Based on policy review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when multi-use blood glucose meters were not cleaned and disinfected to prevent cross-contamination of bloodborne pathogens for 5 of 5 sampled residents (Resident #65, #74, #88, #277, and #376) reviewed for blood glucose monitoring, 6 of 9 nurses (Licensed Practical Nurse (LPN) #1, #2, #4, #5, #6 and Unit Manager #2) failed to perform hand hygiene, failed to place barriers when performing accucheck monitoring, failed to dispose of contaminated sharps and glucose strips in the sharp container, and administered contaminated pills to 8 of 11 sampled residents (Resident #65, #74, #82, #88, #226, #227, #232, and #376) observed during medication administration. The facility's failure to educate staff on the proper use of the glucometer placed residents at risk and resulted in Immediate Jeopardy. The failure occurred during a COVID-19 pandemic. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. The Executive Director and the Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/24/2022 at 4:17 PM, in the Conference Room. The facility was cited Immediate Jeopardy at F-880. The IJ existed from 3/23/2022 through 3/24/2022. An acceptable Removal Plan, which removed the immediacy of the jeopardy, was received on 3/25/2022 at 10:26 AM, and was validated onsite by the surveyors on 3/25/2022 through review of staff education, interviews with staff on all shifts, and review of the audits conducted. The findings include: Review of the facility's policy titled, Cleaning and Disinfection of Equipment, revised 3/2020, revealed .Resident-care equipment can be a source of indirect transmission of pathogens. Reusable resident-care equipment will be cleaned and disinfected in accordance with current CDC [Center for Disease Control] recommendations in order to break the chain of infection .Blood Glucose Meter .Clean and disinfect blood glucose meters between each resident test to avoid cross-contamination issues .Use a bleach wipe to clean the inside and the outside of the glucometer .Make sure the meter is completely dry before testing a resident's glucose level .Medication carts should be cleaned using bleach wipes .This should be done at change of shift .Hand hygiene shall be performed prior to and after using the equipment .Each user is responsible for routine cleaning and disinfection . Review of the facility's policy titled, Administrating Medications, revised 2/6/2015, revealed .The Director of Nursing Services is responsible for the supervision and direction of all personnel with medication administration duties and functions .Established facility infection control procedures must be followed during the administration of medications ( .handwashing/hand hygiene, antiseptic technique, gloves .) . Review of the facility's policy titled, Hand Hygiene/Hand-washing, revised 1/2019, revealed .Hand-washing/hand hygiene is considered the most important single procedure for preventing healthcare-associated infections .Hand-washing with antimicrobial soap and water is indicated and must be performed under the following conditions .When hands are visibly dirty or contaminated .When hands are visibly soiled .After handling items potentially contaminated .Wash [hands] well under running water for a minimum of 15-20 seconds, using a rotary motion and friction .Turn off faucets with a clean, dry paper towel .Waterless Hand-washing Products .Before direct contact with residents .Before performing any non-surgical invasive procedure .Before preparing or handling medications .After contact with resident's intact skin .After handling .contaminated equipment . Review of the SCOPE OF CONSULTATION SERVICES, revealed .Consultant Pharmacist shall assist the Facility in assessing the performance of the nursing staff in medication administration . Review of the STAFF DEVELOPMENT/EDUCATOR, job description revealed .Identifies and prioritize the facility's educational needs through the completion of an educational needs assessment .Collaborates with the department manager for developing competencies required for meeting resident's needs .Follows established infection control policies and procedures . Observation in the resident's room on 3/22/2022 at 8:28 AM, revealed LPN #6 entered Resident #232's room, placed the medication cup on the resident's nightstand, and failed to clean the nightstand or place a barrier on the nightstand. LPN #6 opened the medication packets, dropped one of the pills on the plastic wrap next to the medication cup, picked the pill up with her bare hand, placed it back in the medication cup, and administered the medication. LPN #6 donned her gloves, administered a nasal spray, removed her gloves, exited the resident's room, and failed to perform hand hygiene. During an interview on 3/22/2022 at 8:36 AM, LPN #6 confirmed she should not have given the Vitamin D pill that was dropped on the resident's nightstand. Observation in the resident's room on 3/22/2022 at 9:14 AM, revealed LPN #4 donned her gloves to crush Resident #82's medication, placed the medications on a Styrofoam tray, entered the resident room, went into the resident's bathroom, filled the plastic cup with water, removed her gloves, donned a new pair of gloves, and failed to wash her hands after removing the gloves. LPN #4 administered the medications through the Percutaneous Endoscopic Gastrostomy (PEG) tube (a tube to administer medications, water, and nutrition into the stomach). LPN #4 removed her gloves, donned new gloves, failed to wash her hands after the removal of the gloves, and helped reposition Resident #82 in the bed. Random observation of the 100 Hall Medication Cart on 3/22/2022 at 12:23 PM, revealed the medication cart had a dried white powdery substance and a clear liquid splattered on top of the cart. Observation in the resident's room on 3/23/2022 at 8:52 AM, revealed LPN #4 removed the blood glucose meter from the medication cart, donned her gloves, cleaned the top of the blood glucose meter with an alcohol pad, placed the blood glucose meter on a Styrofoam tray with the supplies, removed her gloves, and failed to perform hand hygiene. LPN #4 entered Resident #74's room, placed the Styrofoam tray on the dresser, donned her gloves, and checked the resident's blood sugar. LPN #4 removed her gloves, entered the resident's bathroom, and washed her hands for 5 seconds. LPN #4 exited the resident's room and placed the blood glucose meter strip and lancet that was contaminated with blood in the trash can with the Styrofoam tray. LPN #4 donned her gloves, cleaned the top of the blood glucose meter with an alcohol pad, and placed the blood glucose meter into the medication cart. During an interview on 3/24/2022 at 7:50 AM, LPN #4 was asked what the process was for checking a resident's blood sugar. LPN #4 stated .wash your hands first .clean the meter before you use it .I asked someone here do I use alcohol wipe .they said to use that [alcohol wipes] .I should have used the bleach cloths . LPN #4 confirmed the lancet and strips should be placed in the sharp container. LPN #4 confirmed she should wash her hands for 15-20 seconds and hands should be washed when gloves were removed. Observation in the resident's room on 3/23/2022 at 9:37 AM, revealed LPN #4 entered Resident #82's bathroom, washed her hands for 5 seconds, donned her gloves, checked the resident's vital signs, and started his nebulizer treatment. LPN #4 completed the resident's nebulizer treatment, removed the face mask, entered the bathroom, washed and dried the equipment, removed her gloves, washed her hands for 6 seconds, exited the bathroom, donned new gloves, and checked the resident's vital signs again. LPN #4 removed her gloves and washed her hands for 5 seconds. Observation in the resident's room on 3/23/2022 at 10:13 AM, revealed LPN #1 entered Resident #227's room, placed the medications on the table and failed to clean the table or place a barrier on the table. LPN #1 went into the bathroom, washed her hands for 10 seconds, donned her gloves, cleaned and dried the back of Resident #227's neck, applied a medicated ointment, removed her gloves, and exited the room. LPN #1 collected her supplies, donned her gloves, assisted Resident #227 to the bathroom in her wheelchair, pulled down the resident's pants, cleaned and dried the resident's hip, and applied the medicated patch. LPN #1 failed to change her gloves and wash her hands prior to cleaning the resident's hip and applying a medication patch. LPN #1 assisted the resident back to her room, removed her gloves, and washed her hands for 9 seconds. During an interview on 3/24/2022 at 1:14 PM, LPN #1 confirmed that she should have washed her hands or used hand sanitizer when she removed her gloves. LPN #1 confirmed she should have removed her gloves when she touched Resident #227's wheelchair and should have washed her hands before applying the medication patch. Observation in the resident's room on 3/23/2022 at 10:55 AM, revealed LPN #4 removed the blood glucose meter from a plastic bag in the medication cart and placed it on a Styrofoam tray. LPN #4 donned her gloves, collected the supplies, cleaned the top of the blood glucose meter with an alcohol pad, placed the blood glucose meter on the Styrofoam tray, and removed her gloves. LPN #4 entered Resident #88's bathroom and washed her hands for 7 seconds. LPN #4 placed the Styrofoam tray on the over bed table, donned her gloves, removed her gloves, and exited Resident #88's room to obtain a container of glucose strips. LPN #4 entered the resident's bathroom, washed her hands for 5 seconds and exited the room to obtain a box of gloves. LPN #4 donned her gloves, checked the residents blood sugar, placed the lancet and strip back on the Styrofoam tray, removed her gloves and placed them on the Styrofoam tray, washed her hands for 4 seconds, exited the room with the Styrofoam tray and placed the entire Styrofoam tray with the lancet, strip, and gloves into the trash can on the medication cart. LPN #4 failed to place the sharps in the sharp container. LPN #4 placed the blood glucose meter back into the plastic bag and placed it in the top drawer of the medication cart. LPN #4 failed to disinfect the blood glucose meter after use and did not perform hand hygiene. Observation in the resident's room on 3/23/2022 at 11:13 AM, revealed LPN#1 assembled the supplies, donned her gloves, cleaned the blood glucose meter with a bleach wipe, and placed the blood glucose meter on top of some papers that were on top of the medication cart, contaminating the blood glucose meter that had just been cleaned. LPN #1 entered Resident #277's room with the blood glucose meter in her bare hands and the supplies in a plastic cup. LPN#1 placed the blood glucose meter on top of a book on the resident's nightstand. LPN #1 failed to clean or place a barrier on the medication cart or the resident's nightstand. During an interview on 3/24/2022 at 1:14 PM, LPN #1 confirmed she should have used a barrier before placing the blood glucose meter on the medication cart and on the book in the resident's room. Observation at the 300 Hall Medication Cart on 3/23/2022 at 12:16 PM, revealed Unit Manager #2 assembled her supplies and medications and placed them on a barrier on the medication cart. Unit Manager #2 walked to the nursing station to obtain a container of bleach wipes. Unit Manager #2 walked back to the medication cart with the bleach wipes and with her bare hands cleaned the medication cart. Unit Manager #2 donned her gloves and dried the medication cart. Unit Manager #2 removed her gloves and failed to perform hand hygiene. Unit Manager #2 entered Resident #226's bathroom, washed her hands for 13 seconds, exited the resident's room to obtain a towel from the cart in the hallway, reentered the resident's room, entered the bathroom and washed her hands for 6 seconds. Unit Manager #2 placed the medications under the blue towel that was on the resident's bed. Unit Manager #2 donned her gloves, cleaned the over bed table, removed her gloves, entered the bathroom, washed her hands for 8 seconds, and using the same wet paper towel turned the faucet off. Unit Manager #2 donned gloves, positioned the resident in her wheelchair with her gloved hands, failed to remove her gloves or perform hand hygiene and assessed the IV (intravenous) site with the same gloved hands. Unit Manager #2 mixed the IV medication, removed her gloves, donned a new pair of gloves, failed to perform hand hygiene, spiked the IV bag, primed the tubing by placing the end of the tubing on the resident's bed, and failed to perform hand hygiene after removal of the gloves and prior to donning a clean pair of gloves. Unit Manager #2 removed her gloves and went to the medication cart to obtain the 2 normal saline flush syringes to flush the IV line. Unit Manager #2 removed her gloves, donned a clean pair of gloves, cleaned the port, flushed the IV line, and started the infusion of the IV medication. Unit Manager #2 entered the bathroom, washed her hands for 6 seconds, and using the same wet paper towel, turned the faucet off. Observation in the resident's room on 3/23/2022 at 1:22 PM, Unit Manager #2 entered Resident #226's room, washed her hands for 13 seconds, and turned the faucet off with the same wet paper towel. Unit Manager #2 donned her gloves, disconnected the IV line, cleaned the site, flushed the IV with normal saline, disposed of the IV bag in the trash, removed the trash bag, exited the room, walked to the biohazard room, and placed the trash in a red bag. Unit Manager #2 removed her gloves and washed her hands for 7 seconds. During an interview on 3/24/2022 at 8:11 AM, Unit Manager #2 confirmed she should wash hands for at least 20 seconds. Unit Manager #2 confirmed she should not have placed the resident's medication on the resident's bed. Observation in the resident's room on 3/23/2022 at 5:06 PM, revealed LPN #5 collected her supplies, removed the blood glucose meter from the medication cart, placed the supplies and blood glucose meter into her front pocket. LPN #5 entered Resident #376's room, administered the oral medications, removed the blood glucose meter and supplies from her front scrub pocket, donned her gloves, checked the resident's blood sugar, removed her gloves, folded the lancet and strip into her gloves and placed the contaminated strip and lancet in the resident's trash can. LPN #5 exited the resident's room and placed the blood glucose meter and bottle of strips back in the top drawer of the medication cart. LPN #5 failed to disinfect the blood glucose meter before or after use and failed to perform hand hygiene. LPN #5 failed to place the contaminated lancet and strip into the sharp container. During an interview on 3/24/2022 at 12:54 PM, LPN #5 confirmed she should not have placed the blood glucose meter into her front pocket and should disinfect the blood glucose meter before and after use. LPN #5 stated .clean the meter with an alcohol pad before .that is what I was told .after you clean with a bleach wipe .I was supposed to put it on a tissue .I was out of tissue at the time so I had to improvise . LPN #5 confirmed she should have washed her hands or used hand sanitizer before and after medication administration and the blood glucose check, and also when she removed her gloves. LPN #5 confirmed the lancet and glucose strip should be disposed in the sharps container. Observation in the resident's room on 3/24/2022 at 7:20 AM, revealed LPN #2 removed the blood glucose meter from the top drawer of the medication cart, removed the blood glucose meter from the plastic bag and placed it on top of the medication cart, collected the supplies, and placed the supplies in the front pocket of her uniform. LPN #2 carried the blood glucose meter with her bare hands, entered Resident #65's room and placed the blood glucose meter on the resident's over bed table without a barrier. LPN #2 donned her gloves, removed the supplies from the front pocket of her uniform, and checked the resident's blood sugar. LPN #2 placed the blood glucose meter into the front pocket of her uniform with the supplies, removed her gloves, folding the strip and lancet inside of her gloves. LPN #2 went back to the medication cart and disposed of the gloves in the sharp container. LPN #2 removed the supplies and the blood glucose meter from her front pocket, wiped the blood glucose meter with a bleach wipe and placed it in the plastic bag on the medication cart. LPN #2 failed to allow a 4-minute contact time for the blood glucose meter to dry before placing it in the plastic bag in the medication cart. During an interview on 3/24/2022 at 7:34 AM, LPN #2 stated the blood glucose meter should be disinfected after use. LPN #2 confirmed after cleaning the blood glucose meter, she did not allow a contact time of 4 minutes for the meter to dry before placing the blood glucose meter back in the plastic bag. LPN #2 confirmed she should not have put the blood glucose meter and supplies in the front pocket of her scrubs. LPN #2 confirmed she should have a barrier on the table before placing the blood glucose meter and supplies on the table. LPN #2 confirmed she should have used hand sanitizer or washed her hands when she removed her gloves. During an interview on 3/24/2022 at 3:58 PM, the DON confirmed the staff should wear gloves, should disinfect the entire blood glucose meter with bleach wipes, and allow the blood glucose meter to dry. The DON confirmed nursing staff should not disinfect blood glucose meters with alcohol wipes. The DON confirmed staff should clean their medication cart and place a barrier during preparation of the medications or medication administration. The DON confirmed nursing staff should not place the blood glucose meter and supplies in their scrub pocket. The DON confirmed Nursing Staff should wash their hands for 15-20 seconds or use hand sanitizer when they remove their gloves or when touching contaminated items in the residents' rooms. The DON confirmed nursing staff should not use the same wet towel they used to dry their hands to turn the faucet off. The DON confirmed when a pill is dropped on a contaminated surface, the nursing staff should not administer the medication. The DON confirmed staff should place the lancets and strips into the sharp container. The DON confirmed she is ultimately responsible to ensure that the nursing staff members are trained and monitored. During an interview on 3/25/2022 at 8:09 AM, the Medical Director confirmed the blood glucose meters should be cleaned with bleach wipes and the nursing staff should not place the blood glucose meters and supplies in the pocket of their uniform. The Medical Director confirmed nursing staff should wash their hands when they remove their gloves. The Medical Director confirmed nursing staff should place contaminated sharps and glucose strips in the sharp container. During a telephone interview on 3/25/2022 at 6:51 PM, the Pharmacy Customer Reaction Specialist stated, .I do a medication pass with the nurses .whatever they mess up on .I do an in-service .I get with Unit Manager .get the policy out .go over everything found in the medication pass with the nurse and unit manager .I ask for the facility policy .for example of a medication pass .I try to look at the beginning of every shift .make sure nurses verify orders .gather supplies .I have a check sheet as well .how they enter the residents rooms .wash hands before putting on their gloves .when staff remove gloves .wash their hands .if they don't wash their hands long enough .I will intervene .I will remind them to sing the song while they are washing their hands . The Pharmacy Customer Reaction Specialist confirmed nurses should disinfect the blood glucose meter with the bleach wipes, allowing 4 minutes contact time before and after use, and have a barrier or a Styrofoam tray. The Pharmacy Customer Reaction Specialist confirmed the nurses should not use alcohol swabs to disinfect the blood glucose meter. The surveyors verified the Removal Plan by: 1. The Administrator and DON reviewed the Facility's policy regarding the proper cleaning and disinfection of all blood glucose meters and determined the Facility's policy was consistent with current infection control standards. The surveyors reviewed the policy and interviewed the DON. 2. The DON or Designee will ensure all blood glucose meters are immediately cleaned and disinfected. Blood glucose meters will be cleaned and disinfected per manufacturer's instructions. The surveyors interviewed nursing staff on all shifts. 3. The DON or Designee will ensure all licensed nursing staff have a documented 1 on 1 re-in-service on proper cleaning and disinfection of all blood glucose meters according to facility policy. This re-in-service will include return demonstration to verify compliance with the policy. This re-in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records and interviewed nursing staff on all shifts. 4. The DON or Designee will ensure all licensed nursing staff have a 1 on 1 re-in-service on handwashing. This re-in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records and interviewed nursing staff on all shifts. 5. The DON or Designee will ensure all licensed nursing staff have a 1 on 1 in-service on the disposal of sharps according to the facility policy. This in-service training will begin on 3/24/2022 and any licensed nursing staff not working on 3/24/2022 will be re-in-serviced prior to returning to work. The surveyors reviewed the in-service and return demonstration records interviewed nursing staff on all shifts. 6. For 14 days the DON or Designee will conduct unscheduled audits of handwashing, sharps disposal and proper blood glucose meter cleaning and sanitation to ensure compliance with facility policies is maintained and in-service training is understood by all staff. During the initial 14 days, the DON or Designee will conduct the unscheduled audits by making 4 observations per day of licensed nursing staff to ensure handwashing, sharps disposal, and cleaning and disinfection of blood glucose meters are in accordance with facility policies. Results of these audits will be documented. Staff will be randomly selected to ensure multiple staff are observed demonstrating these infection control skills. Any licensed nursing staff not demonstrating proper technique or failing to follow facility policy will be immediately removed from resident care and given additional in-service training. The surveyors interviewed the DON and reviewed the audit forms. 7. After 14 days, if facility staff demonstrate continued compliance, the observation audit schedule will be adjusted to 4 observations per week, The audits will be conducted weekly for 1 month, then monthly for the next 2 months. Any negative findings will be corrected immediately and reported to the Quality Assurance Committee for review and appropriate action will be taken. The surveyors interviewed management staff. The facility's noncompliance at F-880 continues at a scope and severity of E for monitoring the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction.