**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the glucometer's (device used to calculate a finger-stick blood glucose level) manufacturer's instructions, review of disinfectant wipe instructions, review of the Centers for Disease Control and Prevention (CDC) document, and review of the facility's policies, 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 to implement interventions to protect the residents. The deficient practice had the potential to affect 34 of 34 residents, to who received fingersticks for blood glucose testing, with observations to include (Resident (R)7, R45, R37, and R244 ). Additional observations of deficient practice revealed they affected 4 of 27 sampled residents (R13, R27, R70, and R72). Observations revealed Registered Nurse (RN)1, Licensed Practical Nurse (LPN)1, and LPN3 failed to properly clean and disinfect shared glucometers after obtaining blood glucose measurements. Review of the manufacturer's recommendations revealed the staff was to use specific wipes validated by the manufacturer. Further review revealed staff was to use two wipes, one for cleaning and one for disinfecting, leaving the surface wet for a specific amount of time for the wipe, which the staff failed to do. Review of the product information for Sani-Cloth Bleach wipes, which the facility used to clean and disinfect glucometers, revealed its Environmental Protection Agency (EPA) number was not listed by the manufacturer as approved for the glucometer. Further review revealed the incorrect wipe had a dwell time of four minutes. Review of the facility's list of residents with bloodborne illnesses revealed one resident, Resident (R) 45, with human immunodeficiency virus (HIV), and the resident received blood glucose checks using the facility's shared glucometers. Immediate Jeopardy (IJ) was identified on 05/22/2025 and was determined to exist on 05/21/2025, in the area of 42 CFR 483.80 Infection Control, F880, at a Scope and Severity (S/S) of an K. The facility's Executive Director was notified of the IJ on 05/22/2025. The facility provided an acceptable Immediate Jeopardy Removal Plan, on 05/23/2025, alleging removal of the IJ on 05/23/2025. The State Survey Agency (SSA) determined the IJ was removed on 05/23/2025, prior to exit on 05/23/2025, with remaining non-compliance at an S/S of an E while the facility develops and implements a Plan of Correction (POC) and the facility's Quality Assurance (QA) monitors to ensure compliance with systemic changes. The findings include: Review of the facility's policy titled, Infection Control, revision date 03/21/2024, revealed the facility was to provide a comprehensive infection control program involving all departments to prevent and control infections acquired or brought into the facility. Review of the facility's policy titled, Standard Precautions, revision date 07/05/2022, revealed standard precautions were used as the first line of defense against preventing transmission of microorganisms. The policy stated the procedure included to utilize personal protective equipment (PPE), and resident care items for multiple residents were disinfected between uses with the approved disinfectant. Review of the CDC's document Standard Precautions for All Patient Care, Infection Control Basics, Health Care Providers, dated 04/03/2024, revealed hand hygiene meant cleaning hands with water and soap (e.g., plain soap or with an antiseptic) or antiseptic hand rub (alcohol-based foam or gel hand sanitizer); immediately before touching a patient [resident]; before performing an aseptic task such as placing an indwelling device or handling invasive medical devices; before moving from work on a soiled body site to a clean body site on the same patient [resident]; after touching a patient [resident] or patient's [resident's] surroundings; after contact with blood, body fluids, or contaminated surfaces; and immediately after glove removal. It also stated gloves were not a substitute for hand hygiene, and if the task required gloves, perform hand hygiene before donning (putting on) gloves and touching the patient [resident] or the patient's [resident's] surroundings. Further review of the CDC's document, dated 04/03/2024, revealed staff should always clean hands after removing gloves. Per the document, it stated to wear gloves when coming in contact with blood or other infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment. Additionally, the document stated to change gloves and clean hands if gloves became damaged or soiled with blood or body fluids after a task; if moving from work on a soiled body site to a clean body site on the same patient [resident]; if moving from care on one patient [resident] to another patient [resident]; if they looked dirty or had blood or body fluids on them after completing a task; and before exiting a patient's [resident's] room. Review of the facility's glucometer manufacturer's instructions for cleansing the machine to reduce the risk of transmission of blood-borne pathogens, revised 04/2021, revealed it was to be cleaned and disinfected after each use on each patient [resident] using standard precautions and the manufacturer's disinfection procedures. Per the policy, the procedure included to clean the glucometer with the approved wipe (Super Sani-Cloth, EPA number 9480-4, purple top) with a contact time of two minutes before its next use. The instructions stated to use two wipes, one for cleaning and one for disinfecting, wiping the surface of the meter three times vertically and three times horizontally. Review of Super Sani-Cloth (EPA number 9480-4), the approved wipe for the glucometer utilized by the facility, revealed the instructions for cleaning and disinfecting was to clean with one wipe and disinfect with the second wipe allowing the surface to remain wet for two (2) minutes and allowing to air dry. Review of the facility's list for residents with Blood Borne Illnesses, dated 05/19/2025, revealed one resident, R45, diagnosed with Human Immunodeficiency Virus (HIV) Disease. Review of the facility's Midnight Census Report, dated 05/19/2025, listed the census with 34 residents receiving fingersticks for blood glucose testing, including R45. 1 a. Review of R45's admission Record revealed the facility admitted R45 on 01/19/2019 with diagnoses to include diabetes, encephalopathy,high blood pressure, and Human Immunodeficiency Virus (HIV). Review of R45's quarterly Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/20/2025 revealed the facility assessed the resident to have a Brief Interview for Mental Status [BIMS] score of two out of 15, which indicated the resident was severely cognitively impaired. Review of R45's Physician's Orders, revealed an active order set, dated 03/20/2024, for a fingerstick to be obtained one time a day to check for blood glucose level. b. Review of R7's admission Record revealed the facility initially admitted the resident on 02/22/2021 with diagnoses including diabetes, cerebral vascular accident, and pneumonia. Review of R7's annual MDS, with an ARD of 04/25/2025, revealed the facility assessed the resident to have a BIMS score of 14 out of 15, indicating intact cognition. Further review revealed the resident received five insulin injections during the last seven days. c. Review of R58's admission Record revealed the facility initially admitted the resident on 05/26/2020 with diagnoses including stroke, dementia, and atrial fibrillation. Review of R58's quarterly MDS, with an ARD of 03/24/2025, revealed the facility assessed the resident to have a BIMS of 12 out of 15, indicating moderate cognitive impairment. Observation on 05/21/2025 at 10:00 AM on the [NAME] Hall revealed RN1 checked R7's glucose. RN1 removed the glucometer from Medication Cart 2. The glucometer was in the top drawer, it was not in a container or a bag, and there was another glucometer in the same spot touching the other glucometer. RN1 put on gloves without sanitizing her hands and performed the glucometer check on R7. She then went to R7's roommate's bed (R58) and placed the glucometer on his bedside table. She talked with R58, picked up the glucometer, and placed it on the top of the medication cart. She removed her gloves and did not sanitize her hands. She opened the bottom right drawer of the medication cart and wiped the glucometer from 10:07:01 AM to 10:07:010 AM, nine seconds. After wiping the glucometer, she placed the glucometer back on the top of the medication cart, without using a barrier. RN1 left the glucometer on the top of the cart and went to give medications. Observation of the Sani-Cloth Bleach Germicidal Disposable Wipes RN1 used for R7's glucometer disinfection revealed its EPA number was 9480-8 (unapproved, orange top), and it was to remain visibly wet with the disinfectant for four minutes. During interview with RN1 on 05/21/2025 at 10:26 AM, she stated the facility's policy instructed to wipe all sides of the glucometer. She stated she always did three swipes on each side with a Sani-cloth wipe. She stated she thought she should wipe the glucometer and let it dry. She stated she did not think there could be any contamination because she wiped all sides of the glucometer. She said it was just an oversight that she did not let the glucometer stay wet for four minutes. She stated she had two glucometers, and she switched them for use. Per the interview, the RN revealed she was not aware the glucometers needed to be wet for four minutes. d. Review of R244's admission Record revealed the facility admitted the resident on 05/16/2025 with diagnoses to include dysphagia, diabetes mellitus, adult failure to thrive, and dependence on renal dialysis. Review of R244's admission Minimum Data Set [MDS], with an Assessment Reference Date (ARD) of 05/20/2025, revealed the resident had a Brief Interview for Mental Status [BIMS] score of 10 out of fifteen 15, which indicated the resident had moderate cognitive impairment. Further review revealed the resident received four insulin injections during the last seven days. Review of R244's Physician's Orders, dated 05/16/2025 revealed a verbal order was given for fingerstick blood sugars four times a day for diabetes mellitus. Observation on 05/21/2025 at 11:50 AM revealed Licensed Practical Nurse (LPN) 3, prior to performing a fingerstick on R244, removed the glucometer which was lying on top of the South Hall Medication Cart without a barrier underneath. LPN3 entered R244's room, placed the glucometer on the overbed table, and donned PPE. After cleansing R244's right middle finger with an alcohol pad, LPN3 lanced R244's finger and obtained blood for checking the glucose level. After administering medications and insulin, LPN3 removed PPE and put on different gloves, picked up the glucometer, and placed it on top of the medication cart without a barrier underneath. LPN3 wore the same gloves, opened the bottom drawer of the medication cart, and removed a container of Sani-Cloth Bleach wipes, which was not the acceptable wipe. She removed one cloth and wiped the front and back of the glucometer for approximately four to five seconds with the one cloth and placed the glucometer on top of the medication cart without a barrier underneath. During interview with LPN3 at the time of the observation, on 05/21/2025 at 11:52 AM, she stated she did not have another resident to check for a glucometer check at that time. When asked about the dwell time for the disinfectant wipe for the glucometer, she stated, I don't know, probably two to three minutes. LPN3 further stated she did not know if the glucometer was clean when she used it, but she guessed it was. She stated it was important to clean and disinfect equipment properly to prevent spreading germs from resident to resident. e. Review of R37's admission Record revealed the facility initially admitted the resident on 10/21/2016 with diagnoses of diabetes, anemia, and coronary artery disease. Review of R37's annual MDS, with an ARD of 04/24/2025, revealed the facility assessed the resident to have a BIMS score of 15 out of 15, indicating intact cognition. Further review revealed the resident received seven insulin injections during the last seven days. Observation on 05/21/2025 at 3:42 PM revealed LPN1 prepared to check R37's glucose. She opened the top drawer of Medication Cart 2 on the North Hall. She took one of two glucometers that were not in containers and lying next to each other. She did not sanitize her hands, and she put on gloves. She performed the glucose check on R37 and placed the glucometer without a barrier underneath on the top of the medication cart. She removed her gloves and did not sanitize her hands. She took out her keys and opened the bottom right drawer of the medication cart. She took out the Sani-Cloth Bleach Germicidal Disposable Wipes container. She removed a wipe and wiped the glucometer from 3:44:40 to 3:44:50 (10 seconds). She then put the glucometer in a cup and set it on top of the medication cart, started the timer for five minutes, and left. During interview with LPN1 at the time of the observation, on 05/21/2025 at 3:50 PM, she stated she was taught to wipe the glucometer three times each way and then let it dry for five minutes with the orange top sani-wipes. She stated she did not know to use the purple top sani-wipes. Further, she stated she had received training from the staff development coordinator in cleaning the glucometer a few months ago. During interview with the Infection Preventionist on 05/21/2025 at 3:20 PM, she stated each medication cart had two glucometers, and the process was for staff to wipe down the glucometer, using the proper wipe, set to the side, and use the other glucometer while the first was drying. Observation revealed two medication carts on the South Hall, and each had two glucometers which were lying in the top drawer of each medication cart side-by-side. When asked if there was a concern if staff did not follow the proper cleaning procedure, she stated it would cause cross contamination, and she would be concerned for the spread of bloodborne pathogens. During interview with the Director of Nursing (DON) on 05/22/2025 at 4:00 PM, she stated her expectation was for staff to follow guidelines to properly clean glucometers with the orange top wipes. She stated her concern would be if they did not follow the process, infection could be spread throughout the residents. Review of the facility's policy titled, Enhanced Barrier Precautions, revision date 04/22/2025, revealed staff providing high-contact care activities for residents in EBP isolation included dressing, bathing/showering, transferring, providing hygiene, linen or brief change, medical care device use, wound care, and assisting with toileting. It stated, during these high-contact care activities, staff was to wear PPE and follow EBP signage. Review of the facility's EBP signage (procedure to be used), posted on residents' doors in EBP, revealed everyone was to clean hands before entering and leaving the room. The signage revealed providers and staff must also wear gloves and a gown for high-contact resident care activities. Review of the facility's list of residents on EBP, dated 05/19/2025, revealed there were 24 residents listed, including R13, R27, R70, and R72. 2. a. Review of R27's admission Record revealed the facility initially admitted the resident on 06/08/2024 with diagnoses including respiratory failure, protein-calorie malnutrition, and diabetes. Review of R27's significant change in status assessment MDS, with an ARD of 03/25/2025, revealed the facility assessed the resident to have a BIMS score of four out of 15, indicating the resident had severe cognitive impairment. Further review revealed the resident had one stage 2 pressure ulcer and one stage 3 pressure ulcer. Observation on 05/19/2025 at 4:08 PM revealed Certified Nurse Aide (CNA)2 placed herself partially in Resident (R)27's bed and hugged the resident while she was in the bed without wearing a gown or gloves. Additional observation revealed R27's room door had signage placed for Enhanced Barrier Precautions (EBP) with Personal Protective Equipment (PPE) hanging on the back of the door. Further observation revealed R27 had an indwelling urinary catheter to bedside drainage. During interview with CNA2 on 05/20/2025 at approximately 12:00 PM, she stated she had received training on infection control and isolation procedures. When asked when staff should put on PPE if a resident was in EBP isolation, she stated anytime there was direct resident care or touching a resident to prevent germs from spreading. During continued interview with the Infection Preventionist (IP) on 05/21/2025 at 3:20 PM, she stated R27 was in EBP for a urinary catheter and wounds. b. Review of R13's admission Record revealed the facility admitted the resident on 01/28/2025 with diagnoses to include zoster encephalitis, malignant neoplasm of the brain, and infection with multidrug resistant organisms (MDRO). Review of R13's quarterly MDS, with an ARD of 03/24/2025, revealed the facility assessed the resident to have a BIMS score of 12 out of 15, which indicated the resident had moderate cognitive impairment. Observation on 05/19/2025 at 5:20 PM revealed RN1 went into R13's room to give an injection. R13 was in EBP due to infection with Multi Drug Resistant Organisms (MDRO). RN1 was only wearing gloves. She opened the left side of the brief and gave the injection. RN1 then left the room and went to the medication cart still wearing the same gloves. She took the keys out of her pocket and opened the drawer and removed an alcohol pad. RN1 returned to R13's room and went to the right side of the bed. She opened the right side of the resident's brief and gave the injection in the right hip, exited the room with her contaminated gloves on, and obtained ice without taking her gloves off. She removed her gloves and put them in the trash can, moving the can with ungloved hands. She did not sanitize or wash her hands. During immediate interview with RN1 after the observation, on 05/19/2025 at 5:30 PM, she stated she could not remember when she was trained in infection control. She stated she had received so much training she could not remember if she had infection control training. She stated she should have sanitized her hands before putting on her gloves and after removing the gloves, she just forgot. c. Review of R72's admission Record revealed facility admitted the resident on 03/01/2025 with diagnoses to include diabetes, stroke, and heart disease. Review of R72's quarterly MDS, with an ARD of 04/10/2025, revealed the facility assessed the resident to have a BIMS score of nine out of 15, which indicated the resident had moderate cognitive impairment. Review of R72's Progress Note, dated 05/12/2025 and untimed, revealed the resident had a stage 3 pressure wound to her lower sacrum. During interview with R72 on 05/19/2025 at 3:50 PM, she stated she had a sore on her butt, which was getting better, and the nurses were putting something on it to take care of it. Observation on 05/21/2025 at 8:05 AM revealed CNA5 entered R72's room without wearing a gown or gloves after the resident requested help to reposition. Additional observation revealed R72's door had signage for EBP. During immediate interview with CNA5 after exiting R72's room at 8:10 AM, she stated she had helped the resident to reposition and had not donned Personal Protective Equipment (PPE), but she should have to prevent the spread of germs. d. Review of R70's admission Record revealed the facility admitted the resident on 12/02/2022 with diagnoses which included unspecified protein-calorie malnutrition, unspecified dementia, and acute ischemic heart disease. Review of R70's significant change in status assessment MDS, with an ARD of 03/20/2025, revealed the facility assessed the resident to have a BIMS score of five out of 15, which indicated severe cognitive impairment. Review of R70's Wound Assessment, dated 04/17/2025 revealed the resident had an acute Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer acquired on 02/10/2025 and has received a status of Not Healed. Initial wound encounter measurements were 1cm [centimeter] length x 1.5cm width with no measurable depth, with an area of 1.5 sq cm [square centimeter]. There was a Moderate amount of purulent drainage noted. Observation on 05/22/2025 at 1:15 PM revealed there was EBP signage on R70's door. Continued observation of R70's dressing change by LPN7 revealed LPN7 did not follow EBP. The LPN did not wear a gown during this high-contact activity, and the wound cleaner container was hung on the scrub pocket with the spray tip touching the scrubs. During interview with LPN7 on 05/20/2025 at 8:50 AM, she stated it was important to wear proper PPE each and every time direct care was provided to a resident in EBP to prevent the spread of infection and germs. During interview with RN2 on 05/19/2025 at 5:25 PM, she stated if a resident was on EBP, staff should put on PPE prior to touching the resident for prevention of spreading germs. During continued interview with the Infection Preventionist (IP) on 05/21/2025 at 3:20 PM, she stated anytime there was high-contact care given that involved touching a resident, PPE should be put on correctly. She stated hand hygiene audits were performed randomly with yearly training. She stated staff was trained to use soap and water after providing care to a resident with diagnoses of C-difficile or Noravirus (gastrointestioanl infection characterized by diarrhea, vomiting, and stomach pain) but was allowed to use hand sanitizer other times. Review of the facility's policy titled, Cleaning and Disinfection of Non-Critical Patient [Resident] Care Equipment, revision date 08/22/2022, revealed non-critical reusable patient [resident] care equipment was cleaned daily and before and after reuse with an approved disinfectant based on manufacturer guidelines or Environmental Protection Agency (EPA)-registered hospital disinfectant. 3. Observation on 05/19/2025 at 4:10 PM, 05/20/2025 at 11:20 AM, and 05/22/2025 at 12:18 PM, revealed the Hoyer lift (mechanical lift used to transfer residents from one surface to another) on the South 2 Hall had drops of a brown-colored substance on the base of the lift. During interview with CNA5 on 05/21/2025 at 8:10 AM, she stated the entire Hoyer lift should be cleaned after each use. During continued interview with the DON on 05/22/2025 at 4:00 PM, when asked how often the Hoyer lifts should be cleaned, she stated after each use, including the base of the lift. During interview with the Executive Director on 05/22/2025 at 4:20 PM, he stated his tasks included oversight of the building and assuring the needs and safety of the residents and staff were met. The Executive Director revealed he expected staff to follow the infection control policies and procedures for the prevention of spreading infection throughout the facility. The facility provided an acceptable IJ Removal Plan on 05/23/2025 verbatim: 1. How corrective action will be accomplished for those residents found to have been affected by the deficient practice? On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the North Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the South Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) removed the Orange topped Sani-Cloth Bleach wipes from the [NAME] Unit medication carts #1 and #2 and replaced with the Purple topped Sani-Cloth Germicidal Disposable wipes which Environmental Protection Agency (EPA) number is listed by the manufacturer as approved for the glucometer. On 5/22/25, the Director of Nursing (DON) provided Resident (R) 45 with his own personal glucometer device to be kept in his room to ensure his glucometer device is to be used for his own personal use and not shared with other residents. The Executive Director, Director of Nursing and Interdisciplinary Team completed a Root Cause Analysis (RCA) on 5/23/2025. 2. How facility will identify other residents having the potentlal [sic] to be affected by the same deficient cract1ce [sic]? All residents receiving finger stick blood glucose checks have the potential to be affected. 3. What measures will be put into place or systemic changes made to ensure that the deficient practice will not recur? On 5/22/2025, the Regional Director of Clinical Services provided education to the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator and Infection Preventionist Nurse on the following: o Blood Glucose Monitoring Policy o Assur Prism multi® Blood Glucose Monitoring System Reference Manual o Omnicare Glucometer Cleaning Poster o [NAME] Blood glucose monitoring, long-term care procedure o [NAME] Blood glucose monitoring, long-term care skills checklist o Glucometer Cleaning and Disinfecting-Quick Reference Guide o [NAME] Glucometer Assure Quality Control Checks and Cleaning Procedures o [NAME] Skills Checklist-Cleaning and Disinfecting the Meter Starting on 5/22/2025, the Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SDC), Infection Prevention Nurse and/or Regional Director of Clinical Services will provide education to fill licensed nurses (Registered Nurses and Licensed Nurses) on the following: o Blood Glucose Monitoring Policy o Assur Prism multi® Blood Glucose Monitoring System Reference Manual o Omnicare Glucometer Cleaning Poster o [NAME] Blood glucose monitoring, long-term care procedure o [NAME] Blood glucose monitoring, long-term care skills checklist o Glucometer Cleaning and Disinfecting-Quick Reference Guide o [NAME] Glucometer Assure Quality Control Checks and Cleaning Procedures o [NAME] Skills Checklist-Cleaning and Disinfecting the Meter Any associate who has not completed training by 5/23/2025 will not be allowed to provide direct resident care until training is completed. The Director of Nursing (DON), Staff Development Coordinator (SOC), Infection Prevention Nurse and/or Regional Nurse will provide education to all new associates upon hire during orientation. [The facility's name] does not utilize agency staffing. As of 5/23/25, the facility has educated 23 out of 26 licensed nurses. On 5/23/25, the Director of Nursing (DON) placed a copy of the Omnicare Glucometer Cleaning poster and the Quick Reference Guide for glucometer cleaning on each medication cart as a guide to ensure the facility follows standard precautions during the performance of routine testing of blood glucose and ensure proper cleaning and disinfecting of the shared glucometer monitors that are used for more than one resident. The Medical Director reviewed and agreed with this plan of removal on 5/22/2025 with a copy provided to him on 5/23/25. AD Hoc QAPI meeting was held on 5/23/2025 regarding this plan of removal. Attendees were Executive Director, Medical Director, Director of Nursing, Staff Development Director, Infection Preventionist, Activity Director, Social Service Director, Health Information Manager, MOS Coordinator, Director of Rehabilitation, and Dietary Manager. A second AD Hoc OAPI [sic] meeting will be conducted on 5/23/25 to review audit tools that were completed to identify any deficient practice and provide re-education as indicated. 4. How the facilitv [sic] clans [sic] to monitor its oerformance [sic] to make sure that solutions are sustained. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SOC), Infection Prevention Nurse and or Regional Nurse will conduct [NAME] Skills Checklist-Cleaning and Disinfecting the Meter for one nurse per unit per shift (dayshift & nightshift), seven (7) days a week until IJ removal and then five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks. The Director of Nursing and/or Regional Director of Clinical Services will Audit (Audit #4 A Skills Checklist- Cleaning and Disinfecting the Meter) the skills checklists to ensure the facility follows proper cleaning and disinfecting of the shared glucometer monitors that are used for more than one resident. If any non compliance is identified, a licensed nurse will provide re-education. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Staff Development Coordinator (SOC), Infection Prevention Nurse and or Regional Nurse will conduct a visual observation and complete [NAME] Blood glucose monitoring, long-term care skills checklist for one nurse per unit, seven (7) days a week until IJ removal, then five (5) times a week for four (4) weeks, then three (3) times a week for four (4) weeks, then one (1) time a week for four (4) weeks. The Director of Nursing and/or Regional Director of Clinical Services will Audit (Audit #4 B Skills Checklist- Blood Glucose Monitoring) the skills checklists to ensure the facility follows standard precautions during the performance of routine testing of blood glucose. If any non-compliance is identified, a licensed nurse will provide re-education.