**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident's right to be free from neglect for one of three residents (Resident 1), when the Registered Nurses failed to perform a comprehensive nursing assessment (a detailed physical examination of the patient's entire body, to gather information about the patient's status) on Resident 1 upon his initial admission to the facility on July 3, 2024, and his readmission from the hospital on July 9, 2024,after Resident 1 was sent out due to being unresponsive. This failure resulted in Registered Nurse 6 (RN 6) being unaware of Resident 1's paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity) and connecting the enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) to the paracentesis drainage tube, instead of the gastrostomy tube feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach). The administration of the enteral feeding formula into the peritoneal cavity (space within the abdomen that contains the intestines, the stomach and the liver) caused Resident 1 to experience unnecessary abdominal pain from the retained enteral feeding formula into the peritoneal cavity Resident 1 was transferred to a general acute care hospital (GACH) in the intensive care unit (ICU), where he died. Findings: During a review of Resident 1's admission Record (contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, cardiac arrest (when a person's heart stop pumping blood around the body), end stage renal disease (condition in which kidneys can no longer function adequately to meet the body needs) with hemodialysis (a treatment to filter wastes and water from the blood), liver cirrhosis (condition in which liver is permanently damaged), diabetes mellitus type 2 (a condition in which pancreas can't produce enough insulin), tracheostomy status (a surgically created hole in the front of the neck and into the windpipe, to allow to insert a tube to keep it open for breathing) and gastrostomy status (a surgically that creates an opening in the stomach through the abdomen, allowing for a tube to be inserted and used for feeding). During a review of Resident 1's document [NAME], Facility: [name of the facility] . History and Physical (H&P-information about a patient's health status and to establish diagnosis), for Resident 1, dated July 5, 2024, the H&P indicated Resident 1 had diagnoses which included, tracheostomy dependence, ventilator dependence (a machine that pumps air into the lungs when a patient is unable to breathe independently), dependence on renal dialysis (a treatment to filter wastes and water from the blood), paracentesis with peritoneal drain placement (peritoneal drainage tube) and gastrostomy tube dependent. During a concurrent interview and record review on July 12, 2024, at 9:15 AM, with the Director of Nursing (DON), Resident 1's Admit/Readmit Screener V.2 (screener assessment - a basic health assessment), effective July 3, 2024, at 2:01 AM, was reviewed. The Admit/Readmit Screener V.2 indicated, Resident 1 had a PEG-TUBE (PEG - percutaneous endoscopic gastrostomy tube inserted surgically through the abdomen into the stomach), received nutrition via tube feeding and received oxygen via tracheostomy. The Admit/Readmit Screener V.2, did not include Resident 1 had a paracentesis drainage tube and it was signed by License Vocational Nurse 7 (LVN 7). The DON was not able to provide documented evidence of a Registered Nurse conducted Resident 1's comprehensive assessment upon admission on [DATE], and readmission from the hospital, on July 9, 2024. The DON stated, LVN 7 completed the screener assessment, not a comprehensive assessment. During a review of Resident 1's nursing Progress Notes . Type: Alert Note, dated July 9, 2024, at 2:26 AM, the Progress Notes indicated, @ [at] 0145 [1:45 AM] Family at bedside stated pt [patient] having difficulty breathing. RT [respiratory therapist] notified and performed interventions. Pt [Resident 1] observed unresponsive to verbal and tactile stimuli. Respirations observed, pulses palpable. Patient bagged at 100 % FiO2 [fraction of inspired oxygen - the percentage of oxygen in the air a person is breathing] via ambu-bag [ a bag valve mask used to force air into the lungs of a person who cannot breathe] and regained consciousness . @ 0210 [ 2:10 AM] RT responded to mechanical ventilator alarm. Pt unable to respond appropriately. Pt was removed from ventilator and bagged again by RT. Rapid response called. Pt noted having 3 episodes of vomiting. RT suctioned copious amount of chunky secretions from tracheostomy tube and suspected patient may have aspirated. RN supervisor called 911 to send patient to ER for further evaluation . The Progress Notes . Type: Alert Note, was signed by Registered Nurse 2 (RN 2). During a review of Resident 1's nursing Progress Notes . Type: admission Summary, dated July 9, 2024 at 2:00 PM, the Progress Notes indicated, Resident returned from [name of the GACH] ER [emergency room] via gurney and [Name of ambulance ] transport, without incident or injury, no new orders noted at this time from ER visit, resting in bed, no s/s [signs or symptoms] of distress to note, patient's wife at bedside, charge nurse aware, call light within reach, cooling measures implemented, all needs met by staff, will continue to monitor, bed in lowest position. The Progress Notes . Type: admission Summary, was signed by the Subacute Manager/LVN (SM). During a review of Resident 1's nursing Progress Notes . Type: Transfer to Hospital Summary, dated July 9, 2024, at 10:06 PM, the Progress Notes indicated, Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient] CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident. After assessment RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation . The Progress Notes . Type: Transfer to Hospital Summary, was signed by Licensed Vocational Nurse 5 (LVN 5). During an interview on July 12, 2024, at 9:55 AM, with the DON, the DON stated, she received a call from Registered Nurse 2 (RN 2) on July 9, 2024, at approximately 10:00 PM, informing her that Resident 1's wife reported her husband complained of abdominal pain. The DON stated, RN 2 noticed the enteral feeding formula was infusing through Resident 1's paracentesis drainage tube. The DON further stated Resident 1 was transferred to GACH on July 9, 2024, at 1:45 AM due to difficulty breathing and returned to the facility at 2:00 PM, on the same day. The DON stated, it was Registered Nurse 6 (RN 6)'s responsibility to assess Resident 1 upon his return from GACH and connect the enteral feeding formula to the G-tube, but she did not. During an interview on July 12, 2024, at 11:35 AM, with Registered Nurse 2 (RN 2), RN 2 stated, on July 9, 2024, at approximately 8:20 PM, Resident 1's wife reported her husband was having abdominal pain. The RN 2 stated, she assessed Resident 1 and observed the enteral feeding formula was infusing through the paracentesis drainage tube, which was on the floor. RN 2 further stated, she removed the feeding from the paracentesis drainage tube and called the physician. During an interview on July 12, 2024, at 3:00 PM, with Registered Nurse 1 (RN 1), RN 1 stated, she saw Resident 1 in his room, on July 9, 2024, at 3:30 PM, when she [RN 1] was doing rounds. RN 1 stated, she did not conduct a comprehensive nursing assessment to Resident 1. RN 1 further stated she should have performed it to Resident 1, after he [Resident 1] returned from the hospital. During a follow up interview on July 12, 2024, at 3:20 PM, with the DON, the DON stated, when residents are admitted or readmitted from GACH, the license vocational nurse who admits the residents, perform Admit/Readmit Screener (a basic health assessment), not a comprehensive nursing assessment. The DON further stated, Registered Nurses are expected to complete a comprehensive nursing assessment within 24 hours of admission. During an interview and record review on July 12, 2024, at 4:23 PM, with the Subacute Manager (SM), Resident 1's medical records were reviewed. The SM was not able to find documented evidence that demonstrate a comprehensive nursing assessment was performed to Resident 1. The SM stated, there was no documented evidence to indicate a comprehensive nursing assessment was conducted for Resident 1 upon his admission on [DATE], and readmission on [DATE]. During a concurrent interview and record review on July 12, 2024, at 9:15 PM, with the DON, the DON reviewed Resident 1's medical records and was unable to find documented evidence that a comprehensive nursing assessment was performed for Resident 1 after his admission on [DATE], and his re-admission on [DATE]. During a concurrent interview and record review on July 12, 2024, at 9:48 PM, with the DON, the facility's policy and procedure (P&P), titled, admission Evaluation/Assessment & Follow Up: Role of Nurse, revised September 2012, was reviewed. The P&P indicated, The purpose of this procedure is to gather information about the resident's physical, emotional, cognitive, and psychosocial condition upon admission or readmission for the purpose of managing the resident, initiating the care plan and completing the required assessment instruments . The DON stated, the P&P did not indicate the staff responsible to perform the assessment. During an interview on July 12, 2024, at 9:58 PM with Registered Nurse 3 (RN 3), RN 3 stated it is the responsibility of the Registered Nurses to perform a comprehensive nursing assessment to the residents upon an admission or readmission to the facility. The RN 3 further stated the registered nurses would have 24 hours to complete a comprehensive nursing assessment and would need to endorse to the next shift if unable to complete a comprehensive assessment during admission. The RN 3 stated, the admission assessment must be documented in the residents' medical records. During a record review of the Registered Nurse job description, undated, the job description indicated, .4. Collect resident pre-admission and/or admission information and assist Director of Nursing Service to determine appropriate level of care . 19. Assess resident upon admission/readmission, change of condition, resident equipment, and supply needs, and make recommendations to the DON. An Immediate jeopardy (IJ- a situation in which an entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death ) was called on July 12, 2024, at 10:15 PM under CFR 483.12(a)(1) Freedom from abuse, neglect, and exploitation. It was determined that due to the Registered Nurses lack of awareness, they failed to perform a comprehensive assessment to meet the needs of Resident 1, upon admission, on July 3, 2024, and on readmission on [DATE], and resulted in Resident 1 being transferred out to GACH, in the intensive care unit (ICU). The IJ was called in the presence of Administrator and DON. A corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested. The Administrator provided CAP on July 14, 2024, at 7:17 PM, the CAP was reviewed and approved on July 15, 2024, at 11:35 AM, and included the following: 1) In-Service was conducted by the DON and Assistant director of Nursing (ADON), on July 12, 2024, and completed on July 14, 2024, regarding new admissions and readmissions to be assessed by RN upon admission/arrival to include head to toe assessment as soon as practically possible or within the first 2 hours from the time of admissions to assess stability of the resident, with documented evidence of full assessment by the end of the shift and according to the regulatory standards. 2) In-Service was conducted by the DON and ADON, on July 12, 2024, and completed on July 14, 2024, regarding Licensed staff including RNs will be educated by DON or Designee on the assessment process to ensure compliance prior to starting shifts. Ongoing training will be provided via verbal education and skills-check to existing and new staff, as needed and upon orientation, respectively, to ensure compliance. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties. 3) In-Service was conducted by the DON and ADON on July 12, 2024, and completed on July 14, 2024, regarding the policy and procedures of admission Evaluation / Assessment & Follow-up: Role of Nurse. During a record review of three (3) residents (Resident 4, 5 and 6) admitted on [DATE], the comprehensive nursing assessment was performed by a Registered Nurse, within two (2) hours of admission. The acceptable CAP was verified with the facility through observations, interviews, and record review. The IJ was removed on July 15, 2024, at 8:00 PM, in the presence of the Administrator and DON. During a record review of the hospital H&P, dated July 9, 2024, the H&P indicated Resident 1 .presents w [with]/ 1d [one day] severe, constant, diffuse abdominal pain after received tube feeds though the peritoneal drain instead of his PEG tube [Percutaneous endoscopic gastrostomy - a feeding tube inserted through the skin and the stomach wall directly to the stomach]. MICU [Medical Intensive Care Unit] consulted d/t [due to] septic shock [when an infection causes dangerously low blood pressure and organ failure] 2/2 [secondary to] peritonitis [inflammation of the peritoneum, the thin tissue lining in the abdominal wall that covers the abdominal organs] in a trach [tracheostomy] dependent patient. During a record review of the hospital Discharge summary, dated [DATE], the discharge summary indicated, . Continue on abx [antibiotic] and bedside washout ( a procedure that involved washing the peritoneal cavity with a saltwater solution) performed by surgery team . family opting for non-surgical management given patient's overall clinical status at this time. Patient's family opting for comfort-focused care given grave prognosis [a prediction about the course of a disease]. He [Resident 1] passed surrounding by family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure licensed nurses were provided training to demonstrate competencies with paracentesis drainage tube (a catheter to remove fluid from the abdominal cavity) and gastrostomy tube feeding (G-tube, a tube inserted through the abdominal wall that brings nutrition directly to the stomach), for one of three residents (Resident 1) when Registered Nurse 6 (RN 6) connected and infused the enteral feeding formula (liquid food designed to provide nutrition directly into the stomach) to the paracentesis drainage tube, instead of the gastrostomy tube feeding, on July 9, 2024. This failure resulted in Resident 1 to experience unnecessary abdominal pain, retained enteral feeding formula into the peritoneal cavity (space within the abdomen that is lined by the peritoneum, a thin, smooth membrane) and Resident 1 was transferred to a general acute care hospital (GACH) in the intensive care unit (ICU), where he died. Findings: During a review of Resident 1's admission Record (contains demographic information), the admission Record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses which included, cardiac arrest (when a person's heart stop pumping blood around the body), end stage renal disease (condition in which kidneys can no longer function adequately to meet the body needs) with hemodialysis (a treatment to filter wastes and water from the blood), liver cirrhosis (condition in which liver is permanently damaged), diabetes mellitus type 2 (a condition in which pancreas cannot 't produce enough insulin- a hormone that lowers the glucose in the blood), tracheostomy status (an artificial opening into the windpipe, that allows to insert a tube into the trachea, allowing a person to breathe) and gastrostomy status (a surgically created opening into the abdominal wall through which liquid nutrition and medication can be administered into the stomach). During a review of Resident 1's document titled, Facility: [name of the facility] . History and Physical (H&P-information about a patient's health status and to establish diagnosis), for Resident 1, dated July 5, 2024, the H&P indicated Resident 1 had diagnoses which included, tracheostomy dependence, ventilator dependence (a machine that pumps air into the lungs when a patient is unable to breath independently), dependence on renal dialysis (a treatment to filter wastes and water from the blood), paracentesis with peritoneal drain placement (peritoneal drainage tube) and gastrostomy tube dependent. During a review of Resident 1's nursing Progress Notes . Type: Transfer to Hospital Summary, dated July 9, 2024, at 10:06 PM, the Progress Notes indicated, Wife asked CN [charge nurse] to connect drainage bag to paracentesis tube. When assessing the pt [patient] CN noted that the LTAD [Long Term Abdominal Drain] did not have the proper connection to connect the drain. CN noted that the tube appeared to have thick viscus cream/tan colored liquid in it. Informed RN supervisor to assess the resident. After assessment RN called NP [Nurse Practitioner] at 2045 [8:45 PM] and informed him of the situation. NP gave order to send patient out for further evaluation . The Progress Notes . Type: Transfer to Hospital Summary, was signed by Licensed Vocational Nurse 5 (LVN 5). During an interview on July 12, 2024, at 9:20 AM, with License Vocational Nurse 1 (LVN 1). LVN 1 stated training and education was done regarding drainage tube in general, but not specifically on how to manage paracentesis drainage tube. During an interview and record review on July 12, 2024, at 9:55 AM, with the Director of Nursing (DON), the DON stated Registered Nurse (RN 6) reported to her she [RN 6] hung Resident 1's enteral feeding and was unaware of the paracentesis drainage tube. The DON further stated, she contacted Resident 1's wife for a follow-up and was informed Resident 1 was in ICU and 200 mL (mL - milliliters, unit of measurement) of fluid was removed from the peritoneal cavity. During an interview on July 12, 2024, at 10:37 AM, with License Vocational Nurse 2 (LVN2), LVN 2 stated he received education on how to check residual and placement of a gastrostomy tube feeding but could not differentiate between a gastrostomy tube feeding and a paracentesis drainage tube. During an interview on July 12, 2024, at 11:03 AM, with Registered Nurse 1 (RN 1), RN 1 stated she received training for gastrotomy tube feeding, but was not familiar with the management of paracentesis drainage tube. During an interview on July 12, 2024, at 11:35 AM, with Registered Nurse 2 (RN 2), RN 2 stated, on July 9, 2024, at approximately 8:20 PM, Resident 1's wife reported her husband was having abdominal pain. The RN 2 stated, she assessed Resident 1 and observed the enteral feeding formula was infusing through the paracentesis drainage tube, which was on the floor. RN 2 further stated, she removed the feeding from the paracentesis drainage tube and called the physician. RN 2 stated she did not receive training or education for management of paracentesis drainage tube. During a concurrent interview and record review on July 12, 2024, at 2:45 PM, with the DON, the facility's policy and procedure (P&P), titled, Managing Draining Tube, revised November 2018, was reviewed. The P&P indicated, Purpose . To Ensure safe Monitoring of drainage tubes such as JP [Jackson Pratt - a thin flexible tube with a bulb at the end that drains fluid away from a wound] Drains, Nephrostomy [a tube that lets urine drain from the kidney through an opening in the skin on the back], Urostomy [an opening in the abdomen that directs urine from the bladder], Paracentesis, G-Tube, etc. 1. All personnel responsible for monitoring drainage tubes will be trained, qualified and competent in his or her responsibilities . Preventing misconnection errors . 1. Assess all drainage tubes prior to treatment. 2. Regularly inspect tubing for proper and secure connections. The DON stated staff did not follow the policy. The DON further stated that education and training was conducted after the incident on July 10, 2024. The DON stated no training or education was done regarding paracentesis draining tube, prior to the incident. During a review of the facility's P&P titled, Competency of Nursing Staff, revised October 2017, the P&P indicated, 1. All nursing staff must meet the specific competency requirements of their respective licensure and certification requirements defined by state law. 2. In addition, licensed nursed and nursing assistants employed (or contracted) by the facility will: a. participate in a facility-specific, competency-based staff development and training program; and b. demonstrate specific competencies and skills sets deemed necessary to care for the needs of the residents, as identified through resident assessments and described in the plans of care. An Immediate jeopardy (IJ- a situation in which an entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment, or death) was called on July 12, 2024, at 10:15 PM under CFR 483.35(a)(3) Nursing Service. It was determined that nursing staff did not have competencies to take care Resident 1's paracentesis drainage tube and gastrostomy tube feeding. The IJ was called in the presence of Administrator and the DON. A corrective Action Plan (CAP- a plan which includes interventions to remove the potential or actual harm of an immediate jeopardy situation) was requested. The facility's Administrator provided CAP on July 14, 2024, the CAP was reviewed and approved on July 15, 2024, at 11:35 AM, included the following: 1) In-service initiated/conducted by Director of Nursing from July 10, 2024, and completed on July 14, 2024, on: a. Proper Infusion of G-Tubes and management of drainage tubes including, but not limited to paracentesis drainage tubes, b. Monitoring of the G-tube feeding by license staff per shift, to verify pump has been infused properly, c. Observe the status of the resident, and ensure resident's needs are met, d. As safety precaution 2 nurses will check to verify g-tube feedings for accuracy and compliance at the change of shift. e. Ongoing education and competency training to be provided to staff to verify competency of the licensed staff particularly as it relates to proper infusion and monitoring of G-tube feeding and managing paracentesis drainage tubes. f. Onboarding Licensed staff and staff who are away will also be oriented of the proper procedures, with documented evidence accordingly, prior to beginning shift/ floor duties. 2) In-service initiated/conducted by DON and Assistant Director of Nurses (ADON) from July 10, 2024, and completed on July 14, 2024, regarding identifying the different type of enteral feeding, enteral tube use and maintenance, tube occlusion: Prevention/Management, g-tube replacement, and patency. During an observation on July 15, 2024, at 7:30 PM, during shift change (AM shift- PM shift). Incoming and outgoing staff, shift report at the bedside of each patient, verifying the gastrostomy tube feedings site, patency [flushing with water], the correct formula and feeding pump settings. The acceptable CAP was verified with the facility through interview and record review. The IJ was removed on July 15, 2024, at 8:00 PM, in the presence of the Administrator and DON. During a record review of the hospital H&P, dated July 9, 2024, the H&P indicated Resident 1 .presents w [with]/ 1d [one day] severe, constant, diffuse abdominal pain after received tube feeds though the peritoneal drain instead of his PEG tube [Percutaneous endoscopic gastrostomy - a feeding tube inserted through the skin and the stomach wall directly to the stomach]. MICU [Medical Intensive Care Unit] consulted d/t [due to] septic shock [when an infection causes dangerously low blood pressure and organ failure] 2/2 [secondary to] peritonitis [inflammation of the peritoneum, the thin tissue lining in the abdominal wall that covers the abdominal organs] in a trach [tracheostomy] dependent patient. During a record review of the hospital Discharge summary, dated [DATE], the discharge summary indicated, . Continue on abx [antibiotic] and bedside washout ( a procedure that involved washing the peritoneal cavity with a saltwater solution) performed by surgery team . family opting for non-surgical management given patient's overall clinical status at this time. Patient's family opting for comfort-focused care given grave prognosis [a prediction about the course of a disease]. He [Resident 1] passed surrounding by family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure their infection control program was followed when: 1. Three dialysis caregivers (Caregiver 1, 2 and 3) from [Name of dialysis center] accessed the Central Venous Catheter (CVC, a flexible thin tube that is inserted to the vein to the large artery of the heart used for hemodialysis, (the process of removing excess water, solutes, and toxins from the blood in people whose kidneys no longer work, a life sustaining procedure) and practiced poor infection control for two of three (Residents 216, and 220) of 3 hemodialysis sampled residents. This deficient practice had the potential to promote development and spread of communicable diseases and infections to Resident 216 and Resident 220, who are vulnerable and immunocompromised (when one's immune system's defenses are low, affecting its ability to fight off infections and diseases) residents who are receiving hemodialysis. 2. One Licensed Vocational Nurse (LVN 1) entered a transmission-based precaution room (a separate room that keep residents with certain medical conditions or infections separate from other people while they receive medical care) with contact precautions (require anyone entering the room to wear gown and gloves) without a gown for one of three residents (Resident 30). This failure had the potential to cause cross-contamination of infectious pathogens (bacteria and microorganisms transferred unintentionally from one object to another) within the facility 3. One Licensed Vocational Nurse (LVN 1) did not clean and disinfect a glucometer (medical device used to measure glucose in the blood) for two of three residents (Resident 416 and Resident 417) and stated she cleaned and disinfected the glucometer only after an isolation room and at the end of her shift. This failure had the potential to result in blood-borne infections (viruses that are carried in the blood). 4. The Certified Nursing Assistant (CNA 1) entered the contact isolation room for Resident 30 without hand hygiene or personal protective equipment (PPE specialized clothing or equipment worn to protect against infectious materials) and exited the room without hand hygiene. This failure had the potential to cause cross-contamination of infectious pathogens from one resident (Resident 30) to others in the facility. 5. The Housekeeping Aide (HA 1) collected trash from one room room [ROOM NUMBER] to another room room [ROOM NUMBER] without observing hand hygiene, then walked along the hallway wearing the same used gloves going to another room. This had the potential to spread contaminants present from the contents of the trash bins into the surrounding areas of the facility. 6. Two trash bins in two resident rooms (Rooms 218 and isolation room [ROOM NUMBER] a room on contact isolation (precaution used when a patient has an infectious disease that may be spread by touching either the patient or other objects the patient has handled) were overflowing with used Personal Protective Equipment (PPE), causing the trash bin lid to remain open. This had the potential to spread infectious organisms from contaminated used PPE. 7. Four sharps containers (used for safe disposal of used needles and syringes) in Rooms 122, 218, 221, and 234, were observed filled past the fill line indicator (a line marker indicating the container needs to be replaced). This had the potential risk for infections related to needlestick injuries (injuries caused by punctures from needles used in medical procedures). These deficient infection control practices had the potential to result in the cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another with harmful effect), of infectious pathogens that increased the risk for blood-borne infections (viruses that are carried in the blood) towards all 120 vulnerable residents in the facility, including 10 residents on hemodialysis with eight residents on artificial airways using tracheostomy ventilation (an opening created at the front of the neck so a tube can be inserted into the windpipe to help you breathe). Findings: 1. During an observation on April 10, 2023 at 6:30 AM, a Dialysis Caregiver 1 (DC 1) repeatedly failed to follow infection control practices, when DC 1 changed the CVC dressing, accessed the CVC and connected the CVC blood lines (plastic tubes that connects resident's to the hemodialysis machine) to Resident 216's CVC. Resident 216 was not wearing a mask. DC 1 did not perform hand hygiene in between seven glove changes, and placed 10 opened sterile syringes on top of a non-sterile blue chux (a pad made of paper with a waterproof backing), and did not clean the exit site of Central Venous Catheter from the center towards the outside (an infection control techniques that requires to disinfect an open skin area from the least contaminated to the most contaminated skin area). During a review of Resident 216's face sheet (a document that contains resident's basic demographic information) indicated Resident 216 was admitted to the facility on [DATE], with diagnoses that included end stage renal disease (kidneys can no longer function on their own), anemia ( deficiency of red blood cells), and encounter for attention to tracheostomy (a hole that surgeons make through the front of the neck and into the windpipes, a tracheostomy tube is placed into the hole to keep it open for breathing). During a concurrent observation and interview on April 10, 2023, at 7:15 AM, DC 2 was accessing and connecting the blood lines to Resident 220's CVC, without following infection control guidelines. He placed 10 cc sterile syringes on top of the non-sterile blue chuck/pad, along with a pile of non-sterile gloves, tape, opened gauge, and alcohol pads. Tips of the sterile syringes were touching the non-sterile gloves and non-sterile chuck/pad. DC 2 did not perform hand hygiene before donning (Putting on) and/or doffing (removing) gloves. DC 2, kept the same blue chuck/pad that was laying across Resident 220's lap during CVC access, folded it and placed it on the clear bag that was hanging on the machine, he stated, I'll save and use it for the end of the treatment. During a review of Resident 220's face sheet (a document that contains resident's basic demographic information) indicated Resident 220 was admitted to the facility on [DATE], with diagnoses that included chronic kidney disease,(kidneys can no longer function on their own), tracheostomy dependence (an opening surgically created through the neck into the trachea to allow air to fill the lungs) and congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should). During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, Patients with a Central Venous Catheter (CVC), effective date December 1, 2020, which indicated, Purpose: To provide care to a resident with a Central Venous Catheter (CVC) .5. The SNF RN/ Caregiver and the resident must be masked during initiation or termination of treatment, during dressing changes, and reversing the bloodlines. DRN 1 stated that Resident 216 wasn't wearing a mask during the initiation of treatment, the policy wasn't followed. During a concurrent interview and record review with the Dialysis Registered Nurse 1 (DRN 1) on April 11, 2023, at 4:47 PM. The DRN 1 reviewed the facility's policy and procedure (P&P) titled, Dressings, Dry-Clean, effective date February 27, 2020, which indicated, Purpose: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings .Steps in the Procedure: 1 .Establish a clean field .5. Wash and dry your hands thoroughly .6. Put on clean gloves .remove soiled dressing .7. Pull glove over dressing and discard .8. Wash and dry your hands thoroughly .15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated are (usually from the center outward) .17. Apply the ordered dressing .18. Discard disposable items into the designated container .19. Remove disposable gloves and discard .wash and dry hands thoroughly . DRN 1 stated that DCs 1 and 2 didn't follow the policy. A request to provide a copy of the facility's policy and procedure indicating sterile technique to be observed while initiating, terminating, and administering intravenous medication (in to the vein) through CVC, was made, but the facility was not able to provide. 2. During a concurrent observation, interview, and record review, on April 6, 2023, at 5:44 AM, with LVN 1, outside of Resident 30's room, Resident 30 was lying in her bed, and called out for LVN 1's assistance because she could not find her television remote. Outside of Resident 30's door was a facility sign titled, Contact Precautions, dated May 30, 2019, which indicated when entering and leaving the room, everyone must clean hands and put on a gown and gloves at the door. LVN 1 told Resident 30 she would help her find her television remote. LVN 1 put on a pair of gloves, entered the room, picked up the remote on the resident's bedside table, and handed the remote to the resident. LVN 1 then removed her gloves, exited the room, and cleansed her hands with hand sanitizer. LVN 1 stated, the standard practice when entering an isolation room would be to wear a gown and gloves, but if there was no physical contact, then only wearing gloves was permissible. LVN 1 further stated, if a person enters an isolation room and touches something, the person should wear a gown and gloves. During an interview, on April 6, 2023, at 10:33 AM, with the Director of Nursing (DON), she stated, it was expected that any person who entered an isolation room, use all personal protective equipment (PPE-gowns, gloves, may include face mask or face shield) for the specific isolation organism. The DON further stated no one should have entered an isolation room without a gown because of the risk of infection transmission in the environment. During an interview on April 7, 2023, at 11:52 PM, with the Infection Preventionist Nurse (IP),the IP stated, if a person passed through the doorway into a contact isolation room, he/she must have their PPE on, which included a gown and gloves. The IP further stated, the risk of isolation precautions not being followed would be to potentially spread infections to those who entered the room without the correct PPE, their families, and everyone that person came in contact with. During an interview, on April 10, 2023, at 8:57 AM, with LVN 6 regarding isolation procedure, LVN 6 stated, if at any point a person went into an isolation room, they must have been, fully dressed in a gown and gloves. During an interview, on April 10, 2023, at 9:07 AM, with LVN 4, LVN 4 stated, after having exited an isolation room and all PPE was removed, sometimes the residents would ask staff to come back into the room for assistance. LVN 4 stated, when that happens, it was still expected that staff put on a gown and gloves before they entered the isolation room. During a review of Resident 30's medical record, the admission Record, (contains admission and demographic information), dated April 7, 2023, the admission Record indicated, Resident 30 was admitted on [DATE], with a diagnosis of enterocolitis (inflammation affecting the large and small intestine) due to clostridium difficile (bacterium that causes diarrhea and colitis) and osteomyelitis (inflammation of bone tissue caused by an infection). During a record review of Resident 30's Order Summary Report, dated April 7, 2023, the Order Summary Report indicated, there was an order from a physician for the resident to be placed on Isolation for Contact Precautions with a diagnosis of Carbapenem-resistant Enterobacterales (CRE-a large order of different types of bacteria that commonly causes infections in healthcare settings) from March 16, 2023, until May 21, 2023. During a review of the facility's policy and procedure (P&P) titled, Personal Protective Equipment, dated on October 2018, the P&P indicated, .PPE required for transmission-based precautions is maintained outside and inside the resident's room. During a review of the facility document titled, CDC Guideline for Isolation Precautions: Appendix A indicated, A Transmission-Based Precautions category was assigned if there was a strong evidence for person-to-person transmission via droplet, contact, or airborne routes in healthcare or non-healthcare settings and/or if patient factors increased the risk of transmission. 3. During an observation and interview with LVN 1, on April 6, 2023, at 6:03 AM, inside Resident 417 and Resident 416's shared room, she had a tray with two medication cups with medications, labeled with the resident's room number, a glucometer (medical device used to monitor glucose in the blood), two lancets (sharp needle used to obtain blood for testing glucose), and two opened alcohol wipes. She placed the tray on Resident 417's bedside table and proceeded to check Resident 417's blood sugar. After LVN 1 administered Resident 417's medications, she picked up the tray and glucometer and placed them on Resident 416's bedside table and proceeded to check Resident 416's blood sugar. After LVN 1 checked Resident 416's blood sugar, she exited the room and placed the glucometer on her medication cart without cleaning or disinfecting the device. During an interview with LVN 1, on April 6, 2023, at 6:18 AM, when asked how often the glucometer was cleaned, LVN 1 stated, she cleaned the glucometer after the device was used in an isolation room and at the end of her shift. LVN 1 stated, she had to check seven more residents' glucose readings that morning. When asked to clarify if she would continue checking all seven residents' glucose without cleaning and disinfecting the glucometer, LVN 1 asked the surveyor to wait while she browsed the Internet on her personal cell phone. LVN 1 stated, she changed her answer, and that the glucometer should be cleaned after each resident use. During a concurrent observation and interview with LVN 1, on April 6, 2023, at 6:20 AM, LVN 1 proceeded to move her medication cart to the next room. When asked if LVN 1 will clean the glucometer before going into the next room, LVN 1 stated, Right. It's a force of habit, and cleaned the glucometer with a bleach wipe. During an interview, on April 6, 2023, at 11:10 AM, with the Director of Nursing (DON), the DON stated, the glucometer should be cleaned and disinfected with bleach wipes after each use. During an interview, on April 7, 2023, at 11:41 AM, with LVN 8, LVN 8 stated, glucometers should be cleaned before use and between patient use with a [Name of cleaning and disinfecting wipe manufacturer] wipe and air dried for five minutes. During an interview, on April 7, 2023, at 11:52 AM, with the Infection Preventionist Nurse (IP), the IP stated, it was the expectation that staff cleaned the glucometer before and after every use and the risk associated with not cleaning the glucometer would be a potential for blood infections including HIV (human immunodeficiency virus - a virus that attacks the body's immune system) and hepatitis (inflammation of the liver). The IP further stated staff were also at risk when the glucometer was not cleaned and disinfected because staff usually first touch the glucometer without gloves. During a concurrent interview and record review of the [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, on April 13, 2023, at 11:05 AM, with LVN 14, LVN 14 stated, she cleaned the glucometer after each patient use with [Name of cleaning and disinfecting wipe manufacturer] bleach wipes. The [Name of cleaning and disinfecting wipe manufacturer] bleach wipes label, undated, indicated, the wipes were intended for use in healthcare settings and was EPA (environmental protection agency - developed and enforced environmental regulations) registered. The [Name of cleaning and disinfecting wipe manufacturer] wipes indicated, when used, the treated surface should remain visibly wet for three minutes and air dried. During a review of Resident 417's History and Physical (H&P), dated March 17, 2023, the H&P indicated, Resident 417 was admitted after being hospitalized with a diagnosis of severe sepsis (organ damage as a result of severe infection), urinary tract infection, and a sacral pressure ulcer (wound formed as a result of pressure over the sacral {area between lower back and tailbone} region). During a review of Resident 416's H&P, dated March 27, 2023, the H&P indicated, Resident 416 was admitted after being hospitalized with a diagnosis of bacteremia (bacteria in the bloodstream), osteomyelitis (inflammation of the bone caused by an infection) of the second toe, septic arthritis (infection that spreads to the joint fluids and tissues) to the left knee, and Covid-19 infection (highly contagious respiratory disease). During a concurrent interview and review of the facility's policy and procedure (P&P) titled, Blood Sampling - Capillary (Finger Sticks), on April 13, 2023, at 9:37 AM, with the DON, the P&P indicated, .1. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . 8. Following the manufacturer's instructions, clean and disinfect reusable equipment, parts, and/or devices after each use . The DON stated, the P&P was not followed when the glucometer was cleaned and disinfected only after an isolation room and at the end of the shift. During a review of the [Name of glucometer device manufacturer} manual titled, User Instruction Manual, the manual indicated, Healthcare professionals should wear gloves when cleaning the [Name of glucometer]. Wash hands after taking off gloves. Contact with blood presents a potential infection risk. We suggest cleaning and disinfecting the meter between patient use. The manual further indicated, Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant detergent or germicide wipe. 4. During an observation, on April 4, 2023, at 12:05 PM, CNA 1 entered the contact isolation room [ROOM NUMBER] without performing hand hygiene or wearing PPE and exited the room without performing hand hygiene. During a subsequent interview, with CNA 1, on April 18, 2023, at 12:10 PM, CNA 1 stated, she was told she doesn't have to wear PPE if she is not providing the direct patient care. CNA 1 also stated, she only put a pillow under the resident's head and did not touch the resident. CNA 1 further stated she will wash her hands at the nursing station. During an interview, with the Infection Preventionist Nurse (IP), on April 7, 2023, at 2:54 PM, the IP nurse stated, staff should don (put on) PPE when entering the contact isolation room and doff (take off) the PPE when exiting the contact isolation room. The IP nurse also stated, staff performs hand hygiene before exiting the room. The IP nurse further stated, all staff should follow the isolation signs posted outside the resident's room. During a concurrent interview and record review, with the Director of Nursing (DON), on April 13, 2023, at 9:36 AM, of facility's policy and procedure (P&P) titled, Isolation-Notice of Transmission-Based precautions, revised August 2019, indicated . Policy interpretation and Implementation .2 . b. contact precautions: (1) A notice at the doorway instructing visitors to report to the nurses' station before entering the room. (2). A sign indicating contact precautions on the door to the resident's room . The DON stated, CNA 1 should have worn PPE and should have performed hand hygiene before exiting the room. The DON also stated, CNA 1 did not follow the policy. 5. During an observation, on April 6, 2023, at 5:55 AM, HA1 was coming out from room [ROOM NUMBER] after collecting the trash. HA 1 was wearing gloves she used for collecting trash when she stepped out of the room [ROOM NUMBER], then went into room [ROOM NUMBER] wearing the same gloves. HA 1 collected the trash from room [ROOM NUMBER] then stepped out and walked along the hallway towards the back of the facility to dispose of the collected trash. During an interview, with HA 1, on April 6, 2023, at 6:05 AM, HA 1 stated she does not usually walk along the hallways with used gloves on, HA 1 further stated she went from one room to another without removing the used gloves and should have washed her hands after. During a concurrent interview and record review, with the Director of Nursing (DON), on April 11, 2023, at 4:49 PM, the DON reviewed the facility's policy and procedure (P&P) titled, Personal Protective Equipment- Using Gloves, revised September 2019, which indicated, .Objectives 1. To prevent the spread of infection .3. To protect hands from potentially infectious material .Removing gloves .4. Discard the glove into the designated waste receptacle inside the room .6. Wash hands. The DON stated HA 1 should have removed her gloves before leaving room [ROOM NUMBER], washed her hands before entering room [ROOM NUMBER], removed the gloves before leaving room [ROOM NUMBER] then washed hands before walking along the hallway. The DON stated HA 1 did not follow their policy. 6. During an observation, on April 6, 2023, at 5:44 AM, the garbage containers for rooms [ROOM NUMBERS] were overflowing, causing the top lid not to close. It was further observed that room [ROOM NUMBER] was placed on contact isolation. During a concurrent interview and record review, LVN 9, on April 6, 2023, at 6:23 AM, LVN 9 reviewed the facility's Isolation list 04/05/23 (April 5, 2023), which indicated room [ROOM NUMBER] was placed on isolation due to Carbapenem-resistant Acinetobacter Baumannii (CRAB- a bacteria resistant to nearly all antibiotics and difficult to remove from the environment). LVN 9 further stated the trash bins should not be overflowing and with the lids closed to prevent contact with contaminated PPE and prevent risk of spreading an infectious organism inside the facility. During a concurrent interview and record review, with the Director of Nursing (DON), on April 11, 2023, at 4:49 PM, of the facility's policy and procedure (P&P) titled, Garbage and Refuse (matter thrown away) Disposal, revised October 2017, which indicated, .Policy Interpretation and Implementation .2. All garbage and refuse containers are provided with tight-fitting lids or covers and must be kept covered when stored or not in use. 3. Housekeeping personnel will empty garbage and refuse containers daily and as needed taking care not to contaminate other areas while cleaning . The DON stated the trash bins should not be overflowing so the lids can close properly. The DON further stated this had the potential to expose residents and staff to infectious organisms that may be present in those used PPE. 7. During a tour of the facility, on April 6, 2023, between 6:30 AM and 6:51 AM, the following observations and interviews indicated: a. Sharps container for room [ROOM NUMBER] was full. LVN 10 stated the container needs to be replaced when full. b. Sharps container for room [ROOM NUMBER] was full. LVN 11 stated it should not be in that condition and should be replaced when full. c. Sharps container in room [ROOM NUMBER] and 221 was full. LVN 12 stated it shouldn't be full all the way to the top. During an interview, with the Infection Preventionist (IP) on April 7, 2023, at 10:12 AM, the IP stated the sharps containers should be replaced when it is three quarters (an amount equal to three of the four equal parts which make up something; equal to 75 percent) full. During a concurrent interview and record review with the DON, on April 11, 2023, at 4:49 PM, of the facility's P&P, titled, Sharps Disposal, revised January 2012, indicated, .The facility shall discard contaminated sharps into designated containers .Policy Interpretation and Implementation .3 .c. Designated individuals will be responsible for sealing and replacing containers when they are 75% to 80% full to protect employees from punctures and/or needlesticks when attempting to push sharps into the container . The DON stated they did not follow their policy. These observations and interviews of deficient infection control practices lead the survey team, to call an Immediate Jeopardy, (a clearly identifiable situation that can cause severe harm or likelihood for serious harm and the immediate need for it to be corrected to avoid further, or future serious harm to the residents) on April 10, 2023, at 5:05 PM, in the presence of Direct of Nursing (DON), Administrator, and Assistant Direct of Nursing (ADON). Facility provided the following written Corrective action plan: 1. On April 10, 2023, in-service was completed by housekeeping staff regarding the importance of ensuring trash cans in isolation rooms are not overfilled. Trash bins were immediately emptied for all the isolation rooms and any other rooms as needed. Trash bins will be emptied every 2 hours with an emphasis on isolation rooms. 2. On April 10, 2023, and in-service was completed with all staff on schedule regarding appropriate PPE for isolation rooms, and hand hygiene practices. An audit was completed on all isolation rooms to observed staff were: 3. On 4/10/23, an in-service was completed with all staff on schedule regarding appropriate PPE for isolation rooms, and hand hygiene practices. All non-scheduled staff will be in-serviced upon return to the facility. Housekeeping staff were immediately in-serviced on the importance of hand hygiene and changing gloves between the room. 4. LVN1 was terminated from the facility upon the identification of not disinfecting the glucometer between residents and not following infection control policies and procedures. All nurses were in-serviced on April 6, 2023 and April 10, 2023 on properly disinfecting glucometers before, after, and in-between use to prevent cross contamination. 5. Central supply and nursing staff were educated on not overfilling sharps containers and changing them when necessary. Over-filled sharps containers were immediately emptied upon notification. 6. Effective April 10, 2023, dialysis caregivers are no longer able to manipulate any dialysis central venous catheter except for the Dialysis Registered Nurse. On April 11, 2023, an in-service was given to the Dialysis RN by the ADON on sterile technique. The survey team verified through observations, interviews, and record reviews the Corrective Action Plan (CAP, interventions to remove the IJ) had been implemented, and the IJ was removed on April 12, 2023 at 11:18 AM, in the presence of the Administrator and DON