**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazards for one (#77) of five residents reviewed for accident hazards out of 37 sample residents. R77 had severe cognitive impairments. On 3/19/25, the resident took a piece of bread from another resident's plate and ate it. R77 choked and required the Heimlich maneuver (abdominal thrusts used to clear food from a person's airway that is choking) to clear the food from his airway. The resident's care plan directed staff to assist R77 with controlling his rate of eating, monitoring the resident's bite sizes to ensure the resident did not choke and monitoring the resident to avoid the resident stuffing food into his mouth. Additionally, R77 was prescribed a mechanically altered diet. Observations during the survey revealed R77 received menu items that were not consistent with his prescribed diet order. The staff failed to provide supervision during meals to ensure the resident did not take food from other residents' plates or monitor the resident's bite sizes which put the resident at a continued risk of further choking incidents for R77. The failure to provide appropriate supervision during times of resident intake placed residents at risk for serious harm or death if not corrected immediately. On 4/25/25 at 10:11 a.m., immediate jeopardy was identified based on the facility failures above that created a situation of potential serious harm for R77, requiring immediate corrective action. Findings include: I. Immediate Jeopardy A. Situation of immediate jeopardy The facility failed to ensure staff provided appropriate supervision and implemented the identified care-planned interventions for R77 after the resident had a choking incident on 3/19/25. The facility's failure to ensure staff provided appropriate supervision and implemented care-planned interventions led to a continued risk of further choking incidents for R77. B. Imposition of immediate jeopardy On 4/25/25 at 10:11 a.m., the Nursing Home Administrator (NHA) was notified of the immediate jeopardy situation created by the facility's failure to ensure R77 received appropriate supervision during times of intake. C. Facility plan to remove immediate jeopardy On 4/25/25 at 4:37 p.m. the facility submitted a plan to remove the Immediate Jeopardy. The removal plan read: 1. Corrective action R77 will be served food per the physician's ordered diet of a mechanical soft diet. The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during times of intake to ensure he is eating safely. R77 will be placed on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture. Any additional safety concerns or behaviors will be addressed, documented in the behavior log and will be updated on the care plan with appropriate interventions. The care plan and interventions will be reviewed and updated every quarter and with every change of condition. 2. Identification of others An audit was completed on 4/10/25 and determined 14 residents required assistance with intake. Each resident identified will be seated at a designated table in the dining room. The Restorative CNA or designee will provide active monitoring of those residents during each meal. 3. Systemic changes On 4/11/25 the facility's Diet Orders and Food Services policies were reviewed by leadership to ensure alignment with current best practices and regulatory standards. The DON (Director of Nursing)/designee provided education, starting on 4/11/25 and completed on 4/16/25, to the nursing staff of the requirement for supervision for the at-risk residents that were identified. CNAs and nurses will observe and supervise the at-risk residents identified for choking, appropriate meal texture and process of notification if an incident or concern arises. The Dietary Manager (DM) provided education, starting on 4/10/25 and completed on 4/11/25, to the cooks and servers on diet extensions to ensure proper diet textures, diet types, food procurement and scoop sizes. The kitchen will follow diet extensions at each meal. The cook appropriately prepares the meals following the diet extensions. The server sets up steam tables with all meals prepared by the cook and verifies that menus and extensions are correct. The server will plate the food based on the diet type report that is located on the steam table. The diet type report is updated as needed and with any new orders. The CNA will verify that the meal served matches the diet type report. One CNA and a nurse will be designated to each dining area for the entire meal service. One leadership member is assigned to meals to round and assist as needed. If a resident on eating supervision is given a snack, a CNA or designee must supervise the resident while they consume the snack. 4. Monitoring The DM/designee will audit the lunch meal on 4/25/25 to ensure extensions are served correctly. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. The DON/designee will audit resident supervision on 4/25/25. Additionally, three meals will be audited daily for one week, then one meal daily for three weeks, then five random meals per week until substantial compliance. The audits will be documented on a written log and concerns will be addressed immediately. D. Removal of the immediate jeopardy The NHA was notified the immediate jeopardy was removed on 4/25/25 at 5:17 p.m. based on the facility's removal plan (see above). However, the deficient practice remained at a D level, no actual harm with potential for more than minimal harm that is not immediate jeopardy. II. Facility policy and procedure The Food Service policy and procedure, undated, was provided by the NHA on 4/25/25 at 3:30 p.m. It read in pertinent part, Special diets as prescribed by a physician are available. Mealtime assistance is available as needed, based on the resident service plan. III. Failure to ensure staff provided appropriate supervision and implemented care-planned interventions A. Resident #77 status R77, age [AGE], was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included severe dementia with agitation and delusional disorders. The 2/10/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired and could never or rarely make decisions regarding tasks of daily life. The resident required partial to moderate staff assistance for eating and was dependent on staff for all other activities of daily living (ADL). The assessment documented the resident was receiving a mechanically altered diet. B. Observations During a continuous observation of the lunch service on 4/8/25, beginning at 12:11 p.m. and ending at 12:42 p.m., the following was observed: At 12:11 p.m. R77 was sitting at a dining table with several other residents. An unidentified staff member delivered R77's meal to him and the resident began eating independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:14 p.m. R77 speared multiple whole baby carrots and sweet potato pieces on his fork and ate them in one bite. No staff member intervened and staff did not provide the resident with supervision to ensure he was eating safely. At 12:19 p.m. multiple staff members were delivering trays of food to residents throughout the dining room and in their rooms. Staff did not provide R77 with supervision to ensure he was eating safely. At 12:22 p.m. an unidentified staff member delivered a second helping of food to R77 and promptly returned to serving trays. The unidentified staff member did not provide the resident with supervision to ensure he was eating safely. At 12:28 p.m. R77 continued eating by himself. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:36 p.m. R77 finished his second helping of food and remained at the dining table with other residents. At 12:42 p.m. an unidentified staff member cleared the plates from the dining table at which R77 was sitting. Staff did not provide the resident with supervision to ensure he did not take food from another resident's plate. During a continuous observation of the lunch service on 4/9/25, beginning at 12:10 p.m. and ending at 12:50 p.m., the following was observed: At 12:24 p.m. R77 was served a slice of pumpkin pie and ate it independently. Staff did not provide the resident with supervision to ensure he was eating safely. At 12:26 p.m. R77 self-propelled to another table in the dining room. R77 grabbed food off of another resident's plate and used that resident's spoon to eat her pumpkin pie. A resident from R77's usual table in the dining room saw what was occurring and yelled out to get the staff's attention. CNA #6 assisted R77 back to his original table and gave him the other resident's remaining pumpkin pie. CNA #6 did not provide the resident with supervision to ensure he was eating safely. At 12:31 p.m. R77 began self-propelling away from the dining room. CNA #6 tried to redirect R77 back to his table and said his food was there. CNA #6 assisted R77 back to his table in the dining room where he was served lunch and began eating. CNA #6 again did not provide the resident with supervision to ensure he was eating safely. At 12:33 p.m. Restorative Nurse Aide (RNA) #1 brought R77 a glass of juice and sat down next to the resident and began providing the resident with supervision and cues for eating more slowly. C. Record review The restorative care plan, initiated 2/26/24, revealed R77 required restorative nursing for dining. Pertinent interventions included assisting R77 with controlling his rate of eating, monitoring bite size to ensure the resident did not choke and monitoring self-feeding to avoid the resident stuffing food into his mouth. The ADL care plan, revised 1/30/24, revealed R77 had a self-care performance deficit due to his dementia. Pertinent interventions included R77 required staff assistance with eating. -Review of the resident's care plan did not reveal the facility identified the resident often took food from other resident's plates. Review of R77's April 2025 CPO revealed a physician's order for a regular diet with a mechanical soft texture, ordered 8/11/24. A progress note, dated 3/7/25 at 4:46 p.m., revealed R77 was observed in the dining room with a plastic soda bottle cap in his mouth. Staff were instructed to remove soda bottles from the dining tables and residents were reminded to throw their trash into the waste receptacles once they were finished with them. A progress note, dated 3/19/25 at 7:26 a.m., revealed R77 had an episode of choking during the previous meal. R77 appeared to be unable to swallow, speak, or cough. Nursing staff assisted R77 with an abdominal thrust and visible food was removed from his mouth. A Registered Nurse (RN) performed an assessment which indicated R77 was able to speak, eat and swallow. No injuries were noted at the time, vital signs were stable. Staff were to continue to observe the resident during meal times and cut his food into smaller pieces. R77's representative and physician were notified. An interdisciplinary team (IDT) note, dated 3/26/25 at 11:34 a.m., revealed R77 choked on an item that was not part of his diet texture. R77 had grabbed food from another resident's plate. R77 was monitored to ensure he was not taking food from other residents' plates. R77 sat at the restorative table while eating. The IDT team suggested the residents in the work therapy program be assigned to pick up plates when other residents were done eating. D. Menu extensions Review of the menu extensions from 4/7/25 through 4/13/25 revealed the following: The mechanical soft texture lunch meal for 4/9/25 included blackened fish, sweet potato wedges, green beans, and a pureed dinner roll. -However, R77 was served a vegetable blend instead of the green beans on the menu extensions (see observations above). IV. Staff interviews CNA #4 was interviewed on 4/10/25 at 9:16 a.m. CNA #4 said R77 spent most of his day wandering around the facility. CNA #4 said R77 sometimes tried to grab items from other residents. CNA #4 said R77 was redirectable when he tried to take other residents' items. CNA #4 said the staff had to monitor R77 during meals because he tried to take other residents' meals and drinks. CNA #4 said other residents would yell when R77 took food or drinks from other residents and would redirect him. Licensed Practical Nurse (LPN) #4 was interviewed on 4/10/25 at 9:53 a.m. LPN #4 said R77 liked to grab items and put them in his mouth so the nursing staff had to keep an eye on him. LPN #4 said she was not aware of any choking incidents R77 had. Nurse Manager (NM) #1 was interviewed on 4/10/25 at 3:26 p.m. NM #1 said the nursing staff had to redirect R77 from going into other residents' rooms and grabbing items in the dining room. NM #1 said the nursing staff needed to monitor R77, especially during mealtimes. NM #1 said the nursing staff were good at monitoring R77 and ensuring he did not put anything inappropriate in his mouth. NM #1 said he could not recall if R77 had experienced any choking incidents. The Director of Nursing (DON) was interviewed on 4/10/25 at 4:44 p.m. The DON said R77 had a tendency to grab food from other residents' plates. The DON said R77 had previously grabbed bread from another resident's plate and choked on it. The DON said if the nursing staff saw R77 grabbing food from another resident's plate they redirected him, which in turn made R77 try to eat or get rid of whatever he had grabbed faster than before. The DON said the facility had the resident work therapy program to help clean up the dining room so there were no trays sitting out and thus limiting the amount of food R77 could potentially grab. The DON said the nursing staff increased their monitoring of R77 during meals, and that the resident sat at the restorative dining table so the RNAs could supervise him during meals. The DON said the facility was also utilizing a feeding training program for non-clinical staff so they could help feed and monitor residents during mealtimes. -However, meal observations revealed staff were not supervising R77 when he was eating (see observations above).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews, the facility failed to provide residents residing on the second and third floors of the facility, including Residents #1, #182, #74, #73, #75, #92, #103, #67, #87, #95, #102, #14, #76, #115, #68, #7, #77, #112, #57, and #8, with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives. Observations and interviews with residents and staff revealed facility practices that showed a disregard for residents' quality of life and were inconsistent with the facility Resident Rights policy to provide residents with a holistic program that provided respect, dignity, and compassion. Resident interviews and observations revealed restrictions on residents' day-to-day lives that were not supported by evidence the facility had considered their impact on residents' quality of life or that the restrictions were necessary to maintain a safe and healthy environment. Facility practices limited and/or precluded residents' ability to meet without staff at Resident Council; their ability to obtain money from their personal needs funds; their ability to access other areas of the facility; their ability to choose where to eat, the tableware to use, and the beverage to drink; their ability to have visitors 24-hours a day; their ability to participate in social activities; and their ability to participate and receive private communications by phone and mail. These restrictions contributed to residents feeling jailed, trapped, incompetent, bad, and angry. Observations confirmed such restrictions and also revealed staff was not responsive to call lights, contributing to residents feeling like no one cared. Observations further revealed residents lacked ready access to information on outside assistance from the state and survey results. The facility's failure to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected. Cross-reference F550, F585, F600, F603, F610, F689, and F699. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Based on observations, record review, and interviews, the facility failed to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives. Observations and interviews with residents and staff revealed facility practices that showed a disregard for residents' quality of life and were inconsistent with the facility Resident Rights policy to provide residents with a holistic program that provided respect, dignity, and compassion. Resident interviews and observations revealed restrictions on residents' day-to-day lives that were not supported by evidence the facility had considered their impact on residents' quality of life or that the restrictions were necessary to maintain a safe and healthy environment. Facility practices limited and/or precluded residents' ability to meet without staff at Resident Council; their ability to obtain money from their personal needs funds; their ability to access other areas of the facility; their ability to choose where to eat, the tableware to use, and the beverage to drink; their ability to have visitors 24-hours a day; their ability to participate in social activities; and their ability to participate and receive private communications by phone and mail. These restrictions contributed to residents feeling jailed, trapped, incompetent, bad, and angry. Observations confirmed such restrictions and also revealed staff was not responsive to call lights, contributing to residents feeling like no one cared. Observations further revealed residents lacked ready access to information on outside assistance from the state and survey results. The facility's failure to provide residents residing on the second and third floors of the facility with an environment that supported and enhanced each resident's dignity, self-worth, sense of satisfaction, and control over their lives created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected. B. Facility plan to remove the immediate jeopardy situation On 5/20/24 at 3:15 p.m., the nursing home administrator (NHA) provided a plan to remove the immediate jeopardy. The removal plan read: Resident Council -Residents will be asked before each Resident Council whether they would like staff to attend the meeting or not. Residents are able to meet without staff present. -This question will be asked at the beginning of each Resident Council Meeting. A new Resident Council Form was implemented, to include this question and the resident's response. The resident's response will be documented in the minutes of each Resident Council Meeting. -Resident Council Meeting Minutes will be reviewed monthly during QAPI to ensure the above. Required Postings -Postings were updated with the correct contact information. -Postings are located in each neighborhood and are at the level that residents in wheelchairs can see them. -Postings will be monitored daily by the Leadership Team to ensure that they are in place, and at the proper level. Right to Survey Results -Survey Results Binder is located in the Front Lobby on the first floor, and the binder contains three years of surveys. -Residents have access to the Survey Results Independently. -NHA or designee will update the binder with all annual and complaint surveys moving forward and will ensure that the binder is in place Monday through Friday. Resident Rights and Quality of Life Services -Per the care plan and guardian input, (Resident #8) did participate in the birthday party on the second floor. -Resident #8's guardian was contacted on 5/16/24, to clarify resident's ability to move throughout the community. -Resident #8's care plan was updated to include guardian input and court-ordered placement stipulations regarding movement throughout the community. -A Resident Preferences Interview was conducted with resident #8 on 5/18/24, and her care plan was updated to reflect her preferences. -Resident #8's preferences will be updated as needed, and the community will maintain contact with resident's guardians for further care plan revisions quarterly and as needed. Meals on Second Floor -All residents are encouraged to eat in the dining areas. -If a resident chooses to eat in their rooms, a room tray will be provided. -The kitchen is open from 7:00 a.m. to 7:00 p.m. If a resident misses a meal, they can request food or a tray during these times. -Snacks are available in the neighborhoods 24/7. (Snacks include, but are not limited to sandwiches, chips, protein bars or other items that are substantial in nature). -The above was reviewed with all residents on 5/16/24, 5/17124, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Dining Services will be reviewed with the Food Committee on a Monthly basis. Soda/Soda Cans -Residents can purchase and/or request soda any time that they wish. -Residents on the second floor will have soda served to them in a disposable cup for safety of all residents. This is due to residents potentially consuming the tabs and/or injuring themselves or others with the cans. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of disposable cups for soda will be discussed monthly during the second floor Resident Council meetings. If any concerns are verbalized by residents, these will be addressed on an individual basis. If no incidents occur, the community may consider returning to the use of soda cans at some point in the future. Private Phones -There is a cordless phone at the Nurses' Station in each neighborhood, that is available to all residents, so that resident can hold a phone conversation in the area of their choice. Phones are accessible and available to residents at all times. -There are also stationary resident phones located throughout the community, and there is a private phone in the Town Hall Room on the first floor. All of these phones are available to the residents. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of cordless phones will be discussed monthly during the Resident Council Meetings for each neighborhood on a monthly basis. Disposable Silverware -Residents on the second floor will utilize plastic cutlery for the safety of all residents in the neighborhood. This is due to residents potentially harming themselves or others with regular metal cutlery. -This information is located in the Resident Handbook for all admissions to the second floor. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17 /24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -The use of plastic cutlery will be discussed monthly during the Resident Council Meetings for second floor, on a monthly basis. Any concerns voiced by residents will be addressed on an individual basis. If no incidents occur, the community may consider having regular cutlery provided to residents. Visiting Hours -Visiting hours are twenty-four hours per day, seven days per week. -If there are concerns related to a visitor bringing in contraband items they will be requested to leave their items in a locker during their visit to prevent further concerns. This information is in the Resident Handbook. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA}, Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -All responsible parties were notified of the above, by the NHA, on 5/17/24 and 5/21 /24. -Visiting hours will be discussed during the Resident Council Meetings, on each neighborhood, on a monthly basis. Elevator -The elevator operates 24 hours per day, 365 days per year, and residents have access to it at all times. Staff do not have the ability to manipulate the operation of the elevator in any way. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM}, on the above. -Elevator availability will be discussed during the Resident Council Meetings, in each neighborhood, on a monthly basis. Smoking -(The facility will) continue to follow the CDPHE (Colorado Department of Public Health and Environment) directed plan regarding safe smoking from 2015. -The community reviews the Smoking Guidelines on an annual basis, and this information is in both the Resident Handbook and the Resident Agreement. -The Smoking Guidelines are reviewed with residents on an annual basis. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. A concern identified by residents was that they do not have funds to smoke more than 3 smoking times per day, and they do not want to run out of cigarettes. The residents voiced that they desire to smoke after each meal. -Resident's smoking abilities are assessed quarterly, and care plans are updated accordingly, based upon each resident's ability. -Resident smoking will be discussed during Resident Council Meetings, on each floor, on a monthly basis. -The community will hold a smoker's meeting on a quarterly basis. Mail Delivery on Saturdays -Mail is delivered Monday through Saturday, if/when the mail is received from the United States Postal Services and will be delivered by the Leader on Duty. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Mail delivery will be discussed during Resident Council Meetings, on each floor, on a monthly basis. Personal Needs Accounts -The community follows the following regulation regarding resident's personal needs accounts: -(The facility) will follow to regulation below. -All business office staff have been educated by the Administrator & dining service manager (DSM) on 5/17/2024 -Resident and staff have been notified by Administrator, DSM, on 5/17/2024, 5/18/2024. -Resident council was conducted on 5/18/2024- residents were also notified that (the facility) can issue a check for larger amounts of money upon resident request. -(The facility) will follow the amount allowed as of July 13, 2023, per our surety bond. -The law and regulations are intended to assure that residents have access to $100.00 ($50.00 for Medicaid residents) in cash within a reasonable period, when requested. Requests for less than $100.00 ($50.00 for Medicaid residents) should be honored within the same day. Requests for $100.00 ($50.00 for Medicaid residents) or more should be honored within three banking days. Although the facility need not maintain $100.00 ($50.00 for Medicaid residents) per resident on its premises, it is expected to maintain amounts of petty cash on hand that may be required by residents. -The above was reviewed with all residents on 5/16/24, 5/17 /24, 5/18/24, 5/19/24, 5/21 /24, and 5/22/24. In addition, staff were educated on 5/17/24, 5/18/24, and 5/19/24 by Nursing Home Administrator (NHA), Director of Wellness, (DOW), and Health Information Manager (HIM), on the above. -Personal Needs Accounts will be discussed during the Resident Council Meetings, on each floor, on a monthly basis. Care Plans -Assessments and behavior care plans are developed and created on a resident specific and individualized basis. Resident needs and preferences are included in each individual care plan. -Due to the nature of the population that is served at (the facility), the care plans must be specific, and in some cases, must include court orders, and/or specific resident-centered behavioral interventions. -The community does provide a culture that supports each individual resident's preferences, choices and values. A Resident Preferences Questionnaire has been completed, and residents have been interviewed, on 5/16/24, 5/17/24, 5/18/24, 5/19/24 and 5/22/24 regarding all of the above topics. All above items will be reviewed monthly in QAPI (quality assurance and performance improvement) and Safety Committee for three months and quarterly thereafter. C. Removal of immediate jeopardy The immediate jeopardy was removed on 5/22/24 at 5:39 p.m. based on the facility's removal plan (see above) that addressed restrictions that impacted the day-to-day lives of residents residing on the second and third floors of the facility. However, the deficient practice remained at an H level, actual harm at a pattern. II. Facility Policy The Resident Rights policy was provided by the NHA on 5/20/24 at 3:11 p.m. It read in pertinent part: The goal of (the facility) is to provide Residents with a holistic program that provides respect, dignity, and compassion. All Residents who live here are entitled to certain rights: -The right to be treated with respect and dignity. -The right to privacy. -The right not to be isolated or kept apart from other residents. -The right not to be sexually, verbally, physically or psychologically abused, humiliated, intimidated or punished. -The right to be free from neglect. -The right to live free from involuntary confinement, or financial exploitation and to be free from physical or chemical restraints. -The right to full use (of) the facility common areas, in compliance with the documented house rules. -The right to voice grievances and recommended changes in policies and services. The facility shall establish a written grievance procedure which shall be posted. It shall be posted in a Resident's record that he/she has read or had such policy for handling grievances explained upon admission. -The right to communicate privately including but not limited to communicating by mail or telephone with anyone. -The right to reasonable use of the telephone, including access to operator assistance for placing collect telephone calls. At least one telephone should have hearing amplification. -The right to have visitors, in accordance with house rules, including the right to privacy during these visits. -The right to make visits outside the facility in which case the administrator and the resident shall share responsibility for communicating with respect to scheduling. -The right to make decisions and choices in the management of personal affairs, funds, or property in accordance with their abilities. -The right to expect the cooperation of the provider in achieving the maximum degree of benefit from those services which are made available by the facility. -The right to exercise choice in attending and participating in religious activities. -The right to be reimbursed at an appropriate rate for work performed on the premises in accordance with the Resident's board and care plan; i.e. volunteer work program. -The right to 30 days written notice of changes in services provided by the facility, including but not limited to changes in charges foresident access to any floor other than the floor they resided on was by elevator?r any or all services. Exceptions to this notice are: -Changes in the resident's medical acuity that result in a documented decline in condition and that constitute an increase in care necessary to protect the health and safety of the resident. -Requests by the resident or family for additional services to be added to the care plan. -The right to have advocates, including members of community organizations, whose purposes include rendering assistance to the residents. -The right to wear clothing of choice unless otherwise indicated in the Resident's board and care plan in accordance with house rules. -The right to choose to participate in social activities, in accordance with resident's board and care plan. -The right to receive services in accordance with the resident agreement and the care plan. III. Residents' concerns with facility practices that impacted their dignity, self-worth, and sense of satisfaction and control over their lives. Forty-six residents resided in the secured unit on the facility's second floor and 84 residents resided on the third floor which was divided into two units, Pinon and Juniper. No residents resided on the first floor. Each floor had a dining room and the first and third floors had a soda machine. Resident access to any floor other than the floor they resided on was by elevator. A. A group interview was conducted with seven alert and oriented residents from the second and third floors of the facility. The group included the resident council presidents for the second and third floors. B. The group interview was conducted on 5/15/24 at 11:00 a.m. The residents (#76, #75, #115, #68, #7, #77, and #112) frequently attended the resident council. According to the residents, their concerns were brought up in previous resident council meetings, however, the concerns were not addressed. C. The group reported the following concerns: -Resident #115, who said she was the resident council president for the second floor, said the resident council was not permitted to meet without facility staff present and council members were fearful of punishment if they pushed the issue. Other residents agreed. -Residents said second floor residents were restricted to having only one soda per day and it was offered at 10:00 a.m. They were not told the reason. They were not allowed to buy soda from the soda machines on the third and first floors. Resident #115 said it made her mad that her sister buys her a 12-pack of soda and she was not allowed to drink it whenever she wanted. -Residents said they were only allowed to take out up to $5.00 a day from their personal needs accounts (PNAs); otherwise, they needed to get permission from the social worker. -Residents said mail is not delivered on Saturdays and, at times, not delivered during the week. -Residents said they were not able to eat in their rooms; they had to eat in the dining room. Two residents said that made them feel bad. -Residents said there was no privacy when they used the phone. The residents said there were no cordless phones and they had to use the phone at the nurses' station. -Residents confirmed the visiting hours were from 9:00 a.m. to 4:00 p.m., but they did not know why. They wanted the visiting hours to be longer. -Residents said they did not know how to file a grievance, know where to find survey results, or where to find information to contact outside support. -Residents said they were all supervised smokers and they were only allowed three smoke breaks and only got to have one cigarette, so only three cigarettes a day. Residents said they wanted the opportunity to have more than three smoke breaks. -Residents said call lights were not answered timely. The residents said the call lights blink all night long and it made them feel like no one cared. -One resident said he would have his chocolate milk taken away if he misbehaved. Another resident said they would have cigarette breaks taken away for misbehaving. The other residents agreed they had seen this happen. IV. Observations confirmed residents' reported concerns about limitations of their rights and the facility's failure to provide residents with an environment that supported and enhanced each resident's quality of life. A. Observations 5/14/24 regarding social activity, tableware, beverages, call lights On 5/14/24 at 10:15 a.m., residents sat at all of the tables in the second floor dining room. An unidentified activity assistant (AA) was observed to have cans of soda and coffee on a cart. The AA opened a can of soda and poured approximately four ounces of soda into a paper cup. There were approximately 20 residents in the dining room. None of the residents received the full can of soda. On 5/14/24 at 11:54 a.m., two call lights on the second floor were observed blinking. The two lights continued to blink until 12:18 p.m. when staff came up from the first floor to check on the first light. At the time, there were two certified nurse aides (CNA) in the dining area, a nurse at the medication cart near the nurses' station, and a nurse sitting at the nurses' station. There was not an audible tone or call light panel alerting staff of the blinking call lights. On 5/14/24 at noon, the second floor dining room was observed. The residents were served their meals with a plastic fork and spoon. The meal was baked chicken. An unidentified resident was observed to use his spoon to hold the chicken while he worked to scrape a piece of the meat off with the fork. On 5/14/24 at 5:32 p.m. the contact information sign for the state was observed on the first floor near the elevator. It did not include the phone number to reach the state office and was posted at the very top of the display case above the line of sight for residents in wheelchairs. On 5/14/24 at 5:34 p.m., the survey results binder was observed on the first floor. It held only the survey results from 2023. B. Observations 5/15/24 regarding call lights, privacy (phone calls), visitation On 5/15/24 at 9:37 a.m. the call light for room [ROOM NUMBER] was observed blinking. At 9:49 a.m., assistant director of nursing (ADON) #2 walked past room [ROOM NUMBER], entered her office, and did not check on the resident. At 9:56 a.m., ADON #2 left her office, walked past room [ROOM NUMBER] again, and did not check on the resident. At 10:03 a.m., ADON #2 passed room [ROOM NUMBER] to return to her office and did not check on the resident. At 10:15 a.m., a CNA entered room [ROOM NUMBER] and turned off the call light. There was no audible tone alerting staff that a call light had been activated. On 5/15/24 at 9:53 a.m. a corded telephone was observed on the desk at the third floor nurses' station. The phone was not in a private or quiet location; the nursing station was centrally located to a medication cart, staff offices, resident rooms, and the common area which also served as the main dining area. As such, conversations had on the phone would be audible to those in the common area and the nurses at the nursing station. On 5/15/24 at 11:56 a.m., the posting of visiting hours at the elevator on the first floor read, Visiting hours. As a courtesy to our resident who resides here at the (name of the facility) please visit your loved ones/friends during these hours: Monday- Sunday 9:00 a.m. -4:00 p.m. Thank you for your cooperation. On 5/15/24 at 2:31 p.m., Resident #118 was observed having an emotional, tearful conversation on the corded phone at the nurses' station on the second floor. The phone was not in a private or quiet location; the nursing station was centrally located to a medication cart, staff offices, resident rooms, and the common area which also served as the main dining area. D. Observations 5/16/24 regarding social activities and privacy (phone calls) On 5/16/24 at 2:25 p.m., Resident #8, who resided on the second floor, was observed crying. Per ADON #2, she was crying because she was not allowed to attend the resident activity on the first floor, celebrating birthdays for May. Observations revealed other residents from the second floor were allowed to attend the activity. On 5/16/24 at 3:20 p.m., four residents were observed crowded around the second floor nurses' station. One resident was speaking on the telephone and three residents were crowded next to him. The unit was noisy with residents singing and socializing. The resident on the phone was heard repeating his conversation and shouting into the telephone. E. Observations on 5/19/24 regarding call lights On 5/19/24 at 5:13 p.m., call lights were activated for rooms 200, 201 and 206. At the time, three employees were observed sitting behind the desk. One nurse was using her personal cell phone. At 5:29 p.m., the lights remained activated. V. Resident interviews Resident interviews confirmed residents' concerns about the limitations of their rights and the facility's failure to provide residents with an environment that supported and enhanced each resident's quality of life. A. Resident #1 was interviewed on 5/15/24 at 2:06 p.m. Resident #1 resided on the second floor. Resident #1 said she was not able to make private phone calls, and she could only make calls at the nurses' station. Resident #1 said this made her feel like she was trapped. B. Resident #182 was interviewed on 5/16/24 at 9:10 a.m. Resident #182 resided on the third floor and said he was new; he had resided in the facility for one to two weeks. He said he was told by staff not to go downstairs via the elevator after 6:00 p.m. each evening. Regarding visitation, he said visitors needed to call the facility to make an appointment. C. Resident #115 was interviewed on 5/16/24 at 9:48 a.m. Resident #115 resided on the second floor and said she did not want to live at the facility and felt trapped. She said she could not leave the second floor without an escort and did not know why. She reported her roommate had broken her cell phone charging cord the previous night and now her cell phone battery was dead so she was unable to call her kids or her sister. Resident #115 said she told staff and they told her she had not been at the facility long enough to be taken off facility property to get a new charger. D. Resident #74 was interviewed on 5/16/23 at 9:54 a.m. Resident #74 resided on the third floor. He said they closed down the elevator on the third floor at 6:00 p.m. because they closed the downstairs (first floor) down. Resident #74 said he had lived at the facility for six and a half years and he was okay with it because he was used to it. E. Resident #73 was interviewed on 05/16/24 at 1:31 p.m. Resident #73 resided on the third floor. He said he never went downstairs at night because the facility didn't let him. F. Resident #92 was interviewed on 05/16/24 at 1:35 p.m. Resident #92 resided on the third floor. Resident #92 said she only received $5 of her personal funds per day and wished it was more. Resident #92 said she only got to smoke three times per day because of facility rules. Resident #92 said she wanted more smoke breaks, and that it was a bummer. G. Resident #103 was interviewed on 5/16/24 at 1:36 p.m. Resident #103 resided on the third floor. Resident #103 said she was not allowed to go to a different floor to use the soda machines after 5:30 p.m. because staff would not let her. Resident #103 said she would rather go to the soda machines on the first floor during cold, rainy, or snowy weather because the soda machines on her floor were located outside on a patio. H. Resident #67 was interviewed on 5/16/24 at 01:43 p.m. Resident #67 resided on the third floor. Resident #67 said he only got $5 per day. Resident #67 said he didn't think that was right, and that he should be able to take out however much money he wanted. Resident #67 said the facility stopped him from going downstairs at night. Resident #67 said he felt like he was in jail because he could not go downstairs when he wanted to get a soda. I. Resident #87 was interviewed on 5/16/24 at 2:14 p.m. Resident #87 resided on the third floor. Resident #87 said he did not go downstairs, because the facility wanted him to stay upstairs. J. The representative for Resident #57 was interviewed on 5/16/24 at 2:14 p.m. Resident #57 resided on the third floor. The representative said she had to call the facility two days ahead whenever she wanted to take Resident #57 out of the facility. The representative said she was required by the facility to allow the facility to search her bag and keep it in a locker downstairs while she visited. K. Resident # 95 was interviewed on 5/16/24 at 4:50 p.m. Resident #95 resided on the third floor. She said she only used the facility telephone for incoming calls from her guardian. She said the facility telephone in the hallway was not adapted for her blindness. As a result, she was unable to dial telephone numbers for outgoing calls unless she requested staff assistance. She said she distrusted the facility staff and did not feel comfortable revealing the identity of the person she was calling. Resident #95 said she had concerns about staff members eavesdropping on her calls in the hallway. Resident #95 said an outside agency provided her with a smart telephone that allowed her to dial numbers through voice activation and[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, observations and interviews revealed the nursing staff lacked knowledge, training, and equipment to manage the residents' routine and emergency blood glucose monitoring needs. The facility's failure to monitor the blood glucose meters (glucometer) according to standard practice, coupled with the staff's lack of knowledge to ensure blood glucose meters were cleaned, sanitized, and stored properly in between each residents' use created the situation for serious harm likely to occur at a level of immediate jeopardy if the blood glucose meters continued to be shared among residents due to potential transmission of blood-borne pathogens. One resident who shared the glucometer with another had a diagnosis of chronic viral hepatitis C. In addition, the staff failed to perform hand hygiene when cleaning resident rooms. Findings include: I. Immediate Jeopardy A. Findings of Immediate Jeopardy Blood glucose meters The facility had two blood glucose meters, which were shared among three residents who required routine blood sugar checks. This included one resident who had a diagnosis of chronic viral hepatitis C. The Infection Control Program overview last updated 1/1/22 facility's policy and procedure documented to clean and disinfect reusable equipment between uses according to the manufacturer's instructions and current standards of practice. Observation During an observation on 1/24/23 beginning at 3:50 p.m. and ending at 4:03 p.m. the following was observed: -At 3:50 p.m. registered nurse (RN) #1 took gloves out of her pocket and entered room [ROOM NUMBER] with the glucometer. -At 3:51 p.m. RN #1 left room [ROOM NUMBER] with the glucometer. She took more gloves out of her pocket and placed a pile of them on the medication cart. She put gloves on both hands without performing hand hygiene. She opened the container of test strips. She took the glove off her left hand and reached into her pocket to obtain her keys with her left hand. She then opened the medication cart. She then put on another glove that was sitting on top of the medication cart back on her left hand. She put her keys back in her pocket. She opened the cart and closed the cart again. She picked up the glucometer. She knocked on room [ROOM NUMBER]'s door and entered the room. She did not perform hand hygiene or take the gloves off prior to entering the room. -At 3:54 p.m. RN #1 came out of room [ROOM NUMBER] with gloves on and the glucometer in hand. She took her gloves off and disposed of them in the trash can. She did not perform hand hygiene. She opened her computer. -At 3:55 p.m. RN #1 crossed her arms across her body. -At 3:56 p.m. RN #1 reopened the cart and began looking in the cart. She put another pair of gloves on without performing hand hygiene. She obtained a bottle of insulin solution and a syringe put the needle into a bottle of insulin and filled it. She closed the cart and went into room [ROOM NUMBER]. -At 3:58 p.m. RN #1 exited room [ROOM NUMBER] and disposed of the used insulin syringe. She picked up the pile of gloves that remained on the medication cart and disposed of them in the trash can. She did not perform hand hygiene. She placed the glucometer in a black pouch without sanitizing it and entered room [ROOM NUMBER]. She exited room [ROOM NUMBER]. -At 4:00 p.m. RN #1 opened the cart and put the keys in her pocket. She obtained more glucometer test strips. -At 4:01 p.m. RN #1 put the test strip in the glucometer. -At 4:02 p.m. RN #1 assisted a resident move by touching their wheelchair. She then entered room [ROOM NUMBER]. Interviews Registered nurse (RN) #1 was interviewed on 1/24/23 at approximately 4:15 p.m. RN #1 who was working on the East cart said she had three residents who had to have their blood sugars checked. She said she only had two glucometers. She confirmed that she had tested two residents with one meter. She said she cleaned the meter with an alcohol swab after the first resident. She said she then cleaned it again with alcohol after the second blood check.The two glucometers were stored in their own bag, with a name on them. -However, observations of the blood glucose meters revealed they were not labeled. The assistant director of wellness (ADOW) was interviewed on 1/24/23 at approximately 4:15 p.m. The ADOW said the glucometers were not to be shared. She said the meters were meant to be individual and labeled with each resident name. She said when the meters were used they were to be cleaned with a purple top sani-wipe. She said then the glucometer needed to stay wet for two minutes since that was the surface disinfectant time. RN #2 was interviewed on 1/24/23 at 4:21 p.m. She stated there were three glucometers on the Pinion unit for three residents and she used alcohol wipes to clean the glucometers. She stated there was one glucometer that was specifically used for one resident but it was not labeled. All glucometers were observed stored together in the medication cart. They were not in individual bags or labeled with a resident's name and were touching each other in the cart. LPN #1 was interviewed on 1/24/23 at 4:28 p.m. She worked on unit 200. She stated she had two glucometers on her cart for two residents. She stated she was unsure what kind of cleaning wipes were used for the glucometers as she had used the last of the wipes and went to central supply for more. She returned with super sani cloth disinfecting wipes. LPN #5 was interviewed on 1/24/23 at approximately 4:30 p.m. She worked on the Juniper [NAME] cart. She said she had three residents who required blood sugar checks, but only had two meters. The meters were stored without individual bags, and were not labeled. The LPN said she used an alcohol pad to clean the meters in between residents. RN #1 was interviewed a second time on 1/24/23 at approximately 5:00 p.m. RN #1 said that when she took the resident's blood sugar with the glucometer, she did not pick and choose which one to use. She said that she just picked one of the glucometers. Facility policy and procedure The Infection Control Program Overview, revised on 1/1/22, was received on 1/24/23 from the assistant nursing home administrator. The policy read in pertinent part, Indirect transmission the transfer of an infectious agent through a contaminated inanimate object. The following are examples of opportunities for indirect contact. -Resident care devices (electronic thermometers or glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared without cleaning and disinfecting between uses for different residents. Reducing and/or preventing infections through indirect contact requires the decontamination (cleaning, sanitizing, or disinfecting of an object to render it safe for handling) of resident equipment, medical devices, and the environment. B. Facility notice of immediate jeopardy On 1/25/23 at 12:15 p.m. the nursing home administrator (NHA) was notified of the immediate jeopardy. C. Facility plan to remove immediate jeopardy On 1/25/23 at 2:00 p.m., the NHA provided a plan to remove the immediate jeopardy. The plan read: Every resident requiring a glucometer has their own rather than sharing. This is a standard of practice to prevent exposure to bloodborne pathogens. No sharing of glucometers is permitted. After use of a glucometer, the device will be cleaned and disinfected after every use per manufacturer's instructions for cleaning and disinfecting are as follows: Glucometer Cleaning instructions Cleaning/Disinfecting equipment: -Perform hand hygiene before handling the meter, then don gloves. -Use Super Sani-Cloth Germicidal Disposable Wipes to wipe down Glucometer, then allow 2-minute wet (dwell) time (to allow for proper disinfection). -Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth wipe. Discard wipe. Using a new Super (sic) Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with (sic) moderate pressure on the front, back , left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. Ensure that the outside of the meter stays wet for 2-minutes. NEVER put the meter in liquids or allow any liquids to enter the test port. Let meter air dry thoroughly before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands thoroughly after removing gloves. -This will be performed after each use of a glucometer. -Disinfection will also be performed and documented each night on the third shift along with the Quality Control check. (The two residents) will be tested on [DATE] for exposure to bloodborne pathogens, specifically Hepatitis C. A par level of ten (10) extra glucometers will be always maintained by central supply staff or designee in addition to the individual glucometers assigned to those residents with current physician orders. Every glucometer will be labeled with the resident's name clearly identified. Each glucometer will be placed in its own bag, also clearly identified with the resident's name. All nurses have been in service with repeat demonstration technique on 1/25/23 on proper cleaning and disinfecting procedures for glucometers. Agency nurses, new and/ or rehired nurses and vacation/absent nurses will be in service with repeat demonstration technique prior to working their shift. An extra glucometer will be retained in each nurse's cart in the event a resident's glucometer malfunctions. The nurse will notify central supply and/or designee for a replacement of the extra. Upon death and/or discharge, the resident's glucometer will be disposed of and not reassigned. The ADOW's assignee to (sic) the specific units will verify in writing every seven (7) days to ensure that every resident requiring a glucometer has their own. ADOW's will complete random visual performance checks on staff to ensure proper cleaning and disinfection of the glucometers. These checks will be documented on the glucometer cleaning form. These visual checks will be conducted daily for 30 calendar days then monthly thereafter. All findings of identification of concerns of witnessed cleaning procedure will be corrected and reported to the Quality Assurance Committee Meeting monthly for three (3) months then quarterly thereafter. D. Removal of immediate jeopardy The facility's plan to remove immediate jeopardy was accepted on 1/25/23 at 5:00 p.m. Record review and observations revealed the facility had not implemented their policy and procedure for blood glucose meter cleaning. They provided new blood glucose meters for each resident. The ADOW said they had to replace five meters. However, deficient practice remained at an E scope and severity, a pattern with the potential for more than minimal harm. II. Failure to ensure blood glucose meters were cleaned, stored, and sanitized in a manner consistent with standards of practice. A. Professional reference According to the Centers for Disease Control and Prevention (CDC) Injection Safety, Infection Prevention during Blood Glucose Monitoring and Insulin Administration, retrieved from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html (2/5/23): The CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Finger stick devices should never be used for more than one person. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared. Meters requiring preloading of the test strip may come in direct or close contact with the resident's finger stick wound. Subsequent residents can be exposed when the meter is used on them. Staff hands can become contaminated with blood that is transferred to the meter when they obtain the reading. Blood remaining on the meter can be transferred to subsequent residents through staff hands when they perform the next procedure. According to the CDC Infection Prevention during Blood Glucose Monitoring and Insulin Administration, obtained from https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html#anchor_1556215485 on 1/25/23, 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. B. Manufacturer instructions The [NAME] True Metrix blood glucose meter manufacturer cleaning recommendations were retrieved from: https://imgcdn.[NAME].com/CumulusWeb/Click_and_learn/TMX-Pro-CleaningGuide-v6.pdf on 1/25/23, read in pertinent part, Always wash hands and wear gloves when performing blood glucose testing, and when cleaning and disinfecting the meter; contact with blood presents a potential infection risk To Clean: Make sure the meter is off and a test strip is not inserted. Wipe the outside of the meter thoroughly with a fresh Super Sani-Cloth Wipe. Discard wipe. Using a new Super Sani-Cloth wipe, rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. To Disinfect: Using fresh wipes, ensure that the outside surfaces of the meter stays wet for 2 minutes. NEVER put meter in liquids or allow any liquids to enter the test port Let the meter thoroughly air dry before using it to test. Properly dispose of gloves and wipes after cleaning. Wash hands after removing gloves. B. Facility cleaning product after immediate jeopardy The facility used a product by PDI manufacturer, Super Sani-Cloth germicidal disposable wipes, to clean all blood glucose meter devices after the immediate jeopardy. The wipe required a two minute surface disinfectant time and was documented to be effective against non-enveloped viruses, bacteria, tuberculosis, fungi, multidrug resistant organisms and blood borne pathogens. The ADOW was interviewed on 1/24/23 at approximately 2:00 p.m The ADOW said new glucometers were replaced for five residents who required blood sugar monitoring. The glucometer would then be disposed of upon discharge. III. Additional interviews The medical director (MD) was interviewed on 1/25/23 at approximately 2:00 p.m. The MD said she was notified the facility received an immediate jeopardy for not cleaning the glucometers correctly. She said although the facility did not clean the glucometer correctly, she did not agree that it was an immediate jeopardy situation. She said the blood borne infection could not be transmitted through the glucometer unless there was a significant amount of blood. She said it could be transferred through the lancet. She said that alcohol was acceptable to clean the glucometer meter. She said hepatitis C was not an airborne disease. The MD said the building had issues acquiring the correct disinfecting wipes due to personal protective equipment shortages The nursing home administrator (NHA) was interviewed on 1/25/23 at 4:00 p.m The NHA said the building had no issues with any PPE shortages in the previous 90 days. IV. Hand hygiene failures while cleaning resident rooms A. Professional reference The Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last reviewed 1/30/2020, retrieved on 2/2/23 from https://www.cdc.gov/handhygiene/providers/guideline.html included the following recommendations, in pertinent part for hand hygiene, Use an alcohol-based hand sanitizer immediately before touching a patient, before performing an aseptic task or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or the patient's immediate environment, after contact with blood, body fluids or contaminated surfaces, and immediately after glove removal. B. Facility policy and procedure The Infection Control Program Overview policy dated 1/1/22 was provided by the assistant nursing home administrator (ANHA) on 1/24/23 at 2:09 p.m. and read in pertinent parts, Associates will wash their hands before and after contact with a resident; after cleaning a room, after handling waste or linen, after using the bathroom, before and after serving in the dining room, any time hands have possibly become contaminated, before and after applying gloves. Waterless hand cleanser, ABHR, will be provided to associates when handwashing facilities are not readily available. The cleanser may not be used more than three times in a row without washing hands. C. Observation On 1/30/23 beginning at 10:02 a.m. a continuous observation of housekeeping services was made outside rooms #312 and #314. -At 9:53 a.m. in room [ROOM NUMBER], housekeeping associate (HA) #1 finished cleaning the resident room. She did remove her gloves and performed hand hygiene with ABHR, however it was for only six seconds, and put on new gloves. -At 10:05 a.m. HA#1 knocked on the room [ROOM NUMBER]'s door. HA#1 entered the room and picked up oxygen tubing off the floor and placed it on the resident's bed. -At 10:07 a.m. HA#1 wiped down the entire toilet in the bathroom, including the tank, seat and base. She did not perform hand hygiene and then changed the hand towels and soap over the hand sink. -At 10:09 a.m. HA#1 removed her gloves and performed hand hygiene with ABHR, however it was only for seven seconds, and then donned a new pair of gloves. D. Staff interviews HA #1 was interviewed on 1/30/23 at 10:35 a.m. She said she should change her gloves when they were contaminated. The NHA was interviewed on 1/30/23 at 4:00 p.m.The NHA said ABHR should be utilized after every resident interaction and when gloves were contaminated. The process was to use ABHR to cover their hands and wrists until it was dry, and the ABHR took 20 to 30 seconds to dry. She said she did hand hygiene audits to monitor if staff performed hand hygiene correctly.