Based on interviews, record review, facility policy review, and facility investigation review, the facility failed to implement care plan interventions for a Resident #1, who was identified as an elopement and wandering risk for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to implement resident's care plan interventions related to wandering and elopement for Resident #1, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ), which began on 2/08/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 2/12/25 at 5:30 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 2/9/25, the SA determined the IJ to be Past Non-Compliance (PNC) and the IJ was removed on 2/10/25, prior to the SA's entrance on 2/11/25. Findings include: A review of the facility's policy, Plans of Care, revised 9/25/2017, revealed, .Policy: An individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and /or resident representative(s) to the extent practicable and updated in accordance with state and federal regulatory requirements . Record review of the care plan for Resident #1 revealed Focus: I am an elopement risk/wanderer r/t (related to) History of attempts to leave facility unattended, Impaired safety awareness, Resident wanders aimlessly .Interventions/Tasks .Ensure wander guard is functioning properly daily . The responsible discipline listed as N (Nurse). A record review of the facility's, Verification of Investigation, revealed it was discovered at approximately 3:00 PM on 2/8/25, that Resident #1 exited the facility. A silver alert was announced and all staff began looking for the resident. A new Certified Nurse Aide (CNA) who had just reported for her 3 PM to 11 PM shift showed a video of an individual she saw walking along the highway. By this time, the resident's girlfriend was in the facility. As soon as they knew where he was, the girlfriend and three (3) CNAs jumped in the car to go to the place where the resident was last seen. Resident #1 was discovered .7 mile from the facility. He was returned to the facility and no injury was noted. On 2/12/25 at 9:55 AM, during an interview Licensed Practical Nurse (LPN) #1 revealed she was working on 2/08/25 and had not checked the wander guard transmitter of Resident #1. She stated that she only checked for placement to ensure the resident was wearing a transmitter. She confirmed that all nurses had access to all resident care plans in computer software. She confirmed that she was aware that Resident #1's care plan included intervention of monitoring the resident's wander guard transmitter for proper functioning daily. On 2/13/25 at 3:55 PM an interview with the Minimum Data Set (MDS) Nurse revealed she stated, care plans were individualized for each resident and that it was very important that care plans be implemented. She described care plans as binding documents that dictates care. She stated that the care plan for Resident #1 included an intervention for monitoring placement and functioning of the resident's wander guard transmitter. She stated that monitoring the functioning of the transmitter was important to provide for his safety and prevent elopement. On 2/13/25 at 5:00 PM, during an interview the Director of Nursing confirmed that implementation of the resident's care plan intervention for monitoring functioning daily was very important for the safety of the resident and prevention of elopement. She said that she expected all nursing staff to follow the care plans for each resident. On 2/13/25 at 5:25 PM, during an interview the Administrator stated that it was very important that residents' care plans be implemented and followed to provide appropriate care and a safe environment for each resident. He confirmed that he expects all nursing staff to follow the residents' care plans and implement interventions including monitoring. He stated that the wander guard transmitters for residents at risk for elopement were not functioning correctly and that proper monitoring could have alerted staff to the problem and that safety protocols/interventions could have been enacted and the elopement prevented. Record review of the admission Record revealed the facility admitted Resident #1 on 1/28/25 with current diagnoses including Aphasia following Cerebral Infarction, Cognitive Communication Deficit and Legal Blindness. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/04/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 and required a staff assessment for his mental status. The staff assessment indicated Resident #1 had a long and short-term memory problem, and his cognitive skills for daily decision making was severely impaired. Further MDS review revealed was assessed as needing partial/moderate assistance for surface-to-surface transfers and walking ten (10) feet. The facility submitted a corrective action plan as follows: 1. On February 8, 2025, at approximately 3:00 pm, CST, Resident #1 exited the center while unsupervised. The unsupervised resident leaving the facility represented an Immediate Jeopardy. The resident was wearing a wander guard device. The Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision. The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting. In addition, staff checked all exit doors out of the facility (including the door the Resident exited from). Also, the staff check all wander guards currently being utilized in the building and placed any not working on 1:1 supervision. Finally, staff performed a complete headcount (all residents were found to be in the building with one exception who had properly signed himself out) and the door codes were changed. Based on the steps the facility initiated and completed, the facility contends that the Immediate Jeopardy was removed and represents past noncompliance. This event was reported to the Mississippi State Department of Health via email on Sunday, February 9, 2025, at 2:37 pm. 2. On February 8, 2025, at 3:00 pm, Licensed Practical Nurse (LPN) #1, was notified that Resident #1 could not be accounted for. At 3:02 pm, the Director of Nursing (DON), Executive Director (ED), Social Services Director (SSD), Medical Director (MD) and Regional Director of Clinical Services (RDCS) were notified. At 3:03 pm, Certified Nursing Assistant (CNA) #1 reported to work for her 3-11 shift and upon hearing that a resident was not accounted for, showed the nurse a video she had taken of a man she saw walking next to Hwy 90 on her way to work. The Resident's girlfriend arrived at the facility approximately 3:00 pm and as soon as she saw the video, she and 3 CNAs jumped in the car to go get Resident #1. LPN #2 called the Residents responsible party (Power of Attorney (POA)) and DON. The DON called the ED, MD, and SSD. At 3:30 pm Resident returned to the facility. At 3:36pm the DON was notified the Resident was located .7 of a mile from the facility and safely returned to the facility. 3. On February 8, 2025, at 3:30 pm, Resident returned to facility. Once Resident #1 was back inside center, LPN #2, completed a head-to-toe body audit and no injuries were noted. Registered Nurse (RN) Supervisor #1 completed a head count of all residents, and all were accounted for. On February 8, 2025, at 4:15 pm, the Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system. His findings determined that all doors were locked and while all alarms were functioning properly, the wander guard bracelet Resident #1 was wearing was not functioning properly. The resident was immediately placed on 1:1 supervision and a 24-hour door monitor put in place at front. The door monitor continued until the wander guard system was verified to function properly and the Quality Assurance monitoring begin (see bullet #8). The door monitor was discontinued on 02/10/2025. The door keypad codes were changed. 4. On February 8, 2025, RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights. The Director of Social Services reassessed Resident #1 Brief Interview for Mental Status (BIMS), which had not changed and was noted to be 99, unable to determine. On February 8-10, 2025, wandering risk evaluation completed on all residents with no newly identified wandering risk. Elopement binders (identifying the 5 residents wearing wander guards) are located at both nurses' stations and up front. At 6:45 pm, an Ad hoc QAPI was held including the ED, DON, and MD to discuss incident and a plan of correction. 5. On Saturday, February 8, 2025, DON conducted interviews to learn of Resident #1's path. It was discovered that Resident #1 most likely exited the front door when a visitor entered the facility. Resident #1 confirmed by a positive head shake that he used the front door and answered yes, that he was trying to go home. 6. On Monday, February 10, 2025, at 2:30 pm, the incident was taken to a quality assurance performance improvement (QAPI) meeting, attended by, Executive Director, Director of Nursing, Infection Preventionist, Medical Director via phone, Director of Dietary Services, Maintenance Director, Minimum Data Set (MDS) LPN #2 and LPN #3. No further action needed. No changes made to policies. 7. On February 8, 2025, in-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies, and included 3 RNs, 1 LPN and 5 CNAs. On February 9, 2025, in-service continued including 6 LPNs, 2 RNs and 8 CNAs. On February 10, 2025, in servicing continued including 6 LPNs, 11 CNAs, and 3 RNs and 4 ancillary staff. On February 11, 2025, 4 LPN, 9 ancillary staff, 4 RNs. No staff was allowed to work before receiving education. 15 CNAs, 1 RN. Education is on-going until it was 100% complete. Furthermore, the system will be check daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff. The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion. (see bullet #8) 8. The following monitoring has been put in place beginning February 10, 2025, and the findings will be evaluated by the Quality Assurance and Improvement Committee. All residents that are assessed and care planned as a potential for elopement will be evaluated for significant change in condition for elopement using the elopement risk evaluation, evaluated quarterly for elopement using the elopement risk evaluation, ensure the care plan reflects elopement risk status and any interventions (i.e., wander guard), wander guard check placement every shift that it is present on the MAR without omissions, order for wander guard check for functionality daily is present on MAR without omissions, elopement books have a current face sheet, resident photograph and risk alert form, binders are in an easily accessible location, staff has been educated on the elopement policy, location of the binders and notification process regarding an possible missing resident, transmitter bands are replaced per manufacturers recommendations if signs of manipulation and/or integrity of the band is compromised, exit doors monitoring system functioning appropriately with supporting documentation, and wand used to test function is easily accessible to check the transmitter function.(once these monitoring task were initiated, we discontinued the door monitor) All the forementioned monitoring task will be conducted by the Director of Nursing enduring 3 times a week for 1 week, then 2 times a week for 2 weeks, then weekly for the next 2 months and then monthly. All results will be presented to the Quality Assurance Committee for evaluation and recommendations as necessary. The Quality Assurance Committee will continue to evaluate all monitoring for 90 days to monitor effectiveness and make changes as necessary. 9. All Corrective Actions were completed on February 9, 2025, and the Immediate Jeopardy was removed on February 10, 2025, prior to the State Agency's entrance on February 11, 2025. Validation: The SA validated on 2/13/25, through interview and record review, that all corrective actions had been implemented as of 2/9/25, and the facility was in compliance as of 2/10/25, prior to the SA's entrance on 2/11/25.

Based on observation, interviews, record review, facility policy review, and facility investigation review, the facility failed to provide adequate supervision and assessment and monitoring of a wandering alarm device to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 On 2/08/25, at approximately 3:00 PM, Resident #1 exited the facility while unsupervised wearing a wander alarm device that was found to be inoperable. The resident was out of the facility unsupervised and walked approximately 0.7 miles for approximately thirty (30) minutes before being located by facility staff and returned to the facility, crossing a four-lane highway. The facility's failure to adequately assess and monitor the resident's wandering alarm device and provide adequate supervision for Resident #1, who was an elopement risk, put this resident and all other residents at risk for wandering and elopement, at risk for serious injury, serious harm, serious impairment, or death. The situation was determined to be Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 2/08/25, when Resident #1 exited the facility. The State Agency (SA) notified the Administrator of the IJ on 2/12/25 at 5:30 PM and provided an IJ Template. Based on the facility's implementation of corrective actions on 2/9/25, the SA determined the IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 2/10/25, prior to the SA's entrance on 2/11/25. Findings include: A review of the facility's policy, Elopement/Wandering Risk Guideline revised 08/01/2020 revealed, Overview: To evaluate and identify patient/residents that are at risk for elopement and develop individualized interventions . Process .If utilizing a wander monitoring system device check placement of the device every shift and functionality every day . A record review of the facility's, Verification of Investigation, revealed it was discovered at approximately 3:00 PM on 2/8/25, that Resident #1 exited the facility. A silver alert was announced and all staff began looking for the resident. A new Certified Nurse Aide (CNA) who had just reported for her 3 PM to 11 PM shift showed a video of an individual she saw walking long the highway. By this time, the resident's girlfriend was in the facility. As soon as they knew where he was, the girlfriend and three (3) CNAs jumped in the car to go to the place where the resident was last seen. Resident #1 was discovered .7 mile from the facility. He was returned to the facility and no injury was noted. Record review of the weather conditions in Ocean Springs, MS on 2/08/2025 according to www.weatherspark.com revealed at 2:53 PM, the temperature was 75 degrees Fahrenheit, and clear, with 9.21 miles per hour wind. On 2/11/25 at 3:00 PM, during an observation of the facility grounds, the side and back doors of the facility were inside a fence with locked gates. The front door opened to a front porch with a ramp that descended to the well-maintained driveway and front parking lot. It was two hundred (200) feet from the front door to the road in front of the facility. The speed limit for the road was fifteen (15) miles per hour and the SA observed for fifteen (15) vehicles in one minute traveling on the road at 3:00 PM. It was 0.2 miles west from the entrance into the facility driveway to the red light where the road intersected with the six-lane highway. One block west of the intersection the highway changed to four (4) lanes. There were no crosswalks observed across the highway. The local business where Resident #1 was located was 0.7 miles from the entrance into the facility driveway across the highway on the west side of the highway. On 2/11/25 at 3:45 PM, during an interview the Administrator revealed that the facility reported incident identified as Elopement was discovered on 2/08/25 at 3:00 PM when Resident #1's visitor inquired to his whereabouts and the resident could not be located in the facility. The Administrator reported that the facility staff initiated the Missing Resident protocol and Certified Nurses' Aide (CNA) #1, who arrived at the facility at 3:00 PM reported that she had observed the resident walking along the nearby highway. The Administrator reported that the visitor and two CNAs retrieved the resident in the visitor's vehicle and returned him to the facility at 3:30 PM. The Administrator said that staff assessed Resident #1 immediately upon return for injury and dehydration and encouraged fluids by mouth. He stated that staff had conducted a one hundred percent (100%) head count/room check with a resident census and performed a door check on all exit door to ensure they were closed and locked. The Administrator stated Licensed Practical Nurse (LPN) #1 notified the Director of Nurses (DON) who reported to the facility and initiated a thorough investigation and reported the incident to the SA Agency on 2/08/25 at approximately 5:37 PM. He said that LPN #2 notified the Resident Representative (RR) for Resident #1. He confirmed that the resident had been wearing a pair of athletic shorts and a sleeveless T-shirt, two pairs of socks, and one house slipper at the time of elopement. The Administrator explained that all the exit doors were closed and locked with wall-mounted numeric keypads next to each and required a code to be entered to open the door. He said that the front door could also be opened from the outside with the press of a red button. He said that in the absence of any evidence of point of exit, facility investigation concluded that the resident had exited the facility when visitors pressed the red button on the outside and entered the facility. The resident was gone from the facility unsupervised for about half an hour. The Administrator stated that Resident #1 did not suffer any injuries of any kind during or due to the elopement. The Administrator revealed the facility conducted an ad hoc Quality Assurance and Assessment (QAPI) meeting on the evening of 2/08/25 in which the appropriate members were in attendance and policies were discussed with no changes recommended. He said the facility conducted in-service /training related to elopements in which staff would not be able to work until in-serviced. The Administrator said all residents assessed with wandering behaviors and at risk for elopement, including Resident #1, had their wander guard transmitters tested and it was discovered that the transmitters were not operating correctly. He said that a staff member was posted at the front door and residents at risk for elopement were provided with one-on-one supervision until the system components were received on 2/10/25 and testing confirmed the system functioned correctly. On 2/11/25 at 4:30 PM, an observation and interview with Resident #1 revealed the resident was sitting on his bed in his room. He was wearing a wander guard transmitter on his right ankle. He was unable to answer questions or describe out he left the faciity on 2/8/25. On 2/11/25 at 5:30 PM, in an interview with CNA #3, she revealed she was working at the time of the elopement of Resident #1 on 2/08/25. She explained that a visitor of Resident #1 arrived and went to the resident's room, and he was not in his room. She said the visitor came out and inquired of staff where he was and the dining room and therapy gym were checked and the resident was not there. After a brief look at common areas LPN #1 called a Code Silver and CNA #1 had just arrived and said she thought she had seen the resident on a nearby highway on her way to the facility. She explained that she and another CNA accompanied the visitor to the area, located the resident and he willingly got into the visitors vehicle and returned to the facility. She said that he did not have any obvious injury. On 2/12/25 at 9:55 AM, during an interview, LPN #1 revealed she was working the 3:00 PM through 11:00 PM shift on 2/08/25 and observed Resident #1 in the lobby minutes before 3:00 (PM). She said she discovered at approximately 3:00 PM that Resident #1 could not be located when a visitor inquired about his whereabouts. She confirmed that the facility policy/procedure for Missing Resident was followed with a Code Silver announced using the overhead public announcement system. She stated that CNA #1 had just arrived and reported that she observed the resident walking along the nearby highway. She confirmed the resident was wearing athletic shorts and a sleeveless T-shirt, two black socks and one house slipper, she confirmed the second slipper had been located in his room upon return to the facility by his visitor and two (2) facility staff at 3:30 PM. She stated that she completed a body audit for Resident #1 immediately upon his return and observed no injuries or signs/symptoms of dehydration and encouraged fluid intake by mouth. She said she notified the resident's primary healthcare provider and received no new orders. She said that all residents at risk for elopement, including Resident #1, had their wander guard transmitter tested and none were functioning correctly. She confirmed that a staff member was posted at the front entrance and all residents at risk for elopement were provided with one-on-one supervision pending system replacement and proper function which was accomplished on 2/10/25. LPN #1 stated that nurses were supposed to test the functionality of the transmitters daily either using a hand-held tester or by taking the resident to the door and observing and documenting the test results in the Medication Administration Record but she had not tested Resident #1's transmitter on 2/08/25. On 2/12/25 at 12:36 PM, during a telephone interview the RR for Resident #1 confirmed that she had been notified shortly after 3:30 PM on 2/08/25 that the resident had left the facility unsupervised and returned to the facility at 3:30 PM with no injuries. On 2/13/25 at 4:50 PM during an interview, the Maintenance Director explained that he tested the functioning of the wander guard system each week and the nurses were supposed to test the transmitters daily. He confirmed that the maintenance department had reported to the facility on 2/08/25, tested all exit doors and confirmed that all doors were closed and locked correctly but it was determined that the transmitters worn by residents at risk for elopement were not functioning correctly, specifically not preventing the door from opening or sounding alarm if a transmitter was within eight feet of the front door. He confirmed that the maintenance department changed all the numeric codes for wall-mounted keypads (magnetic locks) after 3:30 PM on 2/08/25. The Maintenance Director said that replacement transmitters were ordered on 2/08/25 and arrived at the facility on 2/10/25. He stated that he had tested the system with the newly received transmitters and the system functioned correctly. On 2/13/25 at 5:00 PM, in an observation and interview with the DON, she revealed that the front entrance wander guard system was functioning properly. The DON demonstrated the function of the system was to prevent the door from opening if a wander guard transmitter was within eight (8) feet of the monitor at the door and if the door had been opened and was open and the transmitter was within eight feet an alarm sounded, which also sounded at both nurses stations. She confirmed that at the time of the elopement the system was not functioning properly. The DON confirmed that the police were not notified of the elopement, and the resident was not taken to the hospital and had no injuries or change of condition following the incident. She confirmed that she had attended the QAPI meeting on the evening of 2/08/25. She confirmed that the replacement transmitters for the wander guard system arrived at the facility on 2/10/25 and were replaced and the system was tested and functioned correctly. She confirmed that monitoring for placement every shift and functioning daily was on-going. She confirmed that all staff were provided with in-service with no staff allowed to work without participation in the training. Record review of the admission Record revealed the facility admitted Resident #1 on 1/28/25 with current diagnoses including Aphasia following Cerebral Infarction, Cognitive Communication Deficit and Legal Blindness. Record review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/04/25 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 99 and required a staff assessment for his mental status. The staff assessment indicated Resident #1 had a long and short-term memory problem, and his cognitive skills for daily decision making was severely impaired. Further MDS review revealed the resident was assessed as needing partial/moderate assistance for surface-to-surface transfers and walking ten (10) feet. The facility submitted a corrective action plan as follows: 1. On February 8, 2025, at approximately 3:00 pm, CST, Resident #1 exited the center while unsupervised. The unsupervised resident leaving the facility represented an Immediate Jeopardy. The resident was wearing a wander guard device. The Resident was assessed upon return to the facility and had no injuries, the wander guard device was found to be inoperable, and Resident was placed on one-on-one supervision. The facility reviewed the wandering/missing resident policy, educated staff on the wandering/missing resident policy and held a quality assurance meeting. In addition, staff checked all exit doors out of the facility (including the door the Resident exited from). Also, the staff check all wander guards currently being utilized in the building and placed any not working on 1:1 supervision. Finally, staff performed a complete headcount (all residents were found to be in the building with one exception who had properly signed himself out) and the door codes were changed. Based on the steps the facility initiated and completed, the facility contends that the Immediate Jeopardy was removed and represents past noncompliance. This event was reported to the Mississippi State Department of Health via email on Sunday, February 9, 2025, at 2:37 pm. 2. On February 8, 2025, at 3:00 pm, Licensed Practical Nurse (LPN) #1, was notified that Resident #1 could not be accounted for. At 3:02 pm, the Director of Nursing (DON), Executive Director (ED), Social Services Director (SSD), Medical Director (MD) and Regional Director of Clinical Services (RDCS) were notified. At 3:03 pm, Certified Nursing Assistant (CNA) #1 reported to work for her 3-11 shift and upon hearing that a resident was not accounted for, showed the nurse a video she had taken of a man she saw walking next to Hwy 90 on her way to work. The Resident's girlfriend arrived at the facility approximately 3:00 pm and as soon as she saw the video, she and 3 CNAs jumped in the car to go get Resident #1. LPN #2 called the Residents responsible party (Power of Attorney (POA)) and DON. The DON called the ED, MD, and SSD. At 3:30 pm Resident returned to the facility. At 3:36pm the DON was notified the Resident was located .7 of a mile from the facility and safely returned to the facility. 3. On February 8, 2025, at 3:30 pm, Resident returned to facility. Once Resident #1 was back inside center, LPN #2, completed a head-to-toe body audit and no injuries were noted. Registered Nurse (RN) Supervisor #1 completed a head count of all residents, and all were accounted for. On February 8, 2025, at 4:15 pm, the Assistant Maintenance Director performed checks on all exterior doors and windows, along with the wander guard system. His findings determined that all doors were locked and while all alarms were functioning properly, the wander guard bracelet Resident #1 was wearing was not functioning properly. The resident was immediately placed on 1:1 supervision and a 24-hour door monitor put in place at front. The door monitor continued until the wander guard system was verified to function properly and the Quality Assurance monitoring begin (see bullet #8). The door monitor was discontinued on 02/10/2025. The door keypad codes were changed. 4. On February 8, 2025, RN #2/Unit Manager began educating staff on elopement wandering risk policy, missing resident policy, following care plans, abuse and neglect, and resident's rights. The Director of Social Services reassessed Resident #1 Brief Interview for Mental Status (BIMS), which had not changed and was noted to be 99, unable to determine. On February 8-10, 2025, wandering risk evaluation completed on all residents with no newly identified wandering risk. Elopement binders (identifying the 5 residents wearing wander guards) are located at both nurses' stations and up front. At 6:45 pm, an Ad hoc QAPI was held including the ED, DON, and MD to discuss incident and a plan of correction. 5. On Saturday, February 8, 2025, DON conducted interviews to learn of Resident #1's path. It was discovered that Resident #1 most likely exited the front door when a visitor entered the facility. Resident #1 confirmed by a positive head shake that he used the front door and answered yes, that he was trying to go home. 6. On Monday, February 10, 2025, at 2:30 pm, the incident was taken to a quality assurance performance improvement (QAPI) meeting, attended by, Executive Director, Director of Nursing, Infection Preventionist, Medical Director via phone, Director of Dietary Services, Maintenance Director, Minimum Data Set (MDS) LPN #2 and LPN #3. No further action needed. No changes made to policies. 7. On February 8, 2025, in-servicing began on Wandering/Missing Resident, Prevention of Abuse and Neglect, and door alarms policies, and included 3 RNs, 1 LPN and 5 CNAs. On February 9, 2025, in-service continued including 6 LPNs, 2 RNs and 8 CNAs. On February 10, 2025, in servicing continued including 6 LPNs, 11 CNAs, and 3 RNs and 4 ancillary staff. On February 11, 2025, 4 LPN, 9 ancillary staff, 4 RNs. No staff was allowed to work before receiving education. 15 CNAs, 1 RN. Education is on-going until it was 100% complete. Furthermore, the system will be check daily by maintenance staff and the devices will be checked for placement each shift and checked for functionality daily by nursing staff. The daily checks of the door systems and placement of the patient devices, as well as the q shift checks of functionality of the patient devices, will be monitored by DON for completion. (see bullet #8) 8. The following monitoring has been put in place beginning February 10, 2025, and the findings will be evaluated by the Quality Assurance and Improvement Committee. All residents that are assessed and care planned as a potential for elopement will be evaluated for significant change in condition for elopement using the elopement risk evaluation, evaluated quarterly for elopement using the elopement risk evaluation, ensure the care plan reflects elopement risk status and any interventions (i.e., wander guard), wander guard check placement every shift that it is present on the MAR without omissions, order for wander guard check for functionality daily is present on MAR without omissions, elopement books have a current face sheet, resident photograph and risk alert form, binders are in an easily accessible location, staff has been educated on the elopement policy, location of the binders and notification process regarding an possible missing resident, transmitter bands are replaced per manufacturers recommendations if signs of manipulation and/or integrity of the band is compromised, exit doors monitoring system functioning appropriately with supporting documentation, and wand used to test function is easily accessible to check the transmitter function.(once these monitoring task were initiated, we discontinued the door monitor) All the forementioned monitoring task will be conducted by the Director of Nursing enduring 3 times a week for 1 week, then 2 times a week for 2 weeks, then weekly for the next 2 months and then monthly. All results will be presented to the Quality Assurance Committee for evaluation and recommendations as necessary. The Quality Assurance Committee will continue to evaluate all monitoring for 90 days to monitor effectiveness and make changes as necessary. 9. All Corrective Actions were completed on February 9, 2025, and the Immediate Jeopardy was removed on February 10, 2025, prior to the State Agency's entrance on February 11, 2025. Validation: The SA validated on 2/13/25, through interview and record review, that all corrective actions had been implemented as of 2/9/25, and the facility was in compliance as of 2/10/25, prior to the SA's entrance on 2/11/25.

Based on observation, staff interview, record review, review of the Mississippi Board of Nursing Administrative Code, and facility policy review, the facility failed to follow standards of practice for cleaning/disinfecting glucometers (blood glucose testing device), per manufacturer's recommendations, for a minimum of 30 seconds wet time, before, and after use, to ensure bloodborne viral and bacterial pathogens were killed. The facility also failed to ensure that staff washed their hands before, during, and after performing a blood glucose finger stick, for eight (8) of 13 observations for six (6) residents who received blood glucose finger sticks, Residents #13, #20, #52, #77, #84 and #89. This practice had the potential and likelihood to pose a threat of blood borne cross-contamination between residents who received blood glucose testing. The facility's failure of not following standards of practice for cleaning/disinfecting the glucometers, per manufacturer's recommendations between residents; and to perform hand hygiene between procedures, placed these and other residents who receive blood glucose finger sticks (24 total residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 6/25/19, when the facility failed to follow the manufacturer's guidelines to clean and disinfect the glucometer for the minimum amount of wet time of 30 seconds, prior and after use between residents, to ensure all bacterial/viral pathogens were killed; and failed to perform hand hygiene appropriately between residents. The State Agency (SA) notified the Administrator on 6/25/19, of the IJ. An acceptable Removal Plan was received on 6/26/19, in which the facility alleged all corrective actions to remove the IJ were completed on 6/25/19, and the IJ was removed as of 6/26/19. The SA validated the Removal Plan and determined the IJ was removed on 6/26/19, prior to exit. Therefore, the scope and severity for CFR(s): 483 21 (b)(3)(i), F658; Services Provided Meet Professional Standards, was lowered from a K level to an E level, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with the regulatory requirements. Findings include: A review of the Mississippi Board of Nursing Position Statement, titled Blood Borne Pathogens, with a revision date of 4/6/2000, revealed the Board recognized the Centers of Disease Control (CDC) and Prevention Guidelines as the accepted standard of nursing practice and required all nurses to practice accordingly. In accordance with the CDC guidelines, in the provision of nursing care, all nurses should adhere to standard precautions, including washing of hands and comply with current guidelines for disinfection and sterilization of re-useable devices. A review of the Centers for Disease Control (CDC) and Prevention guidelines, updated 6/8/17, which regarded shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. A Review of facility policy titled, Infection Control Monitoring, dated November 2017, revealed: It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread. The objective of the Infection Control Policies: preventing, identifying, reporting, investigating, and controlling infections and other communicable diseases; designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A Review of facility policy titled, Obtaining a Finger stick Glucose Level, dated December 2018, revealed staff were to maintain a clean barrier, maintain clean technique, follow instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading, and to wash hands after removing gloves. The policy also stated to clean the glucose monitor with approved disinfectant before and after each resident use. A review of the booklet titled, EvenCare G2 blood glucose monitoring system users guide (glucose monitor used by the facility), revised January 2018, revealed: Wipe all external areas of the meter or lancing device, including both front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. The booklet documented Micro-Kill bleach germicidal wipes were validated as an effective agent to use on the glucometer. A review of the label of the Micro-kill Bleach wipes, revealed: Contact time: Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria and viruses **on the label**(virucidal-including but not limited to Hepatitis A/B/C, Human immunodeficiency virus type I, influenzas, norovirus, and Rotavirus) of the wipes except a one (1) minute contact time is required to kill Candida albicans and Trichophyton mentagrophytes and a three (3) minute contact time is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet for the entire contact time. A review of the EvenCare G2 booklet titled, Healthcare Professional Operators Manual, revised 3/2011, revealed a self-test question which asked, What is the procedure for disinfecting the EvenCare G2 Meter? with an answer of: Clean the meter with a disinfecting wipe. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then, wipe the meter dry or allow to air dry. The Operator's manual also revealed: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter and lancing device surface. Resident #20 A review of the June 2019 Medication Administration Record (MAR) revealed Resident #20 received finger stick glucose testing twice daily for Diabetes Mellitus. Resident #47 also received Insulin per sliding scale twice daily. During an observation, on 06/24/19 at 3:35 PM, LPN #3 placed two (2) plastic cups on top of the medication cart with each containing a glucometer. LPN #3 stated, I'm using the plastic cups as barriers, is that alright? LPN #3 was instructed to go by the facility's policies and procedures. LPN #3 stated that he was new, he had been in Florida, and he didn't know if the rules were different. LPN #3 did not clean either glucometer and never voiced that he cleaned the glucometers prior to the testing procedure. LPN #3 entered Resident #20's room, gloved, and performed the finger stick. LPN #3 removed his gloves, exited the room, and placed the glucometer on the medication cart. LPN #3 retrieved Micro-kill bleach wipes out of a container, shrugged his shoulders and asked, How long are you supposed to clean the glucometer? I know in Florida it's different. We had to keep it wrapped for several minutes. I'm not sure of the rule here. LPN #3 was instructed again to go by the facility's policy and procedure of cleaning the glucometer. LPN #3 read the label on the back of the Micro-kill Bleach wipe container, and aloud stated that the contact time was 30 seconds to kill all of the bacteria and viruses listed on the label for the virucidal blood borne pathogens, except one (1) and three (3) minute contact time for other pathogens such as Candida albicans and Trichophyton mentagrophytes and Clostridium difficile. LPN #3 cleaned the contaminated glucometer for approximately 10 seconds (timed by watch), then placed the glucometer back into the same dirty cup. LPN #3 retrieved the FlexPen from the cart, placed it in his un-gloved hands, and entered Resident #20's room. LPN #3 gloved, administered the insulin to Resident #20, removed his gloves and exited the room, all without washing or sanitizing his hands. LPN #3 laid the insulin pen on the cart, without a barrier, opened the cart, and placed the insulin pen inside, without sanitizing the pen. LPN #3, without hand hygiene, proceeded to the next resident. Resident #84 A review of the June 2019 MAR revealed Resident #84 received finger stick glucose monitoring twice daily. During an observation on 06/24/19 at 3:45 PM, LPN #3 removed the glucometer from a second cup. He did not clean the glucometer, nor did he voice that he had cleaned it prior to the procedure. LPN #3 went to Resident #84's room door, donned a gown due to isolation set up, then proceeded down the hall to find out why the resident was on isolation. LPN #3 carried the cup/glucometer, not covered, down the hall with him. LPN #3 returned to the Resident's room, still holding the cup/glucometer, entered and crossed over to the B bed, and found the resident wasn't there. LPN #3 stated,Resident #84 is not on isolation, however her roommate is on contact isolation. LPN #3 placed the glucometer/cup back on the medication cart, without cleaning the glucometer or removing the testing strip. LPN #3 did not perform hand hygiene at any time prior, during, or after the procedures. He proceeded to the next resident. Resident #13 A review of the June 2019 MAR revealed Resident #13 received finger stick blood glucose testing twice daily, and received insulin per sliding scale. During an observation on 6/24/19, at 3:55 PM, LPN #3 entered Resident #13's room with the glucometer that was previously taken to Resident #84's isolation room. LPN #3 gloved and obtained the resident's blood sugar (BS). LPN #3 exited the room, placed the cup/glucometer on the medication cart, removed his gloves, obtained the Micro-kill Bleach wipes, and wiped the glucometer for approximately nine (9) seconds, and then placed the glucometer back into the same contaminated plastic cup. LPN #3 opened the medication cart and obtained Resident #13's FlexPen, entered the resident's room, gloved, and administered the insulin. He removed his gloves, exited the room, opened the medication cart, and placed the insulin pen inside the medication cart, without wiping and/or sanitizing the FlexPen. LPN #3 did not perform hand hygiene prior, during, or after the procedure. He proceeded to another resident and gave oral medications. LPN #3 still had not washed or sanitized his hands between all four (4) of these rooms. LPN #3 Interview: During an interview on 06/24/19 at 4:45 PM, LPN #3 stated, When I come out of a room, I wash the glucometer for 30 seconds. But, I did not know to clean it 30 seconds until you told me to read the Micro-kill bleach wipes and then I saw it. I'm from Florida and we kept the glucometer covered for two (2) minutes. When asked about washing his hands, LPN #3 stated, I didn't wash my hands except me handling the bleach wipes when I cleaned the glucometer. You're right, I don't think I washed my hands in all of the rooms I went into, now that I think about it. When I came back to the cart I didn't wash or sanitize my hands. When asked about the insulin pens, LPN #3 stated he did recall laying the pens on the cart and putting them back in the medication cart without cleaning them. He stated that he was extremely nervous. He stated taking the plastic cup with the glucometer into more than one room, without cleaning it, is an infection control issue. He stated that he should have cleaned the glucometer for the 30 seconds. He stated, But again, I didn't know that until you told me to read the Micro-kill Bleach wipe container. He stated that he had received training on infection control and cleaning the glucometer after he was hired. Review of a facility document, Day Five New Hire Orientation, dated 6/5/19, revealed LPN #3 had received training on infection control bloodborne pathogens and use of Glucose Monitors. Resident #84 During an observation on 06/25/19 at 3:40 PM, LPN #1 placed two (2) plastic cups on a tray on top of the medication cart, with each cup containing a glucometer. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the cart's bottom drawer. She obtained the glucometer (glucometer #1) and cleaned the glucometer for approximately five (5) seconds (timed by watch). She then placed the glucometer back into the plastic cup. LPN #1 then took glucometer #2 out of the other cup and cleaned it with a Micro-kill wipe for approximately four (4) seconds, then placed the glucometer back into the cup. LPN #1 removed her gloves and took the cup containing glucometer #1 to Resident #84's room. LPN #1 gloved, performed the finger stick, removed her gloves, and exited the room. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the medication cart and wiped the glucometer approximately seven (7) seconds (timed with watch) and then placed it into a clean cup on the medication cart. LPN #1 did not perform hand hygiene at any time prior, during, or after the procedure. She proceeded to the next resident. Resident #13 (second observation for resident) During an observation on 06/25/19 at 3:49 PM, LPN #1 retrieved glucometer #2, entered Resident #13's room, gloved, and performed the finger stick. LPN #1 placed the glucometer back into the plastic cup, removed her gloves, and exited the room. LPN #1 gloved, obtained a Micro-kill Bleach wipe and cleaned the glucometer for approximately eight (8) seconds (timed by watch). LPN #1 placed the clean glucometer into a clean plastic cup. LPN #1 removed her gloves and obtained the resident's FlexPen. LPN #1 administered the insulin to Resident #13, then placed the insulin FlexPen back into the medication cart drawer, without cleaning/sanitizing the pen. LPN #1 did not perform hand hygiene prior, during, or after the procedure. She proceeded to the next resident. Resident #89 (procedure not performed) A review of the June 2019 MAR revealed Resident #89 received finger stick glucose testing, with sliding scale insulin twice daily. During an observation on 06/25/19 at 3:55 PM, LPN #1 obtained the plastic cup containing glucometer #1, (previously used on Resident #84) entered Resident #89's room, but the resident was not in the room. LPN #1 placed the cup/glucometer on top of the medication cart and covered it with a Kleenex, stating she would leave it there until Resident #89 returned to her room. LPN #1 went to the medication room and returned. She opened the medication box, and obtained a paper cut to her left finger. LPN #1's finger was bleeding and she wiped it with an alcohol wipe. She then placed a band-aid on her finger. LPN #1 still had not performed any type of hand hygiene. Resident #20 (second observation for resident) During an observation on 06/25/19 at 4:05 PM, LPN #1 obtained the glucometer, covered with the Kleenex, and entered Resident #20's room. LPN #3 gloved, performed the finger stick, removed her gloves, and exited the room. LPN #1 took Micro-kill Bleach wipes and cleaned glucometer #1 for approximately 15 seconds (timed with watch), then placed it into a clean plastic cup to dry. LPN #1 stated, I rotate the glucometers to allow one (1) to dry while I use the other one. I've never really timed how long I let it dry, all I know is that it's dry by the time I get ready to use it. LPN #1 failed to perform hand hygiene prior, during, and after the procedure, then continued to the next resident. Resident #89 During an observation on 06/25/19 at 4:20 PM, LPN #1 obtained the cup/glucometer #2, entered Resident #89's room, gloved, and performed the finger stick. LPN #1 removed her gloves, and exited the room. LPN #1 gloved, retrieved a Micro-kill Bleach wipe, and cleaned glucometer #2 for approximately seven (7) seconds (timed with watch), placed glucometer #2 into a clean plastic cup, and removed her gloves. LPN #1 retrieved Resident #89's Novolog FlexPen from the medication cart, entered Resident #89's room, performed the injection, removed her gloves, and exited the room. LPN #1 did not perform hand hygiene prior, during, or after the procedures. LPN #1 interview: During an interview, with RN #4 present, on 06/25/19 at 4:35 PM, LPN #1 stated that she washed her hands prior to beginning work on the medication cart. She stated she used a glucometer that had been cleaned with the Micro-kill wipes and air dried. LPN #1 stated, I wipe the glucometer I guess two (2) minutes, but that seems like a long time to me. I don't time it, I just clean it. I can say I thoroughly clean it and set it up-right to dry. She stated she had two (2) glucometers that she used, both cleaned with Micro-kill wipes. She stated she used one glucometer, cleaned it, and returned it to the cart. She stated she donned gloves, used Micro-kill wipes, and cleaned the glucometer for an estimated two (2) minutes, put it up-right in a clean plastic cup. She stated she moved on to the next resident and used the second glucometer for the next resident. She stated she rotated the glucometers, letting them dry. LPN #1 stated that she cleaned each glucometer approximately two (2) minutes between residents, with the Micro-kill Bleach wipes. She stated that she had been in-serviced yearly on infection control and more often for cleaning of the glucometer. When asked if she felt that she cleaned the glucometer for two (2) minutes like she previously stated, LPN #1 stated, No I don't feel like I cleaned it for 1-2 minutes; time passes. When asked if she washed her hands at any time while obtaining the finger stick glucose tests, LPN #1 stated she had forgotten to wash her hands, she usually did, but she was nervous. LPN #1 stated she thought she was doing the correct wiping time, but she didn't time the cleaning of the glucometer. When asked if she thought not cleaning the glucometer per the manufacturer recommendation was an infection control issue, she stated, I do think it was an infection control issue. You have to make sure stuff gets killed. LPN #1 was not observed to use the hand sanitizer at any time during the observations, nor did she voice that she had used the sanitizer. LPN #1 was observed by the surveyor continuously throughout the process of performing the finger sticks of the four (4) residents, Resident #13, #20, #84, and #89, and did not observe any type of hand hygiene prior, during, or after the procedures between residents. A review of a facility document titled, Competency Check List, dated 5/20/19, revealed LPN #1 signed that she was checked off on handwashing and cleaning the glucometer according to manufacturer's guidelines. A facility document titled, Glucometer Cleaning Skills Checklist, dated 5/20/19, revealed LPN #1 was checked off to disinfect the glucometer, by cleaning the meter surface with Medline Micro-kill Bleach Germicidal wipes by the following instructions: Wipe all external areas of the meter, including front and back surfaces, until visibly clean. Avoid wetting the meter strip port. Allow the surface of the meter to remain wet at least 30 seconds at room temperature. Resident #52 Review of the June 2019 MAR, revealed Resident #52 received finger stick glucose checks daily, scheduled at 4:30 PM. During an observation on 6/25/19 at 3:40 PM, LPN #2 completed the narcotic medication count and prepared to perform a finger stick procedure. LPN #2 cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds, then placed it on a tray on the medication cart. She obtained the glucometer, entered Resident #52's room, applied clean gloves, and performed the finger stick. LPN #2 returned to the medication cart and cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds and allowed it to air dry. LPN #2 did not wash her hands or use any Alcohol Based Hand Gel (ABHG) after counting the narcotic medications, prior to entering the resident's room, before the procedure, during the procedure, after the procedure, or after leaving the resident's room. LPN #2 proceeded to the next resident. Resident #77 Review of the June 2019 MAR revealed Resident #77 received finger stick glucose testing twice daily. During an observation on 6/25/19 at 3:50 PM, LPN #2 entered Resident #77's room, retrieved some paper towels, and placed the silver tray with the glucometer on the resident's nightstand, on the paper towels. LPN #2 applied clean gloves, cleaned the resident's left middle finger, and performed the glucose testing. She then returned to the medication cart, cleaned the glucometer with a Micro Kill germicidal wipe for approximately eight (8) seconds, and placed it in the medication cart. LPN #2 did not wash her hands or use hand sanitizer prior to entering the resident's room, before the procedure, during the procedure, or after the procedure. During an interview on 6/25/19 at 3:55 PM, LPN #2 stated, related to the procedures she'd performed for Resident #52 and Resident #77, that she had gotten all of her supplies out and wiped everything down. She stated she brought her items into the room, put a barrier down, and wiped the resident's finger with alcohol. She stated she did the fingersticks, wiped the resident's finger again, and wiped everything before she put it in the cart. She stated she cleaned the glucometer with the germicidal wipe for one (1) minute she guessed. She stated she would have to use a timer to know for sure. She stated, I don't know what to tell you anymore. She stated she should wash her hands between residents and/or when her hands were soiled. She stated she didn't understand why she had to wash her hands, since she had used gloves to perform the fingersticks. During an interview on 06/25/19 at 6:09 PM, RN #2/Infection Control Nurse/Risk Management Nurse, stated, If there is a pathogen in the blood, by not cleaning the glucometer, you could pass it on. If there is something that could be considered an infectious process, then you could pass it on. RN #2 stated that nurses are taught to clean the glucometer for 30 seconds, with a five (5) minute dry time. She stated there were two (2) glucometers on the cart so one can be cleaned and let dry, while the other is used. She stated she wasn't going to say there couldn't be a problem by not cleaning the glucometer between residents, because it could very well be. She stated she had provided an in-service recently about infection control, but the nurse's weren't there. She stated that she touched on infection control every six (6) months at a minimum, but if there was an issue, she did the in-service more often. She stated that staff were taught to wash their hands when gloves are removed, because there could be pin-holes in the gloves. During an interview on 06/26/19 at 3:25 PM-3:30 PM, RN #3/ Staff Development Nurse stated, Not cleaning the glucometer could cause an infection to go from person to person. If one (1) person has something, then by not cleaning the glucometer, it could spread. Yes, I see it as an infection control issue. I see it as an opportunity for education because we know better. She stated that hand-washing was an issue for the same reasons and that handwashing was always the best practice. During an interview on 06/25/19 at 6:20 PM, the Director of Nursing (DON) stated that not cleaning the glucometer is an infection control issue, because of the potential for transmitting infections or germs. She stated that it could cause cross-contamination. She stated the recommended time of cleaning the glucometer is 30 seconds, with a dry time of three (3)-five (5) minutes. The DON stated education was provided many times about cleaning the glucometer per manufacturer recommendations, as well as handwashing. She stated if staff were not cleaning the glucometers for the allotted time, to make sure there is no blood or body fluids, cross-contamination could occur. She stated hands should be washed before going into a room, when having contact with a resident, afterwards, and sometimes in-between, depending on the procedure. During an interview, on 06/25/19 at 7:05 PM, the Administrator stated, What is the difference in cleaning the glucometer for 10-11 seconds and 30 seconds? She stated that the glucometer was cleaned, just not the 30 seconds. During an interview on 06/26/19 at 9:08 AM, the Medical Director stated that the glucometer itself should not actually touch any blood; the lancet and the glucometer strip touches the blood. He stated that it was his understanding that they are supposed to wipe the glucometer before and after use. He stated that the Center for Disease Control (CDC) recommended handwashing for 20 seconds, so if the glucometer doesn't touch blood, then 20 seconds cleaning the glucometer should be adequate. He stated, If I walk in a room and my hands are in my pocket and I never take them out of my pocket, then they are not dirty. However, if I do physical activity in that room, then I should wash my hands to prevent the spread of germs. The facility submitted an acceptable Removal Plan on 6/26/19, for the Immediate Jeopardy. Review of the facility's Removal Plan revealed the facility took the following actions to remove the Immediate Jeopardy: Brief Summary: On 6/25/19 at 7:00 PM, CST, the State Agency informed the Administrator and the Director of Nursing of an immediate jeopardy with infection control due to a glucometer not being cleaned for a full 30 seconds, according to the manufacturer's guidelines by LPN #1, LPN #2 and LPN #3 prior/after performing a finger stick blood glucose check, which is a standard of practice. Corrective Actions: 1. On 6/25/19 at 7:30 PM, the Administrator called a mandatory meeting with the nursing staff to notify Immediate Jeopardy had been called. Nurses on duty, including a total of four (4) Licensed Practical Nurses (LPN) and two (2) Registered Nurses (RN) were instructed to clean all eight (8) glucometers (by disinfecting for a full 30 seconds) and perform proper handwashing. LPNs that were currently on the medication cart completed proper handwashing and cleaning of the glucometers. Education was then initiated by the DON to follow current policies on glucometer use and infection control with handwashing. This was completed on 6/25/19, by 10:00 PM. 2. On 6/25/19 at 8:00 PM, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated an in-service, including a skills check-off list, in regards to glucometer infection control protocol, handwashing, and safety by following the manufacturer guidelines for cleaning the glucometers. This included four (4) LPNs and two (2) RNs. 3. On 6/25/19 at 9:15 PM, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Infection control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimum Data Set (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admissions/Marketing Nurse, and Food Service Director, to discuss the events after Residents #13, #20, #52, #77, #84, and #89 were exposed to the surface of the glucometer and the importance of following the policy for infection control protocol, handwashing, and safety in regards to the cleaning manufacturer guidelines for the glucometers. The QA committee also reviewed policies on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/disinfecting bleach wipes, and infection control protocol safety in relation to glucose monitoring systems and proper handwashing with no changes to any of the current policies. 4. On 6/25/19 at 9:00 PM, the Care Plan Coordinator revised all diabetic Care Plans to include the proper cleaning of the glucometer machines for all residents that require blood glucose monitoring. There are currently 24 residents receiving blood glucose monitoring. 5. On 6/25/19 at 8:00 PM, the Infection control Officer initiated an all nursing staff that were currently on duty (total of four (4) LPNs and two (2) RNs) on infection control, care planning, manufacturer guidelines for the blood glucose monitoring system/disinfecting bleach wipes, and infection control/handwashing protocol safety in relation to glucose monitoring systems, which is a nursing Standard of Practice. We currently have 40 Licensed Nursing staff members. 6. On 6/25/19 at 8:15 PM, the Administrator completed a one-on-one (1:1) education with LPN #1, LPN #2, and LPN #3 on cleaning/disinfecting glucometers with emphasis on the 30 second time frame for cleaning/disinfecting as well as handwashing protocols. 7. On 6/25/19 at 8:55 PM, all 24 residents who receive blood glucose finger sticks were assessed for exposure complications by the DON and the ADON, with no complications noted. In addition, the assessments completed of the 24 residents, there were no signs and/or symptoms of any acute infection from blood borne pathogens noted. There are currently no residents receiving blood glucose monitoring with a diagnosis of a blood borne pathogen infection. 8. No nursing staff will be allowed to work until they have completed this in-service and competency return demonstration, in regards, to proper handwashing and glucometer cleaning/disinfecting by professional standards. The facility alleges that all corrective actions to remove the immediate jeopardy were completed on 6/25/19, and the immediate jeopardy removed as of 6/26/19. The State Agency (SA) validated through observation, interview, and record review, that the facility completed the following actions to remove the IJ: Corrective Actions: 1. The SA validated through interview, that on 6/25/19, the Administrator called a mandatory meeting with the nursing staff and notified them of the Immediate Jeopardy. Nurses on duty, including a total of four (4) Licensed Practical Nurses (LPNs) and two (2) Registered Nurses (RNs) were instructed to clean all eight (8) glucometers (by disinfecting for a full 30 seconds) and perform proper handwashing. LPNs that were currently on the medication cart completed proper handwashing and cleaning of the glucometers. Review of sign-in sheets and staff interview validated that education was initiated by the DON to follow current policies on glucometer use and infection control with handwashing. This was completed on 6/25/19, by 10:00 PM. 2. The SA validated through staff interview, review of skills check offs and sign-in sheets, that on 6/25/19, the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) initiated an in-service, including a skills check-off list, in regards to glucometer infection control protocol, handwashing, and safety, by following the manufacturer guidelines for cleaning the glucometers. This included four (4) LPNs and two (2) RNs. 3. The SA validated by review of the sign-in sheet and staff interview, that on 6/25/19, an Emergency Quality Assurance (QA) meeting was held with the Medical Director, Administrator, DON, ADON, Infection control Officer, Business Office Manager, Housekeeping Supervisor, Laundry Supervisor, Life Enrichment Director, Minimum Data Set (MDS) Nurse Coordinators, Restorative Nurse, Maintenance Director, Admissions/Marketing Nurse, and Food Service Director, to discuss the events after Residents #13, #20, #52, #77, #84, and #89 were exposed to the surface of the glucometer, and the importance of following the policy for infection control protocol, handwashing, and s

Based on observation, staff interview, record review, review of the Mississippi Board of Nursing Administrative Code, and facility policy review, the facility failed to follow standard precautions of infection control, during the performance of routine finger-stick testing of blood sugars. The facility failed to to clean/disinfect the glucometer, per manufacturer's recommendation of a minimum of 30 seconds wet time, before, and after use, to ensure bloodborne viral and bacterial pathogens were killed; and failed to ensure that staff washed their hands before and after performing a blood glucose finger stick, for eight (8) of 13 observations, for six (6) residents who received blood glucose finger sticks, Residents #13, #20, #52, #77, #84 and #89. This practice had the potential and/or likelihood to pose a threat of blood borne cross-contamination between residents who received blood glucose testing. The facility's failure of not following standard precautions for infection control, by not providing handwashing and not disinfecting the glucometer per manufacturer's recommendations between residents, placed these and other residents who receive blood glucose finger sticks (24 total residents) in a situation which caused a likelihood of serious injury, harm, impairment, or death, related to the spread of blood borne pathogens due to cross-contamination with the multi-resident use of the glucometer. The situation was determined to be an Immediate Jeopardy (IJ), which began on 6/25/19, when the facility failed to clean and disinfect the glucometer for the minimum amount of wet time of 30 seconds, prior and after use between residents, per manufacturer's recommendations, to ensure all bacterial/viral pathogens were killed. The State Agency (SA) notified the Administrator on 6/25/19, of the IJ. An acceptable Removal Plan was received on 6/26/19, in which the facility alleged all corrective actions were completed on 6/25/19, and the IJ was removed as of 6/26/19. The SA validated the Removal Plan and determined the IJ was removed on 6/26/19, prior to exit. Therefore, the scope and severity for CFR(s): 483.80(a)(1)(2)(4)(e)(f), F880; Infection Prevention and Control, was lowered from a K level to an E level, while the facility develops and implements a plan of correction and monitors the effectiveness of systemic changes to ensure the facility sustains compliance with the regulatory requirements. The facility also had an infection control issue that did not rise to the IJ level, related to a urinary catheter drainage bag laying on the floor for one (1) of (6) six residents with urinary catheters observed, Resident #57. Findings include: A review of the Mississippi Board of Nursing Position Statement, titled Blood Borne Pathogens, with a revision date of 4/6/2000, revealed the Board had regulations in place to recognize the Centers of Disease Control (CDC) and Prevention Guidelines as the accepted standard of nursing practice, and to require all nurses to practice accordingly. In accordance with the CDC guidelines in the provision of nursing care, all nurses should adhere to standard precautions, including washing of hands, and comply with current guidelines for disinfection and sterilization of re-useable devices. A review of the Centers for Disease Control (CDC) and Prevention guidelines, last updated 6/8/17, regarding shared blood glucose meters, revealed if blood glucose meters were shared, the device should be cleaned and disinfected after every use, per manufacturer instructions, to prevent carry-over of blood and infectious agents. Review of facility policy titled, Infection Control Monitoring, dated November 2017, revealed: It is the policy of the Center to investigate the cause of infections (nosocomial and community and hospital acquired) and the manner of spread. The objective of our Infection Control Policies are: preventing, identifying, reporting, investigating, and controlling infections and other communicable diseases. It is designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Review of a facility policy titled, Obtaining a Finger stick Glucose Level, dated December 2018, revealed staff were to maintain a clean barrier, maintain clean technique, follow instructions provided by the manufacturer of the glucose monitoring system to obtain a blood glucose reading, and to wash hands after removing gloves. The policy also stated to clean the glucose monitor with approved disinfectant before and after each resident use. A review of the booklet titled EvenCare G2 blood glucose monitoring system users guide (glucose monitor used by the facility), revised January 2018, revealed: Wipe all external areas of the meter or lancing device, including both front and back surfaces, until visibly clean. Avoid wetting the meter test strip port. Allow the surface of the meter or lancing device to remain wet at room temperature for the contact time listed on the wipe's directions for use. The booklet documented Micro-Kill bleach germicidal wipes were validated as an effective agent to use on the glucometer. A review of the label of the Micro-kill Bleach wipes, revealed: Contact time: Allow surface(s) to remain wet for 30 seconds to kill all of the bacteria and viruses **on the label**(virucidal-including but not limited to Hepatitis A/B/C, Human immunodeficiency virus type I, influenzas, norovirus, and Rotavirus) of the wipes except a one (1) minute contact time is required to kill Candida albicans and Trichophyton mentagrophytes and a three (3) minute contact time is required to kill Clostridium difficile spores. Reapply as necessary to ensure that the surface remains wet for the entire contact time. A review of the EvenCare G2 booklet titled, Healthcare Professional Operators Manual, revised 3/2011, revealed a self-test question which asked, What is the procedure for disinfecting the EvenCare G2 Meter? with an answer of: Clean the meter with a disinfecting wipe. Wipe all external areas of the meter including both front and back surfaces until visibly wet. Allow the surface of the meter to remain wet at room temperature for the contact time/kill time listed on the canister. Then, wipe the meter dry or allow to air dry. The Operator's manual also revealed: Cleaning and disinfecting the meter and lancing device is very important in the prevention of infectious disease. Cleaning is the removal of dust and dirt from the meter and lancing device surface, so no dust or dirt gets inside. Cleaning also allows for subsequent disinfection to ensure germs and disease-causing agents are destroyed on the meter and lancing device surface. Record review of a facility document titled, Order Listing Report, dated 6/25/19, revealed that a total of 24 residents received finger stick blood glucose testing at the facility. Resident #20 A review of the June 2019 Medication Administration Record (MAR) revealed Resident #20 received finger stick glucose testing twice daily for Diabetes Mellitus. Resident #47 also received Insulin via FlexPen, per sliding scale, twice daily. An observation on 06/24/19 at 3:35 PM, revealed LPN #3 placed two (2) plastic cups on top of the medication cart with each containing a glucometer. LPN #3 turned and stated, I'm using the plastic cups as barriers, is that alright? The LPN was instructed to go by his facility's policies and procedures. LPN #3 stated I'm new here and I came from Florida and the rules are different there. I don't know the rules here yet. LPN #3 did not clean either glucometer and LPN #3 never voiced that he had cleaned the glucometers before starting the testing procedure. LPN #3 entered Resident #20's room, without performing hand hygiene. LPN #3 gloved and set the plastic cup containing the glucometer on the over-bed table. LPN #3 obtained Resident #20's Blood Sugar (BS). LPN #3 put the glucometer back into the same plastic cup. LPN #3 removed his gloves and exited the room, without washing or sanitizing his hands. LPN #3 placed the cup/glucometer back on the medication cart. LPN #3 took Micro-kill bleach wipes out of a container, shrugged his shoulders and asked, How long are you supposed to clean the glucometer? I know in Florida it's different. We had to keep it wrapped for several minutes. I'm not sure of the rule here. LPN #3 was encouraged to go by facility's policy and procedure of cleaning the glucometer and also to look on the back of the Microkill wipes for contact time. LPN #3 read out loud the label on back of the Micro-kill Bleach wipe container, as he pointed with his forefinger, that the contact time was 30 seconds to kill all of the bacteria and viruses listed on the label for the virucidal blood borne pathogens, except one (1) and three (3) minute contact time for other pathogens such as Candida albicans and Trichophyton mentagrophytes and Clostridium difficile. LPN #3 then placed the Micro-kill Bleach wipes back on the medication cart and took the contaminated glucometer out of the cup and cleaned it for approximately 10 seconds (timed by watch). After wiping the glucometer, LPN #3 then placed the glucometer back into the same dirty cup. Without performing hand hygiene, LPN #3 opened the medication cart, pulled out the Novolog insulin FlexPen, and laid it on the medication cart, without a barrier. LPN #3 obtained a needle from the cart drawer and applied the needle to the pen. LPN #3 put the insulin pen in his un-gloved hands and entered Resident #20's room. LPN #3 laid the insulin pen on the over-bed table, without a barrier. LPN #3 gloved, administered the insulin to Resident #20, removed his gloves, and exited the room; all without washing or sanitizing his hands. LPN #3 went back to medication cart, laid the insulin pen on the cart, without a barrier, opened the cart, and placed the insulin pen inside, without sanitizing the pen. LPN #3, without hand hygiene, proceeded to the next resident. Resident #84 A review of the June 2019 MAR, revealed Resident #84 received finger stick glucose monitoring twice a day, related to hypoglycemia. An observation on 06/24/19 at 3:45 PM, revealed LPN #3 removed the glucometer from the second cup. LPN #3 did not clean the glucometer, nor did he voice that he had cleaned it prior to the procedure. LPN #3 placed the glucometer strip into the glucometer, approached Resident #84's room door, and donned a gown due to isolation set up. LPN #3 proceeded down the hall to find out why the resident was on isolation. LPN #3 carried the cup/glucometer with the strip inserted into the glucometer, which were not covered, down the hall with him. LPN #3 returned to the Resident's door, still holding the cup/glucometer, and stated that Resident #84 is not on isolation, however her roommate is on contact isolation. LPN #3 entered the room, crossed over to the B bed area, and found that Resident #84 was not there. LPN #3 placed the glucometer/cup back on the medication cart. LPN #3 did not destroy the strip or clean the glucometer. LPN #3 left the plastic cup/glucometer sitting on the cart and did not wash his hands or perform hand hygiene at any time prior, during, or after the procedures. He proceeded to the next resident. Resident #13 A review of the June 2019 MAR revealed Resident #13 received finger stick blood glucose testing twice daily, with sliding scale Novolog FlexPen Insulin. An observation on 6/24/19, at 3:55 PM, revealed LPN #3 entered Resident #13's room with the glucometer that was previously taken to Resident #84's isolation room. He did not perform hand hygiene, nor clean the glucometer. The glucometer still had the unused strip in the slot. LPN #3 entered Resident #13's room, sat the plastic cup holding the glucometer on the over-bed table, gloved, and obtained the resident's blood sugar (BS). LPN #3 put the contaminated glucometer back into the same plastic cup. LPN #3 picked up the plastic cup, still having his gloves on, walked out into the hall, and placed the cup/glucometer on the medication cart. LPN #3 removed his gloves, obtained the Micro-kill Bleach wipes, and wiped the glucometer for approximately nine (9) seconds, and then placed the glucometer back into the same contaminated plastic cup. LPN #3 opened the medication cart and obtained Resident #13's Novolog insulin FlexPen, laid it on top of the cart without a barrier, obtained and applied a needle from the cart, and laid the pen on a sheet of paper (census sheet) that was lying on the cart. LPN #3 picked up the insulin pen and entered the resident's room, laid the insulin pen on the over-bed table without a barrier, and gloved. LPN #3 did not wash or sanitize his hands. LPN #3 administered the insulin, then laid the FlexPen on the over-bed table, without a barrier, and removed his gloves. LPN #3 exited the room, laid the insulin pen on the medication cart without a barrier, opened the medication cart, and placed the insulin pen inside the medication cart, without wiping and/or sanitizing the FlexPen. LPN #3 did not perform hand hygiene prior, during, or after the procedure. He proceeded to administer oral medications to Resident #192, on 06/24/19, at 4:05 PM. During this medication administration, LPN #3 used a spoon to help get the Sucralfate pill out of a medication cup and placed it on the pill splitter. LPN #3 then used his un-gloved hands to help balance the pill into the splitter. He administered the medication to the resident. LPN #3 still had not washed or sanitized his hands between all four (4) of these rooms. LPN #3 Interview: During an interview on 06/24/19 at 4:45 PM, LPN #3 revealed his process during the blood glucose testing for Resident's #13, #20, and #84. He stated that he put the glucometer in a cup that was used as a barrier. Then, he checked the blood sugars. LPN #3 stated that when he came out of a room, he put the glucometer back into the same cup, then after he cleaned the glucometer, he again placed it in the same dirty cup. He stated he had always used the same cups over and over. He stated, When I come out of a room, I wash the glucometer for 30 seconds. But, I did not know to clean it 30 seconds until you told me to read the Micro-kill bleach wipes and then I saw it. I'm from Florida and we kept the glucometer covered for two (2) minutes. Now that I think about it, I probably should have put the cup in the garbage can after I used it, but I sat it back on the medication cart and I should have just thrown it away. He stated that he took the same plastic cup into two (2) different rooms. When asked about washing his hands, LPN #3 stated, I didn't wash my hands except me handling the bleach wipes when I cleaned the glucometer. You're right, I don't think I washed my hands in all of the rooms I went into, now that I think about it. When I came back to the cart I didn't wash or sanitize my hands. When asked about touching the pill with his bare hands, LPN #3 stated I didn't realize I touched the pill with my hands. I was using a spoon and maybe I inadvertently touched the pill with my hand and didn't realize it. I was so nervous. You're right. At that point I still had not washed my hands. When asked about the insulin pens, LPN #3 stated he did recall laying the pens on the cart without a barrier and without cleaning them. He stated that he was extremely nervous. He stated, It all was stupid of me. Yes, I do see for sure that not washing my hands and taking the plastic cup with the glucometer into more than one room, without cleaning it, is an infection control issue. I also know that placing the cleaned glucometer into the dirty cup is an infection control issue. I should have cleaned the glucometer for the 30 seconds, but again, I didn't know that until you told me to read the Micro-kill Bleach wipe container. Thank you for explaining it all to me. I could have done better, and I should have done better. I did receive training when I was hired on infection control and cleaning the glucometer. A review of facility document titled Day Five New Hire Orientation, dated 6/5/19, revealed LPN #3 signed that he had received training on infection control bloodborne pathogens and use of Glucose Monitors. Resident #84 An observation on 06/25/19 at 3:40 PM, revealed LPN #1 placed two (2) plastic cups on a tray, that was on top of the medication cart, with each cup containing a glucometer. LPN #1 took one (1) of the glucometers and laid it on a Kleenex on the medication cart. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from bottom drawer on medication cart. LPN #1 picked up the glucometer (glucometer #1) and cleaned the glucometer for approximately five (5) seconds (timed by watch), and then placed it back into the plastic cup. LPN #1 then took glucometer #2 out of the other cup and cleaned it with a Micro-kill wipe for approximately four (4) seconds and placed the glucometer back into the cup. LPN #1 removed her gloves and took the cup containing glucometer #1 to Resident #84's room. LPN #1 gloved, performed the finger stick for Resident #84, and placed the glucometer back into the cup. She removed gloves, and exited the room, all without washing or sanitizing her hands. LPN #1 gloved and retrieved a Micro-kill Bleach wipe from the medication cart and wiped the glucometer approximately seven (7) seconds (timed with watch) and then placed it into a clean cup on the medication cart. LPN #1 removed her gloves and proceeded to the next resident. LPN #1 did not perform hand hygiene at any time prior, during, or after the procedure. Resident #13 (second observation for resident) Observation on 06/25/19 at 3:49 PM, revealed LPN #1 took the plastic cup containing glucometer #2, entered Resident #13's room, gloved, and performed the finger stick. LPN #1 placed the glucometer back into the plastic cup, removed gloves, and exited the room. LPN #1 laid the tray with the cup/glucometer on the medication cart and then gloved. LPN #1 reached into the bottom drawer of the cart and obtained a Micro-kill Bleach wipe and cleaned the glucometer for approximately eight (8) seconds (timed by watch). LPN #1 placed the clean glucometer into a clean plastic cup. LPN #1 removed her gloves, placed the cup/glucometer #2 behind cup/glucometer #1, and obtained the Novolog FlexPen Insulin. LPN #1 administered the insulin to Resident #13, then placed the insulin FlexPen back into the medication cart drawer, without cleaning/sanitizing the pen. LPN #1 did not perform hand hygiene prior, during, or after the procedure. She proceeded to the next resident. Resident #89 (first attempt-procedure not performed) A review of the June 2019 MAR, revealed Resident #89 received finger stick glucose testing, with sliding scale Novolog FlexPen Solution injector twice daily. Observation on 06/25/19 at 3:55 PM, revealed LPN #1 obtained the plastic cup containing glucometer #1, (previously used on Resident #84) to perform the finger stick blood glucose test, but Resident #89 was not in the room. LPN #1 placed the cup/glucometer on top of the medication cart and covered with a Kleenex, stating she would leave it there until Resident #89 returned to her room. LPN #1 went to the medication room for another medication. LPN #1 returned and opened the medication box, and obtained a paper cut to her left finger. LPN #1's finger was bleeding and she wiped it with an alcohol wipe. She then placed a band-aid on her finger. LPN #1 still had not performed hand hygiene. Resident #20 (second observation for resident) Observation on 06/25/19 at 4:05 PM, revealed LPN #1 picked up the tray, which contained the cup/glucometer covered with a Kleenex, and entered Resident #20's room. LPN #3 gloved, performed the finger stick, removed her gloves, and exited the room without washing or sanitizing her hands. LPN #1 took Micro-kill Bleach wipes and cleaned glucometer #1 for approximately 15 seconds (timed with watch) then placed it into a clean plastic cup to dry. LPN #1 sat the cup/glucometer behind the plastic cup containing glucometer #2. LPN #1 stated that she forgot the reading of the resident's BS, so she picked up glucometer #1 with a Kleenex, reviewed the BS, then placed the glucometer back into the same cup. LPN #1 stated, I rotate the glucometers to allow one (1) to dry while I use the other one. I've never really timed how long I let it dry, all I know is that it's dry by the time I get ready to use it. LPN #1 failed to perform hand hygiene prior, during, and after the procedure, then continued to the next resident. Resident #89 (procedure performed) An observation on 06/25/19 at 4:20 PM, revealed LPN #1 obtained the cup/glucometer #2, entered Resident #89's room, gloved, and performed the finger stick. LPN #1 removed her gloves, and exited the room. LPN #1 went to the medication cart, gloved, and retrieved a Micro-kill Bleach wipe from the bottom drawer of the medication cart. LPN #1 cleaned glucometer #2 with Micro-kill Bleach wipes for approximately seven (7) seconds (timed with watch) and then placed glucometer #2 into a clean plastic cup. LPN #1 removed gloves and placed the cup/glucometer #2 behind glucometer #1. LPN #1 retrieved Resident #89's Novolog FlexPen from the medication cart and laid it on top of the cart without a barrier. LPN #1 obtained a needle from the med cart and applied it to the FlexPen. LPN #1 entered Resident #89's room, performed the injection, removed her gloves, and exited the room. LPN #1 did not perform hand hygiene prior, during, or after the procedures. LPN #1 interview: During an interview, in the presence of RN #4, on 06/25/19 at 4:35 PM, LPN #1 stated that she washed her hands prior to working the medication cart. She stated her process was to use a Kleenex or a paper towel for a barrier. She stated she used a glucometer that has been cleaned with the Micro-kill wipes and left to air dry. She stated, I wipe the glucometer I guess two (2) minutes, but that seems like a long time to me. I don't time it, I just clean it. I can say I thoroughly clean it and set it up-right to dry. She stated she had two (2) glucometers that she used, both cleaned with Micro-kill wipes, and she placed one in front of the other in plastic cups on top of the cart. She stated she used one glucometer, cleaned it, and returned it to the cart. She stated she donned gloves, used Micro-kill wipes, and cleaned the glucometer for an estimated two (2) minutes, put it up-right in a clean plastic cup, and then place it behind the second glucometer, which had already been cleaned. She stated she moved on to the next resident and used the second glucometer for the next resident. She stated she rotated the glucometers, letting them dry. LPN #1 stated that she cleaned each glucometer approximately two (2) minutes between residents with the Micro-kill Bleach wipes. She stated that she had been in-serviced yearly on infection control and more often for cleaning of the glucometer. She stated that it had been a while, but yes, she had seen policy and procedure on handwashing and infection control. When asked if she felt that she cleaned the glucometer for two (2) minutes like she previously stated, LPN #1 stated, No I don't feel like I cleaned it for 1-2 minutes; time passes. When asked if she washed her hands at any time while obtaining the finger stick glucose tests, LPN #1 stated, Oh man, I forgot to wash my hands. I do it but I'm just nervous. LPN #1 stated Yes I should do different. I want to do it correctly. I thought I was doing the correct time wiping it. I didn't time the cleaning of the glucometer. It's my issue, not the facility's issue. I'm the one that didn't do it correct. I take whole responsibility of self. When asked if she thought not cleaning the glucometer per the manufacturer recommendation was an infection control issue, she stated I do think it was an infection control issue. You have to make sure stuff gets killed. At this time, RN #4 stated, We learned in school that you could use hand sanitizer in-between residents if your hands aren't soiled. RN #4 stated that LPN #1 used hand sanitizer. LPN #1 reached into her pocket and pulled out Germ-x and said Yea, I used Germ-x during procedures. I keep Germ-x in my pocket. LPN #1 was not observed to use the hand sanitizer at any time during the observations, nor did she voice that she had used the sanitizer. LPN #1 was observed by the surveyor continuously throughout the process of performing the finger sticks of the four (4) residents, Resident #13, #20, #84, and #89, and did not observe any type of hand hygiene prior, during, or after the procedures between residents. A review of a facility document titled, Competency Check List, dated 5/20/19, revealed LPN #1 signed that she was checked off on handwashing and cleaning the glucometer according to manufacturer's guidelines. A facility document titled Glucometer Cleaning Skills Checklist dated 5/20/19, revealed LPN #1 was checked off to disinfect the glucometer by cleaning the meter surface with Medline Micro-kill Bleach Germicidal wipes by the following instructions: Wipe all external areas of the meter including front and back surfaces until visibly clean. Avoid wetting the meter strip port. Allow the surface of the meter to remain wet at least 30 seconds at room temperature. A review of a facility document titled, Day Four New Hire Orientation, dated 6/19/18, revealed LPN #1 was in-serviced on Handwashing, Bloodborne Pathogens, use of FlexPen, infection control, and use of Glucose Monitors. Review of a facility document titled, In-Service Training Record, dated 2/13/19, revealed LPN #1 was in-serviced on Cleaning Blood Glucose (CBG's) cleaning the machine storage and other usage. Resident #52 Review of the June 2019 MAR, revealed Resident #52 received finger stick glucose checks daily, scheduled at 4:30 PM. On 6/25/19 at 3:40 PM, after LPN #2 had completed the narcotic medication count, she prepared to perform a finger stick procedure. LPN #2 cleaned a silver tray with a Micro Kill germicidal bleach wipe and cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds. After cleaning the glucometer, she placed the glucometer on the silver tray and allowed it to air dry. She entered Resident #52's room, applied clean gloves, cleaned the resident's left index finger with an alcohol prep pad and pricked the resident's finger with the lancet. She cleaned the resident's left index finger again with an alcohol prep pad. She placed the soiled lancet in a plastic cup and the alcohol prep pad in another plastic cup. LPN #2 returned to the medication cart, where she discarded the lancet and alcohol prep pad. She cleaned the glucometer with a Micro Kill germicidal wipe for approximately 10 seconds and allowed it to air dry. LPN #2 sat the glucometer on the silver tray. LPN #2 did not wash her hands or use any Alcohol Based Hand Gel (ABHG) after counting the narcotic medications, prior to entering the resident's room, before the procedure, during the procedure, after the procedure, nor after leaving the resident's room. She proceeded to the next resident. Resident #77 Resident #77's June 2019 MAR revealed he received finger stick glucose testing twice daily. On 6/25/19 at 3:50 PM, observation revealed LPN #2 entered Resident #77's room, retrieved some paper towels, and placed the silver tray with the glucometer on the resident's nightstand on the towels. She applied clean gloves, cleaned the resident's left middle finger with an alcohol prep pad, pricked his left middle finger with the lancet, and performed the glucose testing. She placed the soiled lancet in a plastic cup, and the soiled alcohol prep pad in a plastic cup. She walked back to the medication cart and disposed of the soiled items. She then cleaned the glucometer with a Micro Kill germicidal wipe for approximately eight (8) seconds, and placed it in the medication cart's uppermost top right drawer in an empty alcohol prep pad box. She cleaned the silver tray with the Micro Kill germicidal wipe. LPN #2 did not wash her hands or use hand sanitizer prior to entering the resident's room, before the procedure, during the procedure, nor after the procedure. On 6/25/19 at 3:55 PM, interview with LPN #2 revealed her overview of the steps she had taken while performing the fingersticks on both Resident #52 and Resident #77. She stated she had gotten all of her supplies out and wiped everything down. She stated she brought her items into the room, put a barrier down, and wiped the resident's finger with alcohol. She stated she did the fingerstick, wiped the resident's finger again, and wiped everything before she put it in the cart. She stated she should clean the glucometer with the germicidal wipe for one (1) minute she guessed. She stated she would have to take a timer out and physically set it to know. She stated I don't know what to tell you anymore. She stated she knows about hand washing, but she had worn gloves. She stated she should wash her hands between residents and/or when her hands are soiled. She stated, Wash your hands before care, well, I mean if you wear gloves to do an accucheck, I don't understand, I really don't. An interview on 06/25/19 at 6:09 PM, with RN #2, Infection Control Nurse/Risk Management Nurse, revealed, If there is a pathogen in the blood, by not cleaning the glucometer, you could pass it on. If there is something that could be considered an infectious process, then you could pass it on. RN #2 stated that nurses are taught to clean the glucometer for 30 seconds, with a five (5) minute dry time. She stated there were two (2) glucometers on the cart so one can be cleaned and let dry, while the other is used. She stated, I'm not going to say that it couldn't be a problem not cleaning the glucometer between residents, because it could very well be. I'd be crazy to say it wouldn't. She stated that there had just been an in-service on hand-washing, with the Certified Nursing Assistants (CNA's), but not the nurses; they would be next. She stated that she touched on infection control every six (6) months at a minimum, but if there was an issue, she did the in-service more often. She stated, As a matter of fact, I just did an in-service the other day on infection control. She stated that staff was taught to wash their hands when gloves are removed, because there could be pin-holes in the gloves. She stated that having Germ-x in a pocket is an infection control issue. She stated, You don't put anything in your pockets. An interview on 06/26/19 at 3:25 PM-3:30 PM, with RN #3, Staff Development Nurse, revealed, Not cleaning the glucometer could cause an infection to go from person to person. If one (1) person has something, then by not cleaning the glucometer, it could spread. Yes, I see it as an infection control issue. I see it as an opportunity for education because we know better. She stated that hand-washing was an issue for the same reasons. She stated, Spreading germs from one to another is an issue. Safe hand washing is best practice. During an interview on 06/25/19 at 6:20 PM, the Director of Nursing (DON) stated, Yes ma'am, not cleaning the glucometer is an infection control issue. There is the potential for transmitting infections or germs. It could cause cross contamination. She stated the recommended time of cleaning the glucometer is 30 seconds, with a dry time of three (3)-five (5) minutes. The DON stated that was taught in in-services many, many times. She stated, It is an infection control issue for a nurse not to wash her hands between caring for residents, because it could spread infection. She stated if staff are not cleaning the glucometer for the allotted time, to make sure there is no blood or body fluids, that could cause cross contamination. [TRUNCATED]