**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. Licensed nurses in three out of three nursing stations: LVN B, LVN C, LVN E, LVN F, LVN G and Registered Nurse D (RN D), did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and, 1c. The Infection Preventionist/Director of Staff Development (IP/DSD) did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions. Furthermore, concurrent interview and record review with the IP/DSD reflected there had been no staff in-services provided regarding proper disinfection of shared glucometers since 2021. The facility identified 41 residents that had active physician orders for Finger Stick Blood Glucose (FSBG, a procedure where the finger is pricked with a poking device to obtain a blood sample to measure blood glucose level) checks. One out of 41 residents (Resident 90) also had a diagnosis of Chronic Viral Hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids) at the time of admission on [DATE]. As of 2/6/23, Resident 90 did not have a designated glucometer and had been given FSBG checks daily with a shared glucometer. The facility's noncompliance with infection control procedures had the potential to cause the development and the widespread transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, is a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C) to 41 of 41 residents. It was unknown when the noncompliance began according to an interview with the DON. Due to the widespread lack of knowledge of proper disinfection procedures demonstrated by eight (8) nursing staff, including IP/DSD, the facility needed to take immediate action to correct the non-compliance. On 2/6/23 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator and Administrator In Training (AIT), due to the facility's failure to ensure that LVN A properly disinfected a shared glucometer for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; failure to ensure LVN B, LVN C, LVN E, LVN F, LVN G and RN D knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; failure to ensure the IP/DSD knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and not having staff in-services provided regarding proper disinfection of shared glucometers since 2021. On 2/7/23, at 3:30 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1. Identify residents whose blood sugars (BS) need to be monitored. All residents (41 residents) on FSBG checks will be monitored for the following symptoms (ascites [condition in which fluid collects in spaces within your abdomen], tremors, confusion, vomiting of blood, blood in the stool and fatigue) per the Medical Director for 14 days. Resident[s] directly affected will have lab works done on 2/7/2023 for hepatitis B and C. 2. IP/DSD/Designee in-service and educated facility and/or registry licensed nursing staff (nurses employed through a contracted agency) on the glucometer manufacturer's guidelines for proper cleaning and disinfecting and return demonstration done to ensure it is done correctly. a. Glucometer to be cleaned and disinfected immediately after resident use (Sani-Cloth or equivalent) with 2 minutes wet time. b. Check if glucometer is in proper working condition prior to use. c. Daily QA (quality assurance) maintenance of each glucometer and to ensure glucometer is in proper working condition and if Licensed Nurses are cleaning/disinfecting it according to manufacturer's guidelines and proper use of recommended wipes. 3. IP/DSD/Designee will randomly perform spot check on all shifts daily × 2 weeks then monthly, and findings will be reported to QAPI (Quality Assurance and Performance Improvement) Committee. 4. IP/DSD/Designee in-service and education will be completed with the licensed nursing staff prior to the start of their shift and by 02/07/2023. 5. Corrective Action Plan reviewed at QAPI Committee Meeting on 02/07/2023. 6. A separate glucometer machine was provided for the resident identified with hepatitis, cleaned after each use and routine QA started. (forms/Sig [signature] attached) 7. Skills competency glucometer cleaning/disinfectant in serviced to Licensed nurse by IP/DSD/Designee. 8. P and P [Policy and Procedure] on bloodborne pathogens updated according to updated systemic changes and discussed and approved by QAPI Committee. On 2/8/23, at 9:48 a.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the facility's IJRP by observations, interviews, and record reviews. The DON, Administrator, AIT and DSD/IP were informed. 2. The Director of Nursing (DON) and IP/DSD did not know the disinfectant wipe manufacturer's instructions for wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect); and LVN B and RN H did not allow enough wet time, according to the manufacturer's instructions, during the disinfection of a shared glucometer for three of 41 residents (Residents 25, 39, and 97). 3. A nurse (LVN I) failed to perform hand hygiene between tasks during medication administration for one of 6 residents (Resident 72). 4. Four nursing staff (Certified Nursing Assistants R, S, U and LVN X) failed to wear proper PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) when working in facility areas that required them. 5. A nurse (LVN X) failed to take her temperature with a thermometer and screen for COVID-19 upon entering the facility to start work. 6. Nursing and maintenance staff failed to maintain oxygen concentrators in good working condition for two of two residents (Residents 15 and 24) with oxygen concentrators when the filters of their oxygen concentrators had a layer of grayish matter buildup on them. These failures placed residents at increased risk of healthcare-associated infections. Findings: 1a. During a medication administration observation on 2/6/23, at 8:36 a.m., with Licensed Vocational Nurse A (LVN A), a registry nurse, at Station 2, LVN A completed a blood check on Resident 25 with a glucometer. She placed the glucometer on the top of the medication cart without cleaning or disinfecting it. At 8:40 a.m., LVN A moved down the hall to Resident 9's room and prepared medications for Resident 9. She brought the prepared medications along with the same glucometer used for Resident 25, without wiping it down first, to Resident 9's bedside. At 8:49 a.m., LVN A administered the medications. After medications were given to Resident 9, LVN A was asked to exit Resident 9's room before completion of the BS check. During a concurrent observation and interview on 2/6/23, at 8:53 a.m., with LVN A, when asked how the shared glucometer was disinfected between Resident 25 and Resident 9, LVN A stated she used alcohol wipes. LVN A stated she did not know the facility's procedure for glucometer disinfection. LVN A reached for the Lysol wipes (a common household disinfecting wipe typically found at grocery stores) in the medication cart and wiped the glucometer with a Lysol wipe. LVN A stated she needed to ask a supervisor about the glucometer disinfection procedure because she did not know it. After a few minutes, LVN A returned to the medication cart and stated, They [supervisor] said Lysol wipe is ok. At 9:08 a.m., LVN A completed the BS check for Resident 9 with the shared glucometer. 1b. During an interview on 2/6/23, at 9:45 a.m., with LVN B, at Station 3, when asked about the glucometer disinfection method, LVN B stated she used alcohol wipes to clean and disinfect it, and the wet time should be three minutes. She stated the glucometers were shared among residents. During an interview on 2/6/23, at 10:35 a.m., with LVN C (a registry nurse), at Station 1, LVN C was asked about the glucometer disinfection method, LVN C stated she used Lysol wipes to clean and disinfect it. During an interview on 2/6/23, at 4:05 p.m., with LVN E, at Station 2, LVN E stated the glucometer was used for all residents at the nursing station and alcohol wipes were used to clean the glucometer between residents. LVN E stated she did not know the wet time. During an interview on 2/6/23, at 5:01 p.m., with RN D, at Station 1, when asked about the facility's glucometer disinfection method, RN D stated, he used Lysol wipes with a two-minute wet time. RN D stated he did not remember when an in-service about glucometer disinfection was provided, but he remembered there was one. During a concurrent observation and interview on 2/6/23, at 5:05 p.m., with LVN E, at Station 1, LVN E used alcohol wipes to clean a glucometer after a BS check was completed. LVN E then placed the glucometer inside the medication cart. When asked how to disinfect shared glucometers, LVN E stated she used alcohol, Lysol, or whatever was available in the cart. When asked about the wet time, LVN E stated, It dries by itself. During an interview on 2/6/23, at 5:11 p.m., with LVN F, at Station 2, when asked about the facility's glucometer disinfection method, LVN F stated she wiped the glucometer with alcohol wipes and dried it with the tissue. LVN F stated it could take 5 to 10 minutes to dry. LVN F stated an in-service on glucometer cleaning was provided in 2022. During an interview on 2/6/23, at 5:14 p.m. with LVN G (a registry nurse), at Station 3, LVN G stated it was her first day of work at the facility. LVN G stated she had not completed a BS test yet, but had to do one later. When asked how to clean and disinfect the glucometer, LVN G stated she would use alcohol swabs to clean the glucometer. LVN G showed a small basket that contained a glucometer and alcohol swabs. LVN G stated no in-service was given regarding glucometer disinfection upon orientation. 1c. During a concurrent interview and record review on 2/6/23, at 4:09 p.m., with the IP/DSD, the IP/DSD reviewed the facility's binder that contained documentation of nursing staff in-services/training completed between January 2021 to February 2023. The IP/DSD confirmed there were no in-services/training or competencies completed by licensed nurses regarding the facility's procedure for cleaning and disinfecting shared glucometers. During an interview on 2/6/23, at 5:22 p.m., with the IP/DSD, the IP/DSD stated, there were no in-services since 2021. When asked how staff cleaned and disinfected glucometers, the IP/DSD stated, with the Lysol yellow [package] or purple [top] disinfectant wipes. The IP/DSD stated, We tell the staff to use Lysol disinfectant. The IP/DSD stated alcohol is not an antiviral (A drug used to treat infections caused by viruses) or disinfectant and should not be used. The IP/DSD was asked by a surveyor if Lysol kills hepatitis or HIV, the IP/DSD reviewed the Lysol package instructions and stated, No, it doesn't. The IP/DSD stated she did not know what the glucometer manufacturer recommended to use for disinfection of the glucometer. The IP/DSD stated she was not aware that the nursing staff used alcohol to disinfect the glucometers. She said glucometer disinfection instructions were not part of the orientation for registry nursing staff. During a review the product labeling for the Lysol disinfectant wipes provided by the facility, it indicated, Kills Salmonella [a bacteria that can cause an infection in the intestinal tract through contaminated water or food], Influenza A Virus (H1N1) [a virus that causes an infection of the nose, throat and lungs], Herpes Simplex Virus Type 1 [a virus that causes herpes infection], Staphylococcus aureus [a bacteria found on human skin], Escherichia coli [E.Coli, a bacteria that is commonly found in the lower intestine] and Respiratory Syncytial Virus [RSV, a common respiratory virus that causes cold-like symptoms] on hard, non-porous surfaces in 4 minutes .To Disinfect: Allow [surface] to remain wet for 4 minutes. Allow surface to air dry . The Lysol disinfectant wipes did not contain a disinfectant that would protect against bloodborne infectious diseases such as Hepatitis B, Hepatitis C, or HIV. On 2/6/23, the facility provided a list of residents with physician's orders for FSBG in the facility. The list identified 41 residents. During a review of Resident 90's admission Record, dated 7/19/21, it indicated, Resident 90 was admitted to the facility with diagnoses including Chronic Viral Hepatitis B and Diabetes. Resident 90 had a BIMS of 15 (Brief Interview for Mental Status, is an assessment tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment), which indicated he was cognitively intact. During an interview with Resident 90 on 2/6/23, at 4:40 p.m., he stated his BS was checked daily. When asked whether he had his own glucometer, Resident 90 stated, No, the girls [nurses] use the machine they have here. I don't have my own machine. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. During a review of the Food and Drug Administration's (FDA) Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA, dated 12/27/17, it indicated, The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens. (https://www.fda.gov/medical-devices/in-vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda) According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Centers for Disease Control and Prevention (CDC), dated 3/2/2011, it indicated, An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B virus], hepatitis C virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin (medication to lower blood glucose) administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings . Blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, The meter [glucometer] should be cleaned and disinfected after use on each patient . our testing confirmed the wipes listed will not damage the functionality or performance of the meter . [manufacturer] recommends using these wipes to clean and disinfect the [glucometer]: Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels, Super Sani-Cloth Germicidal Disposable Wipes, CaviWipes . please read the manufacturers' instructions before using their wipes on the meter. The manufacturer's instructions indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 2. During an interview on 2/7/23, at 9:44 a.m., with the DON and IP/DSD, the DON and IP/DSD were asked to explain the wet time during glucometer disinfection and to describe how nurses would maintain wet time. The IP/DSD stated they will wipe [the glucometer] and let it dry for two minutes. The DON stated, they wipe [the glucometer] with solution, then leave to dry. When asked, How does the glucometer stay wet?, the IP/DSD reviewed and read the manufacturer instructions on the Super Sani-Cloth (disposable disinfection wipes for hard surfaces and medical devices) disinfectant wipe container out loud, allow surface to remain wet for two minutes. The DON stated, We will repeat the in-service [for glucometer disinfection]. When asked how long the nursing staff had been using alcohol swab or Lysol to disinfect the glucometers, the DON stated, I do not know when it started .when I started [employment here], we were supposed to use Sani-Cloth . when I started in December 2022, I did a spot check and we had Sani-Cloth; so in my mind, the nurses were using that . the Lysol is new to me. During an interview on 2/7/23 at 9:55 a.m. with the DON, he stated the manufacturer instructions for the sanitizing wipes indicated the wet time is 2 minutes; so, we wipe the glucometer and let it sit for two minutes to let it dry before it can be used again (instead of properly keeping it wet for the two minutes). During an observation on 2/7/23, at 11:42 a.m., with LVN B, at Station 2, LVN B completed a BS check for Resident 39. LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds before she proceeded to perform a BS check for Resident 25. After completion of the BS check, LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. During an interview on 2/7/23, at 12:00 p.m., LVN B stated she was given an in-service about glucometer disinfection, was instructed to wipe it for two minutes with the Purple wipe [Sani-Cloth] and to let it air dry. LVN B said she did not understand why the glucometer needed to stay wet. LVN B stated she thought that letting the glucometer dry was included in the two minutes, During a concurrent observation and interview on 2/7/23, at 12:09 p.m., with RN H, at Station 2, RN H completed a BS check for Resident 97. RN H wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. RN H stated, We had an in-service yesterday on how to wipe the glucometer with Sani-Cloth wipes . I knew that already . wipe for two minutes . then let air dry . important to keep it wet to remove microorganisms and sanitize . I did not time it . I let it wet for about 1 minute. During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 3. During a medication administration observation on 2/8/23, at 8:19 a.m., with LVN I, at Station 3, LVN I prepared medications for Resident 72. LVN I went into Resident 72's room, put on new gloves at bedside, touched the bed remote to elevate the head of bed and turned off the feeding pump (machine that delivers nutrition into the stomach) with her right gloved hand. LVN I proceeded to administer medications to Resident 72 via the G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without changing gloves. During an interview on 2/8/23 at 8:44 a.m., with LVN I, LVN I acknowledged she should have changed gloves after touching the bed remote and feeding pump. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 5/2020, the P&P indicated, Handwashing: soap .and water for the following situations . Before preparing or handling medications . After contact with objects (e.g. [example] medical equipment) in the immediate vicinity of the resident . 4a. During an observation on 2/6/23 at 5:28 p.m., certified nursing assistant (CNA) R was observed inside an isolation resident room wearing a face mask and gloves. The signs outside of the isolation room indicated anyone entering the room should wear face mask, face shield, gown, and gloves. During an interview on 2/6/23 at 5:28 p.m., with RN D, RN D stated, the room was still in isolation; therefore, CNA R should have had on the required PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) as posted. During an interview on 2/7/23 at 10:56 a.m. with CNA R, CNA R stated, regarding her entrance into an isolation room yesterday evening, in addition to the PPE she had on, she should have had a gown and face shield on. CNA R stated there was an isolation cart outside of the room, and one of the residents in the room was COVID-19 positive. She accidentally went in the room without proper PPE. 4b. During an observation on 2/8/2023 at 1:20 p.m., CNA S went inside the isolation room wearing an N95 (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) only. CNA S picked up the lunch tray from Bed A, went outside carrying the tray with her bare hands, walked along the hallway and passed the tray to another CNA. There were three postings near the outside the isolation room. The first post indicated, STOP, CHECK WITH CHARGE NURSE BEFORE ENTERING ROOM. VISIT NURSE. It also had pictures of a surgical mask, N95, Gloves, Face shield, and Disposable Gowns. The second post indicated, STOP Transmission Based Precautions STOP. Donning. 1. Hand Hygiene; 2. Gown; 3. Mask; 4. Goggles/Face shield; 5. Gloves. The third posting indicated, STOP Transmission Based Precaution STOP. DOFFING. 1. Gloves; 2. Goggles/Face shield; 3. Gown; 4. Mask; 5. Hand Hygiene. There was an isolation drawer (storage unit containing PPE, such as gowns, gloves, face shields and masks) near the outside the isolation room with a sign that indicated, RED ZONE (a dedicated area for COVID-19 residents). During an interview with CNA S, on 2/8/2023 at 1:25 p.m., she confirmed the isolation room had residents with Coronavirus disease (COVID-19, a disease caused by a contagious virus). CNA S stated, I just picked up the tray . Should I gown up? During a concurrent interview and review of the postings of the isolation room, on 2/9/2023 at 9:28 a.m., LVN T stated the isolation room was their Red Zone. LVN T confirmed there were residents with COVID-19 in the isolation room. LVN T stated any staff who entered the isolation room should wear the proper personal protective equipment (PPE, such as: N95, disposable gown, gloves, face shield or goggles) prior to entry. 4c. During an observation on 2/9/2023 at 12:37 p.m., certified nurse assistant U (CNA U) entered the isolation room wearing N95, disposable gown, and gloves. CNA U did not wear a face shield or goggles inside the isolation room. During an interview with CNA U on 2/9/2023 at 1:30 p.m., CNA U stated she needed to wear N95, gown, gloves and face shield every time she entered the isolation room. The CNA U stated, I'm sorry. I should have worn it (face shield). During an interview with the infection preventionist (IP) on 2/9/2023 at 1:48 p.m., the IP confirmed the isolation room had residents with COVID-19. The IP stated all staff and visitors should wear full PPE prior to entering the isolation room. The IP stated full PPE should be worn when trays are picked up from the isolation room because it was their Red Zone. 4d. During an observation on 2/9/23 at 1:30 p.m., LVN X was observed wearing a mask with ear loops (straps that go around each ear). LVN X was questioned about wearing a mask with ear loops instead of an N95 (which has straps that are placed behind the neck and at the crown of the head). LVN X stated This is my first day here . I am a registry nurse . No one told me I could not wear this mask with ear loops. During an interview with the IP/DSD on 2/13/23 at 8:12 a.m., she stated the facility instituted the wearing of N95s due to an outbreak of Covid-19 and that all staff were required to wear N95s until the positive resident's isolation had been completed on 2/10/23. The IP/DSD stated the facility did not allow staff to wear KN95s (masks with ear loops). She stated LVN X should be wearing an N95. A review of the All Facilities Letter (AFL) 23-12 titled Coronavirus Disease 19 (COVID-19) Recommendations for Personal Protective Equipment (PPE), Resident Placement/Movement, and Staffing in Skilled Nursing Facilities, dated 1/24/2023, referenced a chart of COVID-19 recommendations titled COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category that indicated, COVID Positive Residents . N95 respirator - Yes . Eye Protection - Yes . Gowns - Yes . 5. Review of the facility's COVID-19 Self Screening form for employees, dated 2/9/23, indicated there was no evidence that LVN X completed self-screening on 2/9/23. LVN X was listed on the daily staffing assignment of 2/9/23 as assigned to station 2B for the day shift. During a concurrent interview with the IP/DSD, on 2/13/23 at 8:45 a.m., she stated staff are instructed to take their temperature and to complete the COVID-19 screening questionnaire at the start of their work shift. The IP/DSD confirmed there was no evidence LVN X took her temperature or completed either the screening questionnaires for staff or for visitors on 2/9/23. The IP/DSD stated LVN X should take her temperature and complete the questionnaire. 6a. Review of Resident 24's clinical records indicated, Resident 24 was admitted to the facility with diagnoses including critical illness polyneuropathy (condition involving damage to many nerves in different parts of the body), other pulmonary embolism (occurs when a clump of material, most often a blood clot, gets stuck in an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) in the lungs, blocking the flow of blood) and dependence on supplemental oxygen (a continuous flow of oxygen delivered to people deficient in oxygen). During an initial observation on 2/6/2023 at 9:48 a.m., Resident 24 laid in bed with oxygen delivered to him via (through) nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and with two prongs that are placed in the nostrils for oxygen administration) at 2.5 liters (L- a metric unit of capacity) per minute. The dust filter located at the back of the oxygen concentrator (a machine that concentrates the oxygen from air to supply an oxygen-enriched gas stream) had a buildup of grayish matter. During another observation inside Resident 24's room, on 2/7/2023 at 11:45 a.m., Resident 24's oxygen concentrator's dust filter still had the grayish matter build up. 6b. Review of Resident 15's admission RECORD, dated February 10, 2023, indicated Resident 15 was admitted to the facility with diagnoses including unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease (COPD - a long lasting lung disease). During an initial observation on 2/6/2023 at 9:55 a.m., Resident 15 laid in bed, with oxygen in placed via NC at 2.5 L per minute. Resident 15's oxygen concentrator's dust filter located at the right side of the machine had some grayish matter build up. During a follow up observation on 2/7/2023 at 11:47 a.m., Resident 15's oxygen filter still had some grayish build up. During an interview with LVN L, on 2/7/2023 at 11:50 a.m., LVN L stated it was the responsibility of both nursing and maintenance staff to keep oxygen concentrators in good working condition. During a concurrent observation and interview with LVN L, on 2/7/2023 at 11:55 a.m., LVN L confirmed the oxygen filters of Resident 24 and Resident 15 were dirty and needed to be cleaned. LVN L further stated the oxygen filters should be cleaned to provide clean air to residents on supplementary oxygen. During an interview with LVN P, on 2/7/2023 at 12:02 p.m., LVN P stated nurses should change the oxygen humidifiers (device used to increase the level of moisture in the oxygen) and maintenance should change or clean the filters. During a concurrent observation of oxygen concentrator filters and interview with assistant director of nursing A (ADON A) on 2/7/2023 at 12:07 p.m., ADON A confirmed the oxygen filters of Resident 24 and Resident 15 needed to be changed. ADON A stated the oxygen filters should be clean. ADON A further stated one staff was assigned to check all oxygen concentrators every two weeks. During a concurrent interview and record review regarding the oxygen log checks, on 2/7/2023 at 12:15 p.m., the central supply staff (CSS) stated he checked the resident's oxygen every other week. The CSS reviewed the log and confirmed he missed checking Resident 24 and Resident 15's oxygen filters for the month of February, 2023. A review of the oxygen log indicated the last time the oxygen filters were cleaned for Resident 24 and Resident 15 was on January 21, 2023. Review of the facility's policy and procedure titled, Oxygen Administration, date revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guidelines . 3. For concentrators, clean lint and dust filters every 2 weeks and PRN (pro re nata - is a Latin phrase meaning as the circumstances arises) basis.