Benefis Senior Services - Grandview

Based on observation, interview, and record review, the facility failed to ensure staff member C followed proper infection control practices while performing blood glucose monitoring with a portable handheld glucometer between residents for 2 (#s 1 and 3); and failed to perform hand hygiene before donning clean gloves prior to blood glucose monitoring for 1 (#3) of 2 sampled residents for blood glucose monitoring.

These deficient practices increased the risk of transmission of bloodborne pathogens between residents in the facility.

Findings include:During an observation on 8/12/25 at 7:37 a.m., staff member C retrieved a portable handheld glucometer from a locked room by the nurses' offices.

The glucometer was seated on a charger on the counter, next to a case which contained blood glucose monitoring supplies.

During an observation on 8/12/25 at 7:38 a.m., staff member C entered resident #3's room and donned gloves to perform her blood glucose monitoring.

Staff member C did not sanitize her hands before donning the gloves.

Staff member C performed the blood glucose monitoring for resident #3, and then laid the handheld glucometer on a supply cart in the bathroom, doffed her gloves, and washed her hands.

Staff member C then returned to her medication cart, prepared to perform another resident's glucose monitoring.

She laid the handheld glucometer onto the top surface of the cart.

Staff member C did not clean or sanitize the portable handheld glucometer.During an observation on 8/12/25 at 7:45 a.m. staff member C entered resident #1's room and performed her blood glucose monitoring.

Staff member C returned the portable handheld glucometer to the locked supply room and placed it onto the charger, then left the room.

Staff member C did not clean or sanitize the portable handheld glucometer before, in between residents, or after the use of the device.

During an interview on 8/12/25 at 8:56 a.m., staff member C stated the portable handheld glucometer was to be cleaned with purple top Sani wipes, in between each resident use and after use, before returning the device to the charger.

Staff member C stated she did not clean the handheld glucometer after each use, between each resident, and after use before it was placed onto the charger.

During an interview on 8/12/25 at 8:56 a.m., staff member C stated hands were to be washed or sanitized before donning gloves and after doffing gloves.

Staff member C stated she did not perform hand hygiene before donning gloves to perform resident #3's blood glucose monitoring.

During an interview on 8/12/25 at 9:56 a.m., staff member B stated the portable handheld glucometer should be sanitized between each resident's use and after the last resident's monitoring before replacing the glucometer onto the charger.

Staff member B stated hand hygiene should be performed before donning gloves and after the removal of gloves.

Review of the facility's policy titled, Point of Care Testing Safety Manual, last revised 2/2024, showed:- . 4.

Safe Handling of Portable Handheld Testing Devices- In order to prevent transmission of infection, portable handheld testing devices must be disinfected after each patient use.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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