**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility's training, and review of the facility's policies, it was determined 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 and control the development and transmission of communicable diseases and infections. This deficient practice affected two (2) of fourteen (14) sampled residents, Resident #112 and #160. Observation of State Registered Nurse Aide (SRNA) #1, on 08/03/2022 at 5:00 PM, revealed she took extra supplies, in a plastic sealed bag, between resident rooms, to perform finger sticks for blood glucose levels. One (1) room was non-isolation, and one (1) room was identified as Airborne and Contact Precautions isolation, which was designated per signage on the door. Observation of Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician exiting room [ROOM NUMBER] with gloves on then doffing gloves and placing in the garbage can outside room [ROOM NUMBER], identified as Airborne and Contact Isolation per signage on the door. The findings include: Review of the facility's policy titled, Standard and Transmission-Based Precautions, origination date 12/01/2020, revealed Standard Precautions meant to treat all patients' blood or body fluids as infectious material. Per the policy, under Contact Isolation, gloves were to be removed before leaving the resident care area to prevent possible contamination of the environment outside the residents' rooms. Further instructions revealed gloves and gown were to be removed before leaving the room. Review of the facility's policy titled, Personal Protective Equipment (PPE), Inf-Cntrl-P-01, revision date 12/01/2020, revealed employees received training, during orientation, on the proper selection, use, and indicators for PPE. Continued review revealed PPE must be removed prior to leaving the work area or clinical areas. Review of the facility's Computer Based Learning (CBL) training titled, Infection Control Update, All Clinical Associates, revision date 09/2021, under Transmission-Based Precautions, revealed, for all isolation types, to use dedicated or disposable equipment when available and take only necessary supplies into a resident's room. Further review revealed to remove all PPE before exiting the resident's room. Review of SRNA #1's training records revealed the SRNA received training for Infection Control and NOVA StatStrip glucose meter (glucometer, medical device that was used to measure blood glucose levels) on 03/23/2022. 1. Observation of Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician exited Resident #160's room, room [ROOM NUMBER], an Airborne and Contact Precautions Isolation room, with gloves on. Physician #1 then doffed (removed) the gloves and placed them in the garbage can outside the room. Interview with Physician #1, on 08/02/2022 at 11:55 AM, revealed the physician had received training from the facility for donning (putting on) and doffing PPE, but it had been some time ago. 2. Observation of SRNA #1, on 08/03/2022 at 5:00 PM, revealed she entered the room of Resident #112 to obtain a blood glucose level. She had, in her hand, a plastic bag, which could be sealed at the top, and contained lancets, alcohol pads, glucose monitoring strips, and 2 x 2 gauze pads. She also carried the glucometer in her hand. Per the observation, SRNA #1 placed a paper towel on the overbed table, and then placed the glucometer and the needed supplies from the plastic bag on the paper towel. The first attempt to get a drop of blood from Resident #112 yielded an amount that was insufficient for a blood glucose level reading, but the second attempt was successful. Per the observation, SRNA #1 properly disposed of supplies, properly performed hand hygiene, disinfected the plastic bag and the glucometer with sanitizing wipes, and left the room. Continued observation of SRNA #1, on 08/03/2022 at 5:15 PM, revealed she donned PPE, took the glucometer, including the plastic bag with supplies, and entered room [ROOM NUMBER], Resident #160's room. which was an Airborne and Contact Precautions Isolation room. Additional observation revealed, upon exiting room [ROOM NUMBER], she began donning PPE to enter room [ROOM NUMBER], which was an Airborne and Contact Precautions Isolation room with the plastic bag of supplies and the glucometer. At this point, SRNA #1 was stopped and interviewed by the State Survey Agency (SSA) Surveyor about entering different resident rooms with the same plastic bag of extra supplies. Interview with SRNA #1, on 08/03/2022 at 5:15 PM, revealed she knew the policy of taking only needed supplies into resident rooms which would decrease possible cross contamination of residents and knew better than to take the same plastic bag with numerous supplies into each room. Additional interview with SRNA #1, on 08/02/2022 at 2:20 PM, revealed she had worked at the facility since March 2022 and had received new orientation training upon hire at that time which included isolation training for PPE and training for usage of glucometers. She stated there were two (2) glucometers for the unit, and they were cleaned with sanitizing wipes after use for the isolation rooms but not always for the non-isolation rooms. Interview with SRNA #2, on 08/04/2022 at 11:40 AM, revealed, for blood glucose monitoring, he placed the glucometer on a barrier, performed hand hygiene, and put on new gloves. Additionally, he stated he never took the bag of supplies into a room and would never reach in the bag or place supplies in his pockets. He also stated the glucose strip was scanned prior to entering the resident's room. Interview with Licensed Practical Nurse (LPN) #1, on 08/03/2022 at 4:00 PM, revealed her job duties included medication administration, assessments, drawing labs, and contacting the physician as needed. She stated the PPE supply was plentiful. She stated she would don PPE prior to entering the resident's room and doff PPE prior to exiting the room. LPN #1 also stated glucometers were to be cleaned after each use with sanitizing wipes for all rooms, including non-isolation rooms, and wipes were inside each room. Interview with the Infection Preventionist (IP) Manager, Registered Nurse (RN) # 4, on 08/04/2022 at 10:00 AM, revealed she had been the IP at this facility for three (3) years and was covering for the IP nurse at this time. She stated doffing (removing) PPE, including gloves, should occur inside isolation rooms. The IP Manager stated only needed supplies should be taken into residents' rooms. She stated the plan for the facility was to begin audits for PPE use, but the audits had not begun yet. Interview with the Director of Nursing (DON) and Unit Manager, on 08/04/2022 at 1:50 PM, revealed her expectations were for staff to abide by PPE use and glucometer checks for residents according to guidelines and regulations by taking gown and gloves off in the room. Per the interview, the DON said scanning of supplies should take place before entering the room and only (2) lancets and strips should be taken inside the room; the strip bottle should be left outside the room. She stated 2 x 2 gauze pads and alcohol pads were in the room, and supplies not used should be thrown away inside the room. The DON stated training for staff occurred annually, with hands on training for glucometer use, donning and doffing of PPE, and infection control videos. Interview with the Assistant [NAME] President of Post-Acute Services, on 08/04/2022 at 3:15 PM, revealed she had been in this role for four (4) months but had been the Administrator for the facility since December 2021. She stated her expectations for staff was to know and follow policies and to maintain training. She stated training for staff was conducted in person as well as with CBL, and she also expected staff to follow current practice concerning any medical equipment.