Every finding on record at Mecklenburg Heath and Rehabilitation

Based on observations, record review, and staff interviews, the facility failed to maintain a resident's dignity when Nurse Aide (NA) #1 and NA #2 transferred Resident #67 in a mechanical lift out of her room into the common area hallway to a shower bed on the other side of the hallway with the front of her nude body covered with a bath sheet, exposing her bare hips and the bare sides of her buttocks for 1 of 2 sampled residents reviewed for dignity. Resident #67 stated the NAs would cover the front part of her body with a sheet and would leave her sides exposed, but she really didn't like that. Findings included:Resident #67 was readmitted to the facility on [DATE] with diagnoses which included hemiplegia (complete or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebral infarction affecting right dominant side and vascular dementia. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #67 was assessed as having clear speech, was able to express ideas and was able to understand others. The quarterly MDS indicated she was severely cognitively impaired. The assessment indicated Resident #67 required the use of a wheelchair for mobility, was dependent on staff for transfers, dressing and bathing and no limitations upper body or lower body range of motion. The MDS further revealed Resident #67 was coded for rejection of care, but no other behaviors. A review of Resident #67's care plan, last revised 6/27/26, revealed a focus area for Activities of Daily Living (ADLs) due to impaired mobility, chronic pain, morbid obesity, hemiplegia and hemiparesis, and general weakness. Resident #67 required the use of a mechanical lift with two staff members for all transfers. An intervention included assistance with positioning, transfers toileting, personal hygiene, and bathing as necessary or as requested. Resident #67 had an additional focus area relating to behavioral symptoms to include becoming agitated, inappropriate behaviors such as undressing with the door open, refusing care, and crying and cursing. Interventions included reassuring and providing emotional support to Resident #67, providing appropriate level of privacy as indicated, and redirecting her during periods of inappropriate behaviors. During a continuous observation on 7/21/26 at 10:10AM until 10:15 PM in the 200 Hall, NA#1 and NA #2 were observed transferring Resident #67 in a mechanical lift out of her room into the common area hallway to a reclining shower bed on the other side of the hallway (approximately eight feet from Resident #67's room door, across the hall to the other side of the hallway) with the front of her nude body covered with a bath sheet, exposing her bare hips and the bare sides of her buttocks. Other staff members and residents were observed in the hallway during Resident #67's transfer into the reclining shower bed. During an interview with Resident #67 on 7/23/26 at 11:06 AM she revealed the NAs would assist her into the mechanical lift and pushed her in the lift out of the room to the reclining shower bed in the hallway. She explained the NAs would cover the front part of her body with a sheet and would leave her sides exposed, but she really didn't like that and did not know getting a shower could be done differently. An interview with NA #1 on 7/23/26 at 11:40 AM revealed she was on the shower team on first shift, and she and NA #2 had given Resident #67 a shower on 7/21/26. She explained there was not enough room to get the reclining shower bed in Resident #67's room along with the mechanical lift. NA #1 stated she typically left the reclining shower bed in the hallway directly in front of Resident #67's door. She stated on 7/21/26, someone must have moved the bed to the other side of the hall across from Resident #67's room and they typically would not push the mechanical lift across the hall. NA #1 stated it was not normal for them to place the reclining bed across the hallway. She was not aware Resident #67 was not completely covered with the bath sheet during the transfer. An interview with NA #2 occurred on 7/23/26 at 1:23 PM. She stated she and NA #1 usually put the reclining shower bed right outside Resident #67's room door as there was no room to put the mechanical lift and reclining shower bed in the room. NA #2 explained that someone must have moved the bed out of the way and put it across the hall from Resident #67's room. NA #2 stated her normal process was to get Resident #67 undressed in her bed as Resident #67 usually wore a shirt that she (NA #2) would have to take off over Resident #67's head and then NA #2 would cover her with a shower sheet to transfer Resident #67 in the mechanical lift. NA #2 indicated she typically made sure Resident #67 was covered up before transferring her and did not realize Resident #67 was exposed on 7/21/26. An observation on 7/23/26 at 2:00 PM of Resident #67's room with the Director of Nursing (DON) and NA #2 revealed the mechanical lift was able to fit in between the two beds in the room, but the reclining shower bed barely fit at the footboard of Resident #67's bed. There was not enough room for the side rail of the reclining shower bed to be lowered. It was determined by the DON the reclining shower bed could not safely be utilized to transfer Resident #67 inside her room due to space constraints. An interview with the DON on 7/23/26 at 2:30 PM revealed she knew having the reclining shower bed and the mechanical lift would be a tight fit in the room. She had the expectation staff would place the reclining shower bed right outside Resident #67's door in the hallway and that she would be transferred by the mechanical lift to the reclining shower bed. The DON stated she would expect nursing staff to preserve Resident #67's dignity by completely covering her during these transfers to the reclining shower bed. An interview with the Administrator on 7/23/26 at 2:53 PM revealed she expected staff to ask Resident #67 about her shower preference and to be transferred with dignity.

Based on record review, and staff and Medical Director interviews, the facility failed to implement their abuse policy and procedure in the areas of reporting to the state survey agency and investigating an injury of unknown source for a dependent resident who sustained an acute non-displaced proximal (upper) tibia (larger inner shinbone) and fibula (small outer shinbone) fracture and an acute right tibia fracture for 1 of 3 residents reviewed for accidents (Resident #1).The findings included:A review of the facility's abuse, neglect, and exploitation policy and compliance with reporting alleged violations policy and procedure dated January 2025 indicated the following: - It is the policy of this facility to report all allegations of abuse/neglect/exploitation or mistreatment, including injuries of unknown sources to appropriate agencies in accordance with current state and federal regulations within prescribed timeframes. - Injuries of unknown source include circumstances when both the following conditions are met: 1. The source of the injury was not observed by any person or could not be explained by the resident. 2. The injury is suspicious because of the extent of the injury, location of the injury, the number of injuries observed at one particular point in time, or the incidence of injuries over time. - The Administrator or designee will notify the appropriate agencies, in the case of serious bodily injury, no later than 2 hours after discovery or forming the suspicion.-Immediate investigation is warranted when suspicion of abuse neglect or exploitation or reports of abuse neglect or exploitation occur. -Written procedures for investigations include:1. Identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. 2. Focusing the investigation on determining if abuse, neglect or exploitation and/or mistreatment has occurred, the extent and cause, and providing complete and thorough documentation of the investigation. Resident #1 was admitted to the facility on [DATE]. The significant change Minimum Data Set, dated [DATE] revealed Resident #1 was severely cognitively impaired and dependent on staff for assistance with activities of daily living (ADL). The radiology report dated 8/28/25 at 1:14 PM indicated an x-ray obtained of Resident #1's left knee revealed an acute non-displaced proximal (upper) tibia (larger inner shinbone) and fibula (small outer shinbone) fracture. The emergency department (ED) report dated 8/28/25 revealed x-rays obtained in the ED indicated Resident #1 had an acute comminuted (broken in multiple pieces) mildly displaced (bone fragments are only slightly out of position) left tibia and fibula fracture and an acute right tibia fracture. The ED report noted Resident #1 was non-ambulatory, wheelchair bound, required the use of a mechanical lift for all transfers and that the source of the injury was unknown and that the facility denied any recent falls. A review of the facility reported incidents from 8/22/25 through 9/17/25 indicated no initial allegation report or 5-day investigation report was completed or submitted to the state agency regarding Resident #1's injury of unknown source. During a phone interview with the interim DON on 9/18/25 at 4:57 PM she stated she was notified immediately on 8/28/25 when Resident #1's x-ray results were received and indicated a left tibia and fibula fracture. She stated the ADON assisted her with interviewing staff and there were no reports of Resident #1 having an accident or incident that would have caused a fracture. The interim DON stated Resident #1 had a history of fractures and osteoporosis and due to no reports of a fall or trauma to her leg they determined the fracture was pathological. A phone interview with the Medical Director indicated she was notified on 8/28/25 that Resident #1 obtained a left tibia and fibula fracture and was transferred to the ED for further evaluation. She stated on 8/29/25 she reviewed Resident #1's medical record and due to her history of fractures, diagnoses of osteoporosis and osteopenia and no reports of a fall or trauma to her leg she determined the fracture was pathological in nature. The Medical Director indicated she did not review Resident #1's ED or hospital records nor was she aware of the right tibia fracture however Resident #1 having bilateral leg fractures made it more evident that the fractures were pathological. An interview conducted with the Administrator on 9/17/25 at 2:30 PM revealed she was notified immediately on 4/28/25 of Resident #1's x-ray results and that she had a leg fracture. She indicated interviews were conducted with nursing staff to determine if there was an incident or accident that occurred to cause the fracture, and no incidents or accidents were reported. She stated on 4/29/25 the Medical Director reviewed Resident #1's medical record and determined the fracture was pathological. She stated they determined the source of the injury was pathological, so an initial allegation report was not submitted to the state agency nor was a 5-day investigation report completed.

Based on record review and staff interviews, the facility failed to provide a safe transfer for 1 of 3 residents reviewed for accidents (Resident #1). The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included end stage renal disease, dependence on renal dialysis, and dementia. The resident care guide dated 8/27/24 indicated Resident #1 required 2-person assistance and the use of a mechanical lift for transfers. The significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and dependent on staff for assistance with activities of daily living (ADL) including transfers. A phone interview conducted with Nurse Aide (NA) #1 on 9/16/25 at 8:41 AM revealed she was Resident #1's Responsible Party (RP) and worked at the facility on night shift (7:00 PM to 7:00 AM). She stated she was not assigned to Resident #1 when she worked but would check on her and provide care as needed. She revealed on 8/26/25 at approximately 8:00 PM Resident #1 was complaining of leg pain during incontinence care. She stated Nurse Practitioner (NP) #1 was making rounds the next morning and assessed Resident #1 due to her complaints of leg pain. NA #1 revealed after NP #1 assessed Resident #1, NA #2 assisted her with transferring Resident #1 with the mechanical lift from the bed to the wheelchair. A phone interview was conducted with NA #2 on 9/17/25 at 7:45 AM. NA #2 revealed she was assigned to Resident #1 on 8/26/25 from 7:00 PM to 7:00 AM on 8/27/25. She stated NA #1 provided incontinence care for Resident #1 at approximately 8:00 PM and told her she would be back at the end of her shift to assist Resident #1 with morning care. NA #2 stated on the morning of 8/27/25 she did not assist NA #1 with transferring Resident #1 using the mechanical lift. A follow-up phone interview was conducted with NA #1 on 9/17/25 at 9:34 AM. She stated on 8/27/25 she transferred Resident #1 from the bed to the wheelchair with the mechanical lift without a second person. She stated she wanted to ensure Resident #1 was transferred gently due to her leg pain and felt she would accomplish this by transferring her alone. NA #1 revealed the transfer was successful and without incident. She indicated the facility's policy was to have a second person when transferring a resident with the mechanical lift and she should have requested for another staff member to assist her with the transfer. An interview with the Assistant Director of Nurse (ADON) on 9/16/25 at 4:26 PM revealed she was aware that NA #1 reported on the morning of 8/27/25 NA #2 assisted her with transferring Resident #1 using the mechanical lift, however, NA #2 denied that she assisted with the transfer. The ADON indicated two staff members should assist with mechanical lift transfers to ensure resident safety An interview conducted with the Administrator on 9/17/25 at 2:30 PM revealed two staff members should assist with all mechanical lift transfers to ensure the resident was safe.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) in the area of Special Treatments, Procedures, and Programs regarding Chemotherapy for 1 of 19 residents reviewed for accuracy of assessment (Resident #9). The findings included:Resident #9 was admitted to the facility on [DATE] with diagnoses which included colorectal cancer and heart failure.A nursing note dated 6/24/2025 at 5:18 PM indicated Resident #9 began chemotherapy every 2 weeks, starting on 6/24/2025.An Oncologist note dated 8/5/2025 indicated Resident #9 had a chemotherapy infusion pump placed for a 2-day continuous infusion with pump removal in 2 days.A nursing progress note dated 8/5/2025 at 3:50 PM stated Resident #9 returned to the facility after her oncology appointment with a chemotherapy infusion pump currently in use, secured and taped to her chest.The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #9 was cognitively intact. Under section O-Special Treatments, Procedures, and Programs the resident was not coded as receiving chemotherapy while a resident and within the last 14 days.On 8/20/2025 at 11:22 AM an interview with the Regional Minimum Data Set (MDS) Coordinator, MDS Coordinator #1 and MDS Coordinator #2 revealed they obtained Resident #9's assessment information from the daily clinical meetings, medical record progress notes and physician consult notes. The Regional MDS Coordinator stated the MDS was coded incorrectly. She stated the information was missed when the assessment was completed.On 8/21/2025 at 2:21 PM an interview with the Interim Director of Nursing revealed she was not involved with the MDS process but knew the MDS Coordinators attended the clinical meetings each morning when the residents were discussed. She stated the MDS should be coded accurately.On 8/21/2025 at 2:38 PM an interview with the Administrator indicated that the MDS should be coded accurately. The Administrator stated nursing should be consulted if the MDS Coordinators had questions regarding a resident's condition or treatments received.

Based on observation, record review and staff interviews, the facility failed to administer insulin pen injection according to directions when the Unit Coordinator failed to wait at least 6 seconds prior to removing insulin pen from Resident #4's skin. This deficient practice occurred for 1 of 5 residents observed for medication administration (Resident #4). The findings included:The Insulin Pen policy implementation date 1/7/25 revealed when injecting insulin pen the nurse should:- Cleanse the skin with alcohol pad.- Inject the needle straight at a 90-degree angle to the skin.- Fully depress plunger until the dosing number count back to zero.- While still pressing the plunger, keep the needle in the skin for up to 6-10 seconds and then remove the needle from the skin. - May use bandage if needed.- Remove the needle from the pen by turning counterclockwise and dispose of the needle in the sharps container. Resident #4 was admitted to the facility on [DATE] with diagnoses that included diabetes type 2. A review of Resident #4's July 2025 physician orders included an order for Novolog FlexPen, give 4 units with meals, hold for blood sugar level less than 100. An observation was conducted on 8/21/25 at 12:50 PM with Resident #4. The Unit Coordinator donned a clean pair of gloves and dialed the Novolog insulin pen to 6 Units and discarded 2 Units, leaving 4 Units on the insulin pen dial. The Unit Coordinator cleaned Resident #4's upper posterior right arm with alcohol wipe. Next, she pressed the pen on Resident #4's arm 3 times in 3 different locations on the right upper arm of Resident #4 with the insulin pen. When the Unit Coordinator pressed insulin pen for the third time at a 90-degree angle to Resident #4's skin, pressed the top button on the pen to inject the insulin until the dial registered 0 units. Next the Unit Coordinator immediately removed the pen less than one count. The surveyor observed a clear fluid draining from Resident #4's arm. The Unit Coordinator wiped Resident #4's arm with a dry gauze and disposed of the insulin needle in the sharps container, removed gloves, and applied antiseptic gel to her hands. An interview was conducted on 8/21/25 at 1:07 PM with the Unit Coordinator. The Unit Coordinator stated that she was nervous and was not aware of how long she held the insulin pen to Resident #4's skin after insulin pen registered 0 units. An interview was conducted on 8/21/25 at 2:04 PM with the Director of Nursing (DON). The DON stated that she asked the Unit Coordinator if she held the pen for a few seconds when the insulin pen reached 0. The DON reported that the Unit Coordinator stated she did not count to know how long she held the insulin pen to Resident #4's skin. The DON stated after she reviewed the policy, the Unit Coordinator should not have removed the insulin pen immediately and should have held the insulin pen to Resident #4's skin with the pen at 0 units for at least 6 seconds.

Based on observations and staff interviews the facility failed to remove expired medications stored in 1 of 3 medication storage rooms (Central Supply).The findings included: An observation of the Central Supply medication storage room was conducted on 8/19/25 at 11:19 AM in the presence of the Unit Coordinator. The following medication was found in the Central Supply room: one box of hemorrhoidal suppositories. The expiration date on the box was July 2025 and contained 12 suppositories. The Unit Coordinator confirmed the expiration date by reading aloud the date printed on the box. An interview with the Unit Coordinator was completed on 8/19/25 at 11:32 AM. The Unit Coordinator stated that all staff who administer medications were responsible for checking medication expiration dates prior to leaving the Central Supply room and before administration of all medications. She also reported that expired medications were disposed of to prevent circulation to residents.An interview with the Central Supply Coordinator on 8/19/25 at 11:34 AM revealed that she expected all staff to check the expiration dates on medications prior to leaving the Central Supply room and dispose of the item if it was expired. The Central Supply Coordinator indicated she checked the Central Supply room monthly to reorder supplies as needed but did not check for expired medication. The interview with the Director of Nursing (DON) on 8/21/25 at 2:04 PM revealed that when a nurse retrieved a medication from the Central Supply room the expiration date was reviewed and if a nurse identified an expired medication, the medication was disposed of immediately. The interview with the Administrator was completed on 8/21/25 at 2:37 PM. The Administrator stated that she expected staff to check the expiration date prior to the medication leaving the Central Supply storage room and discard any expired medication prior to leaving the Central Supply room.

Based on observations, record review, and staff interviews, the facility failed to follow their Handwashing/Hand Hygiene policy when the Unit Coordinator did not perform hand hygiene prior to donning clean gloves to perform blood glucose fingerstick and insulin injections for Resident #4 and Resident #105. This deficient practice occurred for 1 of 6 staff members observed for infection control practices (Unit Coordinator).The findings included: The Hand Hygiene policy implementation date 1/2/25 revealed all staff would perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents and visitors. Hand hygiene was defined as cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known as alcohol-based rub. The policy also revealed staff should perform hand hygiene for the following:- Before and after direct resident contact- Upon and after coming in contact with a resident's intact skin- After contact with a resident's mucous membranes and body fluids- After removing gloves or aprons Observation #1 was conducted on 8/21/25 at 12:19 PM while Resident #105 received an insulin injection. The Unit Coordinator was observed entering Resident #105's room wearing a gown, gloves and carrying a plastic box that contained alcohol wipes, insulin vial and glucometer supplies. The Unit Coordinator stated she had to exit the room to obtain an insulin syringe. The Unit Coordinator removed her gown, gloves, and disposed of them in the trash before exiting the room. The Unit Coordinator retrieved 4 insulin syringes from the medication cart and placed them in the clear plastic supply box. The Unit Coordinator returned to Resident #105's room and donned gown and gloves without performing hand hygiene. Then the Unit Coordinator wiped the insulin vial with an alcohol wipe and used a syringe to draw up 15 Units of Humalog insulin. The Unit Coordinator cleaned the posterior upper right arm of Resident #105 with alcohol wipe and administered the insulin injection. The Unit Coordinator removed her gown, gloves and returned to medication cart and applied antiseptic gel to hands. A second observation was conducted on 8/21/25 at 12:50 PM with Resident #4. The Unit Coordinator obtained the glucometer supply box for Resident #4, applied antiseptic gel to both hands and applied clean gloves. The Unit Coordinator wiped Resident #4's right ring finger with alcohol wipe, pricked the finger with a lancet to obtain blood sample. The Unit Coordinator applied a sample of Resident #4's blood to the glucometer test strip. The glucometer reading resulted in an error reading. The Unit Coordinator removed her gloves and returned to the medication cart to retrieve another test strip for the glucometer. She then donned clean gloves without performing hand hygiene and cleaned Resident #4's right ring finger with alcohol wipe, pricked the finger with the lancet, wiped the finger with a dry gauze, and collected the blood sample with the glucometer. The Unit Coordinator disposed of the lancet, test strip and gloves. She then donned a clean pair of gloves without doing hand hygiene and before administering the insulin. An interview was conducted on 8/21/25 at 1:07 PM with the Unit Coordinator. The Unit Coordinator stated that she was nervous and forgot to perform hand hygiene prior to putting on clean gloves prior to insulin injection for Resident #105 and prior to glucometer test and insulin injection for Resident #4.An interview with the Infection Preventionist on 8/21/25 at 1:06 PM revealed that the Unit Coordinator should have performed hand hygiene after removing gloves while insulin injection for Resident #105 and prior to glucometer test and insulin injection for Resident #4. The Infection preventionist stated that staff were educated on hand hygiene and glucometer testing July 2025 and the Unit Coordinator attended the training. An interview was conducted on 8/21/25 at 2:04 PM with the Director of Nursing (DON). The DON stated the Unit Coordinator was nervous and should have performed hand hygiene after removing gloves when performing insulin injection for Resident #105 and prior to glucometer test and insulin injection for Resident #4.

Based on record review, hospital case manager, physician, and staff interviews, the facility discharged a resident when the resident was sent out to the local hospital for a physician ordered geriatric psychiatric consult. There was also no documentation by the physician stating the reason for the discharge or details about how the facility could not meet the resident's needs or how the resident endangered other residents for 1 of 2 sampled residents reviewed for transfer and discharge (Resident #1) . The findings included: Resident #1 was admitted to the facility on [DATE] to an unlocked unit with diagnoses that included unilateral primary osteoarthritis-right hip, history of other toxic encephalopathy, unspecified atrial fibrillation, major depressive disorder, anxiety disorder, insomnia, and delirium due to known physiological condition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was cognitively intact. The MDS further coded Resident #1 for delusions and no physical or verbal behavioral symptoms directed towards others. Resident #1's psychiatric service note dated 11/4/23 revealed Resident #1 was seen for a psychiatric evaluation for management of medication for psychiatric issues as the facility was utilizing a new psychiatric provider. The facility's Psychiatric Mental Health Nurse Practitioner (PMHNP) reported history of major depressive disorder, anxiety, insomnia, and anorexia and behaviors to include yelling, throwing things, and combativeness. PMHNP agreed with diagnosis and was unclear if Resident #1 had psychosis. No medication changes were suggested. Resident #1's psychiatric service note dated 11/21/23 revealed Resident #1 was seen for a recent episode where she, per staff, attempted to throw silverware at another resident and continued to have behaviors that were not redirectable. The facility's PMHNP reported that per the SW, consideration was given to a 30-day discharge notice. The PMHNP agreed Resident #1 could be sent to ER for further psychiatric evaluation and possible hospitalization to stabilize underling psychiatric issues. No medication changes were suggested. Review of a Nursing Home notice of transfer/discharge revealed the date of notice was 11/21/23 and the discharge date was 12/21/23. The reasons for discharge were marked as it is necessary for your welfare and your needs cannot be met in this facility, the safety of individuals in this facility is endangered due to the clinical or behavioral status of the resident, and the health of the individuals in this facility would otherwise be endangered. The discharge location was listed as Hospital Inpatient Gero Psych. Review of the Social Worker's (SW) progress note dated 11/21/23 revealed a care conference with Resident #1's family member was held regarding the facility issuing a 30-day discharge notice from the facility effective 12/21/23. Resident #1 would be discharged because the facility was not able to meet Resident #1's needs as resident needed geriatric psychiatric services as requested by the facility provider, the safety of the individuals in the facility were endangered due to clinical or behavioral status of the Resident #1, and the health of individuals in this facility would otherwise be endangered. Resident #1's daughter stated she understood as she was made aware by the nursing staff of Resident #1's combativeness towards residents and staff members. The facility Physician's Assistant (PA) requested a geriatric psychiatric consult as Resident #1 was to be discharged to inpatient geriatric psychiatric unit. A copy of the 30-day discharge letter was mailed to Resident #1's daughter and a copy was given to Resident #1. A review of Resident #1 physician order dated 11/21/23 read geriatric psychiatric consult. There were no physician progress notes stating the reason for the discharge or details about how the facility could not meet Resident #1's needs or how Resident #1 endangered the other residents located in the medical record. The discharge MDS dated [DATE] indicated that Resident #1 was discharged to inpatient psychiatric facility. Nursing progress note dated 11/22/23 at 8:39am indicated Resident #1 was discharged from the facility at 7:30am and the ambulance arrived and provided her transportation to geriatric psychiatric hospital. Resident #1 was discharged with her belongings including glasses, dentures, and phone. Review of the hospital records revealed Resident #1 was medically evaluated in the emergency room (ER) on 11/22/23 for a psychiatric evaluation and Resident was documented as medically stable, and appropriate for behavioral health evaluation. In addition, medical provider note dated 11/29/23 revealed that Resident #1 initially presented to theER on [DATE] from local rehab unit after reportedly exhibiting combative and aggressive behaviors towards staff and other residents, progressively worsening over the past several weeks. Resident #1 was evaluated by the ER provider and psychiatry and was cleared for discharge, however unfortunately the local rehab unit would not accept her back. Resident #1 remained in the ER while awaiting other nursing facility placement. The medicine team was asked to admit the patient to the medical unit after 8 days. Resident #1 was diagnosed with acute urinary cystitis and received treatment. Hospital note dated 11/30/23 continued that Resident #1 was discharged to another skilled nursing facility. An interview with the SW on 12/12/23 at 12:43pm revealed Resident #1 needed a geriatric-psychiatric facility-a higher level of care. The SW stated that she called the hospital behavioral psychiatric hotline on 11/20/23 and spoke to an intake hospital representative. The intake hospital representative advised the SW to send Resident #1 to the ER and she would be evaluated for the geriatric-psychiatric unit. She sent Resident #1's belongings to the ER because the responsible party did not elect for a bed hold. The SW indicated she emailed the 30-day discharge notice to the Ombudsman and the responsible party. An interview with the Hospital Case Manager on 12/12/23 at 1:38pm revealed Resident #1 was sent to theER on [DATE] with all her belongings. After evaluation, Resident #1 did not meet the criteria for geriatric psychiatric unit and needed to return to the facility. She revealed that she had spoken to the social worker at the facility regarding Resident #1's discharge on 11/27/23. An interview with the Medical Director (MD) on 12/13/23 10:10am revealed Resident #1 had a history of challenging behaviors. It was the understanding of the MD that Resident #1 would be sent to the ER and would be evaluated and admitted to the geriatric psychiatric unit. The MD spoke to the ER physician on 11/27/23 and understood that the resident received multiple IM injections and Resident #1 was not appropriate for the facility at that time. An interview with the Administrator on 12/13/23 11:10am revealed Resident #1's care was outside of the facility's scope. She stated the DON would be better suited to answer questions about what care the facility could not provide for Resident #1. The Administrator explained that the facility had to give a 30-day discharge notice to any resident who needed to go out for treatment. An interview with the Director of Nursing (DON) on 12/12/23 at 12:59pm revealed that he was not directly involved with this discharge. He stated that he spoke to Resident #1's daughter about the discharge notice and noted Resident #1 was exhibiting acute psychosis. A continued interview with the DON on 12/13/23 at 11:43am revealed the facility would always send a 30-day discharge notice to all residents who went to the hospital and was not aware of any resident who appealed the notice.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions the committee put into place following the Focused Infection Control and Complaint Investigation survey conducted on 1/19/21 and the Complaint Investigation survey conducted on 12/14/23. This was for a repeat deficiency in the area of Transfer and Discharge Requirements that was originally cited on 1/19/21 during the Focused Infection Control and Complaint Investigation survey, and subsequently recited during the Complaint Investigation survey completed on 12/14/23. The continued failure of the facility during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. The findings included: This tag is cross referenced to: F622- Transfer and Discharge Requirements: Based on record review, hospital case manager, physician, and staff interviews, the facility discharged a resident when the resident was sent out to the local hospital for a physician ordered geriatric psychiatric consult. There was also no documentation by the physician stating the reason for the discharge or details about how the facility could not meet the resident's needs or how the resident endangered other residents for 1 of 2 sampled residents (Resident #1) reviewed for transfers and discharges. During the Focused Infection Control and Complaint Investigation survey conducted on 1/19/21 the facility failed to communicate a Resident's guardianship status to the hospital and failed to arrange for a supervised transfer and handoff of the Resident who was deemed incompetent and had a legal guardian. The nursing home provided confidential guardianship information to a contracted van driver in a sealed envelope. The van driver reportedly provided the sealed envelope to hospital staff and left the resident alone at the hospital. Hospital staff denied receiving any resident documentation in written, scanned, or telephonic format. This was evident for 1 of 3 residents reviewed for hospital discharges and transfers.

Based on record review and staff and resident interviews, the facility failed to ensure staff spoke to residents in a respectful and dignified manner for 1 of 3 residents reviewed for dignity (Resident #51). The findings included Resident #51 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, dislocation of left and right shoulder joint, altered mental status, and depression. A review of Resident #51's quarterly Minimum Data Set Assessment revealed Resident #51 to be cognitively intact. During an interview with Resident #51 on 12/14/22 at 10:05 AM, she reported she recently had an interaction with a nurse aide (NA #3) who was being mean to her while assisting her to bed. Resident #51 reported she began to cry and Resident #51 stated NA #3 then told her we don't care for babies around here. Resident #51 stated she became more upset, and that NA #3 made her feel like her feelings were unimportant. During an interview with NA #3 on 12/14/22 at 3:48 PM, she reported she remembered the interaction and stated she felt Resident #51 misunderstood what she said. She reported that night, she was assisting Resident #51 to bed and noticed that she was crying and upset. NA #3 stated she asked her multiple times what was wrong with no answer from Resident #51. She then told Resident #51 that we were all adults here and we don't cry. Babies cry and that Resident #51 needed to tell her what was wrong. NA #3 stated she was eventually able to get her comfortable and her calmed down. She stated although she believed that Resident #51 misunderstood what she was saying, she agreed that the verbiage was not appropriate, and she should not have compared Resident #51's behavior that evening to the behavior of babies. During an interview with the Director of Nursing on 12/15/22 at 11:58 AM, she reported she was aware of the interaction between NA #3 and Resident #51. She reported staff should not be comparing actions of residents to the actions of children or babies. She stated she expected her staff to resolve issues, not add to them. During an interview with the Administrator on 12/15/22 at 12:36 PM, she reported she was aware of the interaction between Resident #51 and NA #3. She reported she investigated it when she was made aware of the incident and educated NA #3 on customer service. She stated she expected her staff to speak to residents in a dignified and respectful manner.

Based on record review and staff and resident interviews, the facility failed to ensure a resident's need was accommodated resulting in a resident who was mobile in a standard wheelchair being placed in a large reclining chair on wheels which inhibited the resident's ability to propel around the facility independently for 1 of 2 residents reviewed for accommodation of needs (Resident #4). The findings included Resident #4 admitted to the facility on [DATE] with diagnoses that included end stage renal disease, hypotension, chronic pain, major depressive disorder, anxiety disorder, and type II diabetes mellitus. A review of Resident #4's quarterly Minimum Data Set assessment dated [DATE] revealed her to be cognitively intact with no behaviors, rejection of care, or instances of wandering. Resident #4 was coded as activity did not occur for locomotion on and off the unit and was coded with no use of physical restraints or alarms. Resident #4 was coded as receiving dialysis while a resident. During an interview with Resident #4 on 12/12/22 at 12:04 PM, she reported the facility had misplaced her wheelchair a couple weeks ago and she was not getting out of bed. She reported while her wheelchair was lost, the facility had gotten her up on a few occasions and placed her in a large reclining chair on wheels but that she could not move the chair so she would have to call for assistance when she wanted to move to another place in the facility. Resident #4 reported when she was in her regular wheelchair, she had the ability to mobilize around the facility on her own. She reported it became such a nuisance that after 3 or 4 times of getting up in the large reclining chair; she stopped asking to get out of bed at all. Resident #4 reported she had informed the Housekeeping Director of her missing wheelchair and he had attempted to locate it. During an interview with Nurse Aide (NA) #8 on 12/14/22 at 11:41 AM, she reported Resident #4 did not get out of bed a lot. She reported when Resident #4 did get out of bed, she had to be placed in the large reclining chair on wheels that was kept in her room because her wheelchair had been misplaced. NA #4 verified that Resident #4 could not propel freely when in the large reclining chair on wheels like she could when she was in her own wheelchair. During an interview with NA #7 on 12/14/22 at 12:18 PM, she reported Resident #4 did not get out of bed a lot. She stated with Resident #4's wheelchair missing, when she was gotten out of bed, she was placed in a large reclining chair on wheels. NA #7 reported when Resident #4 was in her regular wheelchair, she had the ability to propel herself around the facility and stated she did not believe Resident #4 would have the same ability when she was in the large reclining chair on wheels. During an interview with the Housekeeping Director on 12/14/22 at 2:04 PM he reported he knew that Resident #4's wheelchair was missing. He also stated he had replaced her wheelchair with a replacement wheelchair but that one had went missing as well. He stated he could not remember how long Resident #4 had gone without a wheelchair while the other wheelchairs were missing. He reported while the missing wheelchairs were being located, Resident #4 was being placed in a large reclining chair on wheels when Resident #4 wanted to get up and out of bed. During an interview with the Director of Nursing on 12/15/22 at 11:58 PM, she reported she did not know about Resident #4's missing wheelchair. She reported she would have wanted her staff to locate another wheelchair and provide it to Resident #4 as she was aware Resident #4 would be unable to propel herself in the large reclining chair on wheels that facility staff had reported they placed her in. She stated she felt the facility had plenty of extra wheelchairs and did not understand why staff began placing Resident #4 in the large reclining chair on wheels. During an interview with the Administrator on 12/15/22 at 12:36 PM, she reported she was aware Resident #4's wheelchair had been misplaced. She also reported she would have preferred her staff find another wheelchair for Resident #4 to use while hers was misplaced instead of using the large reclining chair on wheels to put Resident #4 in since she would not be able to propel in it.

Based on observations, record review, and staff and resident interviews, the facility failed to ensure a dependent resident received the assistance they required to complete activities of daily living resulting in long, dirty fingernails for 1 of 5 residents reviewed for Activities of Daily Living (ADL)(Resident #38). The findings included: 1. Resident #38 was admitted to the facility on [DATE] with diagnoses that include hemiplegia and hemiparesis follow a stroke, contracture to left hand, muscle weakness, and major depressive disorder. A review of Resident #38's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #38 to be cognitively intact with no psychosis, behaviors, or rejection of care. Resident #38 was coded as requiring extensive assistance with personal hygiene and was totally dependent with bathing. A review of Resident #38's care plan last revised on 10/19/22 revealed a care plan for Resident requires assistance from staff for ADLs . Interventions included provide assistance with all ADLs including mobility and transfers as needed, being careful not to overwhelm resident. During an observation and interview with Resident #38 on 12/12/22 at 11:50 AM, she reported she had to pitch a fit to get her nails trimmed. Resident #38's fingernails were observed to be long, extending 1/2 to 1 inch past the tips of her fingers, with black matter caked underneath the nails. An additional observation made of Resident #38 on 12/13/22 at 1:03 PM, revealed resident to be eating her lunch meal that consisted of a hotdog on a bun with chili and French fries. Resident #38 was feeding herself with her right hand. Resident #38's nails continued to be 1/2 - 1 inch beyond the end of her fingers with black matter under all 5 nails on her right hand. During an interview with NA #7 on 12/14/22 at 12:12 PM, she reported nail care should be completed on shower days and as needed, unless the resident was diabetic; then a nurse would be responsible for trimming a resident's nails. NA #7 also reported nails should be monitored on shower days, when passing trays, or when general care was being provided. She reported she had not seen Resident #38's nails and could not speak to their current condition. During an interview with NA #8 on 12/14/22 at 1:42 PM, she reported she was familiar with Resident #38 and that she needed assistance with her ADLs. NA #8 reported she checked nails on shower and bathing days. She reported she last worked with Resident #38 on 12/11/22 and could not recall the condition of Resident #38's fingernails at that time. During an interview with Nurse #3 on 12/14/22 at 2:48 PM she reported nail care was typically provided by the NAs on the hall unless the resident was diabetic, then the NAs would inform the nurse and the nurse would trim the nails. She reported that NAs were responsible for ensuring that nails were kept clean. Nurse #3 was shown the condition of Resident #38's fingernails at this time and she reported they needed to be cleaned and that they should not have been that dirty. During an interview was completed with the Director of Nursing on 12/14/22 at 2:48 PM after she observed the condition of Resident #38's fingernails. She reported the condition of Resident #38's fingernails was unacceptable and since Resident #38 was not diabetic, it would be the responsibility of the NAs to ensure they were neatly trimmed and cleaned. She stated she was unaware of the condition of Resident #38's fingernails and reported she would ensure they were cleaned. During an interview with the Administrator on 12/15/22 at 12:36 PM, she reported she expected ADLs to be completed as required for each resident in the facility.

Based on observations, record reviews and interviews the facility failed to prevent a urinary catheter bag and tubing from touching the floor and failed to anchor the catheter tubing to prevent pulling and trauma for 1 of 2 residents (Resident #61) reviewed for urinary catheters. The findings included: Resident #61 was admitted to the facility on [DATE] with diagnoses that included neurogenic bladder. Review of Resident #61's care plan dated 11/01/22 indicated the Resident required a catheter due to neurogenic bladder. The goal to not experience no signs and symptoms of complications related to the use of the catheter would be attained by keeping the catheter free of kinks and keeping the catheter below the bladder. Review of Resident #61's physician orders dated 11/26/22 revealed, Secure (catheter) tubing with leg strap. The quarterly Minimum Data Set assessment dated [DATE] revealed Resident #61's cognition was severely impaired, and he had an indwelling urinary catheter. On 12/12/22 11:02 AM an observation was made of Resident #61 lying in bed with his urinary catheter bad tied to the left side of the bed frame by a string and the catheter tubing looped below the catheter bag and touching the floor. (Unable to determine if a catheter anchor was being used). During a second observation of Resident #61 on 12/12/22 2:51 PM the Resident's urinary catheter bag and the catheter tubing was touching the floor. On 12/12/22 2:52 PM Unit Manager (UM) #2 who also functioned at the Infection Preventionist walked into Resident #61's room and looked around the room then proceeded to converse with the roommate then walked back out of the room. At 2:54 PM on 12/12/22 the UM walked back into Resident #61's room and gave the Resident's roommate a snack then looked around the room again before she exited the room. During an interview with Nurse Aide (NA) #1 on 12/12/22 2:58 PM she confirmed that she was responsible for Resident #61 that shift. The NA acknowledged the catheter bag and tubing touching the floor and stated that the bag and tubing should be below the bladder but not touching the floor because it was a sanitary issue, and the Resident could develop a urinary tract infection. The NA was asked to determine if the Resident wore a stabilizing device for the catheter tubing and the NA looked for the device but there was no stabilizing device in use for the catheter tubing. The NA explained the Resident should be wearing a stabilizing device to prevent from pulling and causing trauma. The NA observed the catheter bag was tied to the bed frame with a string and stated the bag should have a hook to hang the bag and attempted to untie the string from the bed frame but could not untie the string and stated she needed to inform the UM #2 and laid the catheter bag back on the floor. An interview was conducted with Unit Manager #2 at 3:20 PM 12/12/22. The UM acknowledged the Resident's catheter bag and tubing were resting on the floor and there was no stabilizing device in place. The UM explained that all residents should wear an anchoring device to stabilize the catheter tubing to prevent trauma and the catheter bag and tubing should not be touching the floor for infection control purposes. She stated the Resident had a tendency to pick at things and could have removed the anchoring device himself. The UM replaced the catheter bag with a new one and taped an anchoring device to the Resident's thigh to prevent pulling and trauma. On 12/15/22 9:32 AM during an interview with the Interim Director of Nursing she explained that the catheter bag and tubing should never touch the floor for infection control purposes and the catheter tubing should be anchored to the residents' thighs as to not cause pulling and trauma. An interview was conducted with the Administrator on 12/15/22 10:48 AM. The Administrator indicated the residents who had urinary catheters should be monitored frequently to prevent the catheter bag and tubing from touching the floor and ensure the stabilizing device was utilized.

Based on observations, record reviews and interviews the facility failed to obtain a physician order for supplemental oxygen for 1 of 2 residents (Resident #37) reviewed for respiratory care. The finding included: A review of an undated standing order policy related to supplemental oxygen revealed O2 @1-5 liters per minute (LPM) via nasal cannula (NC) as needed (PRN) to keep oxygen saturation >92%. If the patient needs oxygen longer than 24 hours physician (MD) order needed to continue. Resident #37 was admitted to the facility on [DATE] with diagnoses that included cerebral vascular accident. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #37's cognition was severely impaired and was not coded for oxygen use. Review of Resident #37's care plan updated 09/28/22 revealed there was no care plan for supplemental oxygen. Review of Resident #37's physician orders revealed there was no order for supplemental oxygen. A review of Resident #37's Medication Administration Record (MAR) for 12/01/22 through 12/12/22 revealed there was no order for supplemental oxygen administration. A review of Resident #37's medical record on 12/12/22 7:48 AM revealed the oxygen saturation was 97%. On 12/12/22 12:39 PM during an observation of Resident #37 the Resident wore supplemental oxygen via nasal cannula at 4 liters per minute (l/min) via the oxygen concentrator. An observation of Resident #37 on 12/13/22 9:06 AM revealed the Resident received 3 l/min of supplemental oxygen via the nasal cannula by the oxygen concentrator. During an observation of Resident #37 on 12/14/22 3:45 PM the Resident received supplemental oxygen via nasal cannula at 3 l/min by the oxygen concentrator. An interview was conducted with Nurse #5 on 12/14/22 3:45 PM who explained that Resident #37 was sent to the hospital last week and came back from the hospital with continuous oxygen via nasal cannula at 3 l/min. The Nurse searched through the Resident's Medication Administrator Record and could not find the order for oxygen. The Nurse stated she knew the Resident was supposed to be on oxygen because she was the Nurse who readmitted her to the facility when she returned from the hospital and since she was new to the facility, she forgot to obtain an order for the oxygen from the physician. An interview with Nurse #6 conducted on 12/15/22 1:47 PM revealed the Nurse confirmed she worked with Resident #37 on 12/12/22 and 12/13/22. The Nurse explained that the Resident wore oxygen on the days she provided care vial nasal cannula at 2 l/min. The Nurse stated she should have noticed the oxygen order was not on the Resident's MAR and obtained the order for the oxygen. An interview was conduced with Unit Manager (UM) #2 on 12/14/22 3:50 PM who explained that Resident #37 was sent to the hospital on 12/02/22 and returned to the facility on [DATE] with diagnosis of acute congestive heart failure and required supplemental oxygen via nasal cannula. The UM reviewed the Resident's readmission orders from the hospital and noted there was no order for supplemental oxygen included in the orders. The UM stated the admitting nurse should have noticed that there was no order for supplemental oxygen and obtained an order from the physician. The UM continued to explain that there were standing orders to administer oxygen for acute episodes but if the oxygen was needed to continue then they should obtain a physician's order for the oxygen. On 12/15/22 at 9:20 AM an interview was conducted with the interim Director of Nursing (DON) who explained that the clinical managers made rounds every day and should have noticed that Resident #37 was on oxygen and followed through with obtaining the order for the oxygen. During an interview with the Administrator on 12/15/22 10:42 AM she explained that the admitting nurse should have recognized that Resident #37 was on oxygen when she returned from the hospital and obtained a physician's order for the oxygen.

Based on observations and staff interviews the facility failed to remove expired medications and failed to date open insulin pens for 1 of 3 medication carts reviewed for medication storage (200 hall Medication Cart #2). The findings included: An observation of the 200 hall Medication Cart #2 was made on 12/12/22 at 3:30 PM along with Nurse #4. The observation revealed the following: - Advair Diskus (inhaled medication) 100 micrograms (mcg)/50 mcg that expired on November 30, 2022 and was opened on 12/10/22 and had 24 doses remaining. - Hyoscyamine (used to treat spasms) 0.125 milligrams (mg) 15 tablets that expired 11/22. - 2 Novolog insulin vials that were opened with no date of when they were opened and no pharmacy label to indicate when they had been sent to the facility. - Levemir Flex touch insulin pen that was opened with no date of when it was opened and no pharmacy label to indicate when it had been sent to the facility. Nurse #4 was interviewed on 12/12/22 at 3:35 PM and revealed that she only worked at the facility as needed and had not worked in the last two weeks until today (12/12/22). Nurse #4 stated she had not gone through her medication cart to determine if there were any expired medications and was not sure who was responsible for doing so. She also stated she could not tell when the insulin expired because there was no date when they were opened. Nurse #4 could not recall if they had been opened and on the medication cart two weeks ago when she worked. Nurse #4 stated she knew who her chain of command was and that Unit Manager (UM) #1 was her direct supervisor. UM #1 was interviewed on 12/13/22 at 1:42 PM. UM #1 stated that she tried to go through the medication carts routinely, but night shift staff was also expected to go through the medication carts on a weekly basis and all expired or outdated medications should be removed and returned to the pharmacy. UM #1 stated that whoever opened the insulin vial or pen was responsible for dating it and then each medication cart had a sheet in the front of the book on their medication carts that told them how many days each type of insulin was good for. When the nurses were using the insulin, they should be checking the dates on the vial or pen to ensure that the insulin was still in date and if not, it should be discarded, and a new vial or pen obtained. The interim Director of Nursing (DON) was interviewed on 12/14/22 at 11:42 AM and confirmed that the night shift staff along with the UMs were expected to go through the medication carts and rooms at least weekly and discard any expired medication and any undated or outdated insulins pens/vials. These medications were to be discarded and new obtained.

Based on record review and interviews with staff, family, Nurse Practitioner (NP), and the Medical Director (MD), the facility failed to administer the correct medications to a resident when Nurse #1 administered medications prescribed for Resident #8 to Resident #4. Resident #4 received 5 medications which included long-acting insulin, muscle relaxer, blood pressure medication, antidepressant, and a dietary supplement/sleep aid. This resulted in Resident #4 becoming unresponsive and she had a critically low blood pressure (BP) of 70/40 that required intravenous fluid (IVF) resuscitation upon Emergency Medical Services (EMS) arrival. Resident #4 was transferred to the emergency room (ER) for evaluation of altered mental status (AMS). This failure occurred for 1 of 3 sampled residents reviewed for significant medication error. The findings included: Resident #4 admitted to the facility on [DATE] from an acute hospital. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] assessed Resident #4 with severe impairment in cognition. She had clear speech and was coded with adequate hearing and vision. The MDS indicated Resident #4 used a wheelchair as her mobility device. Resident #4 received antipsychotic and diuretic medications daily and required one-person physical assist for locomotion on unit that occurred only once or twice during this assessment. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] [MEDICATION(S)] 10 milligrams (mg) once daily (antipsychotic) [MEDICATION(S)] 20 mg once daily at bedtime (cholesterol lowering agent) [MEDICATION(S)] 50 micrograms (mcg) once daily in the morning ([CONDITION(S)] hormone) [MEDICATION(S)] 15 mg once daily (antipsychotic) [MEDICATION(S)] 40 mg once daily (stomach acid reducer) [MEDICATION(S)] 10 mg once daily (diuretic) [MEDICATION(S)] 100 mg twice daily (anticonvulsant) Review of Resident #4's medical records from 08/18/21 through 09/24/21 revealed her baseline vital signs (VS) were within normal limits as follows: Blood pressure (BP): 90/60 to 120/80 Respiratory rate (RR): 12 to 18 breaths per minute. Heart rate (HR): 60 to 100 beats per minute. The facility's medication variance report dated 09/24/21 indicated Nurse #1 entered room [ROOM NUMBER]A on 09/24/21 at 9:30 PM and found Resident #4 was watching television. Nurse #1 called Resident #8's name. Resident #4 answered to Resident #8's name. Nurse #1 gave Resident #4 the following medications prescribed for Resident #8: 18 units of [MEDICATION(S)] (long-acting insulin) 1 tablet of [MEDICATION(S)] 40 mg ((cholesterol lowering agent) 1 tablet of [MEDICATION(S)] 4 mg (muscle relaxer) 1 tablet of [MEDICATION(S)] 5 mg (dietary supplement/sleep aid) 1 tablet of [MEDICATION(S)] 50 mg (antidepressant) 1 tablet of [MEDICATION(S)] 6.25 mg (blood pressure lowering agent) Further review of the medication variance report revealed Resident #4's blood sugar (BS) was checked and recorded once before EMS arrival, and it was 144 milligram/deciliter (mg/dl). Nurse #1 also checked Resident #4's VS which were BP 90/60, HR 68, body temperature (T) 97.6 F, and RR 16. The last set of VS before the EMS arrived were BP 80/58, HR 66, T 97.6 F, and RR 16. During a phone interview with Nurse #1 on 02/03/22 at 3:12 PM, she stated Resident #4 used to reside on the 200 Hall and had been moved to the 100 Hall shortly before 09/24/21 and would wander back to 200 Hall at times. Nurse #1 recalled she was passing medications on 09/24/21 evening on the 200 Hall and when she reached the end of the Hall around 9:30 PM, Resident #4 was sitting in the bed in room [ROOM NUMBER]A with pajamas on. Nurse #1 stated that she thought Resident #4 was Resident #8 when she retrieved the medications. When Nurse #1 entered room [ROOM NUMBER]A, she said to Resident #4 How are you doing today Ms. (Resident #8's name)? Resident #4 replied she was doing good. At around 10:00 PM, Nurse #1 realized that she had given the medications prescribed for Resident #8 to Resident #4 when Nurse #2 came on the hall looking for Resident #4 and told her the resident sitting in room [ROOM NUMBER]A was Resident #4. She and Nurse #2 immediately brought Resident #4 back to her room on the 100 Hall. Nurse #1 checked Resident #4's VS and bedside BS level, gave her oral fluids, and called the on-call physician and the Responsible Party (RP) while Nurse #2 called the Director of Nursing (DON). Nurse #1 could not recall the details of Resident #4's vital signs after the incident, but stated they were all within the normal limits. She added Resident #4 had never been unresponsive and was alert throughout the time until EMS arrived. Nurse #1 could not recall when the EMS arrived. Nurse #1 stated that she received a verbal in-service via phone from the DON on the night of 09/24/21 and an in-person in-service a couple days later. A phone interview was conducted with Nurse #2 on 02/03/22 at 9:31 PM. She stated she came from the 100 Hall looking for Resident #4 on the 200 Hall on the evening of 09/24/21 and she found Resident #4 sitting on the bed in room [ROOM NUMBER]A (Resident 8's room). Nurse #2 told Nurse #1 that Resident #4 was in Resident #8's room. When Nurse #1 told Nurse #2 that she had administered Resident #8's medication to Resident #4, Nurse #2 stated she called the DON immediately and was told to instruct Nurse #1 to stay off the medication cart. Then, she checked the medication administration records to find out what medications had been administered to Resident #4 in error. She recalled Resident #4 had never become unresponsive but was lethargic before the EMS arrived. EMS report dated 09/24/21 indicated a call was received from the facility at 11:14 PM and the EMS arrived at the facility at 11:19 PM. Upon arrival to the scene at 11:22 PM, Resident #4 was found lying semi-fowlers (between 30 to 45 degrees) in the bed unconscious and unresponsive. Initial assessment of Resident #4 revealed she had a Glasgow Coma Scale (GCS) of 3. The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses. A person's GCS score could range from 3 (unresponsive) to 15 (responsive). At 11:29 PM, Resident #4's BP was 71/45 and HR was 59. IVF resuscitation with normal saline (NS) was initiated at 11:31 PM. At 11:34 PM, Resident #4's BP and HR dropped to 70/44 and 55 respectively. The BP was rebounded to 98/68 at 11:44 PM after administration of the bolus IVF with NS. The EMS departed the facility with Resident #4 at 11:35 PM and arrived at the hospital at 11:43 PM. ER report dated 09/25/21 indicated Resident #4 was brought into the ER from a skilled nursing facility as she was noted to be unresponsive and apparently given the wrong medications. About one and a half hours after receiving the wrong medications, Resident #4 was found unresponsive, bradycardic (pulse lower than 60 beats per minute), and hypotensive (BP lower than 90/60). Upon EMS arrival to the facility, Resident #4 was noted to have a GCS of 3-4, BP 70/40, and HR in the low 50s. Upon arrival to ER, Resident #4's BS at 11:57 PM was 91 mg/dl. IVF resuscitation was initiated. Per the hospital discharge summary dated 10/01/21, Resident #4 was sent toER on [DATE] for AMS due to a medication error at the facility. She was admitted to the hospital on 09/26/21 and discharged on [DATE]. While in the ER, Resident #4's BS was back to normal, BP was stabilized, and her AMS was improved. Resident #4 was admitted to the hospital for further evaluation to ensure her mental status was back to the baseline. An interview was conducted with the DON on 02/03/22 at 9:28 AM. While referring to the medication variance report, the DON stated she received a call the evening of 09/24/21 from Nurse #2 who stated that Nurse #1 had given Resident #4 medications prescribed for Resident #8. She asked Nurse #2 the status of Resident #4 and was told Resident #4 was alert but tired, and ready to go to sleep. She ordered Nurse #1 to check the BS level for Resident #4 and the results were 144 mg/dl. Nurse #1 also checked Resident #4's VS which were BP 90/60, HR 68, T 97.6 F, and RR 16. She instructed Nurse #1 to call the on-call physician while Nurse #2 stayed with Resident #4. The on-call physician ordered to send Resident #4 to ER for evaluation. The last set of VS checked by Nurse #1 for Resident #4 before the EMS arrived were BP 80/58, HR 66, T 97.6 F, and RR 16. She stated Resident #4 had never been unresponsive while in the facility after the medication error incident on 09/24/21. The DON stated Resident #4 stayed alert and verbal even after the EMS arrived. During a phone interview with Resident #4's RP on 02/02/22 at 12:43 PM, she stated Resident #4 was not a diabetic and she became unconscious after receiving medications, which included insulin, that were not prescribed for her. During an interview with the NP on 02/03/22 at 10:16 AM, he stated the long acting [MEDICATION(S)] could drop Resident #4's BS drastically, the [MEDICATION(S)] could drop her BP to an extent, and the [MEDICATION(S)] and [MEDICATION(S)] could make Resident #4 sedated. A phone interview was conducted with the MD on 02/03/22 at 1:49 PM. He denied there were any long-term clinical impacts of insulin to Resident #4 as it would be eliminated out of her system in a few hours due to her weight. He stated Resident #4's BP of 70/40 was critically low, but denied it was directly related to those wrong medications. The MD indicated [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] could lower Resident #4's BP but not to a critical level in his opinion. The rest of the medications which included [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)] would only make Resident #4 sedated without causing any long-term clinical impacts. The MD added Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #4 in EMS or ER could mimic her [CONDITION(S)]. He would expect Resident #4 to be drowsy from the wrong medications but not unresponsive. The Administrator was notified of Immediate Jeopardy on 2/4/22 at 11:57 AM. The facility provided the following corrective action plan with a completion date of 10/02/21. On 9/24/21 at 9:30 PM, Nurse #1 entered room [ROOM NUMBER]A and found Resident #4 in the bed. Nurse #1 called Resident #8's name and Resident #4 answered to Resident #8's name and engaged in conversation with Nurse #1. Due to Resident #4 responding to the name of Resident #8, Nurse #1 administered the medications. At 10:10 PM, Nurse # 2 identified the error. At 10:20 PM, Nurse #2 called DON to notify her of the medication error and DON directed Nurse #1 to take vital signs and blood sugar and give snacks with juice. DON instructed Nurse #1 to call the on-call MD while Nurse #2 stayed with Resident #4. Order received from on call to send Resident #4 to emergency room . At 10:45 PM, vital signs taken by Nurse #1 and EMS arrived. DON told Nurse #2 to cover medication cart for Nurse #1. Nurse #1 was immediately in-serviced via telephone on 09/24/21 by the DON regarding the 6 Rights of Medication Administration. Nurse #1 was removed from the cart immediately following the medication error. Nurse #2 was educated as well. Nurse #1 and # 2 were immediately in-serviced via telephone on 9/24/21 by the DON regarding the 6 Rights of Medication Administration; right person, right drug, right route, right time, right dose and right documentation. Nurse #1 was removed from the cart immediately following the medication error. On 09/24/21 Resident #8 received her medication as ordered at 11:00 PM. Staff education was initiated on medication administration immediately on 09/24/21 including the 6 rights of Medication Administration. This in-service was done via phone by DON on 09/24/21 with all nursing staff on shift at the time. On 09/24/21 Responsible Party was notified at 10:35 PM. Medical Director was notified 09/25/21 via phone. For the residents with the potential to be affected, staff education was initiated on 09/24/21 on medication administration, including the 6 rights of Medication Administration. On 09/27/21, the DON completed in-person in-services on medication administration, all other nurses received her education via telephonic voice message system. No nurses were allowed to work after 09/27/21 until they completed the in-service. All new hires, those on vacation, and those who were as-needed staff were included in the telephonic voice message system in-service. On 09/27/21 100% audit of resident name tags on doors and photos in electronic record system was completed for accuracy. On 09/27/21 alert and oriented residents were interviewed by Regional Operations Manager to ensure they received correct medications. Starting the week of 09/27/21, the DON and Regional Nurse Manager completed a skills checkoff on medication administration for all new hires prior to any nurse conducting a medication pass, this would be ongoing. On 9/30/21, the consultant pharmacist and nurse consultant visited [NAME] Health and Rehabilitation to perform a medication pass audit on 2 nurses. Both nurses observed were immediately corrected and re-educated regarding any errors made during the medication administration assessment. Ad-Hoc Quality Assurance Meeting was held on 10/01/21 to discuss corrective action for the alleged deficient practice. Ad-Hoc meeting was attended by Medical Director via phone, Administrator, Director of Nursing, Regional Operations Manager, Regional Nurse, and Divisional Vice President in-person. Starting 10/01/2021 three nurses would be assessed by the DON or Designee 3 nurses per week for 4 weeks, 1 nurse per week for 4 weeks; 3 nurses randomly for 1 month. Those completed medication pass without error, he or she will be assessed on a random basis going forward. Those with any errors noted during the medication pass assessment would be immediately re-educated by the DON or designee and would continue to be assessed weekly for 4 weeks or until they could pass a medication pass assessment. Medical Records Director would update resident photos as needed. This process would be added to quarterly Quality Assurance. The Interdisciplinary Team would inform Medical Records Director of resident changes that might need photo update to ensure they reflected accurate resident likeness to ensure Resident Identity could be verified. 10 resident name plates would be checked at least weekly for 4 weeks by the Administrator or designee. Daily room rounds would include checking for correct name plate on door. Consultant pharmacist would complete random medication pass audits monthly during routine visits. This corrective action would be monitored by our quality assurance committee; however, any immediate or unanticipated adjustments that were deemed necessary to protect residents would be discussed in the morning meeting where the Administrator, DON and other facility leadership would be in attendance. This plan would also be revised as needed as a result of ongoing quality assurance discussions. The facility's alleged correction date of 10/02/21 was verified by the following: On 02/04/22, the facility's corrective action plan with correction date of 10/02/21 was validated on-site by record review, observation, and interview with resident and staff. Medication pass was conducted from 02/02/22 through 02/03/22. No concerns related to medication errors were identified. It consisted of 29 medications, 5 different residents, and 3 different nurses. Nurses were seen applying the 6 Rights of medication administration during medication passes. They were observed checking resident's picture in the computer, verifying the name plate at the door, and asking alert-oriented resident open-ended question for resident's name before administering medication. For residents who were nonverbal, nurses referred to another nursing staff to confirm residents identify before administering medication. Interviews with nursing staff from both shifts revealed they had been re-educated per the documentation of in-services provided related to effective identification of the right resident during medication administration. Nurses were knowledgeable about the 6 Rights of medication administration and observed utilizing the pictures, name plate, and open-ended questions or referring to another nursing staff to confirm the identification a resident before administering medication. Interviews with alert and oriented residents revealed nursing staff had been asking open-ended questions for their name before administering medication. The medication records of sample residents were reviewed with focus on medication error. No concerns related to medication errors were identified. Review of in-service records revealed on 09/27/21, the DON completed the in-person in-services on medication administration. All other nurses not in the facility on 09/27/21 received the in-services via telephonic voice message system. The in-service sign-in sheet indicated all 15 nurses had received the re-education on 09/27/21. In addition, 14 new hires or as needed nurses had received the in-service from 10/04/21 through 02/03/22. Review of monitoring tools revealed the management staff had completed audits and monitoring per the audit tools and monitoring documentation provided.

Based on staff interviews and record review, the facility failed to post complete and accurate daily nursing staff data for 13 of 13 days of data reviewed (12/21/21, 12/22/21, 12/24/21, 12/25/21, 12/28/21, 12/29/21, 12/30/21, 12/31/21, 1/5/22, 1/7/22, 1/8/22, 1/16/22 and 1/18/22). The findings included: 1a. A review of daily nurse staffing data sheets revealed the resident census was not recorded on 12/29/21 for the 7A - 7P shift or for the 7P - 7A shift. 1b. A review of daily nurse staffing data sheets for the 7A - 7P shift, revealed licensed and unlicensed nursing staff was not recorded accurately for the following days: ·12/21/21, daily nurse staffing data sheets recorded 5 nursing aides (NA) provided 60 hours of nursing care; staff assignment data recorded 6 NA ·12/22/21, daily nurse staffing data sheets recorded 1 medication aide (MA) provided 12 hours of nursing care; staff assignment data recorded 0 MA ·12/24/21, daily nurse staffing data sheets recorded 4 licensed practical nurses (LPN) provided 44 hours of nursing care; staff assignment data recorded 3 LPN ·12/29/21, daily nurse staffing data sheets recorded 3 LPN provided 36 hours of nursing care; staff assignment data recorded 4 LPN ·1/5/22, daily nurse staffing data sheets recorded 6 NA provided 72 hours of nursing care; staff assignment data recorded 5 NA ·1/7/22, daily nurse staffing data sheets recorded 5 NA provided 60 hours of nursing care; staff assignment data recorded 6 NA ·1/8/22, daily nurse staffing data sheets recorded 1 MA provided 12 hours of nursing care; staff assignment data recorded 2 MA ·1/16/22, daily nurse staffing data sheets recorded 1 MA provided 5 hours of nursing care; staff assignment data recorded 0 MA 1c. A review of daily nurse staffing data sheets for the 7P - 7A shift, revealed licensed and unlicensed nursing staff was not recorded accurately for the following days: ·12/22/21, daily nurse staffing data sheets recorded 4 NA provided 48 hours of nursing care; staff assignment data recorded 5 NA ·12/25/21, daily nurse staffing data sheets recorded 6 NA provided 72 hours of nursing care; staff assignment data recorded 4 NA ·12/28/21, daily nurse staffing data sheets recorded 3 LPN provided 36 hours of nursing care; staff assignment data recorded 4 LPN -12/28/21, daily nurse staffing data sheets recorded 6 NA provided 72 hours of nursing care; staff assignment data recorded 5 NA ·12/29/21, daily nurse staffing data sheets recorded 2 LPN provided 24 hours of nursing care; staff assignment data recorded 3 LPN ·12/30/21, daily nurse staffing data sheets recorded 2 LPN provided 24 hours of nursing care; staff assignment data recorded 4 LPN ·12/30/21, daily nurse staffing data sheets recorded 6 NA provided 72 hours of nursing care; staff assignment data recorded 5 NA ·12/31/21, daily nurse staffing data sheets recorded 0 MA provided nursing care; staff assignment data recorded 1 MA ·12/31/21, daily nurse staffing data sheets recorded 5 NA provided 60 hours of nursing care; staff assignment data recorded 7 NA ·1/5/22, daily nurse staffing data sheets recorded 6 NA provided 72 hours of nursing care; staff assignment data recorded 5 NA ·1/7/22, daily nurse staffing data sheets recorded 3 LPN provided 36 hours of nursing care; staff assignment data recorded 4 LPN ·1/7/22, daily nurse staffing data sheets recorded 0 MA provided nursing care; staff assignment data recorded 1 MA ·1/8/22, daily nurse staffing data sheets recorded 4 NA provided 48 hours of nursing care; staff assignment data recorded 5 NA ·1/18/22, daily nurse staffing data sheets recorded 5 NA provided 60 hours of nursing care; staff assignment data recorded 4 NA An interview with the scheduler occurred on 2/4/22 at 11:41 AM and revealed she recorded the nurse staffing data sheets and posted the sheets in the lobby the first thing each morning, unless she was on leave. She stated she recorded the staff assignment sheets a week in advance and updated the sheets each morning. The scheduler stated she updated the nurse staffing data sheets when there was a change in staffing but could not explain why nurse staffing data sheets were not accurate for 13 of the 13 days reviewed or why the census had not been recorded and posted on 12/29/21. An interview with the director of nursing (DON) occurred on 2/4/22 at 3:55 PM. The DON stated that she expected the scheduler to post accurate staffing data and to reflect the current staffing patterns per the facility's policy. The DON stated that re-education would be provided to the scheduler and any staff who assisted in posting staffing data in the scheduler's absence. An interview with the administrator on 2/4/22 at 6:14 PM revealed she expected the nurse staffing data to be accurately recorded and when posted the data should reflect the current staffing patterns in the facility.

Based on observations, record review and staff interviews, the facility failed to label, and date opened food items stored for use in 1 of 1 walk in refrigerator and 1 of 2 nourishment rooms. Findings included: 1. An observation of the kitchen conducted with the Food Service Supervisor on 06/01/21 at 11:30 AM revealed the following items were not labeled or dated upon opening: a. An undated and unlabeled package of opened sliced turkey breast was observed in the walk-in refrigerator. b. An undated and unlabeled opened plastic bag of lettuce was observed in the walk-in refrigerator. c. An undated and unlabeled opened plastic bag of cheese cubes was observed in the walk-in refrigerator. 2. An observation of the kitchen on 06/03/21 at 9:30 AM conducted with the Food Service Supervisor revealed the following items observed in the walk-in refrigerator were not labeled or dated upon opening: a. An undated and unlabeled opened plastic container of strawberries. b. An undated and unlabeled opened plastic bag of hard, boiled eggs. c. An undated and unlabeled opened plastic bag of grapes. 3. An observation of the nourishment room on 06/03/21 at 10:15 AM on the 200-hall revealed two undated and unlabeled opened plastic bottles of lemonade located in the refrigerator. Review of the facility policy titled Outside food for patients states items brought in by family must be labeled and dated with the patient's name, room number and use by date. An interview was conducted with the wound nurse on 06/03/21 at 10:17 AM. The wound nurse stated the lemonade must belong to a resident. The wound nurse further stated items brought into the facility for residents must be labeled with the resident's name and date. An interview conducted with the Food Service Supervisor on 06/03/21 at 03:40 PM revealed the staff member that opened the food item was responsible for putting the open date and use by date on the item. The Food Service Supervisor further stated only staff have access to the nourishment rooms, and she has a sign on the refrigerator in each nourishment room alerting staff to label and date all resident items. An interview with the Administrator on 06/03/21 at 03:50 PM revealed it was her expectation that the food and beverage items be labeled and dated upon opening.

Based on observations, record review and interviews with staff, pharmacy and construction workers the facility failed to follow The Centers for Disease Control (CDC) guidelines for personal protective equipment (PPE) with Enhanced Droplet Precautions (EDP) in 3 of 6 staff/construction workers observed and failed to wear masks that covered the mouth and nose in 3 of 10 staff/construction workers observed during the COVID-19 pandemic. Findings included 1. An observation was done on 06/01/21 at 12:14 PM of Patient Care Assistant (PCA) #1 on the 100 hall. PCA #1's mask was below the nose for several minutes when she was talking at the desk. She would adjust the mask at times over her nose and it would slide down again. Construction Worker #1 was observed on 06/01/21 at 12:34 PM working on the 100 hall outside of occupied resident's rooms laying new tile with his mask below his nose. An observation was done of Construction Worker #2 in the dining room hallway on 06/03/21 at 11:00 AM with the mask consistently below his nose as he was putting down new tile in the area. Several staff and residents were passing him in the hallway. A phone interview was done with Construction Supervisor #1 on 06/04/21 at 12:30 PM regarding the masks not being worn/worn covering the nose by the construction staff. He stated he had a surgical mask on 06/01/21 and went down the Enhanced Droplet Precautions (EDP) admission hall for supplies with Construction Worker #1. He stated Construction Worker #1 should have had a mask on and his staff should have worn masks covering their nose consistently. He noted education had been done for him and his staff about wearing appropriate Personal Protective Equipment (PPE) and for masks on all construction workers to cover the mouth and nose this week. An interview was conducted with PCA #1 on 06/01/21 at 12:17 PM regarding the mask protocol. She said the mask should be over her mouth and nose, but it kept falling below her nose when she was talking. An interview was completed on 06/04/21 at 10:39 AM with the Unit Manager regarding PPE for the admission hall and masks protocol. She stated if a resident was down the quarantine admission hallway, anyone entering the hall were to wear full PPE with the delivery of trays or construction workers entering for supplies per the EDP posted sign. When asked about staff with masks below their nose, she stated they were to be worn above the nose and staff had constant reminders to pull the masks up. An interview was done with the Corporate Nurse, former Director of Nursing (DON) in role through May 2021, and the current DON (in role for 1 week) on 06/03/21 at 3:25 PM. They were informed of the 2 construction workers-1 without a mask and 1 with a surgical mask in the EDP hall and the staff with the mask not covering the nose. The Corporate Nurse stated construction workers were to follow the same protocol as staff and always wear their mask and goggles when on the EDP unit and all masks were to cover the mouth and nose. 2. An observation was done on 06/01/21 at 11:50 AM of Construction Worker #1 and Construction Supervisor #1 walking in the Enhanced Droplet Precaution (EDP) hall for new unvaccinated admissions without a gown, N95 mask or gloves. One resident was on the hallway at the time with the door open. An observation of PCA #1 was conducted on 06/01/21 at 12:44 PM taking a lunch tray into the admission hallway with a surgical mask on. The sign on the hallway door for EDP required a gown, gloves, face shield and N95 mask if entering the resident's room. A phone interview was done with Construction Supervisor #1 on 06/04/21 at 12:30 PM regarding the Personal Protective Equipment (PPE) worn by the construction staff. He stated he had a surgical mask on 06/01/21 and went down the EDP admission hall for supplies. He said he was not aware of the requirements as when they first surveyed the hall, there were no residents down that hall and there was no isolation on the hall. He noted education had been done for him and his staff about wearing appropriate PPE, reading the signs and for masks on all construction workers to cover the mouth and nose this week. Patient Care Assistant (PCA) #1 was interviewed on 06/01/21 at 12:45 PM regarding the Enhanced Droplet Precaution signage and the required PPE for that hallway. She stated that when they just took a tray into the resident's room, they did not need to wear the other PPE. An interview was done with the Corporate Nurse, former Director of Nursing (DON) in role through May 2021, and the current DON (in role since 5/24/21) on 06/03/21 at 3:25 PM. They were informed of the 2 construction workers, one without a mask and one with a surgical mask in the EDP hall with no additional PPE. The Corporate Nurse and the current DON stated construction workers and all personnel were to wear N95 masks, gown and gloves on the EDP admission hall and have eye protection when going into resident's room on the admission hall. An interview was conducted with the Administrator on 06/01/21 at 11:56 AM regarding Construction Worker #1 without a mask and the Construction Supervisor #1 with a surgical mask both walking down the admission hallway. The admission hall had the door closed with an Enhanced Droplet Precautions (EDP) sign on the door. The Administrator stated the hallway led to the rooms of the unvaccinated or partially vaccinated new admissions that were in quarantine for 14 days. She stated they should have been in full PPE, but they had not been in resident's rooms. The Administrator said they should have been in full PPE per the EDP signage which included a gown, gloves and N95 mask, and if they had been in resident's room to have face protection. There was one new admission on the hallway at the time. A follow-up interview was conducted with the Administrator on 06/01/21 at 3:52 PM regarding the masks not being worn by the construction staff, staff's mask slipping below the nose, and the EDP PPE not being worn per the CDC guidelines. She said staff and construction workers should wear surgical masks over their mouth and nose. The former DON was interviewed via phone on 06/04/21 at 12:15 PM and she stated she had been the Infection Prevention nurse until 2 weeks ago. She stated inservices had been completed previously, and that week for staff regarding masks covering the mouth and nose at all times, and the appropriate PPE with new admissions in EDP. She noted staff that entered the hallway were to wear the N95, gown, gloves and in addition, eye protection if going in the room. She said this included when meal trays were taken to a resident. An interview was conducted with the Administrator and the current DON on 06/04/21 at 1:13 PM regarding infection control findings. The Administrator and DON both stated the expectation for masks and Enhanced Droplet Precautions is that staff and construction workers followed the signage on the room doors and the hallway door and wore the appropriate masks and PPE, and all masks were to worn above the nose.

Based on observation, record review and interviews with staff, pharmacy and physician the facility failed to ensure an intravenous (IV) medication was prepared utilizing sterile technique in 1 of 1 intravenous antibiotic medication administration observed (Resident #29). Findings included: Resident #29 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Record indicated [MEDICATION(S)] 1 Gram every 6 hours was ordered IV on 5/28/21 for [CONDITION(S)]. An observation was completed with Nurse #1 on 06/03/21 at 12:02 PM as she was mixing an IV antibiotic for Resident #29. She removed the 100 milliliter (ml) normal saline solution (NSS) bag from the sterile packaging and placed it on top of the medication cart. The nurse diluted the antibiotic vial with 10 ml NSS after wiping the antibiotic vial top with alcohol. She wrote a medication label with the dose, date and time and turned the NSS bag over on top of the medication cart and applied the label. Nurse #1 turned the NSS bag over again and instilled the 5 ml dose in two increments of 2 ml and 3 ml, utilizing a 3 ml syringe into the port of the 100 ml bag and failed to disinfect the port with alcohol both times. An interview was conducted with Nurse #1 on 06/03/21 at 12:10 PM and she was asked why she had not disinfected the instillation port of the 100 ml NSS bag. She stated she did not know that she needed to do that. A phone interview was conducted on 06/04/21 at 11:36 AM with the Pharmacist that covered the facility regarding the process for the IV antibiotic mixture and instillation into the 100 ml NSS bag. He stated that once the NSS bag was removed from the package it was no longer sterile and the nurse should have cleaned the port prior to inserting the syringe into the NSS bag each time. He also noted that the nurse should have used the proper syringe size to ensure she would not have to reenter the NSS bag a second time. An interview was conducted with the Medical Director on 06/04/21 at 1:05 PM regarding the IV antibiotic medication instillation into the NSS bag without disinfecting the port. He stated the medication should have been mixed properly under sterile technique and the nurse should have ensured that no cross contamination occurred. The former DON was interviewed via phone on 06/04/21 at 12:15 PM and she stated she had been the Infection Prevention nurse until 2 weeks ago. She said that when IV antibiotics were mixed and instilled into the NSS bags, the nurse should wipe the port off prior to injecting the medications. An interview was conducted with the Administrator and the current DON (in the DON role since 5/24/21) on 06/04/21 at 1:13 PM regarding the technique used for the intravenous antibiotic medication when it was instilled into the 100 ml NSS bag. The DON noted that the port of the NSS bag should have been disinfected prior to insertion of the IV antibiotic medication and sterile technique followed.

Based on record review, legal guardian interview, facility staff and hospital staff interviews, the facility failed to communicate Resident #1's guardianship status to the hospital and failed to arrange for a supervised transfer and handoff of Resident #1 who was deemed incompetent and had a legal guardian. The nursing home provided confidential guardianship information to a contracted van driver in a sealed envelope. The van driver reportedly provided the sealed envelope to hospital staff and left the resident alone at the hospital. Hospital staff denied receiving any resident documentation in written, scanned, or telephonic format. This was evident for 1 of 3 residents reviewed for hospital discharges and transfers. Resident #1 exhibited behaviors at the hospital, stated he wanted to leave and left after registration and before triage. The whereabouts of Resident #1 were unknown for four days. On 1/11/21, the police located Resident #1 and he was returned to the hospital where he was found medically stable and was involuntarily committed. Immediate Jeopardy (IJ) began on 01/07/2021 when Resident #1, who was deemed incompetent, was discharged from the facility to a hospital and the facility failed to provide or arrange for the resident to be supervised when he was transported to the hospital. This resulted in Resident #1 exiting the hospital while unsupervised and his whereabouts being unknown for the next four days. IJ was removed on 01/16/2021 when the facility implemented a credible allegation (CA) of Immediate Jeopardy (IJ) removal. The facility remains out of compliance at a lower scope and severity of D (no actual harm with the potential for more than minimal harm that is not IJ) to ensure monitoring systems in place are effective. Findings included: Resident #1 was admitted to the facility on [DATE] and was under the guardianship of the Mecklenburg County Department of Social Services. Resident #1 had medical [DIAGNOSES REDACTED]. Review of Resident #1's medical record revealed guardianship documentation which appointed Mecklenburg County Department of Social Services as being responsible for the resident's emergency medical treatment and authorization to consent to emergency medical care for Resident #1, Mecklenburg county ward. The form was signed by the facility's administrator on 11/20/20. Resident #1's quarterly Minimum Data Set ((MDS) dated [DATE] identified him as being cognitively intact. The MDS also indicated he had verbal behavior symptoms directed towards others, feeling depressed, difficulty falling asleep and staying asleep, loss of appetite, feeling bad about self or thoughts of hurting self, occasional incontinence of urine, frequent incontinence of bowel, a stage 2 pressure ulcer. Record review of a progress note dated 12/28/20 written by the psychiatric Nurse Practitioner (NP) dated 12/28/20 revealed NP visit with Resident #1, chief complaint/nature of presenting problem was depression and verbal aggression toward staff. NP noted Resident #1 was angry, demanding and acknowledged he threatened to hurt staff. NP also noted Resident #1 stated he wanted to leave facility and stated, I will do what I have to do to get out of here. Visit note indicated Resident #1 verbalized a desire to leave facility and go to men's shelter. NP noted information regarding Resident #1's request was verbalized to administrative staff. Resident #1's care plan updated on 1/4/21 included focus areas for nutritional risk, hypo/[MEDICAL CONDITION] episodes related to DM2, potential for decreased cardiac output related [MEDICAL CONDITION], hypertension (HTN), and [MEDICAL CONDITION] (CAD), assistance for all activities of daily living related to impaired mobility, history of shortness of breath related to respiratory disease, risk for falls and fall related injuries, pain management and monitoring related to muscle weakness, [MEDICAL CONDITION], bilateral above knee amputation, and pressure ulcer related to impaired mobility stage 2 located on the sacrum. Resident #1's care plan also included focus areas for mood state (feeling tired and having little energy, trouble concentration, feeling down and depressed, thoughts that he would rather be dead) and manipulative-attention seeking-demanding behaviors and a long time smoker in a smoke free facility. Record review of a progress note written by the Administrator dated 1/7/21 at 4:12 PM for Resident #1 revealed he had smoked at the facility in non-smoking areas. Resident #1 was redirected by facility staff and he continued to demonstrate noncompliance with smoking restriction, verbalized foul language and made verbal threats to others. Further review of Resident #1's progress notes dated 1/7/21 at 8:45PM, the Administrator noted per Resident #1's request and responsible party notification, he was discharged to the hospital and his personal belongings were sent with him via transportation services. An interview was conducted with the Administrator on 1/12/2021 at 11:12AM. The Administrator stated he contacted Resident #1's guardian and reported verbal threatening behaviors towards others by Resident #1 on 1/7/21 and his desire to leave the facility. The Administrator reported Resident #1's guardian was not in agreement for Resident #1 to be discharged to the community, therefore, Resident #1 would be discharged from the facility and transferred to the hospital ED (Emergency Department) for medical evaluation and clearance for a possible psychiatric admission. The Administrator reported Resident #1's guardian was agreeable with the discharge and hospital transfer. The Administrator reported no written notice of discharge was given to Resident #1 or his legal guardian on 1/7/21. A phone interview was conducted with Resident #1's Guardian on 1/12/21 at 10:21AM. The Guardian stated he was contacted by the Administrator on 1/7/21 regarding Resident #1's refusal to comply with the facility's non-smoking policy, his desire to leave the facility and verbal threats towards others at the facility. The Guardian reported options were discussed with the Administrator based on Resident #1's request to leave the facility. Resident #1 stated he wanted to leave the facility and go to an extended stay hotel; however, the Guardian was not in agreement with Resident #1 going into the community. The Guardian stated he was later notified by the Administrator that a facility provider gave orders for Resident #1 to be transferred to a hospital ED for a focused medical assessment, psychiatric consult, and possible admission. The Guardian agreed to the hospital transfer and discharge from the facility. During an interview with the facility's psychiatric NP on 1/12/21 at 2:45PM, she stated the facility's Administrator contacted her 1/7/21 regarding Resident #1's safety in the in the community because he was requesting to leave the facility and go to an extended stay hotel. The psychiatric NP stated she had short visits with Resident #1, however, based on his history he could be impulsive and facility staff should be responsive to his threats towards others. An interview conducted with the facility's Nurse Practitioner (NP) on 1/12/21 at 12:45PM revealed he was contacted by the administrator on 1/7/21 regarding Resident #1's behaviors of noncompliance with smoking restrictions, verbal threats towards staff and a desire to leave the facility. The NP also stated the Administrator informed him that he had spoken to Resident #1's Guardian regarding his behaviors. The NP reported he was only aware of a psychiatric unit located in another county and gave a verbal telephone order for transfer to their ED for evaluation and psychiatric consultation. Resident #1's electronic physician orders [REDACTED]. · Discharge to behavioral health hospital dated 1/07/2021 at 4:20 PM Resident #1's medication orders at discharge on 1/07/2021 included; [MEDICATION NAME] 10 milligram (mg) daily for HTN, Atorvastatin 80 mg at bedtime for [MEDICAL CONDITION], Carvedilol 25 mg twice a day for HTN, [MEDICATION NAME] 75 mg daily for cerebral infarction, [MEDICATION NAME] 10 units daily for DM2, [MEDICATION NAME] 40 mg daily for HTN, [MEDICATION NAME] 500 mg twice a day for DM2, [MEDICATION NAME] (sliding scale) before meals and at bedtime for DM2, [MEDICATION NAME] 150 mg daily for major [MEDICAL CONDITION], [MEDICATION NAME] 20 mg daily for [MEDICAL CONDITION], and [MEDICATION NAME] 5 mg daily for DM2. On 1/12/21 at 2:29PM during an interview with Nurse #1, she reported that on 01/07/21 she was informed by the Administrator, Resident #1 was transferring to the ED and she prepared the discharge summary for Resident #1. A follow up interview with the Administrator was conducted on 1/12/2021 at 1:21PM. He stated that on 01/07/21 he notified a nurse in the hospital ED via telephone call of Resident #1 being transported for evaluation. He stated he also notified staff in the ED; Resident #1 had a guardian in place with Mecklenburg Department of Social Services (DSS). The Administrator was not able to recall the name of the nurse in the ED he gave the report of the transfer. The Administrator communicated the following information was sent with Resident #1 in a sealed envelope via the transportation service: · Facility face sheet · Guardianship documentation · Continuity of care information inclusive of medication list, diagnoses, allergies [REDACTED]. The Administrator explained he gave a sealed envelope containing these documents to the van driver of a contracted company. The Administrator stated he gave the driver instructions to hand over the documents to the hospital staff upon arrival to the ED. Additional information was provided by the Administrator on 1/15/21 at 3:54PM via a telephone interview. The Administrator stated Resident #1 was transported by a van owned by a contracted company with the facility. The Administrator also reported facility staff had not accompanied Resident #1 to the ED. An interview was completed with the Van Driver on 1/12/21 at 1:25PM. During the interview, the driver stated he received a call to transport a resident from the facility to the ED in another county. He reported upon his arrival, the Van Driver was told by the Administrator the hospital had been notified of Resident #1's need for an evaluation in the ED. The Van Driver stated he was given a sealed envelope and was told by the Administrator to give the envelope to hospital staff in the ED. The Driver also stated he was not told by the Administrator he had to stay with Resident #1 until he was seen by the ED staff. The Driver reported the Administrator informed him that he would place another call to notify the ED of their time of departure from the facility. The Driver described what took place on arrival to the ED by stating he and Resident #1 went through the COVID screening process, then on to the registration desk. The Driver reported Resident #1 became upset when hospital staff told him he had to change to a new mask, but he complied. The Driver inquired if he could place Resident #1's belongings on a cart while Resident #1 spoke with hospital staff at the registration desk. The Driver was asked by hospital staff if Resident #1 was a direct admit and he responded by stating the facility Administrator indicated the hospital had been notified of the transfer. The driver reported he gave the sealed envelope to hospital staff (not sure of staff's role). The Driver stated that he was told he could leave after Resident #1 completed registration. By his report, the driver stayed until he was told by ED staff he could leave when Resident #1 completed registration. An interview was conducted with the Emergency Department (ED) nurse manager on 1/13/21 at 1:38PM. She reported no record of a pre-arrival form or emergency staff reporting a call had been received on 1/07/2021 regarding Resident #1 being transported from a long-term care facility for evaluation in the ED. The ED nurse manager stated Resident #1 had registered and received a hospital name badge but was not triaged by clinical staff. She also reported no documents had been scanned in Resident #1's medical records from facility. On 1/14/21 at 4:45PM, an interview was conducted with the ED day shift (7:00 AM to 7:00 PM) charge nurse who worked on 1/07/2021. She could not recall receiving a call from a Mecklenburg County facility regarding Resident #1 coming to the ED for a medical evaluation. The ED charge nurse also stated she was not informed by any staff in the ED on 1/07/2021, Resident #1 was coming for an evaluation. An interview was completed with a registration ED Clinician I who worked on 1/07/2021. The interview was conducted on 1/14/21 at 3:36PM. The registration Clinician I stated she completed the registration process with Resident #1 who provided information regarding his identity, date of birth, and purpose for visit. The registration Clinician I stated Resident #1 began to yell and use profanity during the registration process. The registration Clinician I also reported Resident #1 stated he did not want to stay in the ED. The registration Clinician I stated no documents were given to her for Resident #1 and he left without being seen in triage. An interview with the ED night shift charge nurse (7:00 PM to 7:00 AM) on 1/14/21 at 4:31PM revealed she received no report during change of shift that Resident #1 was due to arrive in the ED. She further stated she did not receive a call from a facility in another county that Resident #1 was being transported to the ED for a medical evaluation. The night ED charge nurse on night shift stated she was told by staff in registration of a male patient that arrived via transportation service to be seen in the ED, but he began to scream obscenities and wanted to smoke. The night ED charge nurse stated the ED was very busy and when she was able to inquire about the patient's whereabouts, staff informed her he left without being triaged. The ED night nurse was not told by the registration staff the name of the male patient who had left the ED. During an interview with the Administrator on 1/12/2021 at 1:21PM, the Administrator stated on 1/8/21 he contacted the hospital ED to follow up with Resident #1's medical evaluation and he was told that Resident #1 left the hospital without being seen by the ED physician. A follow up interview with the Guardian on 1/15/21 at 3:48PM revealed he was aware Resident #1 had a credit card and money on his person when he left the hospital on [DATE]. The Guardian stated Resident #1 reported he had no medications, and that he purchased food and paid for lodging after leaving the ED on 1/7/21. On 1/19/21 at 2:05PM during an interview with Resident #1's Guardian, he reported he contacted the hospital on [DATE] and was informed Resident #1 had not been admitted on [DATE]. The Guardian stated he placed a missing person report on 1/8/21, and a senior alert on 1/9/21 as well as involuntary commitment. The Guardian reported the police were able to view footage at the hospital that showed Resident #1 leaving in a van on 1/7/21. He also reported after leaving the hospital, Resident #1 was residing in an extended stay hotel until picked up and taken to the hospital on involuntary commitment on 1/11/21. The first time the guardian spoke with Resident #1 was after his admission to the hospital on [DATE]. Review of hospital medical record for Resident #1 dated 1/11/21 revealed he presented to the ED under involuntary commitment. He was seen by the medical team and was noted to be medically stable. laboratory results dated [DATE] at 7:46 AM for Resident #1's identified an elevated blood glucose level of 305 milligrams per deciliter. The facility's Administrator was notified of the immediate jeopardy on 1/16/21 at 10:00 AM. The facility provided an acceptable credible allegation of immediate jeopardy removal which included: Mecklenburg Health and Rehabilitation Credible Allegation January 16, 2021 Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident #1 has suffered, or was likely to suffer, a serious adverse outcome as a result of the noncompliance. Resident was at risk for serious harm because he was not accompanied by staff member or legal guardian to ensure proper transfer of custody. Resident #1's departure from the emergency room created a potential for serious harm or decline in physical or mental condition. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome as a result of the noncompliance. On January 16, 2021 Regional Reimbursement Manager completed a review of all active residents' electronic medical records for documentation of resident competency. Any resident who has been legally deemed incompetent will be accompanied by a facility employee to outside appointments. The facility employee will obtain written acknowledgement from the receiving entity that the resident has been placed in their custody. No other resident was identified as legally incompetent. If a resident is newly admitted and is legally incompetent or if a current resident becomes legally incompetent, facility will place a file at each nurses' station and reception desk listing the face sheets of those residents that are deemed legally incompetent. Personnel responsible for new admissions were notified of this responsibility on Saturday, January 16th through a telephone in-service. The written acknowledgement is a facility generated form. On January 16, 2021, all employees, including licensed and unlicensed employees and therapists were in-serviced by the Regional Clinical Manager, Regional Operations Manager, and Administrator that legally deemed incompetent residents will be accompanied by a facility employee to outside appointments and that a file will be kept at each nurses' station and reception desk listing the face sheets of those residents that are deemed legally incompetent. No employees will be allowed to work until this in-service is received. Administrator, Director of Nursing Services, or Department Supervisor will notify employees in advance of an appointment for a resident who is legally incompetent and who must be accompanied by a facility employee to the outside appointment. All facility personnel have been in-serviced by the Administrator on January 16, 2021 on the new procedures related to accompanying legally incompetent residents to an outside appointment. In the event an employee must accompany a legally incompetent resident, Administrator of Director of Nursing will provide one-on-one instruction prior to the appointment that is resident specific. This employee training will contain the following information: Meet transportation driver and resident at appointment entity/location; Accompany driver and resident to the entity/location's reception desk; Remain with resident until you receive the signed acknowledgement from the entity/location confirming the resident has completed the registration process and the entity/location assumes custody of the resident; Give the signed form to the facility's receptionist when you return to the facility. Administrator is notified by receptionist of each upcoming appointment. Receptionist receives completed form the receiving entity and files it in a binder. Receptionist reviews form for completion and will notify Administrator or Director of Nursing of any discrepancy. The form is then scanned uploaded in the resident's medical record. This plan does include ER visits via private transportation. The facility alleges the immediate jeopardy was removed on January 16, 2021. On 01/19/21, the facility's credible allegation of immediate jeopardy removal was validated by review of documentation regarding staff training of residents deemed incompetent with outside appointments. Staff interviews revealed receipt of training related to legally deemed incompetent residents will be accompanied by a facility employee to outside appointments. The facility's date of IJ removal of 01/16/21 was validated.

Based on observation, record review, physician, and staff interviews the facility failed to provide training to 3 of 4 facility nurses (Nurse #2, and Nurse #3) on how to disinfect a glucometer (a device used to test glucose level in the blood) that was shared among 5 residents and on how to dispose of a used sample test strip (Nurse #1) to avoid cross contamination of the residents' environment and to prevent disease transmission. The failed practice had the potential to affect 6 of 30 residents who had physician ordered blood glucose monitoring in the facility by exposing the residents to the risk for cross-contamination of potential bloodborne pathogens (Resident #47, Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). Immediate Jeopardy began on [DATE] when lack of training resulted in Nurse #1 transporting a blood sample test strip used on Resident #36 during blood glucose monitoring in his right scrub top pocket commingled with clean and dirty supplies that included a nebulizer treatment that would be later administered to Resident #47. On a separate medication pass observation Nurse #2 was observed not disinfecting a shared glucometer after each use to collect blood samples for blood glucose readings from 5 residents (Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). Immediate jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (pattern with no actual harm with potential of more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to disinfecting glucometers, transporting supplies exposed to blood, and preventing transmission of bloodborne pathogens. The findings included: A review of a facility policy for Exposure Control Policies and Procedures dated [DATE], titled, Training Records read in part, 1. The Health and Rehabilitation Center maintains records which include the following information: a. Names of Employees b. Dates of the training sessions c. Contents or a summary of the training session d. Names and qualifications of persons conducting the training e. Names and job titles of all persons attending 2. Bloodborne Pathogens Orientation Acknowledgement and the Employee Record of annual Administration (OSHA) Medical record which is maintained as confidential by the Staff Development Coordinator. 3. All Health and Rehabilitation Center training records regarding bloodborne pathogens are available upon request to employees, employee representatives, the Assistant Secretary, and the Director of OSHA, for examination and copying in accordance with 29 CFR 1910.20. A review of a facility policy for Patient Care Equipment dated [DATE], Section 13, titled, Glucometers read in part, Clean the outside of the meter using a lint-free cloth. Clean in accordance with manufacturer's recommendation. A review of the manufacturer's guidelines noted in the User Instruction Manual revised on ,[DATE], titled, Maintenance, Cleaning and Disinfecting Guidelines read in part, Healthcare professionals should wear gloves when cleaning the meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. A review of the PDI Sani Cloth Bleach Germicidal Disposable Wipe manufacturer guidelines read in part, to disinfect: unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full 4 minutes. Use an additional wipe(s) if needed to assure continuous 4 minute wet contact time. A review of a facility policy for Handwashing Requirements dated [DATE], Section A, titled, Hand Hygiene read in part, situations that require hand hygiene: before and after performing any invasive procedure (e.g. fingerstick blood sampling). A review of a facility policy for Infection Control Policies and procedures dated [DATE], Section C, 2., read in part, Unit Managers assure that staff follows infection control procedures to maintain patient safety. Section C, 6., Equipment will be disposed of or properly disinfected. An observation on [DATE] at 9:00am on Hall 200 for cart #2 revealed Nurse #1 placed a nebulizer treatment for [REDACTED]. On [DATE] at 9:01am Nurse #1 was observed to gather alcohol wipes, gloves, a lancet, glucometer, insulin syringe, a vial of Humalog (insulin used to treat diabetes), a [MEDICATION NAME] (insulin), and pen needle and then placed the supplies in his right scrub top pocket. Nurse #1 walked down the hall to Resident #36's room and took out the alcohol wipes, gloves, lancet, glucometer, insulin syringe, vial of Humalog, [MEDICATION NAME] and pen needle. Nurse #1 then placed the supplies on the dresser for Resident #36. Nurse #1 collected a blood sample to test the blood glucose from the resident's forefinger. He then squeezed the drop of blood onto blood glucose test strip. The glucometer read the blood glucose to be 282. Resident #36 asked what was his blood sugar and Nurse#1 stated, I'm sorry I need to get another [MEDICATION NAME] since I do not have enough in the [MEDICATION NAME] I brought. Nurse #1 then gathered the used gloves, the clean gloves, used test strip with the blood drop, the used lancet, alcohol wipes, gloves, the dirty glucometer, insulin syringe, vial for Humalog, [MEDICATION NAME], and pen needle inserted with a cap and put them in his scrub's top pocket. Nurse #1's right scrub top pocket was noted to have 1 ink pen, the second nebulizer treatment for [REDACTED].#36. On [DATE] at 9:20am Nurse#1 was observed as he walked down the hall to room for Resident #47 and then reached into his right pocket to administer the second nebulizer treatment. He placed the nebulizer face mask on to Resident #47 and started the treatment using the second medication. An interview with Nurse #1 on [DATE] at 9:35am revealed there was no one to ask for help when needed. He stated he had received no job training before his first shift when he was assigned to a medication cart. Nurse #1 explained Nurse #4 who no longer worked at the facility, pulled the medications and he had administered the medications to the residents during his first shift in the facility. An interview on [DATE] at 3:27pm with the Administrator was conducted. The Administrator revealed Nurse#1 had received orientation training by the Staff Development Coordinator (SDC) and had received ongoing training on time management and consolidating methods to use during a medication pass. The Administrator was unable to provide any evidence of specific training given to Nurse #1. During observations on [DATE] between 4:48pm to 5:12pm of a medication pass with Nurse #2, Nurse #2 was observed not disinfecting a shared glucometer, changing her gloves but not washing her hands between glove changes for 5 residents (Resident #73, Resident #72, Resident #67, Resident #74, and Resident #223). During an interview on [DATE] at 5:10pm, Nurse#2 was asked if she had been washing her hands in between removing gloves and placing new gloves on. Nurse #2 stated no, she had been so nervous that she had forgotten. She explained she knew how essential it was to wash her hands when taking off gloves to put on new gloves. She then sanitized her hands with the hand gel stored on top of her medication cart. During an observation on [DATE] at 5:18pm, Nurse #2 was observed asking Nurse#3 how the shared glucometer was to be disinfected. Nurse #3 instructed Nurse #2 to disinfect the glucometer with an alcohol wipe for 2 minutes. Nurse #2 walked back to her cart, found alcohol wipes and wiped the used glucometer. During an observation on [DATE] at 5:27pm, Nurse #2 walked to the office by the nurse's station on Hall 100 and asked the Director of Nursing (DON) and UM #1 how to disinfect a shared glucometer. Both the DON and UM#1 instructed Nurse #2 to use a sani wipe for 2 minutes and together walked back to the cart with Nurse #2 to assist. During an observation on [DATE] at 5:27pm, UM#1 and the DON were observed educating Nurse #2 on how to disinfect the glucometer. The observed instructions given by the DON and UM #1 to Nurse #2 was to wipe the glucometer off for 2 minutes with a PDI (PDI Sani Cloth Bleach Germicidal Disposable Wipe) wipe, then air dry for 1 minute, then dry off any leftover chemical on the device and to follow the steps after every use of the shared glucometer. An interview on [DATE] at 5:35pm with Nurse#2 revealed she had never been told how to disinfect a glucometer and had not received formal orientation. Nurse #2 explained, since she had worked at the facility for the last 3 weeks, she had used alcohol wipes to disinfect the glucometer when it had been available. She explained she had just moved from another state and was taught to disinfect glucometers with alcohol there. An interview on [DATE] at 5:50pm was conducted with the Nurse Consultant who stated the contact time for the PDI wipe was 4 minutes. An interview on [DATE] at 6:13pm after observation of a medication pass with Nurse #3, revealed she had been in-serviced about 15 to 20 minutes ago and was told to use alcohol wipes for 4 minutes now instead of 2 minutes as before to disinfect the glucometers. She stated she had not received formal training and had only worked in the facility for 3 weeks. Nurse #3 indicated the only in-service she had received since working in the facility had been on falls. Nurse #3 explained she had received a Human Resources (HR) employee handbook but nothing about glucometers. During an interview with the Administrator on [DATE] at 7:40pm she revealed Nurse #3 was a return employee to the facility from 1 year ago and had not received formal training. She indicated that Nurse #1, Nurse #2, and Nurse #3 had all received training and should have known how to disinfect the shared glucometers as part of their training. An interview on [DATE] at 9:19am with the facility Medical Director was conducted via the telephone. He stated the breach in infection control due to absence of disinfection of the glucometers in his prospective was absolutely concerning. He explained the risk for cross-contamination was always there. The Medical Director further explained that we may not know if a resident had [MEDICAL CONDITION] or [MEDICAL CONDITION] and mandatory Universal precautions were to be used always. The Medical Director stated the need for training for all nurses including new hires was imperative. He explained the facility needed to set the standards from Day 1 regarding all nursing education including disinfecting glucometers. The Medical Director revealed the SDC (Staff Development Coordinator) who was responsible for educating the staff had left about 2 weeks previous and had given her notice 2 to 3 weeks before her last day. The last 5 to 6 weeks while the SDC worked in the facility, she was pulled to a medication cart due to nurse call-outs sometimes 15 to 20 minutes prior to a shift. At the same time nurses were let go by the facility for not meeting professional standards. It had been a bad time for staffing he explained. The Medical Director revealed the SDC had been physically in the building but could not train staff because she kept getting pulled to a cart. The Medical Director explained a germicidal must be used for a shared glucometer and the only time alcohol would be acceptable was if each resident had their own glucometer and were individually bagged and labeled. An interview on [DATE] at 11:09am with the Corporate Nurse Consultant revealed the facility did not have any signed off education for Nurse #1, Nurse #2, and Nurse #3 for any specific training or orientation records. On [DATE] at 12:20pm the Nurse Consultant provided orientation training acknowledgement related to bloodborne pathogens dated [DATE] and signed by Nurse #2 and the SDC. No documentation could be provided for the training of disinfecting a shared glucometer for Nurse #1, #2, or #3. No evidence of any training for Nurse #3 was provided. An interview on [DATE] at 9:52am with the SDC was conducted via the telephone. The SDC revealed she was on vacation and had planned on returning to the facility in the role of a MDS Coordinator. She indicated glucometer disinfection was taught verbally during the Bloodborne Pathogen PowerPoint on the third day of orientation. Handwashing training was taught during the Bloodborne Pathogen PowerPoint presentation, during infection control, and multiple times during orientation. New hires were given written and verbal education but no return demonstrations were included in the training. The SDC revealed she personally had been on the floor with Nurse #1 and also rounded on him and had never seen Nurse #1 transport a used blood sample test strip in his pocket. The SDC stated she had expected for nurses to take a small sharps container into the room and they should absolutely not put a used test strip in their scrub pocket. She reiterated, Nothing goes in the pocket, the strip goes directly into the sharps container. During the interview the SDC indicated Nurse #2 had received training on bloodborne pathogens but she could not remember who had trained Nurse #3 and believed there had been a scheduling conflict. She stated Nurse #3 did receive orientation to the best of her memory. The SDC stated she expected nurses to wash their hands before putting on new gloves, disinfect the glucometer, and then the nurse should use the second glucometer on the medication cart for the next resident until the 4 minute contact time for the PDI wipes had expired. The SDC explained the new hire nurses received a skills validation form and their preceptor checked the skills off once on the floor. She continued, once the skills validation form was completed the new nurse would bring the form back to the SDC and the SDC would review any competencies unsigned. She revealed new hires received mentors who were considered to be the preceptor on the floor. The SDC explained there were no records on who the new nurse was trained by and the nursing leadership team determined who precepted who based on the schedule and best fit between the nurses. The SDC revealed neither Nurse #2 nor Nurse #3 had been rounded by her because they were new to the facility. An interview on [DATE] at 10:42am with the Nurse Consultant revealed Nurse #4 had been the mentor for Nurse #1, Nurse #5 had been the mentor for Nurse #2, and Nurse #6 had been the mentor for Nurse #3. (The SDC had explained the mentor was considered to be the preceptor for a new hire.) During an interview on [DATE] at 11:07am, the Administrator revealed the Regional Manager had included UM #1 and the DON in the training on [DATE] related to correctly disinfecting the glucometers due to both giving incorrect directions to Nurse #2 on [DATE]. The Administrator indicated she was aware of the facility training policy and explained the nurse turn-over in the facility had been high. She stated the facility needed a solid orientation to be successful. The administrator added that Nurse #2 and Nurse #3 should have been rounded (rounds by the leadership team to ensure nurses provided appropriate care) on by the UM #1. An interview with Nurse #5 on [DATE] at 12:25pm revealed the facility did not have mentors in place and she had only trained Nurse#2 for one shift. Nurse #5 indicated Nurse #2 had not asked her how to disinfect a glucometer and the topic had not been discussed. An interview on [DATE] at 12:32pm with UM #1 revealed she had worked in the facility for 2 months and attended orientation for Day 1 only. She indicated after Day 1 she followed the past DON for a few days reviewing the facility policies and daily checklist for managers. UM #1 revealed there had been no training related to disinfecting a glucometer. She added, overall the nursing staff needed better training. The Administrator and Corporate Nurse Consultant were informed of Immediate Jeopardy on [DATE] at 3:32pm. The Administrator provided an acceptable credible allegation of compliance on [DATE] at 4:32pm. On [DATE] at 3:52pm, record review revealed the specific Skills Competency Validation Record for nurses regarding resident care located in the facility assessment notebook had not been completed for Nurse #1, Nurse #2, and Nurse #3. Credible Allegation F726: The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited. · As part of the root cause analysis of the deficient practice by the administrator, a review and analysis of the facility orientation for licensed nursing staff was conducted; it was noted that there was not a specific skills validation for the competency of nursing staff in cleaning glucometers and hand washing signed as part of their blood borne pathogens training. When the staff development coordinator was questioned, she stated that she gave the forms to the staff and expected them to complete them with their training nurse and return them to her but did not validate their completion. · The root cause analysis also revealed that the Director of Nursing was not evaluating competency on newly hired nurses prior to a nurse being released to floor. · Nurse #2 did not clean the glucometer after the accucheck on Resident #73 and proceeded to perform accuchecks on residents # 72, 74, 67, 223. Nurse #2 was also observed not sanitizing her hands between glove changes. Nurse #2 was immediately removed from patient care, and in-serviced. Nurse #2 did not return to patient care until a return demonstration was validated by an RN; any further demonstration of incompetent practices will result in immediate termination. · Nurse #3 expressed lack of knowledge by instructing Nurse #2 to disinfect the glucometer by using the wrong cleaning supply by using alcohol wipes after the completion of an accucheck. Nurse #3 was in-serviced immediately and returned to patient care as soon as she verbalized correct cleaning procedures, return demonstration, and a quiz following the education to determine knowledge retention. · During the analysis of the deficient practice of Nurses #2 & #3, the nurses expressed to the direct supervisor that they knew to clean the glucometers but also thought alcohol wipes were an appropriate alternative for cleaning. After receiving the first inservice education on [DATE], Nurse #3 was unable to verbalize the correct process when questioned by the surveyor. Nurse # 3 then received additional training with return demonstration conducted by the Regional Nurse Consultant on [DATE]. Nurse #2 admitted that she knew she needed to disinfect the glucometers but did not. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. · Facility nursing staff are being in-serviced beginning on [DATE] on the policy on Patient Care Equipment including: use of PDI Sani-Wipes, and wet time. Facility nursing staff are being in-serviced beginning on [DATE] on the policy Handwashing Requirements. Facility nursing staff also acknowledged by signature the understanding of transmission precautions and that proper hand washing and glucometer disinfecting was required to prevent the transmission of blood borne pathogens. Education was provided by the Regional Nurse Consultant to the Director of Nursing and Unit Managers with return demonstration and then Education was provided by DON, Unit managers, and Regional Nurse Consultant to the facility licensed nursing staff. New hires will be educated during general orientation by a member of nursing administration. All nursing staff will be in-serviced before returning to work. · Facility medication carts were provided with a job aide describing the steps to cleaning a glucometer as a visual reference for the staff on the competent technique to use on [DATE] by the Regional Nurse Consultant. · Beginning [DATE], current nurses will have skills validation sheets completed on Glucose Monitor Cleaning/Disinfecting and Blood Borne Pathogens. All new nurses will receive the skills validation on Glucose Monitor Cleaning/Disinfecting and Hand washing requirements during orientation and have return demonstration validated by the Director of Nursing or the Unit Manager before being released to work on the medication carts. · To ensure staff competency before performing independent resident care, any nurse unable to show competency after the orientation and training program will be retrained or employment ended as directed by the Director of Nurses The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements. · Regional Nurse Consultant (or designee) will audit skills validation worksheets for completion once weekly beginning [DATE] for 4 weeks and then monthly x 5 months. · Beginning on [DATE], random audits will be conducted to ensure glucometer cleaning and hand washing are performed per facility policy. Audits will be done 5 times weekly x 2 weeks, 3 times weekly x 2 weeks, and then once weekly x 2 months. Audits will be performed by Director of Nursing, Unit managers, Regional Nurse Consultant or designee. The nurse consultant will review the audits with the Director of Nursing and the Administrator who will report findings to the QAPI committee. · The Administrator will validate that each licensed nurse has a skills validation completed within 30-days of hire and annually and report findings to the QAPI committee. · The Administrator will confirm that each licensed nurse has received the skills validation on Glucose Monitor Cleaning/Disinfecting and Hand washing requirements during orientation and has been observed with return demonstration validated by the Director of Nursing or the Unit Manager before being released to work on the medication carts. The title of the person responsible for implementing the acceptable plan of correction: Regional Nurse Consultant, Director of Nursing and Administrator with completion by [DATE]. Immediate Jeopardy was removed on [DATE] at 6:34pm when observations, interviews, and review of the in-services provided on [DATE] revealed nurses were knowledgeable about disinfecting glucometers and transporting used blood glucose test strips safely to a sharps container. Nurses demonstrated how to obtain blood glucose readings and disinfecting glucometers after each use as recommended by the manufacturer's instructions on the wipes provided by the facility.

Based on observations, record review, physician, and staff interviews the administration failed to provide oversight and leadership to facility nurses to ensure policies and training related to infection control practices were reviewed and updated to guarantee the current standards of practice were followed for disinfecting multi-use blood glucometers, safe handwashing practices, transporting used blood glucose test strips safely to a sharps container, and preventing transmission of bloodborne pathogens. The failed practice was observed with 6 of 30 residents who had physician ordered blood glucose monitoring and had the potential to expose the residents to the risk for cross-contamination of bloodborne pathogens (Resident #47, Resident #73, Resident #72, Resident #67, Resident # 74, and Resident #223). Immediate Jeopardy began on 5/23/18 when Nurse #1 was observed during a medication pass to transport a blood sample test strip used on Resident #36 during blood glucose monitoring in his right scrub top pocket commingled with clean and dirty supplies that included a nebulizer treatment that would be later administered to Resident #47. On a separate medication pass observation Nurse #2 was observed not disinfecting a shared glucometer while collecting blood samples for blood glucose readings from 5 residents (Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). The Immediate Jeopardy was removed on 5/25/18 when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (pattern with no actual harm with potential of more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to disinfecting glucometers, transporting supplies exposed to blood, and preventing transmission of bloodborne pathogens. The findings included: 1.Cross Refer to F880 Based on record review, observations, physician, and staff interviews the facility failed to transport a used blood glucose test strip safely by placing the test strip in a scrub top pocket containing clean and dirty supplies for 2 of 2 residents (Resident #47 and Resident #36). In addition, the facility failed to follow safe practices for disinfecting a shared glucometer and performing handwashing during a medication pass for 5 of 5 residents (Resident # 73, Resident #72, Resident #67, Resident #74, and Resident #223). The failed practices had the potential to affect 6 of 30 residents who had physician ordered blood glucose monitoring in the facility at the time of the annual recertification by exposing the residents to the risk for cross-contamination of potential bloodborne pathogens (Resident #47, Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). 2.Cross Refer to F726 Based on observation, record review, physician, and staff interviews the facility failed to provide training to 3 of 4 facility nurses (Nurse #2, and Nurse #3) on how to disinfect a glucometer (a device used to test glucose level in the blood) that was shared among 5 residents and on how to dispose of a used sample test strip (Nurse #1) to avoid cross contamination of the residents' environment and to prevent disease transmission. The failed practice had the potential to affect 6 of 30 residents who had physician ordered blood glucose monitoring in the facility by exposing the residents to the risk for cross-contamination of potential bloodborne pathogens (Resident #47, Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). A review of the facility assessment dated ,[DATE] included a facility profile report that indicated 14% of current residents had infections and 32.6% received injections during 9/2016 through 9/2017. During an interview on 5/25/18 at 11:07am revealed the Administrator indicated she was aware of the facility training policy and explained the nurse turn-over and retention in the facility had been high. She stated the facility needed a solid orientation to be successful. She explained the past DON who had been responsible for the oversight had not been able to execute expectations and had been terminated due to the inability to retain nursing staff and stay organized. On 5/24/18 at 3:32pm, the Administrator and Nurse Consultant were informed of the Immediate Jeopardy for F835. On 5/25/18 at 3:52pm, record review revealed the specific Skills Competency Validation Record for nurses regarding resident care located in the facility assessment notebook had not been completed for Nurse #1, Nurse #2, and Nurse #3. On 5/25/18 at 4:32pm, the facility provided the following Credible Allegation of Immediate Jeopardy removal. The plan of correcting the specific deficiency. The plan should address the processes that led to the deficiency cited. · On (MONTH) 23, (YEAR) during the evening shift, before dinner, Nurse #2 failed to display the proper technique for the cleaning and disinfecting of the glucometer between patient uses. Nurse #2 did not clean the glucometer after the accucheck on Resident #73 and proceeded to perform accuchecks on residents # 72, 74, 67, and 223 without cleaning or disinfecting the glucometer. Nurse #2 was immediately removed from patient care and in-serviced on the proper method for cleaning glucometers by the regional nurse consultant. She was also given a copy of the glucometer cleaning policy and procedure as well as the hand washing policy, as soon as the deficient practice was identified. Nurse #2 was then validated by return demonstration of the appropriate steps, following manufacturer guidelines for the cleaning of the glucometer, observed by the regional nurse consultant before returning to patient care. Any further demonstration of incompetent practices by nurse #2 will result in immediate termination. · Nurse #3 was asked by Nurse #2 which wipes were to be used to clean the glucometer and incorrectly stated it was cleaned with an alcohol wipe. Nurse #3 was in-serviced immediately by the regional nurse consultant and returned to patient care as soon as she verbalized correct cleaning procedures, return demonstration, and a quiz following the education to determine knowledge retention of the appropriate cleaning agent to use per manufacturer guidelines. · During the analysis of the deficient practice of Nurse #2, the nurse denied being trained on the cleaning of glucometers despite being presented with her signed acknowledgement of blood borne pathogens training on 4/18/18. The nurse expressed to her direct supervisor that she knew to clean the glucometers but thought alcohol wipes were the appropriate product for cleaning. The nurse also stated was rushing because the surveyor watching her made her feel anxious and stressed. Upon review of the nurse's medication cart, the appropriate supplies were available; there were two glucometers and the Sani-Wipes in a box in the bottom drawer of the cart for the disinfection of the glucometers. Further analysis confirmed that sufficient staff and supplies were available to perform the procedure per policy. · The cause of the nurses' inability to perform was that they were unable to recall their training on cleaning of glucometers. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. · Beginning 5/24/18, the Director of Nursing and Unit Managers will be in-serviced on nurse education and competency skill validations, including the cleaning and disinfecting of glucometers) by Regional Nurse Consultant. · On 5/25/18, Director of Nursing and Unit Managers was in-serviced on performing a medication pass audit and observing accuchecks for proper technique by the Regional Nurse Consultant. · Facility nursing staff are being in-serviced beginning on 5/24/18 using a skills competency validation worksheet and return demonstration to ensure understanding of the training provided for glucometer cleaning and disinfecting. Facility nurses will not be able care for residents until they have received the skills competency validation. · New nurses hired will be given a skills competency validation worksheet that must be completed within 30 days of hire, training on blood borne pathogens, and all new hires will be observed performing accuchecks and disinfecting the glucometer with the supplies and process recommended by the glucometer manufacturer. The nurse's skills in the areas of blood borne pathogens understanding and glucometer cleaning and disinfection will be validated by nursing administration before the nurse can be released from orientation to do a medication pass independently. · Nursing staff will continue to have med-pass observations performed by the nursing administration team monthly x 3 months and then quarterly to ease their comfort to enable them to be less anxious and stressed an in being observed during their observation by a surveyor. · The facility administrator in conjunction with the Regional Nurse Consultant will monitor the infection control program in the facility including effective leadership by nursing administration. The facility administrator will review the facility policies, procedures, manufacture instructions, and QAPI analysis of the infection control process in the facility with the QIO. · The facility will not tolerate breaches of the infection control polices and expectations; staff will be disciplined using the progressive discipline process. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements. · Regional Nurse Consultant (or designee) will audit skills validation worksheets including glucometer cleaning, for completion once weekly beginning 5/24/18 for 4 weeks and then monthly x 5 months. · Administrator (or designee) will review medication pass observation worksheets for completion monthly x12 months during the monthly QAPI meeting. · Facility pharmacy nurse consultant will monitor a sample of medication carts during his monthly visits for supplies and glucometer cleaning techniques. · The medical director will review the monitoring for trends and patterns during the quarterly QAPI meetings. · The director of nursing reported Nurse #2 to the board of nursing on 5/25/18. The title of the person responsible for implementing the acceptable plan of correction: Director of Nursing, Regional Nurse Consultant, Pharmacist, and Administrator with completion by 5/25/18. Immediate Jeopardy was removed on 5/25/18 at 6:34pm when observations and interviews revealed nurses were knowledgeable about disinfecting glucometers, handwashing safe practices, and transporting used blood glucose test strips safely to a sharps container. Nurses demonstrated how to obtain blood glucose readings and disinfecting glucometers after each use as recommended by the manufacturer's instructions on the wipes provided by the facility.

Based on record review, observations, physician, and staff interviews the facility failed to follow safe practices for disinfecting a shared glucometer and performing handwashing during a medication pass for 5 of 5 residents (Resident # 73, Resident #72, Resident #67, Resident #74, and Resident #223). In addition, the facility failed to transport a used blood glucose test strip safely by placing the test strip in a scrub top pocket containing clean and dirty supplies for 2 of 2 residents (Resident #47 and Resident #36). The failed practices were observed with 6 of 30 residents who had physician ordered blood glucose monitoring and had the potential to expose the residents to the risk for cross-contamination of bloodborne pathogens (Resident #47, Resident #73, Resident #72, Resident #67, Resident # 74, and Resident #223). Immediate Jeopardy began on [DATE] when Nurse #1 was observed during a medication pass to transport a blood sample test strip used on Resident #36 during blood glucose monitoring in his right scrub top pocket commingled with clean and dirty supplies that included a nebulizer treatment that would be later administered to Resident #47. On a separate medication pass observation Nurse #2 was observed not disinfecting a shared glucometer while collecting blood samples for blood glucose readings from 5 residents (Resident 73, Resident #72, Resident #67, Resident #74, and Resident #223). The Immediate Jeopardy was removed on [DATE] when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of E (pattern with no actual harm with potential of more than minimal harm that is not immediate jeopardy) to complete education and ensure monitoring systems put into place are effective related to disinfecting glucometers, transporting supplies exposed to blood, and preventing transmission of bloodborne pathogens. Findings included: 1. A review of a facility policy for Patient Care Equipment dated [DATE], Section 13, titled, Glucometers read in part, Clean the outside of the meter using a lint-free cloth. Clean in accordance with manufacturer's recommendation. A review of the manufacturer's guidelines noted in the User Instruction Manual revised on ,[DATE], titled, Maintenance, Cleaning and Disinfecting Guidelines read in part, Healthcare professionals should wear gloves when cleaning the meter. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. A review of the PDI Sani Cloth Bleach Germicidal Disposable Wipe manufacturer guidelines read in part, to disinfect: unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full 4 minutes. Use an additional wipe(s) if needed to assure continuous 4 minute wet contact time. A review of a facility policy for Handwashing Requirements dated [DATE], Section A, titled, Hand Hygiene read in part, situations that require hand hygiene: before and after performing any invasive procedure (e.g. fingerstick blood sampling). a. A review of the admission MDS dated [DATE] for Resident #73 was coded moderate impairment for cognitive skills for daily decision making. [DIAGNOSES REDACTED]. A physician order [REDACTED]. The bacteria spreads by contact with a contaminated object or surface). A physician order [REDACTED]. A review of a critical lab result dated [DATE] for Resident #73 revealed detected toxigenic [DIAGNOSES REDACTED]icile. During a medication pass observation on [DATE] at 4:48pm Nurse #2 stated she had obtained the blood sample for blood glucose monitoring from Resident #73 in her room. Nurse #2 was observed holding the glucometer with a blood glucose result that read 223. Nurse #2 then prepared [MEDICATION NAME] (a blood thinner injection) and a Humalog (insulin used to treat diabetes) syringe for administration for Resident #73. Nurse #2 was observed to place new gloves on for preparation of the medications and then removed her gloves before entering Resident #73's room. New gloves were placed on for administering the medications for Resident #73 and then removed before exiting the room. Nurse #2 walked back to her medication cart and placed new gloves on for the next resident, Resident #72, who was scheduled to have blood glucose monitoring. There were 2 glucometers observed sitting on the medication cart and the same glucometer was chosen to be used for the next assigned resident, Resident #72. No handwashing or disinfecting the glucometer was observed. b. A review of the admission MDS dated [DATE] was coded indicating Resident #72 had intact cognition. [DIAGNOSES REDACTED]. An observation on [DATE] at 4:52pm with Nurse#2 revealed she gathered an alcohol swab, lancet, test strip, and the shared glucometer used for Resident #73 from her medication cart on Hall 100. Nurse #2 placed a new test strip in the shared glucometer and went into the room where Resident #72 resided to collect a blood sample for blood glucose monitoring. The glucometer read 116. Nurse #2 left the room and read the sliding scale physician order [REDACTED]. Nurse #2 was not observed disinfecting the glucometer. Nurse #2 was observed removing her gloves used during the blood glucose check and placing new gloves on for the next resident, Resident #67, who was scheduled to have blood glucose monitoring. There were 2 glucometers observed sitting on the medication cart and the same glucometer was chosen to be used for the next assigned resident, Resident #67. No handwashing was observed. c. A review of the admission MDS dated [DATE] was coded indicating Resident #67 had moderate cognitive patterns. [DIAGNOSES REDACTED]. An observation on [DATE] at 4:57pm with Nurse #2 revealed she gathered an alcohol swab, lancet, test strip, and the same glucometer used for Resident #72 from her medication cart on Hall 100. Nurse #2 placed the test strip in the glucometer and went into the room for Resident #67 to collect a blood sample for blood glucose monitoring. The glucometer read 240. Nurse #2 left the room and read the sliding scale for [MEDICATION NAME] from the eMAR and stated Resident #67 would need 4 units of [MEDICATION NAME] and 3 units of Humalog administered. Nurse #2 was not observed disinfecting the glucometer. She was observed taking off the gloves used during the blood sugar check and placing new gloves on to prepare both insulins for Resident #67. Nurse #2 administered the insulins via subcutaneous injection in the resident's room. Nurse #2 left the room and removed her gloves and then placed new gloves on for the next resident, Resident #74, who was scheduled to have blood glucose monitoring. There were 2 glucometers observed sitting on the medication cart and the same glucometer was chosen to be used for the next assigned resident, Resident #74. No handwashing was observed. d. Resident #74 was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on [DATE] at 5:06pm, Nurse #2 gathered an alcohol swab, lancet, test strip, and the same shared glucometer used for Resident #73, Resident #72, and Resident #67. Nurse #2 placed a test strip in the shared glucometer and went to the room for Resident #74 to collect a blood sample for blood glucose monitoring. The glucometer read 268. Nurse #2 walked to her medication cart to read the sliding scale from the eMAR. The order read to administer 4 units. Nurse #2 was not observed disinfecting the glucometer. She was observed taking off the gloves used during the blood sugar check and putting on clean gloves before proceeding to prepare the insulin needed for Resident #74. Nurse #2 administered the insulins via subcutaneous injection in the resident's room. Nurse #2 left the room and removed her gloves. No handwashing was observed. During an interview on [DATE] at 5:10pm, Nurse #2 if stated she had not been washing her hands in between removing gloves and placing new gloves on. Nurse #2 explained she had been so nervous that she had forgotten. Nurse #2 indicated she knew how essential it was to wash her hands when taking off gloves to put on new gloves. She then sanitized her hands with the hand gel stored on top of her medication cart and put on new gloves for the next resident, Resident #223, who was scheduled to have blood glucose monitoring. There were 2 glucometers observed sitting on the medication cart and the same glucometer was chosen to be used for the next assigned resident, Resident #223. e. Resident #223 was admitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on [DATE] at 5:12pm, Nurse #2 gathered an alcohol swab, lancet, test strip, and the same glucometer that had been used for Resident #73, Resident #72, Resident #67, and Resident #74. Nurse #2 placed the test strip in the shared glucometer and walked to the room for Resident #223 to collect a blood sample for blood glucose monitoring. The glucometer read 169. Nurse #2 walked to her medication cart and threw away the used lancet in the sharps container and began to place the shared glucometer back in her medication cart. Nurse #2 was not observed disinfecting the glucometer. She was observed taking off the gloves used during the blood sugar check. No handwashing was observed after removing her gloves. During an interview on [DATE] at 5:18pm, Nurse #2 stated she had not disinfected the shared glucometer used during collecting blood samples for the blood glucose monitoring for Resident #73, Resident #72, Resident #67, Resident #74, and Resident #223. She indicated her practice was to disinfect the shared glucometer when supplies were available. Nurse #2 explained she did not disinfect the shared glucometer if supplies were not available. Nurse #2 stated she had worked on Monday, [DATE], on the same assignment during the shift of ,[DATE]pm and did not have alcohol wipes on the cart so she did not disinfect the glucometer for any of her assigned residents on that night either. During an observation on [DATE] at 5:18pm, Nurse #2 was observed asking Nurse#3 how the shared glucometer was to be disinfected. Nurse #3 instructed Nurse #2 to disinfect the glucometer with an alcohol wipe for 2 minutes. Nurse #2 walked back to her cart, found alcohol wipes and wiped the used glucometer. During an observation on [DATE] at 5:27pm, Nurse #2 walked to the office by the nurse's station on Hall 100 and asked the Director of Nursing (DON) and Unit Manager (UM) #1 how to disinfect a shared glucometer. Both the DON and UM#1 instructed Nurse #2 to use a sani wipe for 2 minutes and together walked back to the cart with Nurse #2 to assist. During an observation on [DATE] at 5:27pm, UM#1 and the DON were observed educating Nurse #2 on how to disinfect the glucometer. The sani wipes were observed to be located on the bottom drawer of the medication cart. The observed instructions given by the DON and UM #1 to Nurse #2 was to wipe the glucometer off for 2 minutes with a PDI (PDI Sani Cloth Bleach Germicidal Disposable Wipe) wipe, then air dry for 1 minute, then dry off any leftover chemical on the device and to follow the steps after every use of the shared glucometer. During the education both the DON and UM #1 gave reminders to Nurse #2 regarding washing hands between taking off gloves and putting on new gloves. An interview on [DATE] at 5:35pm with Nurse #2 revealed she had never been told how to disinfect a glucometer and had not received formal orientation. Nurse #2 explained, since she had worked at the facility for the last 3 weeks, she had used alcohol wipes to disinfect the glucometer when it had been available. Nurse #2 indicated she had just moved from another state and was taught to disinfect glucometers with alcohol there. An interview on [DATE] at 5:50pm with the Nurse Consultant revealed she had in-serviced all of the nurses on the correct procedure for disinfecting glucometers right after the medication pass observation with Nurse #2. The Nurse Consultant indicated the nurses knew the PDI wipes were located on their medication carts and available stock was on hand. She stated the contact time for the PDI wipe was 4 minutes. An interview on [DATE] at 6:13pm after observation of a medication pass with Nurse #3, revealed she had been in-serviced about 15 to 20 minutes ago and was told to use alcohol wipes for 4 minutes now instead of 2 minutes as before to disinfect the glucometers. She stated she had used [MEDICATION NAME] wipes in the hospital but since the facility did not have that she had used what was available, alcohol wipes. Nurse #3 indicated she had not received formal training and had only worked in the facility for 3 weeks. She explained the only in-service she had received since working in the facility had been on falls. Nurse #3 explained she had received a Human Resources (HR) employee handbook but nothing about glucometers. During an interview with the Administrator on [DATE] at 7:40pm she revealed Nurse #3 was a return employee to the facility from 1 year ago and had not received formal training. She indicated that Nurse #1, Nurse #2, and Nurse #3 had all received training and should have known correct handwashing procedures and how to disinfect the shared glucometers as part of their training. An interview on [DATE] at 9:19am with the facility Medical Director was conducted via the telephone. During the interview, the Medical Director revealed a breach in infection control due to absence of disinfection of the glucometers in his prospective was absolutely concerning. Universal Precautions were to be used regardless if a resident such as Resident #73 had[DIAGNOSES REDACTED]icile or not. He explained the risk for cross-contamination was always there. The Medical Director further explained that we may not know if a resident had [MEDICAL CONDITION] or [MEDICAL CONDITION] and mandatory precautions were to be used always. In regard to Resident #73 with [DIAGNOSES REDACTED].#2, the potential for harm was most certainly there. He revealed Resident #73 had extensive psych issues and had been difficult to manage during her treatment of [REDACTED]. The Medical Director stated the need for training for all nurses including new hires was imperative. He explained the facility needed to set the standards from Day 1 regarding all nursing education including handwashing and disinfecting glucometers. The Medical Director revealed Staff Development Coordinator (SDC) who was responsible for educating the staff had left about 2 weeks previous and had given her notice 2 to 3 weeks before her last day. During the last 5 to 6 weeks while the SDC worked in the facility, she was pulled to a medication cart due to nurse call-outs sometimes 15 to 20 minutes prior to a shift. At the same time nurses were let go by the facility for not meeting professional standards. It had been a bad time for staffing he explained. The Medical Director revealed the SDC had been physically in the building but could not train staff because she kept getting pulled to a cart. As far as Nurse #2 and Nurse #3 using alcohol wipes versus a germicidal for a shared glucometer between residents, was an important distinction. The Medical Director explained a germicidal must be used for a shared glucometer and the only time alcohol would be acceptable was if each resident had their own glucometer and were individually bagged and labeled. He added, disinfecting supplies have to be made available to the staff in order to take care of the residents. An interview on [DATE] at 9:52am with the SDC was conducted via the telephone. The SDC revealed she was on vacation and had planned on returning to the facility in the role of a MDS Coordinator. She indicated glucometer disinfection was taught during the Bloodborne Pathogen PowerPoint verbally on the third day of orientation. Handwashing training was taught during the Bloodborne Pathogen PowerPoint presentation, during infection control, and multiple times during orientation. New hires were given written and verbal education but no return demonstrations were included in the training. She indicated rounds by the SDC and Department heads included monitoring handwashing technique and real time education was provided with any negative observations. The SDC stated she had not rounded on Nurse #2 or Nurse #3 since both were new employees. The SDC stated she expected nurses to wash their hands before putting on new gloves, disinfect the glucometer, and then the nurse should use the second glucometer on the medication cart for the next resident until the 4 minute contact time for the PDI wipes had expired. During an interview on [DATE] at 11:07am, the Administrator stated it was her expectation for the staff to follow facility policy and manufacturer guidelines in regards to disinfecting shared glucometers and handwashing after the removal of gloves. The Administrator revealed the Regional Manager had included UM #1 and the DON in the training related to correctly disinfecting the glucometers due to both giving incorrect directions to Nurse #2 on [DATE]. 2. A review of a facility policy for Infection Control Policies and Procedures dated [DATE], Section C, 2., read in part, Unit Managers assure that staff follows infection control procedures to maintain patient safety. Section C, 6., Equipment will be disposed of or properly disinfected. a. A review of the admission Minimum Data Set ((MDS) dated [DATE] for Resident #47 was coded for moderate cognitive status and her staff assessment for mental status could not be conducted. [DIAGNOSES REDACTED]. Resident #47 was coded as receiving Hospice services. An observation on [DATE] at 9:00am on Hall 200 for cart #2 revealed Nurse #1 placed a nebulizer treatment for [REDACTED]. On [DATE] at 9:20am Nurse#1 was observed as he reached into his right scrub top pocket for the scheduled nebulizer treatment to be administered to Resident #47. He placed the nebulizer face mask on Resident #47 and started the treatment using the nebulizer treatment from his right pocket. The nebulizer was observed commingled with used gloves, clean gloves, a used test strip with a blood specimen, a used lancet, alcohol wipes, gloves, the dirty glucometer, an insulin syringe, a vial for Humalog, a [MEDICATION NAME], a pen needle inserted with a cap, and an ink pen. b. A review of the annual MDS dated [DATE] for Resident #36 was coded for intact cognition and independent with activities of daily living. [DIAGNOSES REDACTED]. On [DATE] at 9:01am Nurse #1 was observed to gather alcohol wipes, gloves, a lancet, glucometer, insulin syringe, a vial of Humalog (insulin used to treat diabetes), a [MEDICATION NAME] (insulin), and pen needle and then placed the supplies in his right scrub top pocket. Nurse #1 walked down the hall to Resident #36's room and took out the alcohol wipes, gloves, lancet, glucometer, insulin syringe, vial of Humalog, [MEDICATION NAME] and pen needle. Nurse #1 then placed the supplies on the dresser for Resident #36. Nurse #1 collected a blood sample to test the blood glucose from the resident's forefinger. He then squeezed the drop of blood onto blood glucose test strip. The glucometer read the blood glucose to be 282. Resident #36 asked what was his blood sugar and Nurse #1 stated, I'm sorry I need to get another [MEDICATION NAME] since I do not have enough in the [MEDICATION NAME] I brought. Nurse #1 then gathered the used gloves, the clean gloves, used test strip with the blood drop, the used lancet, alcohol wipes, gloves, the dirty glucometer, insulin syringe, vial for Humalog, [MEDICATION NAME], and pen needle inserted with a cap. Nurse #1's right scrub top pocket was noted to have 1 ink pen, the nebulizer treatment for [REDACTED].#36. On [DATE] at 9:25am Nurse #1 was observed to grab a new [MEDICATION NAME] pen from the medication room on Hall 200, labeled the pen, and placed the new pen in his right scrub top pocket as he walked back down the hall for Resident #36. Once in the room for Resident #36, Nurse #1 stated he had picked up the wrong pen and still did not have enough insulin for the ordered 95units of [MEDICATION NAME] after combining 2 separate [MEDICATION NAME]. Again, he gathered all supplies, put them in his right pocket and walked back to his medication cart at the end of the hall. He opened the top drawer of the medication cart #2 and walked back to the room for Resident #36. After administering both injectable pens of [MEDICATION NAME] to Resident #36, Nurse #1 put clean gloves from his left pocket into his right pocket where the dirty items were stored. Nurse walked to medication cart and disposed of the used items from his right scrub top pocket. An interview with Nurse #1 on [DATE] at 9:35am revealed he had put all of the supplies into his right pocket including the used test strip, once he had entered the room after checking the blood glucose and realized he did not have enough insulin to administer to Resident #36. Nurse #2 stated he had a heavy assignment with 26 residents including 7 insulin administrations. Nurse #1 indicated there was no one to ask for help when needed. He stated he had received no job training before his first shift when he was assigned to a medication cart. Nurse #1 explained Nurse #4 who no longer worked at the facility, pulled the medications and he had administered the medications to the residents during his first shift in the facility. An interview with the Administrator was conducted on [DATE] at 3:27pm. The Administrator indicated it was her expectation that Nurse #1 would have put the used items inside his glove to keep from the clean items until Nurse #1 could discard the collected blood sample on the test strip into a sharps container. She stated Nurse#1 had been trained by the Staff Development Coordinator (SDC) and had received ongoing training on time management and consolidating methods to use during a medication pass. The Administrator was unable to provide any evidence of specific training given to Nurse #1. An interview on [DATE] at 9:52am with the SDC via telephone revealed she personally had been on the floor with Nurse #1 and also rounded on him and had never seen Nurse #1 transport a used blood sample test strip in his pocket. The SDC stated she had expected for nurses to take a small sharps container into the room and they should absolutely not put a used test strip in their scrub pocket. She reiterated, Nothing goes in the pocket, the strip goes directly into the sharps container. On [DATE] at 3:32pm, the Administrator and Nurse Consultant were informed of Immediate Jeopardy for F880. On [DATE] at 3:52pm, record review revealed the specific Skills Competency Validation Record for nurses regarding resident care located in the facility assessment notebook had not been completed for Nurse #1, Nurse #2, and Nurse #3. On [DATE] at 4:32pm, the facility provided the following Credible Allegation of Immediate Jeopardy removal. The plan of correcting the specific defiency. The plan should address the processes that led to the deficiency cited. During the analysis of the deficient practice of Nurse #1, the nurse admitted to not following proper procedure by placing the glucometer strip for Resident #36 in his scrub pocket comingled with supplies for Resident #47. During the analysis of the deficient practice of Nurse #2, the nurse denied being trained on the cleaning of glucometers despite being presented with her signed acknowledgement of blood borne pathogens training on [DATE]. The nurse expressed to her direct supervisor that she knew to clean the glucometers but thought alcohol wipes were the appropriate product for cleaning. Upon review of the nurse's medication cart, the appropriate supplies were available; there were two glucometers and the Sani-Wipes in a box in the bottom drawer of the cart for the disinfection of the glucometers. During the analysis of the deficient practice of Nurse #3, she expressed to her direct supervisor that she knew to clean the glucometers between patients, but thought alcohol wipes were appropriate for cleaning. On [DATE] Nurse #1 was noted to enter a resident room with blood glucometer supplies and insulin during a medication administration pass. After the blood glucose level was checked, nurse #1 realized that he needed more insulin from his cart. He then proceeded to gather the supplies which included: glucometer, used testing strip, gloves, insulin vial, insulin syringe, insulin pen needle, insulin pen, and alcohol prep pads. He then placed them all into his scrub right pocket. Nurse #2 failed to follow infection control practices and four residents have the potential to be affected by the deficient practice of Nurse #2, Residents #72, 74, 67, 223. Nurse #2 violated the facility infection control policy by not cleaning the glucometer after obtaining Resident #73 accucheck, as she was trained during her orientation. Nurse #2 was also observed not sanitizing her hands between glove changes. Nurse#2 was immediately removed from patient care, and in-serviced; any further demonstration of incompetent practices will result in immediate termination. Nurse #3 expressed knowledge of the wrong cleaning supply by using alcohol wipes after the completion of an accucheck. Nurse #3 was in-serviced immediately and returned to patient care as soon as she verbalized correct cleaning procedures, return demonstration, and a quiz following the education to determine knowledge retention. The procedure for implementing the acceptable plan of correction for the specific deficiency cited. Facility nursing staff are being in-serviced beginning on [DATE] on the policy on Patient Care Equipment including: use of PDI Sani-Wipes, and wet time. Facility nursing staff are being in-serviced beginning on [DATE] on the policy Handwashing Requirements. Facility nursing staff also acknowledged by signature the understanding of transmission precautions and that proper hand washing and glucometer disinfecting was required to prevent the transmission of blood borne pathogens. Education was provided by DON, unit managers, and Regional Nurse Consultant. New hires will be educated during general orientation by nursing administration which will be confirmed by the administrator before they can independently provide glucose checks. Nursing staff will be in-serviced before returning to work The medical director, and physician, for Residents #73, 72, 74, 67, and 223 was notified on [DATE] of the deficient practice of the nurses by the Administrator and the Regional Nurse Consultant. RN assessment of all five residents has not shown any change in condition potentially caused by the deficient practice of the nurses. The physician agreed to order Hep B [MEDICAL CONDITION] on all five residents to rule out the [DIAGNOSES REDACTED]. The local health department will be notified if there are lab results indicating that transmission of a blood borne pathogen has occurred. Nurse #1 was pulled off the cart immediately to discuss the deficient practice for infection control and possible cross contamination. Nurse #1 was then sent home and no longer is an employee of the facility. No other nurses were identified as placing supplies with potential blood borne pathogens comingled into scrub pockets. The responsible parties were notified of the deficient practice by the nurses in the performance of the care of the six residents on [DATE]. The facility contacted the QIO on [DATE] to request additional training on infection control and blood borne pathogens for facility staff; the QIO representative for the(NAME)area agreed to meet with the facility on [DATE]. The director of nursing reported Nurse #2 and Nurse #3 to the local health department and the board of nursing on [DATE]. The monitoring procedure to ensure that the plan of correction is effective and that specific deficiency cited remains corrected and/or in compliance with the regulatory requirements Education was provided by the Regional Nurse Consultant to the Director of Nursing and Unit Managers with return demonstration on the cleaning and disinfecting process for glucometers per manufacturer guidelines on [DATE]. Beginning on [DATE], random audits will be conducted to ensure glucometer cleaning is performed per facility policy and manufacturer instructions Audits will be done 5 times weekly x 2 weeks, 3 times weekly x 2 weeks, and then once weekly x 2 months. Audits will be performed by Director of Nursing, Unit managers, Regional Nurse Consultant or designee. The nurse consultant will review the audits with the Director of Nursing and the Administrator who will report findings to the QAPI committee. The title of the person responsible for implementing the acceptable plan of correction: Director of Nursing and Infection Control Preventionist with completion by [DATE]. Immediate Jeopardy was removed on [DATE] at 6:34pm when observations and interviews revealed nurses were knowledgeable about disinfecting glucometers, handwashing safe practices, and transporting used blood glucose test strips safely to a sharps container. Nurses demonstrated how to obtain blood glucose readings and disinfecting glucometers after each use as recommended by the manufacturer's instructions on the wipes provided by the facility.

Based on resident interview, staff interview and record review the facility failed to safely transfer Resident#54 who was lowered to the floor and sustained a fracture for 1 of 4 sampled residents reviewed for accidents. The findings included: Resident #54 was admitted to the facility on [DATE] with admitting [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #54 was cognitively intact and required extensive assistance with bed mobility and transfers and one person assist for transfers. A review of the MDS revealed Resident #54 had no previous falls since prior assessment. Review of Resident #54's Nursing notes revealed the following: A nursing progress notes dated 08/24/15 revealed while resident was being changed the resident started to shake while on the lift. The progress note further revealed NA#1 lowered resident to the floor, to prevent resident from falling. On 08/25/15 at 7:48 AM revealed Resident #54 had a status [REDACTED]. The nurse's notes further revealed an x-ray was ordered due to pain. A nurses notes dated 08/25/15 at 9:28 AM revealed Resident #54 right knee was swollen but had no redness. A change of condition nurse's note dated 08/25/15 at 10:57 AM revealed x-ray results received and Resident #54 had right knee fracture and Resident #54 was sent out to hospital for evaluation. Review of nurse's notes dated 08/25/15 dated 11:10 AM revealed 911 dispatch called to transport resident to hospital for evaluation per verbal order from NP. Nurse's note on 08/25/15 at 11:25 AM revealed Resident #54 was transported by Emergency Medical Services to the hospital. Review of an x-ray report dated 08/25/15 revealed a right distal femur fracture (knee). Review of the Incident/Accident report documented on 08/24/15 at 9:45 PM recorded in part, that the assigned nurse aide (NA) informed the nurse that she was transferring Resident #54 using a sit to stand lift. During the transfer Resident #54 started to shake. The NA stated, I lowered resident (Resident #54) to floor so she would not fall. When the nurse entered the room, she observed Resident #54 lying on the floor beside her bed. Resident #54 was asked what happened and stated, I did not fall, she put me on the floor. Review of the physician consult document dated on 09/02/15 revealed Resident #54 had a femur fracture. On 09/16/15 at 10:20 AM an interview was conducted with Resident #54 related to the fall she experienced on 08/24/15. Resident #54 stated on 08/24/15 she was out of bed sitting in her wheelchair in her room. Resident #54 stated she mentioned to NA #1 she was ready for bed and needed to be changed. Resident #54 stated she was transferred to the lift only by one NA#1. Resident #54 explained she was not able to stand for a long period of time on the lift due to her knees getting weak. Resident #54 revealed after her knees gave out she was lowered to the floor. Resident #54 further stated two staff members always assisted with her transfers. Resident #54 stated she believed her fall could have been avoided if NA#1 would have requested for another staff member to assist her with the transfers. During the interview, Resident #54 stated they conducted x-rays and explained she was admitted to the hospital the next day for a femur fracture. Interview with Nurse Aide (NA) #1 on 09/16/15 at 3:55 PM revealed Resident #54 was alert and oriented. She explained Resident #54 requested to be put back to bed. She stated when Resident #54 was on the sit to stand lift she started shaking and she became nervous and lowered Resident #54 closer to the edge of the bed and she was lowered to the floor. NA#1 stated Resident #54 required a two person assist but could not find staff to assist and she transferred Resident #54 without the proper assistance. NA#1 explained she was re-educated after Resident #54's fall that two staff members were required to assist with lift transfers. A telephone interview was conducted on 09/17/15 at 3:05 PM with Nurse#1. She stated Resident #54 was alert and oriented. She stated she was working on 08/24/15 the night Resident #54 fell . She stated she didn't witnessed the incident. She stated she was called to the room to assess Resident #54 after a reported fall. She explained Resident #54 should not been transferred with one person assist. During the interview, Nurse #1 reported Resident #54 required two person assist when using the sit to stand lift. She further stated NA#1 should have waited until someone was available to assist her and should not have transferred the resident alone. Interview with Nurse#2 was conducted on 09/17/15 at 3:55 PM stated she was informed NA#1 transferred Resident #54 with one person assist on 08/24/15. Nurse#2 stated she was made aware of the incident by Nurse#1 the same night the accident occurred. During the interview, Nurse #2 stated she was aware Resident #54 was lowered to the floor. Nurse #2 stated Resident #54 required two people to assist with transfers. Interview conducted with Director of Nursing (DON) on 09/17/15 at 4:04 PM stated NA#1 transferred Resident #54 with a one person assist. The DON explained NA#1 was re-educated and counseled on mechanical lifts requiring two person transfer. During the interview, she stated the mechanical device would remain out of order until all staff were trained on all three shifts. She further stated the expectation is for staff to use two person assist for the lifts to help prevent any further injuries.

Based on observations, a review of the medical record and facility records and interviews with the physician and staff, the facility failed to identify, assess, and implement elopement interventions, for a cognitively impaired resident who verbally expressed a desire to leave the facility in 1 of 3 sampled residents reviewed for their risk of elopement. (Resident #5) Immediate jeopardy began on 03/19/14 when Resident #5 exited the building and facility property without staff supervision or knowledge. Immediate jeopardy was removed on 03/29/14 at 3:39 PM when the facility provided and implemented an acceptable credible allegation of compliance. The facility remains out of compliance at a lower scope and severity of D (an isolated deficiency, no actual harm with potential for more than minimal harm that is not immediate jeopardy) for Resident #5 to ensure the monitoring of systems put into place are effective and completion of employee education. The findings included: The facility's policy, "Behavioral Assessment/Behavior Monitoring", effective 09/01/11, recorded in part, "Problematic behavior shall be assessed and monitored. Factors influencing behaviors as well as management interventions shall be evaluated and care planned. Residents shall be observed by staff on all shifts and report any untoward behavior (unusual), that is observed to a licensed nurse. If a resident begins demonstrating unsafe aimless wandering behaviors after the initial admission to the center, utilize the Wandering/Elopement Risk Assessment form and re-evaluate at least quarterly and update care plan accordingly." Resident #5 was admitted to the facility on [DATE] from the hospital for rehabilitation services after sustaining a fall with lumbar (back) fracture at home. [DIAGNOSES REDACTED]. A Wandering/Elopement Risk assessment dated [DATE], completed by nurse #1 documented Resident #5 had dementia, intermittent confusion, ambulated independently with a walker and had no history of wandering/elopement behavior. There were no wandering/elopement interventions documented on this assessment for Resident #5. Instructions for the completion of this risk assessment included "Complete with behavior and cognitive changes. Revise/update the care plan as indicated." A nurse's note by nurse #2 dated 03/06/14 03:39 AM recorded in part, "Was noted to be up wandering in hallway earlier, attempting to use BR (bathroom) in another res (resident's) room and was redirected without incident to his own BR." A clarification nurse's note by nurse #3 from 03/08/14 (3-11 PM shift) dated 03/27/14 4:03 AM recorded in part, "During rounds this resident told this writer he wanted to go home to South Boulevard and requested to speak to his son." The nurse's note further clarified that when asked if he required assistance to contact his son, the Resident informed the nurse that he did not have a son. An admission Minimum Data Set and Care Area assessment dated [DATE] assessed Resident #5 with moderately impaired cognition, without wandering behavior and at risk for increased cognitive decline related to an acute disease process. Resident #5 was not care planned for the risk of wandering/elopement. A nurse's note dated 03/11/14 04:36 PM recorded that Resident #5 was moved on this date to a new room on the same hall. A nurse's note by nurse #2 dated 03/12/14 02:29 AM recorded in part, "(Resident) wandering in hallway, confused due to room change. Easily redirected to new room and shown where BR is." A Physician's Admission Medical Care Plan dated 03/12/14 assessed Resident #5 with dementia, unable to initiate conversation, but able to answer yes/no questions. The physician's assessment also documented that Resident #5 possibly needed a closed memory care unit. A nurse's note by nurse #4 dated 03/19/14 10:24 PM recorded in part, "Resident has increased confusion in the evening." Review of the facility's Incident Report and investigation revealed that Resident #5 exited the facility on 03/19/14 between 8:30 - 9:30 PM through the front doors unsupervised by staff. Staff were unaware that Resident #5 was not in the facility until the hospital called the facility at approximately 12:05 AM on 03/20/14. Nurse #2 was notified by the hospital that police called emergency medical services (EMS) after Resident #5 walked to the police station on 03/19/14 at approximately 10:00 PM asking for a ride home. After two failed attempts to take Resident #5 home, the police determined that Resident #5 was confused and called EMS for hospital transport. The hospital reported to nurse #2 that Resident #5 arrived to the hospital on [DATE] with no apparent injury and would be transferred back to the facility. Nurse #2 notified the director of nursing (DON) on 03/20/14 at 12:15 AM of the elopement. Additionally, the physician, administrator and Resident's Power of Attorney (PoA) were also notified. Resident #5 was observed in his room on 03/26/14 at 4:53 PM with a wander guard to his left ankle. The Resident stated "I want to go home", but did not recall the events of 03/19/14. On 03/26/14 at 5:00 PM, nurse aide #1 (NA #1) stated in interview that she was accustomed to working with Resident #5 on the 3-11 PM shift, but was off the evening he left the facility. NA #1 described Resident #5 as intermittently confused and independent with ambulation. NA #1 stated Resident #5 routinely walked into the hallway looking for his room or the bathroom and often expressed a desire to go home. NA #1 stated Resident #5 did not have a wander guard and never made any previous attempts to leave the facility. On 03/26/14 at 5:16 PM, the administrator was interviewed and revealed that he received notification from the DON on the morning of 03/20/14 that Resident #5 left the facility unsupervised and without staff knowledge on 03/19/14, walked to the police station and was currently in the hospital for evaluation. The administrator stated he notified the Resident's PoA on 03/20/14 of this incident. The administrator also stated he contacted the police station and was informed that Resident #5 walked up to a police officer in the parking lot of the police station requesting a ride home. Resident #5 was unable to accurately state his address and after two attempts the police determined Resident #5 was confused and called EMS for a hospital transport. On 03/26/14 at 7:27 PM, the maintenance director stated in interview that the front door was armed with a wander guard system and was locked by staff around 10:00 PM each night. If a resident, who did not have on a wander guard approached the front door, the resident could exit the front door without incident. The maintenance director stated he checked the wander guard system to the front door daily to ensure it functioned and then provided a return demonstration. He further stated he was notified on 03/20/14 that Resident #5 left the facility unsupervised and did not have a wander guard in place at the time of exit. All other exit doors to the outside were observed with egress bars that alarmed when the bars were pushed. The maintenance director stated the exit doors with egress bars were monitored remotely by a security company which documented each time the egress bars were pushed. Review of the report dated 03/19/14 revealed the egress bar was not pushed on the 200 hall where Resident #5 resided. A physician's interview occurred on 03/27/14 at 08:41 AM and revealed that when Resident #5 was assessed on 03/12/14 the physician had concerns that the Resident was at risk for elopement and needed a memory care unit. The physician further stated she did not verbally share this with the facility, but expected staff to review the progress note and follow-up with her recommendation. On 03/27/14 at 09:04 AM, NA #2 stated in interview that she cared for Resident #5 on 03/19/14 during the 3-11 PM shift. NA #2 stated she received Resident #5 in bed at the beginning of the shift and he spent most of the shift in his room. NA #2 stated that around 9:00 PM "out of nowhere" Resident #5 stated he was leaving the facility. NA #2 further stated the Resident was "determined he was leaving" because he took off his pajamas, dressed himself in pants and a shirt and walked into the hallway. NA #2 informed nurse #4 who was on the hall administering medication of the Resident's behavior. Nurse #4 instructed NA #2 to encourage Resident #5 to put his pajamas back on and to tell the Resident it was night time. NA #2 then reported that she redirected the Resident back to his room, asked him to put his pajamas back on, but he refused. NA #2 informed the nurse that he was in his room, but that he refused to put his pajamas back on. NA #2 then stated she began her rounds around 9:30 PM checking/changing residents. NA #2 stated she did not see Resident #5 for the remainder of her shift which ended 11:00 PM. NA #2 also added that at the end of the shift she was unable to walk down the hall to the room of Resident #5 because the floor was being waxed from one side of the hall to the other. NA #2 stated she did not report off to the oncoming NA because the 11 PM - 7 AM NA assignment had not been completed prior to her leaving shift. On 03/27/14 at 09:22 AM, nurse #2 stated in interview that she cared for Resident #5 on 03/19/14 during the 11 PM - 7 AM shift. Nurse #2 stated that she was familiar with the care Resident #5 required. She described him as confused, easily redirected and independent with ambulation/toileting, but that he did not have a wander guard in place. Nurse #2 stated on 03/11/14 Resident #5 was moved to a new room on the same hall which seemed to cause him increased confusion. Nurse #2 stated after the room change Resident #5 walked to the door of his room or into the hallway and asked staff if he was in the right room, but he never expressed a desire to leave the facility. Nurse #2 stated that although she described Resident #5 as "wandering" in her nurse's notes, she did not see this behavior as requiring further interventions to prevent elopement, because Resident #5 was easily redirected. Nurse #2 described the events of 03/19/14 when she came on shift and stated that she did not conduct walking rounds on the hall of Resident #5, because the entire hall was being waxed. Nurse #2 stated that the shift change report did not include specifics about the location of Resident #5 nor a report of any new behavior; she just assumed he was in his room. Nurse #2 began the med pass on an adjacent hall and reached the hall of Resident #5 around midnight, but had not yet visualized him during her shift. As nurse #2 progressed down the hall of Resident #5, she stated that her med pass was interrupted with a phone call from the hospital around 12:05 AM on 03/20/14. She was asked by the hospital if Resident #5 was still a Resident in the facility and then advised that he had been brought to the hospital by EMS transport called by the police. The hospital informed nurse #2 that Resident #5 was in good condition and would be transported back to the facility. Nurse #2 stated it was at that point that staff ran to the room of Resident #5 and noted he was not there. Nurse #2 stated Resident #5 was returned to the facility by EMS shortly after 05:00 AM on 03/20/14. The nurse stated she then completed a head-to-toe skin assessment, with no new findings noted, placed a wander guard on the Resident and contacted the DON. On 03/27/14 at 11:04 AM, nurse #1 was interviewed and revealed she completed the Wandering/Elopement Risk assessment dated [DATE] for Resident #5. During the time of the assessment, nurse #1 stated she reviewed the Resident's medical record to include the hospital records, but found no indication of wandering/elopement behavior in the Resident's medical record, thus interventions were not warranted. Nurse #1 stated she remembered that Resident #5 had a habit of coming out of his room and asking staff to help him locate the bathroom or his room, but because he was easily redirected, this behavior was not noted as wandering or exit seeking. Nurse #1 stated she was a nurse on duty in the facility on 03/19/14 on the 11 PM - 7 AM shift, but was not assigned to care for Resident #5 and did not see him during her shift. On 03/27/14 at 11:24 AM, the DON stated in interview that on admission staff assess a resident's risk for elopement by asking the resident/family, reviewing hospital records, the FL 2 (level of care screening tool) and making observations of the resident. The DON stated the completion of the Wandering/Elopement Risk Assessment was usually completed by the charge nurse or the 11 PM - 7 AM nurse. The DON stated that she spoke to the PoA when Resident #5 was admitted , but no history of wandering/elopement behavior was indicated. The DON further stated that she expected a wander guard to be implemented if there was a history of exit seeking behavior or if a resident expressed a desire to leave the facility. The DON further clarified that if the expressed desire to leave the facility was easily redirected, she would not expect the intervention of a wander guard in all cases, but would expect this intervention if the resident continued to express a desire to leave regardless of whether or not the behavior was easily redirected. The DON stated she would expect monitoring on regular rounds for all residents and especially those at risk for wandering/elopement. The DON further revealed that she expected the physician to provide nursing staff with verbal instruction regarding recommendations from their assessments, hand write orders or enter the new order into the computer. The DON also stated that nursing staff should review the physician's progress notes, but recommendations and physician orders [REDACTED]. The DON reviewed the 03/12/14 physician's progress note regarding the recommendation of a memory care unit for Resident #5 and stated the charge nurse should have reviewed this and brought it to the attention of nurse administration for further evaluation of placement. On 03/27/14 at 11:56 AM, nurse #4 stated in interview that she typically worked with Resident #5 on the 3-11 PM shift. She described Resident #5 as confused, but cooperative. Nurse #4 stated that almost every night he approached the nurse's station around 9:00 PM or 10:00 PM confused, looking for his room, car keys, or the bathroom. Nurse #4 stated this confused behavior increased when Resident #5 was moved to a new room on the same hall. The nurse stated his behavior was easily redirected and not assessed as wandering or exit seeking. The nurse stated that on the evening of 03/19/14, Resident #5 was in his room when she came on shift at 3:00 PM and stayed in his room most of the shift. Nurse #4 stated that around 9:05 PM on 03/19/14, Resident #5 walked from his room to the nurse's desk wearing pajamas and confused about the location of his room; she redirected him to his room, administered medication to him and continued her med pass. Around 9:30 PM on 03/19/14, the nurse stated she saw Resident #5 in his room fully dressed, no longer wearing pajamas, but wearing pants, a shirt and shoes and asked NA #2 to encourage Resident #5 to put his pajamas back on. The nurse stated she then went into a supervisor's office, closed the door and began to complete her nurse charting. Nurse #4 then stated that NA #2 told her that Resident #5 was in his room, but refused to put his pajamas back on and she told the NA "okay." Nurse #4 stated she remained in the supervisor's office until she gave report to the oncoming nurse at 11:00 PM. Nurse #4 stated she could not account for the location of Resident #5 after about 9:30 PM on 03/19/14 because she did not conduct walking rounds at the end of shift since the floor was being waxed. Nurse #4 further stated that she was not aware that Resident #5 verbally expressed that he was leaving the facility, but when it was reported to her that Resident #5 refused to put back on his pajamas, she should have gone in to talk to him. The nurse stated she did not because "we see this behavior all the time." Nurse #4 stated Resident #5 did not have a wander guard in place, nor did she assess his change in behavior when she noticed him in his room fully dressed. On 03/27/14 at 12:10 PM, nurse #5 was interviewed and revealed that she cared for Resident #5 on the 7 AM - 3 PM shift. She described Resident #5 as confused, pretty quiet, easily redirected and without a wander guard. Nurse #5 stated that when the physician assessed one of her resident's she reviewed the medical record for any new orders, but did not always review the progress note for recommendations. Nurse #5 reviewed the physician's progress note of 03/12/14 for Resident #5 and stated she remembered reviewing the progress note previously, but did not notice the physician's recommendation for placement in a memory care unit. Nurse #5 stated had she noticed that comment, she would have recommended a wander guard for Resident #5 and communicated it to her supervisor for consideration of placement. On 03/27/14 at 1:46 PM, floor technician #1 was interviewed and stated that he came to work about 9:00 PM on 03/19/14, gathered supplies and began waxing sections of the floor on the 200 hall about 10:30 PM. Floor technician #1 stated he did not see Resident #5 in his room while waxing the floor. On 03/27/14 at 4:30 PM an observation of the police station revealed it was approximately 0.8 miles away from the facility and across from a 7 lane, 4-way intersection, with a speed limit of 45 miles per hour. The facility's Administrator, Director of Nursing, Nurse Consultant and Vice President of Clinical Operations were notified of Immediate Jeopardy on 03/27/14 at 4:55 PM for Resident #5. The facility provided a credible allegation of compliance on 03/29/14 at 3:39 PM. The following interventions were put into place by the facility to remove the Immediate Jeopardy. Credible Allegation of Compliance: This allegation of compliance is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take the actions set forth in the following allegation of compliance. The following credible allegations constitutes the center's allegation of compliance. All alleged deficiencies have been or will be completed by the dates indicated. How the corrective action will be accomplished for those residents found to have been affected by the deficient practice: ? On 3/20/2014 Resident # 5 at approximately 12:05 a.m. was reported to be at the hospital. The hospital nurse reported to our facility charge nurse that the Police Department, reported our resident walked to their station and asked for a ride home. The police assisted the resident. They attempted to take him to two different locations. Both of the locations were the incorrect home addresses for the resident. It was at this point the police realized the resident was possibly confused. Emergency Medical Services was called and the resident was transported to the hospital. The resident was evaluated by hospital ED, and it was determined no trauma or injury was experienced by the resident, which was confirmed by facility nurse upon his return. ? Power of Attorney for Resident #5 decided to transfer resident #5 to a different facility on 3/28/14 as previously planned. Resident #5 is no longer in the facility. ? The Resident had a wander guard applied on him upon return to the facility and the Director of Nursing did every 30 minute checks from 0700 a.m. to 0600 p.m. on 03/20/2014. ? On 03/21/2014 resident #5 Wandering and Elopement Risk Assessment was re-evaluated to ensure appropriate interventions were in place. ? All staff was in-serviced on 3/20/2014 for "code orange" including elopement procedures, patient rounding, and responding to alarms. ? On 3/20/14 maintenance director contacted Fire Monitoring Company who performed in house testing of all doors and alarms. All door alarms were found to be properly working with no malfunctions (Note: An event history report of the alarm system showed two alarms were signaled on the facility ' s 100 hall. Both were accounted for). As a routine practice the Maintenance directors or designee will test door alarms daily. ? As a routine practice, Housekeeping will strip and wax hallways in halves to allow passage for walking rounds. How corrective action will be accomplished for those resident having potential to be affected by the same deficient practice: ? The Director of Nursing (DON) arrived at the facility on 3/20/14 and verified that all residents were accounted for. ? As a routine practice, visual rounds and cross shift communication will be done by nursing every shift to observe and ensure all residents are accounted for. This will be reviewed in Risk Management Meeting on a weekly basis and through quarterly QA as needed. ? On 3/20/2014, under the direction of DON, all current residents with a wander guard in place were assessed for placement. All were in place. All staff was in-serviced on 3/20/2014 for "code orange" including elopement procedures, patient rounding, and responding to alarms. ? On 3/20/14 the maintenance director contacted Fire Monitoring Company who performed in house testing of all doors and alarms. All door alarms were found to be properly working. As a routine practice the Maintenance director or designee will test door alarms daily. ? On 03/21/2014 all residents in house on this date, Wandering and Elopement Risk Assessments were re-evaluated and revised as needed by the DON and Registered Nurse Minimum Data Set (MDS) Coordinator. ? On 03/27/2014 all residents in house on this date, Wandering and Elopement Risk Assessments were re-evaluated by the DON and Registered Nurse Minimum Data Set (MDS) Coordinator. A facility employee was posted in the front lobby by the door to monitor for any attempts by any resident to exit the facility until all wander-guards were checked and in place. ? 03/27/2014 Initially at 05:00 p.m. every 15 minute visual checks were completed on residents that could be at risk based on Wandering Assessment and then at 1100 p.m. an employee was posted at the front door until 2:45 a.m. when all wander-guards were verified to be in place. ? On 3/27/2014 all staff were in-serviced by Director of Nursing, Staff Development Coordinator, Unit Manager and one done by the Regional Vice President of Operations on the following policies and procedures to ensure understanding. New hires will be educated during general orientation. All staff will be in-serviced before returning to work. 1) Nursing Policy and Procedure #401, Behavioral Assessment/Behavior Monitoring, which states that problematic behavior shall be assessed and monitored. Factors influencing behaviors as well as management interventions shall be evaluated and care planned. Under this policy Residents will be observed by staff on all shifts and during visual rounds every shift. Staff will immediately report any untoward (untoward meaning unusual behavior) behavior that is observed to a licensed nurse. Department Heads and Nurse Administration immediately re-in serviced all staff on 03/28/14 on the Stop and Watch Tool which is utilized by all staff in helping to identify and communicate changes in patients to the licensed nurse, even subtle changes, and communicate those changes to nursing staff immediately so that appropriate interventions can be put in place. On 03/28/2014 the facility also began in-service for all staff on wandering/elopement risk assessment form which specifies the behavior of residents at risk for elopement. The form provides the licensed nurse with multiple interventions for residents at risk of elopement including the use of wander guards, frequent monitoring, use of diversion, among others. 2) Policy and Procedure #1539, Safety/Security Systems (Wandering), which states Residents identified as at risk for wandering away from the Center will have the least restrictive monitoring device is in use. This policy gives guidance to initiate safety/security devices as deemed appropriate to minimize the potential for leaving the Center unsupervised. Per this policy complete the appropriate assessments. 3) Nursing Policy and Procedure #802, Potential Transfer/Discharge Due to Behavior, which states Discharge planning staff, in conjunction with the Administrator and designated nursing staff will evaluate patients who exhibit untoward behaviors. Immediately notify the Administrator, DON or Nursing Supervisor. Proper investigation report will be directed by the Administrator. If there is reason that the patient is a danger to self or others then a review of the medical record with the licensed nurse, CNA and interview with patient/responsible party, to determine what triggers the behavior (i.e. bath time, time of day, room change, loud noise, difficulty hearing/understanding, fear, unfamiliar caregivers, unfamiliar surroundings). 4) Nursing Policy and Procedure # 1801, Code Orange, which covers the immediate notification of a missing resident, Code Orange will be activated throughout the Center. All established search and recover plans will be initiated in full force to locate and secure the resident as quickly as possible. All staff will be pre-assigned and trained on their duties and responsibilities during this critical event. 5) Nursing Policy and Procedure #1802, Search and Reporting, in the event a resident is reported missing, all available resources will be utilized to search for and find the resident as quickly as possible. Anyone that suspects or realizes that a resident is missing must notify a licensed nurse and/or the Nursing Supervisor immediately. A Nursing Supervisor on duty must immediately initiate a search of the Center and grounds, and at the same time report to the Administrator, the Director of Nursing and Nurse Consultant that the resident is missing. ? On 3/27/2014 Risk Meeting held consisting of Interdepartmental team members, RN Nurse Consultant, Director of Nursing, Minimum Data Set RN and RN Unit Manager and all in-house resident Wandering Assessments reviewed and updated as needed. ? Wander risk care plans were updated to include appropriate interventions. Pictures of residents at risk for elopement were added as needed to binders at each nurse ' s station and secured behind the receptionist desk. All new staff will receive education on this binder during general orientation. ? Housekeeping will strip and wax hallways in halves to allow passage for walking rounds. This will remain in effect with no end date. ? On March 29, 2014, Director of Nursing contacted Medical Director and attending physician and instructed that orders, recommendations and progress notes be flagged so that nurses can address orders, recommendations or progress notes as needed. Immediate jeopardy was removed on 03/29/14 at 3:39 PM when interviews with nursing staff revealed they were in-serviced to conduct visual walking rounds each shift. Additionally, interviews with nurses revealed they were in-serviced to immediately re-evaluate and assess a resident with changes in behavior consistent with an increased risk for wandering/elopement and to immediately implement interventions as needed. Interviews with nurses also revealed they were in-serviced to review/process any flagged physician progress notes [REDACTED]. Interviews with nurse aides and housekeeping staff revealed they were in-serviced on how to recognize even subtle changes in behavior that would place a resident at increased risk for wandering/elopement and to immediately report this behavior to a nurse. These interviews also revealed they were in-serviced on the use of the facility's Stop and Watch tool for documenting changes in behavior and reporting this behavior to a nurse.

Based on observation, staff interviews and record review, the facility failed to provide a floor mat and prevent a fall during care for one (1) of four (4) sampled residents who were identified as being at risk for falls (Resident #3). The findings are: Review of Resident #3's record revealed an admission date of [DATE]. Resident #3's admission Minimum Data Set ((MDS) dated [DATE] and most recent quarterly MDS dated [DATE] revealed the resident had severe cognitive impairment and required the extensive assistance of two persons for bed mobility, dressing and personal hygiene. The MDSs further revealed the resident required two persons transfers and was totally dependent for bathing. The admission MDS dated [DATE] assessed Resident #3 required two persons for bathing; the quarterly MDS dated [DATE] assessed one person was required for bathing. Review of the care plan dated 11/8/10 and updated on 2/28/11 revealed Resident #3 was at risk for falls. Fall prevention measures listed were: frequent bed checks, assistance with transfers, floor mats at bedside and bed alarm. Further review of the care plan revealed use of a low bed was added as an intervention on 12/13/10. The use of two staff during all care was added to the care plan as an intervention on 2/28/11. Review of Resident #3's nursing notes and fall investigation reports revealed the following: ? On 11/5/10 at 8:30 AM, Resident #3 fell out of the air mattress bed onto the floor. This fall was not witnessed and there was no injury. Floor mats were added as a care plan intervention. ? On 11/9/10 at 1:30 AM, a fall from the bed onto a floor mat occurred. A bed alarm was added as a care plan intervention. Resident #3 was on the floor mat when the Nursing Assistant made her usual rounds. There was no injury. A bed alarm was added as a care plan intervention. ? On 12/10/10 at 4:12 AM Resident #3 fell out of bed onto a floor mat. Resident #3 received a low bed. The type of alternating air mattress was exchanged to an air mattress with no raised vertical columns. ? On 2/25/11 at 10:15 AM, Resident #3 fell out of bed during a bed bath given by a Nursing Assistant (NA) onto the floor. There was no floor mat on the side of the bed where he fell . Resident #3 was transferred to the hospital for evaluation. Review of the emergency department report dated 2/25/11 revealed Resident #3 received one staple for a scalp laceration and returned to the facility. Interview at 9:15 AM on 3/2/11 with Licensed Nurse (LN) #1, who was on duty when the 2/25/11 fall occurred, revealed she had been called to the room by NA #5. LN #1 reported Resident #3 was lying on the floor next to his bed. His head was against the bedside table and there was bleeding from a cut. LN #1 explained the floor mat had not been on the side of the bed where the fall occurred. A floor mat was on the other side of the bed. Continued interview with LN #1 revealed she assessed Resident #3 after the fall and transferred him to the hospital. LN #1 revealed one or two Nursing Assistants bathed and dressed Resident #3 prior to this fall. LN #1 explained the number of persons required varied because nursing assistant would decide if help was required. Some Nursing Assistants did not need help with the bed bath. She explained she did not direct the number of staff required for care. LN #1 reported the care plan for Resident #3 required two persons during care at all times after the 2/25/11 fall. Observation at 9:30 AM on 3/2/11 revealed Nursing Assistant (NA) #2 and NA #3 gave Resident #3 a bed bath. Resident #3 did not move during the bed bath. Both legs were contracted and a splint was on his left hand. There was a floor mat on one side of the bed. Interview with Nursing Assistant (NA) #2 at 9:40 AM on 3/2/11 revealed Resident #3 required one or two staff persons for assistance during care prior to the 2/25/11 fall. NA #2 reported she cared for Resident #3 without assistance until after the 2/25/11 fall. NA #2 explained Resident #3 did not move during care and required total assistance. NA #2 did not know how Resident #3 was able to fall out of bed during care. NA #2 explained she could not remember if she had told NA #5 one or two persons were required for a bed bath. Interview with the interim Director of Nursing (DON) at 11:45 AM on 3/2/11 revealed the 2/25/11 fall investigation was not complete and NA #5 was suspended pending the investigation's outcome. She stated that Resident #3's care plan now required two persons during all care at bedside. The DON reported Resident #3 had required one staff person during a bed bath prior to this fall. She explained new Nursing Assistants followed the lead of experienced Nursing Assistants for training. The DON revealed she expected the Licensed Nurses to give report at the beginning of the shift with instructions for resident care. She expected this instruction to include the number of staff required if the Nursing Assistant was new. Interview with the MDS Coordinator at 12:15 PM on 3/2/11 revealed she used her direct observations and interviews with Nursing Assistants to determine the number of persons required during the bath. She assessed Resident #3 required one person during the bath for the most recent MDS. Telephone interview with NA #5 at 12:20 PM on 3/2/11 revealed Resident #3 fell out of bed when she turned him during a bed bath. NA #5 explained she thought the water on the air mattress contributed to the fall because it was "slick." She reported Resident #3 was in the middle of the air mattress and she turned Resident #3 away from her toward the window. NA #5 explained Resident #3's legs came off the bed and she could not stop the fall. NA #5 reported there was no floor mat on the side of the bed where Resident #3 fell . NA #5 revealed she was new to Resident #3 and thought she did not need help during the bed bath. NA #5 reported she received instructions from other Nursing Assistants regarding Resident # 3's care. Observation at 7:55 AM on 3/3/11 revealed Resident #3 in bed with floor mats on each side. A second interview with the DON at 9:50 AM on 3/3/11 revealed Resident #3's second floor mat was placed yesterday (3/2/11). She explained Resident #3 had one floor mat on 2/25/11 because his other falls occurred on the same side of the bed. The DON reported the facility placed floor mats on the side of the bed where residents fell . The DON explained the second floor mat was to be placed after the 2/25/11 fall but it was delayed due to delivery issues and need for cleaning prior to use.