of and on loading of residents into the vans. Interviews with Transportation Driver #2 and the Maintenance Director verified they received the training with return demonstration of wheelchair securement system in the transportation van according to the restraint system's manufacturer instructions. The monitoring of all residents using the transport van was conducted and presented in the facility's QA meeting. An observation was conducted on 8/15/25 at 10:02 a.m. of Transportation Driver #2 as she secured three residents according to the restraint system's instructions. After securing the wheels of wheelchair to the floor of the transportation van and strapping Transportation Driver #2 tested the immobility of the wheels and the handles of each resident's wheelchair after with positive results of wheelchair immobility. Transportation Driver #2 stated she always tested both areas (top and bottom) of each wheelchair to ensure safety. The facility's IJ removal date and compliance date for the corrective action plan of 2/26/25 was validated.

Based on observations, record reviews, and staff and Medical Director interviews, the facility staff failed to disinfect a shared blood glucose meter (glucometer) between residents in accordance with the instructions provided by the manufacturer of the disinfectant wipes used for 1 of 2 residents whose blood glucose levels were checked (Residents #135). This occurred while there was at least one resident with a known bloodborne pathogen in the facility. Shared glucometers can be contaminated with blood and must be cleaned and disinfected after each use with an approved product and procedure. Failure to use an Environmental Protection Agency (EPA)-approved disinfectant in accordance with the manufacturer potentially exposes residents to the spread of blood borne infections. Care must also be taken by personnel handling glucometers to protect the glucometers against cross-contamination via contact with other surfaces. Immediate Jeopardy began on 8/14/25 when Nurse #1 was observed performing blood glucose checks on residents using a shared glucometer without disinfecting per manufacturer's instructions. Immediate Jeopardy was removed on 8/20/25 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 D (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:The facility's document entitled, Procedure: Fingerstick Glucose Measurement (Reviewed and Revised on 7/15/25) outlined the following process, in part:Step #22 (of 27): Clean and disinfect the blood glucose meter [glucometer] after use with EPA approved disinfectant, following manufacturer's instructions.Upon request, additional documents were provided by the facility in lieu of a Policy / Procedure for glucometer disinfection:---A Glucometer Cleaning & Disinfection Observation described the purpose of the observation as: Bloodborne pathogens such as Hep B [hepatitis B], Hep C [hepatitis C], and HIV [human immunodeficiency virus] can be transmitted to other patients if glucometers are not cleaned & disinfected. Such transmission has occurred in the past in LTC [long term care] facilities that do not use a cleaning & disinfecting procedure. The requirements of the observation included, in part: - .The glucometer is cleaned and disinfected after each use. If the nurse is unsure whether the glucometer is clean, it should be cleaned and disinfected before use. -The glucometer is wiped down with the product specified for use by the manufacturer. Products approved for the [brand name] meter include: [4 brands of disinfectant wipes, including the facility's disinfectant] -Staff clean & disinfect surfaces that come into contact with the glucometer (e.g., overbed tables, med [medication] carts, etc.).-The glucometer remains wet for the time specified in the directions on the cleaning and disinfecting product.---Clinical Competency Validation Fingerstick Glucose Measurement included step #19 (of 23): Cleans and disinfects the blood glucose meter after use with EPA approved disinfectant, following manufacturer's instructions.A Healthcare Professional Operator's Manual & In-Service Guide (Dated 2023) from the manufacturer of the facility's glucometer included a section on Cleaning and Disinfecting your [brand name of the glucometer]. It noted the following information, in part: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease causing agents are destroyed on the meter and lancing device surface. The products listed as having been validated for disinfecting the facility's glucometer included the brand of disinfectant wipes available for use at the facility. The manufacturer instructions for the glucometer used at the facility indicated the cleaning and disinfection procedure required the following step:#4 (of 6). To disinfect the meter, clean the meter with one of the validated disinfecting wipes.Wipe all external areas of the meter including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter to remain wet at room temperature for the contact time listed on the wipe's directions for use.The manufacturer's labeling of the brand of disinfectant wipes used at the facility was reviewed and read, in part: Kills HIV-1 [human immunodeficiency virus], HBV [hepatitis B virus], and HCV [hepatitis C virus] on precleaned environmental surfaces/objects previously soiled with blood/body fluids in health care settings or other settings in which there is an expected likelihood of soiling of inanimate surfaces/objects with blood/body fluids and in which the surfaces/objects likely to be soiled with blood/body fluids can be associated with the potential for transmission of HIV-1 (associated with AIDS), HBV, and HCV. The directions for use of the disinfectant wipes addressed the required contact time for disinfection. The manufacturer instructed that surface(s) should remain visibly wet for 30 seconds to kill the bacteria and viruses (as individually listed on the label), except a 1 minute contact time is required to kill Candida albicans (a fungus) and Trichophyton interdigitale (a fungus); a 2 minute contact time is required to kill Candida auris (a fungus); and a 3 minute contact time is required to kill Clostridium difficile spores (a resistant, dormant structure produced by C. diff bacterium).An observation of blood glucose monitoring was initiated on 8/14/25 at 11:25 AM with Nurse #1. The observation began as Nurse #1 prepared to conduct a blood glucose check for Resident #7. The nurse removed a (brand name) glucometer stored inside a plastic bag from the top right drawer of the medication cart and placed the glucometer on top of the medication cart. It could not be determined by observation whether the surface of the medication cart had been previously disinfected. Nurse #1 then collected additional supplies for monitoring, including alcohol wipes, a glucose strip, and a single-use lancet. At 11:26 AM, the Nurse was observed to insert the glucose strip into the meter. Immediately afterwards, she placed the meter back on top of the medication cart, donned gloves, picked up the glucometer and supplies, then entered Resident #7's room. Nurse #1 used the lancet to obtain a blood sample from the Resident, then placed the meter (with the glucose strip inserted) on top of Resident #7's bedside tray table while she wiped the remaining blood from the resident's finger. The resident's blood glucose result was 137. At 11:28 AM, Nurse #1 was observed as she removed her gloves while still in the resident's room, picked up the used glucometer, and returned to the medication cart. The Nurse obtained a (brand name) disinfectant wipe from the bottom drawer of the medication cart and wiped the glucometer with the disinfectant wipe for a count of 5 seconds. She then placed the glucometer on a paper towel on top of her medication cart. Upon inspection of the meter placed on the paper towel, the meter appeared to be completely dry and had no signs of being visibly wet. The nurse returned to Resident #7's room, washed her hands, then came back to the medication cart to prepare an as needed medication requested by the resident. A continuous observation of the medication cart and glucometer was conducted. On 8/14/25 at 11:35 AM, Nurse #1 moved the medication cart directly in front of another room to conduct a blood glucose check for Resident #135. The medication cart was positioned so that the nurse was at the doorway of the resident's room. At that time, Nurse #1 reported that she had to wait three (3) minutes before she could use the glucometer for another resident after having disinfected the meter. When asked to clarify, the nurse stated the shared glucometer needed to dry for 3 minutes before being used for another resident. Meanwhile, she collected the additional supplies needed for the blood glucose check, including alcohol wipes, a glucose strip, and a single-use lancet. Then, Nurse #1 picked up the shared glucometer and began to insert a glucose strip into the meter. The nurse was already directly in front of the doorway of Resident #135's room, therefore she was asked to stop at that time and review the labeling on the canister containing the disinfectant wipes used on the shared glucometer. When the canister was again pulled out of the medication cart, the directions for disinfection were read. While reviewing the manufacturer's directions on disinfectant wipes, Unit Manager #1 walked by the medication cart. At that time, the disinfection of the shared glucometer was discussed with the Unit Manager. When asked, the Unit Manager reported she herself typically wrapped a wet disinfectant wipe around the glucometer to meet the requirement of a 3-minute contact time. When asked to clarify, she confirmed the 3-minute contact time was the amount of time the shared glucometer remained in contact with a wet disinfectant wipe (not the drying time). An interview was conducted on 8/14/25 at 1:02 PM with the facility's Infection Preventionist (IP). The IP provided a copy of the facility's Procedure: Fingerstick Glucose Measurement (Reviewed and Revised on 7/15/25). During the interview, the IP detailed the steps outlined in the document and reported the education provided to the licensed nurses was based on that information. The IP stated she would expect the nurse to make sure a surface barrier was in place for the glucometer so the meter was not placed directly on a medication cart that may not be clean. She also reported that the glucometer should not be placed on resident property such as a bedside tray table inside a resident's room (because it's dirty) and that a used glucometer should be wrapped in paper towels prior to leaving the room. Additionally, the IP noted a glucometer should be cleaned according to the directions on the disinfectant wipes being used. The IP stated the contact time meant the time the glucometer was wet. She added that the nurse should wait until the glucometer was completely dry before using that glucometer again. When asked, the IP stated a glucometer should be disinfected between residents and after being used for the last resident having his or her blood glucose checked before replacing it into the storage bag kept on the medication cart. A telephone interview was conducted on 8/15/25 at 2:32 PM with the facility's Administrator and DON. During the interview, concerns encountered during the survey were addressed. When the observation of blood glucose monitoring and disinfection of a shared glucometer was discussed, the DON reported she would expect the nurses to wipe and disinfect the glucometer according to the instructions provided by the manufacturer of the disinfectant wipes. Upon further inquiry, the DON stated the contact time noted on the disinfectant wipes' canister referred to the actual contact time with a wet disinfectant wipe, not the drying time of the glucometer. Upon request, the facility provided a Diagnosis Report for its current residents on 8/18/25. The Diagnosis Report indicated 8 residents were identified as having at least one bloodborne pathogen, which included hepatitis C and HIV. A telephone interview was conducted on 8/19/25 at 10:55 AM with the facility's Medical Director. During the telephone interview, the Medical Director was asked what her thoughts were related to the observation of the failure to disinfect a shared glucometer in accordance with the manufacturer's instructions. The Medical Director stated she did not agree that this was an immediate jeopardy situation and declined to make any additional comments.The facility's Resource Operator of the Southeast Market was informed of the immediate jeopardy (IJ) by telephone on 8/18/25 at 1:45 PM (in the absence of the Administrator who was on leave). The facility provided the following plan for IJ removal:How will the corrective action be accomplished for those residents found to have been affected by the deficient practice?Resident #135 was not affected related to the shared blood glucose meter not being cleaned and disinfected according to manufacturer's instructions in between residents. The facility licensed nurse did not clean and disinfect the blood glucose meter per manufacturer recommendations prior to entering Resident # 135's room. The licensed nurse cleaned the glucometer for a time frame less than the manufacturer's instructions. The shared blood glucose meter for Resident #135 was not used to obtain a blood sugar check. The surveyor observing at the time the blood sugar was being obtained, the surveyor intervened and stopped the licensed nurse from using the blood glucose meter. Prior to the deficient practice, the facility licensed nurse was last educated on 2/10/25 on manufacturer instructions related to cleaning and disinfecting blood glucose meters. On 8/14/25, the Infection Preventionist re-educated the licensed nurse on shared blood glucose meters that can be contaminated with blood and must be cleaned and disinfected after each use with an approved EPA product and procedure in accordance with the manufacturer's instructions to prevent potentially exposing residents to the spread of blood borne infections with return demonstration. The EPA registered disinfectant manufacturer's instructions included the following: 3 minute contact time for Sporicidal, 2 minute contact time for Fungicidal, 1 minute contact time for Fungicidal and 30 second contact time for Virucidal and Bactericidal.A root cause analysis was conducted and based on the findings, the facility licensed nurse failed to follow the manufacturer instructions to clean and disinfect shared blood glucose meters prior to inserting a blood test strip. The facility licensed nurse was being observed by the surveyor to ensure infection control practices were being followed and the facility licensed nurse became anxious and nervous during the observation to perform blood sugar check. The Medical Director was immediately notified on 08/14/25 by the Director of Nursing via telephone of the facility Licensed Nurse failing to follow the contact time for cleaning and disinfecting blood glucose meters and inserting a blood test strip in the meter prior to full contact time. On 08/19/25, the Director of Nursing notified the local department via telephone of the facility Licensed Nurse failing to follow the manufacturer instructions to disinfect a shared blood glucose meter potentially exposing residents to the spread of 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.All residents requiring blood glucose monitoring have the potential to be affected by the deficient practice. A list of residents that have orders for blood glucose monitoring was obtained from Electronic Medical Record by the Director of Nursing on 8/18/25 to identify residents who require blood glucose monitoring to observe infection control practices related to cleaning and disinfecting the blood glucose meter according the manufacturer instructions for the EPA- registered disinfectant. 55 residents were identified with orders to obtain blood glucose monitoring. The Director of Nursing or the Infection Preventionist educated licensed nurses and medication aides to include agency licensed nurses and medication aides on cleaning and disinfecting of blood glucose meters after use per manufacturer instructions to prevent contamination and potential to spread blood borne pathogens and outcomes if the facility licensed nurse failed to do so on 08/18/25 - 08/19/25 in person with validation of understanding. Newly hired licensed nurses and medication aides to include newly hired agency licensed nurses and medication aides will be educated on cleaning and disinfecting of blood glucose meters upon hire by the Director of Nursing or Infection Preventionist. The Director of Nursing or the Infection Preventionist completed skilled competency check off through observation for licensed nurses and medication aides on the use of blood glucose meters to include cleaning and disinfecting according to manufacturer instructions on 08/18/25 - 08/19/25. The Director of Nursing or Infection Preventionist will conduct a skilled competency check off for newly hired staff to include newly hired agency staff on the use of blood glucose meters to include cleaning and disinfecting according to manufacturer instructions. On 8/18/25, individual glucometers were ordered by the Director of Nursing for each resident requiring blood glucose testing. An ADHOC Quality Assurance Performance Improvement Committee was held on 08/18/25 to formulate and approve a credible allegation of immediate jeopardy for removal of the deficient practice. Date of Removal of Immediate Jeopardy 8/20/25The facility's credible allegation of immediate jeopardy removal was validated on 8/20/25. A review was conducted of the education for glucometer disinfection procedures provided by the Director of Nursing and Infection Preventionist dated 8/18/25-8/19/25 for licensed nursing staff. Observations were conducted on 8/20/25 as three licensed nurses performed glucose blood checks for four residents. No infection control concerns were identified. Staff interviewed were able to verbalize the education and training provided in reference to the glucometer disinfection and the required disinfectant wet contact times for the glucometer. The immediate jeopardy removal date of 8/20/25 was validated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff, resident, and Nurse Practitioner (NP) interviews the facility failed to transfer a resident safely from a shower to the resident's room. On 06/12/24 Resident #1 was being pushed in a shower chair down the hall by Nursing Assistant (NA) #1 and the resident fell forward out of the chair hitting the floor. The fall resulted in the resident being sent out to the hospital for complaints of severe pain. Resident #1 indicated from a 1-10 (10 being the most pain) her pain level was an 11 in her lower extremities and wanted to be sent out to the hospital immediately. Resident #1 was admitted to the hospital on [DATE] and was diagnosed with a left tibial plateau fracture (top part of the shin bone), right foot great toe fracture, and an acute displaced (bones are out of alignment) spiral (broken by twisting force) fracture of the right femur (thigh bone) requiring surgical repair. This was for 1 of 3 residents reviewed for providing supervision to prevent accidents (Resident #1). Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses which included pain, debility, and abnormalities of gait and motion. Review of Resident #1's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #1 was moderately cognitively impaired and was totally dependent with bathing and transfers. The MDS further revealed Resident #1 was coded for frequent pain and no impairment to range of motion. It was also indicated Resident #1 was coded for anticoagulants daily. Resident #1's MDS revealed the resident weighed 274 pounds (lb.) and was 62 inches in height. Review of Resident #1's care plan revised 06/05/24 revealed Resident #1 was at risk for falls related to impaired mobility, impaired balance, weakness, pain, oxygen tubing (trip hazard), anxiety and use of psychotropics drugs and pain medication. Review of progress note completed by Nurse #1 on 06/12/24 revealed Resident #1 was alert and oriented and was able to make needs known by staff. The note further revealed Resident #1 was being transported back to her room from a shower and the shower chair tilted over and the resident fell to the floor. The note indicated Resident #1 was assessed and Resident #1 appeared to be sluggish and the right hip was malformed. Nurse #1 and other staff attempted to assist Resident #1 off the floor using a mechanical life and Resident #1 screamed and cried of severe pain. The note revealed the Nurse Practitioner (NP), and Responsible Party (RP) were notified, and Resident #1 was sent to the hospital for evaluation and treatment. Review of incident report dated 06/12/24 revealed Resident #1 had fallen with severe pain to the bi-lower extremities. NA #1 reported that as she returned from the shower Resident #1 started to slide from the shower chair and NA #1 immediately reported she stopped to attempt to assist however the resident fell from chair. The incident report further revealed the location of the fall was the hall and predisposing factors were the rugs/carpeting and equipment. Review of Emergency Department note dated 06/12/24 revealed Resident #1 revealed she was in a shower chair that was being rolled across the floor when the wheels got stuck causing her to fall out of the chair. The note further revealed Resident #1 complained of severe right hip pain and bi-lateral knee pain. It was noted Resident #1's right leg was shortened and externally rotated. Resident #1 was given intravenous Fentanyl (narcotic analgesic) and Zofran (antiemetic). X-rays completed on 6/12/24 revealed Resident #1 sustained a left tibial plateau fracture, right foot great toe fracture, and an acute displaced spiral fracture of the right femur. An orthopedic surgeon was consulted and it was determined the femur fracture required surgical repair which would be completed the next day. Resident #1 returned to the facility on [DATE]. Interview conducted with Resident #1 on 09/03/24 at 12:10 PM revealed she had often showered in a shower chair and not had any issues before. Resident #1 further revealed she was only 5'2 and her feet were unable to touch the ground when she was sitting in the shower chair. Resident #1 stated on 06/12/24 she was leaving the shower room and, on the way back to her room NA #1 was pushing her fast pass the nurses' station. She felt the shower chair jerk when shower chair crossed over the threshold onto the carpeted hallway from the wood plank floor. Resident #1 indicated she felt like she went flying and hit her knees first and then went to her back. Resident #1 indicated from a 1-10 (10 being the most pain) her pain level was an 11 in her lower extremities and wanted to be sent out to the hospital immediately. Resident #1 stated she felt like the incident on 06/12/24 was a setback in being able to return home because of her physical mobility due to the injuries received. Resident #1 revealed she had a history of drug and alcohol abuse and was upset that she had to be on more pain medicine and was in more pain than before. A phone interview conducted with NA #1 on 09/04/24 at 3:15 PM revealed on 06/12/24 she was transferring Resident #1 back to her room in a shower chair and the shower chair felt like it got caught and jerked when she passed the threshold onto the carpet past the nurses station. NA #1 further revealed the shower chair tilted forward, and Resident #1 went to her knees and then onto her back. NA #1 indicated Resident #1 immediately started to yell in pain and Nurse #1 had the resident sent out to the hospital. NA #1 indicated she often showered Resident #1, and the resident had always been able to balance and had no issues in the shower chair during transfers. NA #1 indicated the shower chairs were often hard to push on the carpet and the wheels would sometimes get stuck. Interview conducted with Nurse #1 on 09/03/24 at 10:45 AM revealed on 06/12/24 she heard Resident #1 yelling ouch, ouch, it hurts, and observed Resident #1 laying on the hallway floor on her back past the nurse's station in front of the shower chair. Nurse #1 further revealed NA #1 reported she was pushing Resident #1 back to her room in the shower chair and the wheelchair tugged like the resident's leg got caught and caused the wheelchair to tip forward. Nurse #1 stated she assessed Resident #1 and decided to have the resident sent out to the hospital due to the resident being in severe pain. Nurse #1 revealed Resident #1 was alert and oriented and was able to voice her own needs and concerns. Nurse #1 also revealed Resident #1 was able to sit up without assistance and her feet did not touch the floor in the shower chair due to the resident's height. Interview conducted with the Director of Nursing (DON) on 09/03/24 at 11:10 AM revealed on 06/12/24 she was notified by a staff member that Resident #1 had fallen and found Resident #1 on the floor on her back with Nurse #1 and NA #1. The DON further revealed Nurse #1 had already assessed her and it was determined to send the resident out to the hospital due to the resident having pain in her legs. The DON further revealed NA #1 had reported to her that she had transferred the resident back to her room from the shower room and Resident #1 started to slide down in the chair onto the floor. The DON revealed she did not believe any fault in the incident but completed in-service training regarding transfers with staff and interventions included Resident #1 was changed to a shower bed for showers and footrests and safety belts added to shower chairs. A phone interview conducted with the prior Nurse Practitioner (NP) on 09/03/24 at 11:55 AM revealed she was not present in the facility on 06/12/24 but was notified Resident #1 had a fall. The NP further revealed Resident #1 had history of osteopenia and comorbidities but was able to sit up without assistance that she could recall. The NP further revealed she did not recall details of the incident that occurred on 06/12/24. An interview conducted with the Director of Rehab on 09/03/24 at 1:30 PM revealed Resident #1 was last seen for physical therapy in March 2024. It was further revealed Resident #1 was able to sit on the side of her bed with limited to no assistance with sitting up. The Director Rehab indicated the shower chair was appropriate for Resident #1. The Administrator was notified of immediate jeopardy on 09/04/24 at 6:00 PM. The facility provided the following credible allegation of immediate jeopardy removal. The corrective action plan was as followed: Date of Immediate Jeopardy Removal: 06/14/24 How will corrective action be accomplished for those residents found to have been affected by the deficient practice? On June 12, 2024 at 12:21pm, Nursing Assistant (NA) #1 was assisting resident #1 from the shower room back to her room as the resident was seated in the shower chair. Resident #1 fell out of the shower chair as she was being transported from the shower room to her room at an area on the carpeted hallway between the nurses' station and the resident's room. Nurse #1 immediately assessed resident #1 to include vital signs, neuro checks, and pain assessment. Nurse #1 noted Resident #1 to have increased pain to her lower extremities during assessment. Resident #1 was yelling and stating she was in pain. Resident #1 was unable to state specifically where her pain was located. The pain assessment conducted by Nurse #1 noted increased pain with movement to bilateral lower extremities by resident #1. A progress note dated June 12, 2024 at 12:21pm identified resident #1 right hip was malformed. Nurse #1 notified Nurse Practitioner (NP) and obtained an order to send resident #1 to the local hospital for further evaluation. Resident #1 was sent to the local hospital due to severe pain in bilateral lower extremities and her right hip being malformed. The center recognizes that all residents that utilize shower chairs, shower stretchers and wheelchairs have the potential to be affected from the noncompliance with shower chairs, shower stretchers and wheelchairs. A review of resident#1 hospital admission records dated June 12, 2024 at 2:26pm releveled resident #1 had a left tibial plateau fracture, right foot great toe fracture, tibia/fibula fracture of the right leg, and an acute displaced spiral fracture of the right femur. Resident #1 was admitted to the local hospital on June 12, 2024. Resident #1 underwent an open reduction internal fixation of the right distal femur intramedullary (IM) nail retrograde on June 13, 2024. How will the facility identify other residents having the potential to be affected by the same deficient practice? On 6/12/24, the Director of Nursing audited incidents that occurred between 5/12/24 and 6/12/24 to ensure no significant events with any other residents were identified. No additional residents were identified to have significant injuries. The audit revealed no similar events, no injuries to any other residents. On 6/12/24, the Director of Nursing and Unit Manager conducted a quality review to identify residents' mobility status as it relates to requiring the use of wheelchairs, shower stretchers and shower chairs. Identified residents' charts were reviewed to ensure no other significant events occurred during the transport by staff. What measures will be put into place or systemic changes made to ensure that the deficient practice will not occur? The Maintenance Director completed a quality review on 6/12/24 on shower chairs and shower stretchers to ensure safety mechanisms were properly installed to ensure resident safety while being transported to and from the shower rooms. The safety mechanism is a safety belt designed for PVC shower chairs equipped with a quick release buckle. The safety belts were installed on all shower chairs. On June 12, 2024, the Director of Nursing and/or Nursing Supervisor provided education to Licensed Nurses and Certified Nursing Assistants to include Agency Licensed Nurses and Agency Certified Nursing Assistants on Guidelines for Safe Bathing with the use of Shower Chair to prevent incidents and accidents as it relates to properly and safely transporting residents in shower chairs. The education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. All newly hired Licensed Nurses and Certified Nursing Assistants to include newly hired Agency Licensed Nurses and Agency Certified Nursing Assistants will be educated during new hire orientation on Guidelines for Safe Bathing with the use of Shower Chair to prevent incidents and accidents as it relates to properly and safely transporting residents in shower chairs. The education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. How will the facility monitor its corrective actions to ensure the deficient practice will not recur? Effective June 13, 2024, The Unit Manager and/or Director of Nursing will begin to observe a random sample of 8 residents per week for 4 weeks, then 5 residents per week for 4 weeks, then 3 residents per week for 4 weeks to ensure resident safety is maintained during transport in shower chairs by properly securing safety mechanisms on shower chairs. On June 12, 2024, when the deficient practice was identified, The Nursing Home Administrator arranged an ADHOC Quality Assurance Performance Improvement meeting to be conducted on June 13, 2024, in collaboration with the Medical Director to discuss the root cause analysis of the deficient practice, implement a plan of correction to include monitoring beginning on June 13, 2024, to ensure resident safety during transportation in shower chairs. The results of the quality monitoring will be brought to the monthly Quality Assurance meeting to ensure compliance of resident safety x 3 months. The improvement-monitoring schedule will be modified based on the findings of monitoring. On 09/04/24, the facility's corrective action plan for immediate jeopardy removal effective 06/14/24 was validated by the following: Staff interviews revealed they had received education provided to nursing staff includes shower chair use and description, safety instructions, guidelines for safe bathing with the use of a shower chair, stop and watch tool, and safety mechanism intended use. A quality review was conducted to identify residents' mobility status. The Maintenance Director completed a quality review on all shower chairs and shower stretchers to ensure safety mechanisms were properly installed to ensure resident safety while being transported to and from the shower rooms and safety belt were installed on all shower chairs. Audits of transfers had been conducted and will continue to be conducted to be reviewed that residents had been transferred safely in shower chairs and beds. The immediate jeopardy removal plan was verified as corrected by 6/14/24.