**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure staff had the knowledge and resources (cleaning supplies or cleaning materials), required to provide a safe and sanitary environment which promoted the prevention of the spread of infections when 2 of 2 sampled residents (Resident 1 and 2) had C-Diff infections, (C-Diff, a highly contagious bacteria in the intestines that could cause severe diarrhea, inflammation of the colon, abdominal discomfort, lack of appetite, weight loss, isolation, extended hospital stays, and/or death) and resided in a locked memory care unit for dementia (an enclosed living space for residents with dementia, a disease that caused an inability to think, reason, or remember) and; 1. Licensed Nurses (LN) and Certified Nurse Assistants (CNA) used cleansing wipes, with the brand name of, CaviWipes 1 to disinfect (cleaning with a chemical liquid that destroyed bacteria) on objects that were used for resident care on infected and non-infected residents as well as on surfaces touched by infected residents and staff did not know that this product did not kill C-Diff.; and 2. Residents 1 and 2) were not provided with dedicated (used by one resident) medical equipment such as blood pressure cuffs, thermometers, and stethoscope (a device used to listen to a pulse or heartbeat), when they had C-Diff. (according to the Centers for Disease Control (CDC), C-diff bacteria produced spores that could live on surfaces for months and years); and 3. Cleaning and disinfecting supplies that were approved to kill C-Diff were not available for use to clean the rooms of Resident 1 and 2 or the shower which was shared by 18 other residents. These failures resulted in an Immediate Jeopardy (IJ, situation in which the provider's noncompliance with one or more requirements of participation was likely to cause serious injury, harm, impairment, or death to a resident), when 2 out 2 sampled residents (Resident 1 and Resident 2) had C-Diff. and precautions were not taken to kill this bacteria, which had the potential to infect 18 other residents who resided in that memory care unit. An IJ was declared on 12/8/2023 at 2:40 pm, at F880, in the presence of the facility Director of Quality (DOQ) and Interim (temporary) Director of Nurses/Infection Preventionist (DON/IP), when the facility staff lacked adequate cleaning supplies, knowledge, and practices that were required to prevent the spread of C-Diff that included use of dedicated medical equipment such as; blood pressure cuff, thermometer, and stethoscope, and adequate cleaning and disinfection procedures had not been followed when cleaning resident rooms or a shared resident shower room. The facility DOQ provided an acceptable immediate action plan, (a plan to correct these deficient practices immediately) on 12/8/2023 at 4:47 pm. The actions to remove the IJ situation included training/education for facility staff that included the facility ' s C-Diff policy and procedure (P&P), use of dedicated medical equipment for residents that were positive for C-Diff, and aquiring approved cleaning and disinfectant supplies (use of a cleaning products that contained bleach) that were approved to kill C-Diff. The IJ was removed onsite by surveyors on 12/13/2023 at 1:22 pm, when the facility was able to demonstrate the immediate plan of action had been implemented, facility staff were knowledgeable on the C-Diff policy and procedures, dedicated medical equipment was present in the facility, and approved cleaning and disinfectant supplies for residents who had C-Diff were available for staff use. 4. LN A and CNA B were observed touching a contaminated blood pressure cuff that had been exposed to COVID and C-Diff, without wearing gloves. 5. CNA C was observed providing direct resident care to two separate residents and touching CNA C ' s own body in between direct resident care, without performing hand hygiene (HH, cleansing hands with an alcohol-based gel rub or washing hands with soap and water). These failures had the potential to spread infection to all 20 residents who resided in the memory care unit, staff and visitors and result in a serious infectious disease outbreak and negatively impact the residents' ability to attain or maintain their highest practicable level of physical and emotional well-being. Findings: 1. During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated, facility staff would be educated about infection prevention and control guidelines and methods. During a review of the facility ' s undated P&P titled, Clostridium Difficile C. difficile, indicated, facility staff would be educated on the prevention of the spread of C-Diff. A review of Resident 1 ' s undated admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnosis of unspecified dementia (Inability to think, remember, or recall information) and was not her own responsible party (RP). A review of Resident 1 ' s Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/12/23, indicated Resident 1 did not have good cognition (ability to think or be understood). A review of Resident 1 ' s Order Details, dated 11/25/23, indicated, Stools for PCR (test to determine if a person had C-Diff) had been ordered. A review of Resident 1 ' s Physician ' s Note, dated 11/29/23, indicated Resident 1 was diagnosed with C-Diff. During an interview on 12/6/23 at 1:10 pm, CNA D stated, Resident 1 was positive for C-Diff and was on contact isolation precautions. CNA D stated, a cleansing wipe with the brand name of CaviWipes 1 was used to clean Resident 1 ' s commode (a portable toilet that looked like a chair), after Resident 1 ' s use. CNA D incorrectly stated, CaviWipes 1 required a five-minute wet time (the amount of time a disinfectant was required to remain wet on a surface to kill specific bacteria or viruses), and stated CNA D did not know if CaviWipes 1 was an effective cleaning agent in the prevention of the spread of C-Diff. A review of Resident 2 ' s undated admission Record, indicated, Resident 2 was admitted to the facility on [DATE] with the diagnosis of unspecified dementia and was not her own RP. A review of Resident 2 ' s Quarterly MDS, dated 11/12/23, indicated Resident 2 did not have good cognition. A review of Resident 2 ' s Order Details, dated 11/30/23, indicated the facility suspected Resident 2 had C-Diff and the physician had ordered a stool sample. A review of Resident 2 ' s Immunology-Serology (type of laboratory test) report, dated 11/30/23, indicated Resident 2 tested positive for C-Diff. During an interview on 12/6/23 at 1:24 pm, LN E stated Resident 1 and Resident 2 had tested positive for C-Diff. LN E stated, CaviWipes 1 had been used to clean the vital sign cart (portable medical equipment used to check the blood pressure, temperature, and pulse) in-between each resident use and the vital sign cart was used for all 20 residents that resided in the facility ' s memory unit. LN E incorrectly stated, when cleaning objects touched by residents, a five-minute wet time was required for the disinfectant to be effective and stated CNA E did not know if CaviWipes 1 killed C-Diff. During an interview on 12/6/23 at 1:30 pm, CNA F stated, CaviWipes 1 was used to clean high touch resident areas (areas that were touched often by residents). CNA F confirmed using CaviWipes 1 to clean door handles, resident bed rails, and handrails (rails attached to the wall for residents to hold while walking). CNA F stated CNA F, assumed CaviWipes 1 killed C-Diff and did not know if CaviWipes 1 killed C-Diff. During an interview on 12/7/23 at 7:45 am, LN A stated, CaviWipes 1 was used to clean the electronic blood pressure cuff in-between each resident use and LN A liked to spray Lysol on the electronic blood pressure cuff, directly after using the CaviWipes 1 LN A stated that the use of a cleaning product that contained bleach would be effective in prevention of the spread of C-Diff, but did not know if Lysol or CaviWipes 1 contained bleach. LN A stated she did not know if Cavi Wipes 1 killed C-Diff. During an interview on 12/7/23 at 3:44 pm, CNA H stated, CNA H used CaviWipes 1 to clean and disinfect objects the residents touched and did not know if CaviWipes 1 killed C-Diff. During a concurrent observation and interview on 12/8/23 at 7:47 am, CNA B was observed cleaning the electronic blood pressure cuff. CNA 1 stated the electronic blood pressure cuff was cleaned with CaviWipes 1 after each resident use and did not know if CaviWipes 1 killed C-Diff. During a review of the CaviWipes 1 label, the label did not include C-Diff as a bacteria that the product killed. During an interview on 12/8/23 at 8:31 am, DON/IP confirmed bleach wipes were not available for facility staff to clean and disinfect with on the memory unit during the C-Diff outbreak. DON/IP stated, she had not ordered bleach wipes, though she knew that use of bleach for cleaning and disinfecting C-Diff was the preferred cleaning agent in order to kill C-Diff spores. 2. During a review of the facility ' s undated P&P titled, Clostridium Difficile C. difficile, indicated, Dedicated patient care equipment shall be used. During a review of the facility ' s P&P titled, Isolation Precautions, dated 9/29/16, indicated, residents that were suspected for or tested positive for C-Diff would be placed on Contact Precautions and Dedicated patient-care equipment should be considered for the patient. The P&P included a chart that indicated a residents placed on Contact Precautions would be provided with Dedicated Equipment. During an interview on 12/6/23 at 1:39 pm, CNA F stated, there was no dedicated vital sign equipment being used for Resident 1 or Resident 2, confirmed Resident 1 and Resident 2 had tested positive for C-Diff, and that there was one portable vital sign cart that was used for all 20 residents that resided in the memory unit. (Resident 1 was on contact isolation for C-Diff precautions for 12 days, and Resident 2 was on contact isolation for C-Diff for seven days). A review of Resident 1 ' s Order Details, dated 11/25/23, indicated, Stools for PCR (test to determine if a person had C-Diff) had been ordered. Resident 1 was on contact isolation for C-Diff precautions for 12 days without dedicated medical equipment. A review of Resident 2 ' s Immunology-Serology report, dated 11/30/23, indicated Resident 2 tested positive for C-Diff. Resident 2 was on contact isolation for C-Diff precautions for seven days without dedicated medical equipment. During a concurrent observation and interview on 12/7/23 at 7:45 am, LN A was observed walking out of Resident 1 ' s room carrying an electronic blood pressure cuff (small battery-operated blood pressure cuff that wrapped around the resident ' s wrist). LN A confirmed there was no dedicated vital sign equipment for Resident 1 or Resident 2 and stated the electronic blood pressure cuff was used for all residents. During an interview on 12/8/23 at 8:31 am, DON/IP stated use of disposable (dedicated for one person then thrown away) vital sign equipment was ideal and should be used for residents that had C-Diff. DON/IP stated, staff did not notify her that they needed dedicated vital sign equipment for Resident 1 or Resident 2, and indicated it was the staff's responsibility to do so. A review of the undated record titled, Job Description, Department: Infection Control, indicated, the Infection Control Nurse (IP), Confers with medical and nursing staff to determine appropriate implementation of isolation precautions. 3. During a review of the facility ' s P&P titled, Housekeeping Principles, Infection Control, dated 11/27/23, indicated, the facility promoted a sanitary environment by incorporating infection control practices into housekeeping practices. The P&P indicated housekeeping, Personnel are oriented and trained in proper .techniques regarding infection control. During a review of the facility ' s undated P&P titled, Clostridium Difficile C.difficile indicated, An Environmental Protection Agency (EPA)-registered sodium hypochlorite-based disinfectant shall be used for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (i.e., household chlorine bleach), also may be appropriately diluted and used (diluted 1:10 with water). Contact Precautions shall be used for patients with known or suspected C. difficile-associated disease. During an interview on 12/6/23 at 1:10 pm, CNA D stated, CaviWipes 1 were the only cleaning supplies available for CNAs to use when cleaning Resident 1 ' s commode. CNA D stated CaviWipes 1 were used to clean Resident 1 ' s commode after each use, and then housekeeping staff would deep clean Resident 1 ' s room, including Resident 1 ' s commode daily. During an interview on 12/6/23 at 1:30 pm, CNA F stated, CaviWipes 1 were the only cleaning supplies available for staff to use when cleaning resident door handles, wheelchair handles, and handrails. During an observation on 12/6/23 at 3:31 pm, CNA D was observed wiping down the handrails on the memory unit with CaviWipes 1 while residents wandered in the hallway utilizing the handrails to walk. During a concurrent observation, interview, and record review on 12/7/23 at 1:34 pm, with Housekeeper (HSK) 1, the housekeeping closet located in the facility ' s memory care unit was observed. HSK 1 stated for normal, everyday cleaning, E23 was used to clean resident rooms and the shower. HSK pointed to a clear plastic container on the wall that had E23 written on a label. A description of the cleaner was printed on paper an attached the wall near the clear plastic container. HSK reviewed the paper on the wall and confirmed the paper on the wall indicated, E23 was a neutral disinfectant to be used for cleaning the floors inside and outside of bathrooms and could be used to spray and wipe inside and outside restrooms, but did not kill C-Diff. HSK 1 stated on 12/2/23, five days after Resident 1 and 2 tested positive for C-Diff, a bottle of household bleach had been provided for housekeeping staff to use when cleaning and disinfecting the isolation rooms with C-Diff. HSK 1 stated bleach was not being used in the shower room for daily cleaning by housekeeping staff and stated the housekeeping staff was using E23 to clean the shower room. HSK 1 stated HSK 1 did not know bleach should be used when cleaning the shower room, located in the facility ' s memory unit. During an interview on 12/7/23 at 1:44 pm, with CNA L, CNA L stated, the housekeeping staff cleaned the shower room in the memory unit once a day. CNA L stated there was not a specific time that housekeeping staff cleaned the shower room, sometimes housekeeping staff cleaned the shower in the morning and sometimes housekeeping staff cleaned the shower in the afternoon. CNA L stated, in between each resident shower, the CNA who provided the shower, would clean the shower room with CaviWipes 1. During a review of the CaviWipes 1 label, the label indicated that this producte did not contain bleach or kill C-Diff. During a concurrent observation, interview, and record review, on 12/7/23 at 1:55 pm, with Environmental Services Manager (EVSM), a green contact isolation sign was observed outside of Resident 2 ' s door and EVSM stated the contact isolation sign should have been yellow. EVSM stated the green contact isolation sign indicated housekeeping staff did not need to clean the resident ' s room with bleach. EVSM stated the housekeeping staff relied on the isolation signage to determine how the room would be cleaned and disinfected. EVSM stated there was a yellow contact isolation sign that indicated, special considerations were needed. EVSM stated the yellow contact isolation sign was housekeeping ' s cue to clean with bleach and not with E23. EVSM confirmed the housekeeping staff was not provided with bleach for cleaning the special consideration contact isolation rooms until 12/2/23, seven days after the facility knew they had positive C-Diff infections. During an interview on 12/7/23 at 2:14 pm, DON/IP stated, after a resident on contact isolation used the shower room, LNs or CNAs (who ever provided the shower) were expected to call the housekeeping staff to clean and disinfect the shower room. DON/IP stated, when the housekeeping staff was not available to clean and disinfect the shower room, it was the responsibility of LNs and CNAs to clean and disinfect the shower room with the appropriate cleaner. DON/IP stated the shower room needed to be cleaned and disinfected with bleach after Resident 1 and Resident 2 used the shower room and confirmed bleach was not made available to staff until 12/2/23, seven days after the facility knew they had positive C-Diff infections. During an interview on 12/7/23 at 3:40 pm, CNA L stated all 20 memory care unit residents utilized the shower room located on the memory care unit. CNA L stated the shower room was cleaned after each resident use by the CNA who gave the resident a shower. CNA L stated use of CaviWipes 1 was available to staff for cleaning the shower. CNA L confirmed, there was no bleach available for CNA L to clean the shower room. CNA L stated that CNA L did not call housekeeping to clean or disinfect the shower room with bleach after providing showers to residents that were on contact isolation. During an interview on 12/7/23 at 3:48 pm, with CNA M, CNA M stated in between each resident shower, CNA M cleaned the shower room with CaviWipes1. CNA M stated they provided Resident 1 and Resident 2 with a shower on 12/6/23, was aware both residents had been diagnosed with C-Diff, and stated they had not called housekeeping to clean the shower room with bleach after Resident 1 or Resident 2 were showered. CNA M stated the housekeeping staff had cleaned the shower room that morning and CNA M did not know whether or not the shower room had been cleaned after CNA M had showered Residents 1 and 2, that same morning. During an interview on 12/8/23 at 8:31 am, DON/IP stated when a resident had symptoms and was suspected (to think that someone might have an illness without laboratory testing results), to have C-Diff, the resident would be placed on contact isolation. DON/IP stated reviewing the CaviWipes 1 label, with the DOQ, on 12/7/23, that the CaviWipes 1 label did not indicate CaviWipes 1 killed C-Diff. DON/IP confirmed that facility staff were using CaviWipes 1 for cleaning objects touched by residents with C-Diff, including high touch areas, for 13 days, before they were given bleach wipes, and that housekeeping was not provided bleach to clean the C-Diff rooms for 7 days, after the facility was aware that there were C-Diff infections. A review of the undated record titled, Job Description, Department: Infection Control, indicated, the Infection Control Nurse (IP) Monitors proper use of germicides, cleaning products, antiseptics, and disinfectants throughout the facility and indicated the IP Monitors methods of asepsis, sterilization, and disinfection employed throughout the facility. 4. During a review of the facility ' s undated P&P titled, Clostridium Difficile (C. difficile), indicated, Full barrier precautions (gowns and gloves) shall be worn when staff is in contact with patients with CDI During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated, a goal of limiting the transmission of infections associated with procedures. The P&P indicated a component of prevention of the spread of infection was hand hygiene (washing hands with soap and water or use of an alcohol-based hand gel). During a review of the facility ' s P&P titled, Isolation Precautions, dated 9/29/16, indicated, After glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. During a concurrent observation and interview on 12/7/23 at 7:45 am, LN A was observed entering Resident 1 ' s room with medication and an electronic blood pressure cuff. LN A was observed placing the electronic blood pressure cuff onto Resident 1 ' s wrist and then placing the electronic blood pressure cuff onto Resident 1 ' s table, next to Resident 1 ' s breakfast tray. LN A was observed carrying the electronic blood pressure cuff to the counter next to Resident 1 ' s sink and placing it on a paper towel. LN A removed LN A ' s gown and gloves and washed hands with soap and water. LN A picked up the uncleaned electronic blood pressure cuff with bare hands, held the electronic blood pressure against LN A ' s chest area of the uniform top, walked into the nurse ' s station room, and placed the uncleaned electronic blood pressure cuff onto the medication cart (a cart on wheels that contained all resident medication). Approximately 7-10 minutes later, at 8:02 am, LN, A was observed wiping the electronic blood pressure cuff with a CaviWipes 1 and immediately spraying the electronic blood pressure cuff with Lysol and left the nurse ' s station room with the electronic blood pressure cuff. LN A returned to the nurse station room and confirmed LN A touched the uncleaned electronic blood pressure cuff with bare hands, directly after use on a resident with C-Diff, and placing the electronic blood pressure cuff on the medication cart. LN A confirmed LN A should have worn gloves and not placed the electronic blood pressure cuff on the medication cart prior to cleaning and disinfecting and did not know that Cavi Wipes 1 did not kill C-Diff. During a concurrent observation and interview on 12/8/23 at 7:47 am, CNA B was observed standing outside of an isolation room cleaning the electronic blood pressure cuff with CNA B ' s bare hands. CNA B stated the resident was positive for COVID and confirmed CNA B should have had on gloves and did not. 5. During a review of the facility ' s P&P titled, Infection Prevention Plan, dated 5/17/22, indicated the, Infection Prevention Plan was designed to ensure the safety of patients, staff, and visitors within its healthcare environment by reducing the risk of acquiring a healthcare-associated infection (HAI). The P&P indicated, all residents .will be considered potentially infectious, and standard precautions are indicated for all patients. The P&P indicated Hand hygiene procedures were required when coming into direct contact with all residents and resident items. During a concurrent observation and interview on 12/8/23 at 8:06 am, CNA C was observed for 10 minutes assisting Resident 3 and Resident 4 to eat breakfast in the hallway of the facility ' s memory unit. CNA C was observed placing bare hands onto Resident 4 ' s shoulder and arm. CNA C provided Resident 4 with a bite of food and then walked over to Resident 3. CNA C was observed to touch Resident 3 ' s arm and rub Resident 3 ' s back. CNA C provided Resident 3 a bite of food and walked over to Resident 4. CNA C was observed touching CNA C ' s own arms and hair. CNA C touched Resident 4 ' s arm, provided Resident 4 a bite of food and while walking back to Resident 3, CNA C rubbed CNA C ' s eyes with bare fingers and provided Resident 3 a bite of food. CNA C had not performed hand hygiene for the entirety of the observation. CNA C confirmed not performing hand hygiene before or after assisting Resident 3 and Resident 4 with eating breakfast or when touching Resident 3 or Resident 4 ' s body. CNA C confirmed touching CNA C ' s own arm, face, and rubbing own eyes with CNA C ' s fingers, not performing hand hygiene before or after touching self, and stated CNA C should have. CNA C stated the facility expectation was to perform hand hygiene before and after resident care or touching self. CNA C stated the purpose of hand hygiene was to prevent the spread of infection to residents, self, and staff. During an interview on 12/8/23 at 8:31 am, DON/IP stated facility staff should not touch uncleaned medical equipment with bare hands and expectations for cleaning medical equipment after resident use, was to wear gloves while cleaning medical equipment. DON/IP stated uncleaned medical equipment should not be placed against the body and staff were expected to perform hand hygiene before and after resident care or touching themselves with their bare hands.