Every finding on record at Baton Rouge General Medical Center, SNF

Based on interviews and record review, the facility failed to accurately maintain documented records for 1 (#26) of 12 sampled residents. The facility failed to accurately document Resident #26's code status into the electronic health record. Findings: Review of Resident #26's Face Sheet revealed the resident was admitted to the facility on [DATE] with a diagnosis of polyneuropathy. Review of Resident #26's current Physician's Orders revealed the following, in part:[DATE] Full Code - Code Status - Entered by S2MD On [DATE] at 12:56 p.m., an interview was conducted with Resident #26. Resident #26 stated in the event of an emergency she does not want CPR (Cardio Pulmonary Resuscitation) performed. Resident #26 stated she did not want to be resuscitated. On [DATE] at 12:10 p.m., an interview was conducted with S2DON. S2DON confirmed Resident #26 wanted to be a Do Not Resuscitate (DNR). S2DON reviewed Resident #26's electronic medical record and confirmed Resident #26's code status was ordered as a Full Code on [DATE]. S2DON confirmed there was a discrepancy between Resident #26's code status and electronic medical record. On [DATE] at 3:16 p.m., an interview was conducted with S2MD. S2MD confirmed he had spoken with Resident #26 and the entry of Resident #26's code status as a Full Code was an oversight on his part. On [DATE] at 12:13 p.m., an interview was conducted with S1ADM. S1ADM confirmed Resident #26 wanted a code status of DNR. S1ADM confirmed Resident #26's electronic medical record contained an order for Resident #26 to be a Full Code. S1ADM confirmed there was a discrepancy in Resident #26's code status and the electronic medical record.

Based on observation, record reviews, and interviews, the provider failed to develop and implement a Comprehensive Person-Centered Care Plan to meet the needs of 4 (#1, #170, and #171, and #218) of 19 total sampled residents. The facility failed to: 1. Ensure Residents #1, #170, #171 were care planned for anticoagulant medication; 2. Ensure Resident #1 was care planned for antidepressant medication; and 3. Ensure Resident #218 was care planned for indwelling foley catheter. Findings: 1. Resident #1 Review of Resident #1's Clinical Record revealed an admitted [DATE] with diagnoses, which included Major Depressive Disorder, Anxiety Disorder, Angina Pectoris, and Hypertension. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 received Lovenox 30mg/0.3 mL on 03/14/2025 through 03/19/2025. Review of Resident #1's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. Resident #170 Review of Resident #170's Clinical Record revealed an admitted [DATE], with diagnoses, which included Right Leg Pain, Unspecified Fall, and Back Pain. Review of Resident #170's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 40 mg/0.4 mL subcutaneously once daily. Review of Resident #170's March 2025 Medication Administration Record revealed Resident #170 had received Lovenox 40mg/0.4 mL on 03/04/2025 through 03/19/2025. Review of Resident #170's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. Resident #171 Review of Resident #171's Clinical Record revealed an admitted [DATE], with diagnoses which included Diagnostic Heart Failure, Chronic Kidney Disease, and Presence of Artificial Hip Joint Bilaterally. Review of Resident #171's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #171's March 2025 Medication Administration Record revealed Resident #171 had received Lovenox 30mg/0.3mL on 03/04/2025 through 03/19/2025. Review of Resident #171's current Comprehensive Plan of Care revealed no developed care plan or interventions for anticoagulant medication. 2. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lexapro 20 mg by mouth daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 had received Lexapro 20 mg on 03/14/2025 through 03/19/2025. Review of Resident #1's current Comprehensive Plan of Care revealed no developed care plan or interventions for antidepressant medication. 3. Review of Resident #218's Clinical Record revealed an admitted [DATE] with diagnoses, which included Chronic Kidney Disease and Retention of Urine. Review of Resident #218's active Physician Orders failed to reveal orders for indwelling foley catheter. Review of Resident #218's current Comprehensive Plan of Care revealed no developed care plan or interventions for indwelling foley catheter. Review of Resident #218's Physician's Progress Notes revealed, in part, the following: On 03/14/205, Chief Complaint/Clinical Background Resident #218 developed urinary retention and acute cystitis, and had a Foley catheter placed by Urology. Recent Acute Urinary Retention, complicated Cystitis without Hematuria: Resident #218 developed Urinary Retention after her fracture, prior to hospitalization and had foley catheter placed by Urology. Foley catheter to remain in place follow-up with Urology. On 03/18/2025, Plan Acute Urinary Tract Infection while completed antibiotic course. Asymptomatic. Foley placed. On 03/17/2025 at 9:40 a.m., an observation was made of Resident #218. Resident #218 was observed having an indwelling foley catheter. On 03/18/2025 at 10:41 a.m., an observation was made of Resident #218. Resident #218 was observed having an indwelling foley catheter. On 03/18/2025 at 1:32 p.m., an interview was conducted with S2DON. S2DON stated as a resident was admitted the Admit registered nurse would initiate the care plan from admitting diagnoses and problems. She stated all floor nurses were responsible for care plans. S2DON stated care plans were reviewed every shift by the floor nurse and a registered nurse reviewed a report daily to ensure the care plans were reviewed. S2DON further stated there was no one specifically going into the care plans to ensure the nurses' intervention were accurate. S2DON stated as floor nurses identified any problems or concerns they were expected to add the problem and interventions to the care plan when they were reviewing the resident's care plan every shift. S2DON confirmed a resident should be properly care planned with interventions for anticoagulants, antidepressants, and indwelling foley catheters. S2DON reviewed Residents #1, #170, and #171's current Comprehensive Plan of Care, and confirmed residents were care planned for anticoagulant medications. S2DON further confirmed Resident #1 was not care planned for antidepressant medication. S2DON reviewed Residents #218's current Comprehensive Plan of Care, and confirmed she was not properly care planned for indwelling foley catheter, and should have been. 48912

48912 Based on record reviews and interviews, the facility failed to ensure adequate monitoring for side effects with the use of psychotropic and anticoagulant medication was completed for 3 (#1, #170, and #171) of 5 (#1, #168, #169, #170, and #171) residents reviewed for unnecessary medications. The facility failed to ensure: 1. Resident #1 was monitored for side effects of an antidepressant medication; and 2. Residents #1, #170, and #171 were monitored for side effects of anticoagulant medications. This deficient practice had the potential to affect any of the 19 residents residing on the Skilled Nursing Facility unit. Findings: 1. Review of Resident #1's Clinical Record revealed an admitted [DATE], with diagnoses which included Major Depressive Disorder, Anxiety Disorder, Angina Pectoris, and Hypertension. Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lexapro 20 mg by mouth daily. Review of Resident #1's March 2025 Medication Administration Record (MAR) revealed Resident #1 had received the medication on 03/14/2025 through 03/19/2025. There was no documentation of monitoring for antidepressant medication side effects for Resident #1 to review. 2. Resident #1 Review of Resident #1's active Physician Orders revealed, in part, an order dated 03/13/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #1's March 2025 Medication Administration Record revealed Resident #1 had received the medication on 03/14/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #1 to review. Resident #170 Review of Resident #170's Clinical Record revealed an admitted [DATE], with diagnoses which included Right Leg Pain, Unspecified Fall, and Back Pain. Review of Resident #170's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 40 mg/0.4 mL subcutaneously once daily. Review of Resident #170's March 2025 Medication Administration Record revealed Resident #170 had received the medication on 03/04/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #170 to review. Resident #171 Review of Resident #171's Clinical Record revealed an admitted [DATE], with diagnoses which included Diagnostic Heart Failure, Chronic Kidney Disease, and Presence of Artificial Hip Joint Bilaterally. Review of Resident #171's active Physician Orders revealed, in part, an order dated 03/04/2025 for Lovenox 30 mg/0.3 mL subcutaneously once daily. Review of Resident #171's March 2025 Medication Administration Record revealed Resident #171 had received the medication on 03/04/2025 through 03/19/2025. There was no documentation of monitoring for anticoagulant medication's side effects for Resident #171 to review. On 03/18/2025 at 10:43 a.m., an interview was conducted with S6LPN. She stated she was the nurse for Residents #1 and #170. S6LPN reviewed Resident #1's MAR, and confirmed Resident #1 was currently on and Lexapro 20mg and Lovenox 30mg/0.3 mL. S6LPN reviewed Resident #170's MAR, and she confirmed she was currently on Lovenox 40 mg/0.4 mL. S6LPN stated the electronic software system did not have a place to document side effects for antidepressants nor anticoagulants. On 03/18/2025 at 11:00 a.m., an interview was conducted with S7LPN. She stated she was the nurse for Resident #171. S7LPN reviewed Resident #171's MAR, and confirmed Resident #171 was on Lovenox 30 mg/0.3mL. S7LPN confirmed Lovenox was a high risk medication for bleeding, and there was no place to document monitoring in the electronic software system. On 03/18/2025 at 1:32 p.m., an interview was conducted with S2DON. She stated she expected staff to document the monitoring for side effects of antipsychotic medications including antidepressants and of anticoagulant medications. S2DON stated there should be a pop-up box, which appeared when a nurse scanned an antidepressant medication which allowed the nurse to enter a note for monitoring side of effects. S2DON reviewed the electronic software system and stated it did not provide a pop-up box for nurses to document monitoring for side effects for of antidepressants, and it should have. S2DON confirmed there was no place to document monitoring for side effects of anticoagulant medications. S2DON reviewed Residents #1, #170, and #171's March 2025 MAR and Electronic Health Record, and confirmed there was no documentation of monitoring for side effects for Resident #1's antidepressant medication or documentation for Residents #1, #170, and #171's anticoagulant medications, and there should have been. S2DON further confirmed she could not provide any documentation of monitoring for side effects for Resident #1's antidepressant nor Residents #1, #170 and #171's anticoagulant medications.

Based on record review, observation, and interviews the facility failed to implement and maintain an infection prevention control program to help prevent the development and transmission of infection by failing to ensure staff donned proper Personal Protective Equipment (PPE), and performed proper hand hygiene during resident care for of 1 (#218) of 3 (#118, #121, and #218) residents whom required EBP (Enhanced Barrier Precautions). Findings: Review of the facility's policy with a revision date of 06/2024, and titled Isolation Precautions revealed the following, in part: Procedure: Gown and Glove Precautions-Hand Hygiene, Enhanced Barrier Precautions Skilled Nursing Facility 3. Indwelling medical devices may include urinary catheters. 4. EBP is employed when performing the following high-contact resident care activities: d. Providing hygiene f. Changing briefs or assisting with toileting g. Device care or use with indwelling medical devices Review of Resident #218's clinical record revealed an admitted [DATE] with diagnoses, which included Chronic Kidney Disease and Retention of Urine. On 03/17/2025 at 9:40 a.m., an observation was made of Resident #218's room door with EBP signage. Upon entrance to Resident #218's room an indwelling foley catheter was observed. On 03/18/2025 at 3:15 p.m., an observation was made of S5PCA performing catheter care for Resident #218. S5PCA entered the room, performed hand hygiene and applied gloves. S5PCA proceeded to gather her supplies and water, and placed them on Resident #218's bedside table. S5PCS opened the resident's dresser drawers for cleaning supplies, and then repositioned Resident #218. S5PCA then pulled down Resident #218's pants, opened her lightly soiled brief, and performed catheter care without donning a gown. Without removing dirty gloves and performing hand hygiene S5PCA continued. S5PCA then repositioned Resident #218 to expose her backside and cleaned her buttocks. S5PCA then with same gloves went into resident's dresser drawer and obtained a brief, she applied clean brief, repositioned Resident #218, and pulled up her pants, covered Resident #218 with bed linen, lowered her bed, and then removed gloves. On 03/18/2025 at 3:27 p.m., an interview was conducted with S5PCA following catheter care observation. She confirmed Resident #218 had an EBP sign on her door. She read the signage and stated when a resident had an EBP sign on their door staff were expected to don gloves and a gown prior to performing high contact tasks such as performing catheter care. S5PCA confirmed she did not don a gown prior to performing catheter care on Resident #218 and should have. S5PCA also confirmed she did not change her gloves nor perform proper hand hygiene when going from clean to dirty and should have. On 03/19/2025 at 10:15 a.m., an interview was conducted with S2DON. She stated she expected staff to properly don and doff PPE when a resident is on EBP. S2DON confirmed staff were required to don and doff gown and gloves and use proper hand hygiene when performing catheter care. S2DON confirmed Resident #218 had an indwelling foley catheter. S2DON was informed of the aforementioned observations. S2DON confirmed she expected staff to properly don a gown while performing catheter care. S2DON further confirmed the PCA should have changed gloves and performed proper hand hygiene when going from clean to dirty.

Based on observations and interviews, the facility failed to ensure nurse staffing data requirements were posted. This deficient practice had the potential to affect any of the 19 residents residing in the facility. Findings: On 03/17/2025 at 11:14 a.m., an observation was made of the staff posting sheet titled Report of Nursing Staff Directly Responsible For Resident Care dated 03/17/2025. Review of the staff posting sheet revealed no documentation of the facility census nor the actual hours worked for nursing staff. On 03/18/2025 at 8:31 a.m., an observation was made of the staff posting sheet titled Report of Nursing Staff Directly Responsible For Resident Care dated 03/18/2025. Review of the staff posting sheet revealed no documentation of the facility census nor the actual hours worked for nursing staff. On 03/18/2025 at 1:54 p.m., an interview was conducted with S4RN. S4RN reviewed and confirmed the staff posting sheet titled Report of Nursing Staff Directly Responsible For Resident Care dated 03/17/2025 and 03/18/2025 did not contain the facility census nor the actual hours worked for nursing staff. On 03/18/2025 at 2:16 p.m., an interview was conducted with S2DON. S2DON reviewed and confirmed the staff posting sheet titled Report of Nursing Staff Directly Responsible For Resident Care dated 03/17/2025 and 03/18/2025 did not contain the facility census nor the actual hours worked for nursing staff. On 03/18/2025 at 2:34 p.m., an interview was conducted with S1DIR. S1DIR reviewed and confirmed the staff posting sheet titled Report of Nursing Staff Directly Responsible For Resident Care dated 03/17/2025 and 03/18/2025 did not contain the facility census nor the actual hours worked for nursing staff.

Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The facility failed to ensure S5RN and S6PCA wore proper Personal Protective Equipment (PPE) while providing care for 1 (#116) of 2 (#116 and #170) residents with indwelling medical devices. Findings: Review of Resident #116's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Chronic Kidney Disease Stage V, Recurrent Nephrolithiasis Requiring Multiple Ureteral Stents, Jackson Pratt (JP) Drain Placement (03/28/2024) and Peripherally Inserted Central Catheter (PICC) to Right Upper Arm. On 04/29/2024 at 9:18 a.m., an observation was made of S5RN administering antibiotics intravenously through Resident #116's right upper arm PICC. S5RN did not don a gown while accessing Resident #116's PICC. On 04/30/2024 at 8:48 a.m., an observation was made of S6PCA assisting Resident #116 reposition in bed. S6PCA did not don a gown while assisting Resident #116 in bed. On 04/30/2024 at 9:01 a.m., an interview as conducted with S3MD. S3MD verbalized she was Resident #116's physician. S3MD confirmed Resident #116 had multiple indwelling devices. She confirmed Resident #116 was not on EBP. She stated she was not aware of CMS's policy for Enhanced Barrier Precautions for residents with indwelling devices. On 04/30/2024 at 9:14 a.m., an interview was conducted with S2IP. S2IP confirmed she was the facility's Infection Preventionist. She confirmed resident #116 was not on EBP. She confirmed the facility did not have a process in place to implement Enhanced Barrier Precautions for any residents. She stated she was unaware of CMS's policy for Enhanced Barrier Precautions.

Based on interviews and record reviews the facility failed to complete and transmit MDS assessments in the required timeframe for 3 of 3 (#7, #8, and #10) residents reviewed for resident assessment. Findings: Review of the MDS assessments were conducted with S4MDS on 04/30/2024 at 1:31 p.m., which revealed the following: Resident #7 was discharged from the facility on 12/08/2023. A discharge assessment was transmitted on 04/29/2024. Resident #8 was discharged from the facility on 12/08/2023. A discharge assessment was transmitted on 04/29/2024. Resident #10 was discharged from the facility on 12/29/2023. A discharge assessment was not completed nor transmitted. On 04/30/2024 at 1:31 p.m., an interview was conducted with S4MDS. S4MDS stated discharge assessments should be completed 14 days after the discharge was entered and transmitted 7 days after it was signed and completed. S4MDS confirmed the aforementioned discharge assessments were not completed and/or transmitted timely. On 04/30/2024 at 1:48 p.m., an interview was conducted with S1DON. S1DON was made aware of the aforementioned findings. S1DON stated she expects discharge assessments to be completed 1-2 days after discharge. She confirmed the discharge assessments should be transmitted within 7 days of the assessment completion.

Based on observation, record review and interviews, the facility failed to ensure all medical records regarding the resident's code status consistently reflected the resident's wishes for 1 (#67) of 17 residents reviewed in the initial screening for advanced directives. Review of the facility's policy titled Advance Medical Directives Nursing- B. If the patient has an AMD (Advance Medical Directive) and a copy is available, at any time during hospitalization : a. Place the copy of the AMD behind the face sheet in the patient's current medical record. b. Notify the physician of the presence of the AMD. C. Consult SW or House Supervisor (after hours) if: a. The patient has an AMD but a copy is not available. b. The patient has an AMD but would like to review/revise it. c. The patient would like to receive information about AMDs. Findings: Review of Resident #67's clinical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Left Hip Dislocation s/p revision. Review of the most current MDS revealed a BIMS of 14 which indicated Resident #67 was cognitively intact. Review of Resident #67's Physician Orders dated [DATE] revealed the following: [DATE]-Full Code. Review of Resident #67's Resuscitation Order Form dated [DATE] revealed the following: Do Not Resuscitate- Signed by Resident #67's physician. Review of Resident #67's Physician Progress Notes dated [DATE] revealed the following: Full Code On [DATE] at 8:55 a.m., an interview was conducted with S3RN. She reviewed the electronic medical record for Resident # 67 and said she is a full code. She reviewed the Physician Order on [DATE] and confirmed Resident #67 was a full code. She further reviewed the clinical record for Resident #67 and said she had an order for Do Not Resuscitate on the Resuscitation Order Form. She confirmed there was a discrepancy regarding Resident #67's code status and the order should have been changed in the computer and on the Physician Orders. On [DATE] at 09:00 a.m., an interview was conducted with S2DON. She verified the Physician Orders dated [DATE] revealed Resident #67's code status was a Full Code. She confirmed the Physician's Resuscitation Orders dated [DATE] indicated Resident #67's code status was Do Not Resuscitate. She confirmed there were discrepancies in Resident #67's code status in the electronic chart, Physician's Orders and the Physician's Resuscitation Orders. She said the facility did not have a process in place to double check advance directives. On [DATE] at 10:5a.m., an interview was conducted with Resident # 67. She said she wanted staff to perform CPR, but she did not want to be put on a machine if she was found to be brain dead. On [DATE] at 08:15 a.m., an interview was conducted with S1ADM. She said she expected the Physician Orders and the Physician's Resuscitation Orders to match. She said there was no process in place at the present time to ensure the resident's code status was followed.

F600 Based on record review and interviews, the facility failed to ensure a resident's right to be free from abuse for 1 (#1) of 5 (#1, #2, #3, #4, and #5) sampled residents. Findings: Review of the facility's policy titled Abuse/Neglect: Patient Rights revealed the following, in part: Policy: The facility will not tolerate abuse of any kind from facility staff, other patients, consultants or volunteers, staff of other agencies serving the patient, family members or legal guardians, friends or other individuals. When abuse or neglect is alleged to have occurred in the facility, an immediate investigation will be: a. Conducted by the Department Leader and/or House Supervisor, and b. Document the facts of the allegation report of abuse or neglect verified. c. Immediate corrective actions will be taken. Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis, which included Right [CONDITION(S)]- Fall, Acute debility secondary to [CONDITION(S)], Hypertension, [CONDITION(S)], [CONDITION(S)], Anxiety, Depression, and History of [CONDITION(S)]. Review of the most recent MDS with an ARD of 11/05/2021, revealed: Resident #1 had a BIMS of 15, which indicated she was cognitively intact. Functional Status: limited assistance/one person for bed mobility, transfer, walk in room, dressing, eating, toileting, personal hygiene. A review of Nursing Notes for Resident #1 revealed the following, in part: 11/24/22 at 9:10 a.m. Patient very anxious at this time, expressing her fears over an incident that occurred last night with an encounter with her assigned PCA. Spouse at bedside also very upset as well, as the patient discusses in detail what transpired on the previous shift. By: S4LPN On 02/16/22 at 12:50 p.m., an interview was conducted with S4LPN. She stated an abuse situation was reported to her by Resident #1. She stated Resident #1 told her she was threatened by S9PCA during the night and S9PCA threw a water bottle at her hitting her surgical incision and causing pain to the area. She stated she remembers how Resident #1 was very upset and Resident #1 stated she feared for her life during the night and slept with her reacher so she could protect herself if something were to happen. Review of the incident investigation for Resident #1 dated 11/24/2021 revealed the following, in part: Occurred: 11/23/2021 at 10:22 PM Discovered: 11/24/2021 at 9:10 AM Entered: 11/24/2021 at 10:33 AM Incident Description: It was reported about 9:10 a.m. by nurse S4LPN, who was told by Resident #1, I felt threatened for my life last night by S9PCA. I didn't report it out of fear of retaliation. She kept saying she felt threatened, her life was in danger. She said S9PCA threw a water bottle at her and hit her on the surgical site on her right side. She said S9PCA didn't put up her side rail up because S9PCA said, If you can drink all of this water, you can go to the bathroom by yourself. She said she kept her reacher by her side in the bed out of fear of S9PCA. 11/24/21 at 2:01 p.m. Interviewed S9PCA, via telephone. S9PCA admitted to throwing the water bottle as noted. When questioned about the allegations, this is what S9PCA said: She threw the water bottle on the side of the rail. She said I would not throw the water to hurt the lady. When asked why did she throw the water bottle at all? She replied, I don't know why I threw it. On 02/15/2022 at 1:00 p.m., an interview was conducted with S1Nurse Manager, who stated she did remember the incident concerning Resident #1 in which physical abuse was substantiated by the investigative team. She stated S9PCA, had thrown a water bottle at Resident #1 causing pain to Resident #1's surgical site and she remembered Resident #1 felt threatened and was scared of S9PCA. On 02/16/22 at 2:00 p.m., an interview was conducted with S10RM, who stated she was very aware of the incident with resident 1 and S9PCA. She stated the investigation team, which included her, substantiated the alleged abuse on 11/24/21. She confirmed the incident did occur and the S9PCA was terminated on 11/24/21.

Based on interviews and record reviews, the facility failed to ensure an alleged violation of abuse was reported within 2 hours to the state agency for 1 (#4) of 5 (#1, #2, #3, #4, #5) residents reviewed for abuse. Review of the facility's abuse and neglect policy and procedure revealed the following, in part: Definitions Physical Abuse includes hitting, slapping, pinching, kicking, or controlling behavior through corporal punishment. Identify F. Alleged abuse or neglect will be reported to the State Agency by the Regulatory Department or the person completing the report within 24 hours from the initial report. L. For the skilled nursing facility, the reporting process will remain the same but in accordance with the time frames listed below: a. To be reported immediately, but no later than 2 hours: i. All allegations of abuse. Resident #4 Review of Resident #4's clinical record revealed he was admitted on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Grievance report January 2021 to present revealed, in part: Date discovered 05/10/2021. Incident Description: Resident #4's wife called and was tearful. She is upset that last night S1PCA poured mouthwash on Resident #4's crotch. Resident #4 described S1PCA as hateful and rude. Resident #4 did not want to report S1PCA because he feared retaliation. An interview was conducted on 07/13/2021 at 9:22 A.M. with S5RN. She stated Resident #4's wife reported that S1PCA poured mouthwash in his crotch and was rude and hateful. S5RN stated due to the urgency, she immediately reported the complaint to S6RN for prompt investigation. S5RN verified an incident report was completed in the grievance system on 05/10/2021 at 7:17 P.M. An interview was conducted with S6RN on 07/12/2021 at 2:41 P.M. S6RN stated Resident #4 reported to her on 05/10/2021 that S1PCA was aggressive and physically rough with him. S6RN confirmed the incident report in the grievance system was received by S9DOQ, S8DPE, and S11DSNF. An interview was conducted with S7RAM on 07/12/2021 at 2:41 P.M. S7RAM confirmed she was responsible for completing SIMs reports. S7RAM stated S11DSNF and S8DPE discussed the incident reported by Resident #4 and determined the incident did not need to be reported to the State Agency. An interview was conducted with S8DPE on 07/12/2021 at 2:41 P.M. S8DPE confirmed she was aware of the allegations by Resident #4 against S1PCA on 05/10/2021 being aggressive and physically rough with him. S8DPE confirmed the incident was not reported to the State Agency. An interview was conducted with S9DOQ on 07/13/2021 at 10:34 A.M. S9DOQ confirmed she was aware of the allegations made by Resident #4 against S1PCA being aggressive and physically rough with him. S9DOQ confirmed the incident was not reported to the State Agency. An interview was conducted with S11DSNF on 07/13/2021 at 2:33 P.M. S11DSNF confirmed she was aware of the allegations made by Resident #4 against S1PCA being aggressive and physically rough with him. S11DSNF confirmed the incident was not reported to the State Agency.

Based on interviews and record reviews the facility failed to facilitate a resident's right to communicate by failing to ensure 1 (#4) of 5 (#1, #2, #3, #4, #5) residents reviewed, had a working telephone in their room. Findings: Review of the Grievance Report revealed the following: Date: 05/10/2021 Resident #4 wife states the phone in Room A does not work. Review of IT notes for phone in room Room A revealed in part: Ticket #1- 0- initiated on 02/15/2021 Completed before March 8th. Ticket left open for monitoring. Closed out on 07/08/2021 Ticket #2- 2- initiated on 05/10/2021 and merged with ticket # 0 Continued with intermittent issues, ticket remained open. Closed out on 07/08/2021 Ticket #3- 3- initiated on 06/10/2021 Closed on 06/24/2021 An interview was conducted with Resident #4 on 07/12/2021 at 12:38 P.M. He said during his entire stay, from 04/09/2021 to 05/27/2021, in Room A, the phone did not work. He stated the phone did not work in Room A was reported to S5RN and S6RN on 05/10/2021. An interview was conducted with S10DIT on 07/13/2021 at 12:59 P.M. On 02/15/2021, she stated she received the first IT work order for the phone line not working in Room A. On 5/10/2021, another work order request was received for the phone line not working in Room A. On 6/10/2021, again another request was received for the phone line not working in Room A. She said IT could not complete phone line work when a resident was assigned to the room. S10DIT stated IT staff communicated with nursing staff at the desk that Room A needed to be empty before they could fix the phone line. She said IT staff was aware of the problems. An interview was conducted with S6RN on 07/12/2021 at 2:41 P.M. She stated the unit did not have a cordless phone for Resident #4 to use. S6RN stated Resident #4 was expected to use the phone in his private room. She stated she was not aware the phone in room a did not work until 05/10/2021, when Resident #4 reported it. She said she was not aware that the phone line in Room A was not working properly. S6RN said if had she known the phone was not fixed, she would have moved Resident #4 to another room.

Based on observation and interview the facility failed to prepare, distribute and serve foods under sanitary conditions by failing: a) to ensure that the food thermometer was properly cleaned and sanitized prior to checking food temperatures, b) ensure that hot food temperatures were maintained at 135 degrees Fahrenheit (F) or above at the serving line. There were 38 out of 39 residents that were served food from the kitchen. Findings: a) Food Thermometer On 04/27/15 at 11:00 a.m., the lunch serving line observation was made with S2Dietary Supervisor in the kitchen. S2Dietary Supervisor took out a food thermometer from a food thermometer sheath. She wiped the food thermometer stem with a paper napkin. Without washing, rinsing and sanitizing the food thermometer stem, S2Dietary Supervisor placed it in a pan of carrots. She wiped the food thermometer stem with the same used paper napkin that she had held in the palm of her hand. She repeated the same process until she completed taking all the regular food temperatures on the tray line. S2Dietary Supervisor placed the same used food thermometer back in its sheath without washing, rinsing and sanitizing it. Further observation at 11:20 a.m. included S2Dietary Supervisor took the food thermometer out of the food thermometer sheath. Without washing, rinsing and sanitizing the food thermometer, she placed the food thermometer in the individual prepared pureed carrots. She wiped the thermometer stem with the same used paper napkin until she completed taking all the food temperatures on the serving line. S2Dietary Supervisor then wiped the food thermometer stem with a used paper napkin and placed the food thermometer back into the thermometer sheath without washing, rinsing and sanitizing the food thermometer. In an interview conducted with S2Dietary Supervisor on 04/27/15 at 11:30 a.m., she said she was out of the sanitizing wipes and so she thought using a paper napkin was good enough to clean the food thermometer. She acknowledged that she failed to wash, rinse and sanitize the food thermometer prior to checking the food temperatures on the serving line. Review of the inservice training regarding the cleaning and sanitizing of food thermometers conducted on 09/08/14 and 09/13/14 revealed no documentation that S2Dietary Supervisor attended the inservices. On 04/27/15 at 11:35 a.m., an interview was conducted with S1Nutritional Service Director. He acknowledged that S2Dietary Supervisor failed to clean and sanitize the food thermometer prior to checking the food. b) Food temperatures An observation was made on 04/27/15 at 11:00 a.m. in the kitchen. The following food temperatures were below 135 degrees (F) on the steam table: Noodles ----- 123 degrees F Pureed Carrots ----- 114 degrees F Pureed Chicken ----- 92 degrees F Pureed Rice ----- 110 degrees F An interview was held with S2Dietary Supervisor on 04/27/15 at 11:30 a.m. She acknowledged that the foods were not maintained at the appropriate temperatures on the steam table. An interview was held with S1Nutritional Service Director on 04/27/15 at 11:35 a.m. He acknowledged that the foods were not maintained at the appropriate temperatures on the steam table to prevent food borne illnesses. An interview was conducted with S1Nutritional Service Director on 04/27/15 at 11:45 a.m. He verified the above observations and verbally acknowledged that the facility failed to prepare, distribute and serve foods under sanitary conditions.

Based on record review and interview, the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of[DIAGNOSES REDACTED]icile and infection for 1(#303) of 21(#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #303, #305, #306), residents who residing on the Skilled Nursing Facility(SNF) Unit from a total census of 21 residents listed on the Resident Census and Condition document by failing to: 1) Ensure staff disinfected a medication cart/rolling blood pressure cart with a agent effective in killing [MEDICAL CONDITION](C Diff) according to Centers for Disease Control(CDC) Standards before exiting a resident's(#303) room. 2) Ensure staff performed proper hand washing measures before donning gloves/gown and after completion of resident care, on resident (#303) on Contact Precautions for[DIAGNOSES REDACTED]. 3) Ensure staff properly discarded personal protective clothing in a red biohazard bag for a resident (#303) who was on Contact Precautions for [MEDICAL CONDITION]. 4) Ensure the facility's policy and procedure for infection control contained measures staff would implement to prevent spread of [MEDICAL CONDITION] infection. 6) Ensure S10RN was trained on and implemented Contact Precautions for disinfecting a medication cart for a resident (#303) diagnosed for[DIAGNOSES REDACTED]. 7) Ensure therapy staff properly disinfected a gait belt made of porous material after use for a resident (#303) with [MEDICAL CONDITION]. 8) Ensure a sporicidal agent was readily available to use by staff upon exiting a resident's(#303) room with [MEDICAL CONDITION] for cleaning equipment. Residents (#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #303, #305, #306 were placed in Immediate Jeopardy on 3/18/13 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for Resident(#303) who had a positive stool culture on 3/13/13 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the SNF unit. The deficient practice remains in place for all other residents at a level 2. The Administrator was notified of the Immediate Jeopardy on 3/18/13 at 5:50 p.m. A Plan of Removal was presented by the S2Regulatory Coordinator which read: 1. The registered nurse, the physical therapist and the patient care attendant observed during the survey were counseled regarding the appropriate care of patients with [MEDICAL CONDITION] in Contact Precautions Hand Washing (Completed 3/18/13). 2. A. The policy IC-100 Patient Care Cleaning and Disinfecting was reviewed and revised to clearly articulate the requirement for equipment cleaning used on patients in contact precautions (e.g. [MEDICAL CONDITION] (Attachment A). Gait belts that are used by therapy will be cleaned in the same manner as other patient equipment if they are non-porous. If they are porous gait belts, they will be issued to the patient and left in the room; and disposed of upon discharge. B. The computer keyboards attached to the medication carts were replaced with Medigenic Cleaning required when flashing by Esterline Advanced Input Systems, which is a flat keyboard that can be wiped with a hospital approved bleach-based disinfectant (Completed 3/20/13). C. The policy IC-220 Infection Control: Isolation Precautions was revised to clarify that a bleach-based product will be used to clean equipment according to the manufacturer's guidelines. The requirement to wash hands with soap and water prior to leaving the patient's room was already in the policy. (Attachment B). D. The policy IC-230: Handling of Wastes, Sharps and Linens was reviewed and revised to require all waste for [MEDICAL CONDITION] patients to be discarded in a red biohazard bag. (Attachment C). E. The CDC guidelines 2007 Guideline for Isolation Precautions: Preventing Transmissions of Infectious Agents in Healthcare Settings were reviewed for the requirements of PPE equipment (e.g. gowns, gloves). BRG policy IC-215 Infection Control: Standard Precautions was revised to clarify proper disposal of PPE. (Attachment D). F. Accessibility of needed supplies (e.g. bleach-based disinfectant equipment. gowns) and equipment will be evaluated and replenished as needed daily on the night shift. G. The Infection Control Practitioner reviews the CDC Guidelines on an ongoing basis; reviews and revised the Infection Control Policies annually and PRN; and works with the SNF Administrative Staff to ensure the Infection Control Plan is implemented. H. The Housekeeping employee observed by the surveyor entering the patient's room in contact precautions has been counseled (Attachment E). 3. Staffs will be educated (Attachment F) on: Topic: Revised Policies: IC-100 Patient Care Cleaning and Disinfecting IC-215 Infection Control: Standard Precautions IC-220 Infection Control: Isolation Precautions IC-230 Infection Control: Handling of Wastes, Sharps and Linens Target Audience: The following direct care staff: SNF Nursing Staff to include RN's LPN's, PCA's. SNF PT, OT, speech, PTA, COTA, Rehab Technicians Education-"Just In Time" Instructions for patients for Isolation Precautions. A sign will be placed on the door of the patients in Contact Precautions instructing them to report to the nurse's station for instructions prior to entering the room. Targeted Audience: Direct and/or Indirect Support Patient Care staff (e.g. Housekeeping, Social Services, Dietary, etc.) Accessibility of supplies and equipment for patients with [MEDICAL CONDITION]. Targeted Audience: SNF Nursing Staff to include RN's, LPNs, PCA's. Education began on March 18, 2013 at 7:00 p.m. Effective at 7:00 p.m. on March 18, 2013 SNF staff to include RNs, LPNs, PCAs; and SNF PT, OT, Speech, PTA, COTA and Rehab Technicians will not be allowed to work on the SNF unit until the education is completed. Education as outlined above will be completed by all active SNF staff by March 20, 2013. Staff that have not completed the education due to PRN status, Leave of Absence or Vacation will not be allowed to accept a patient care assignment upon return until the education is completed. 3. Auditing and monitoring of the corrective action plan will be coordinated by the SNF Nurse Manager using the SNF Corrective Action Plan Audit Tool (Attachment G) to include the following: a. Beginning Monday March 25, 2013 100% of patients with [MEDICAL CONDITION] who are on Contact Precautions will be observed once daily at a random time of day until 100% compliance with appropriate care and precautions of the patient with [MEDICAL CONDITION] has been achieved for two weeks. b. The SNF Nurse Manager, or designee (e.g. Charge Nurse, Educator) will conduct an observation audit; provide immediate feedback to the staff; and coordinate with the staff'manager for any deficient practice. Once 100% compliance had been achieved for two weeks, weekly random audits will be conducted by the Nurse Manager, or designee until 100% compliance has been achieved for 4 months. During the observation audit, the room will be assessed for the availability of necessary supplies. c. Weekly reports will be provided by the SNF Nurse Manager to the SNF Director for discussion and further actions as needed. The Immediate Jeopardy was lifted on 3/20/13 at 5:35 p.m. when the facility implemented its plan of removal. Findings: Review of the facility's policies received revealed the following in part: Number: IC-220 Title: Isolation Precautions Policy: dated 02/13 Purpose: Isolation Precautions will be implemented to reduce or eliminate the transmission of certain microorganisms including [MEDICAL CONDITION]. Procedure: 7. The Isolation Precautions Kit which contains a disposable blood pressure cuff, thermometer and stethoscope and will be used for patients in the following: b. Contact Precautions Hand Washing Procedure: Hand Hygiene 1. Hand hygiene will be performed: a. Immediately prior to putting on personal protective equipment. This should be done in the patient's room. Contact Precautions Hand Washing 1. Gloves and a long sleeve gown (personal protective equipment) will be worn: a. When providing care to the patient b. When contact with environmental surfaces or equipment in the patient ' s room is anticipated. 2. Personal protective equipment will be removed and hands will be washed with soap and water prior to leaving the patients room. 3. If disposable equipment cannot be used, reusable equipment will be cleaned and disinfected according to policy IC-100: Patient Care Equipment Cleaning and Disinfecting. a. Reusable equipment and environmental surfaces will be disinfected using a bleached -base disinfectant whenever feasible. 5. Everyone will be required to wash their hands with soap and water prior to leaving the patients room. Number IC-230 Title: Handling of Wasted, Sharp, Linen, and Reusable Pillows Policy: dated 01/11 Purpose: To outline the process for handling of waste, sharps, soiled linens, and reusable pillows that minimize exposure to bacteria [MEDICAL CONDITION] that may be found in blood and other potentially infectious materials (OPIM), which includes body fluids. Policy: Medical waste, sharps and dirty linen are handled in accordance with Local, State and Federal guidelines, utilizing Standard Precautions. Definitions: 1. All wastes, sharps, soiled linens, and reusable pillows will be handled using Standard Precautions. A. Liquid or semi -liquid blood or " other potentially infectious material " (OPIM) C. Items caked with dried blood or OPIM that are capable of releasing these materials during handling. D. Pathological and microbiological waste containing blood or OPIM. Procedure: Medical or Biohazard Waste e. Pathological and biological waste containing blood or OPIM. 3. Place all medical waste, except sharps in a red biohazard bag. Resident #303 was a [AGE] year old male admitted to the SNF unit on 03/09/2013 with [DIAGNOSES REDACTED]. Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6... An observation was conducted on 03/18/2013 at 11:30 a.m. of Resident # 303's Door. The Door was labeled with Pink Signage approximately 12 inches x 24 inches in size that revealed the following verbiage. Stop: Please See Nurse Before Entering The Room. Contact Precautions Hand Washing. 1. Clean hands immediately prior to putting on gloves and long- sleeve gown. 2. Wear gloves and a long-sleeve gown when providing any care to the patient. Discard immediately prior to leaving the room. 3. Everyone Must wash their hands with soap and warm water immediately prior to leaving the room. Review of Resident #303's March physician's orders [REDACTED]. 03/13/2013 [MEDICATION NAME] 125 milligrams (mg) by mouth 4 times a day for [MEDICAL CONDITION] Review of Resident #303's Laboratory documentation revealed the following in part: 03/12/13- [MEDICAL CONDITION] Positive Initiate Contact Precautions- Hand Washing for inpatients Review of Resident # 303 's Plan of Care revealed no plan of care for Contact Precautions or [MEDICAL CONDITION]. Review of Resident # 303 's Nursing flow sheet revealed the following in part: 03/14/2013- 2 Stools: Bowel Control- Continent, Description: large liquid brown 03/15/2013-2 Stools: Bowel Control- Continent, Description: as reported by previous nurse and stated by the patient had loose stool large amount. 03/16/2013- 1 Stool: Bowel Control- Continent, No Description 03/17/2013- 1 Stool: Bowel Control- Continent, No Description 03/18/2013- 2 Stools: Bowel Control- Continent, No Description 03/19/2013-4 Stools: Bowel Control- Continent, No Description On 3/18/13 at 12:15 p.m. an observation was made of S10RN standing in the hallway putting on a gown and a pair of gloves. Further observation noted S10RN did not wash her hands before putting on a gown and gloves in Resident #303's room. S10RN was observed pushing a medication cart; that contained other resident's medicines, in Resident #303's room who was on Contact Precautions for [MEDICAL CONDITION]. On 3/18/13 at 12:32 p.m. an observation was made of S10RN standing in the hall with her medication cart. Further observation revealed that she never properly disinfected the cart; with an agent that killed [MEDICAL CONDITION], before pushing it out of the resident's room. On 3/18/13 at 12:45 p.m. an interview was conducted with S10RN. She stated Resident #303 was on Contact Precautions for [MEDICAL CONDITION]. She said the facility's protocol was to wash your hands and put a gown and gloves on when entering a resident room on Contact Precautions. She verified she did not wash her hands immediately before downing gown and gloves. She said she washed her hands down the hall in front of the nurses station. She acknowledged she pushed a medication cart in Resident #303's room; that contained other resident's medications, and did not properly disinfected it with an agenct that killed [MEDICAL CONDITION] before removing it from the resident's room. She stated that she did not know the facility policy stated she was supposed to wash her hands in the resident's room before putting on the gown and gloves and said she would have to refresh herself on that policy. An interview was conducted with on 03/18/2013 at 3:00 p.m. with S4UnitManager. He stated they would use Sani- Wipes-Bleach that contains a bleach solution to clean the room and equipment with residents with [MEDICAL CONDITION]. He stated that they did not have any Sani Wipes-Bleach on the unit and they can order more from Environmental Services. He further reveled that every Resident who had [MEDICAL CONDITION] should have Sani-Wipes-Bleach in the room to clean equipment that was brought out of the room of a resident with[DIAGNOSES REDACTED]. He stated that each Contact Isolation room had bleach wipes in the room. He checked the room and verified that no Sani- Wipes-Bleach cleaning supplies were in the room. He exited the room and returned with 3 individual packs of Sani-clothes for the room and stated he would order more from Environmental Services. An observation was conducted on 03/18/2013 at 3:05 pm. S7PhysicalTherapy was gowned and gloved walking the resident in the hall with a gait belt around his waist. S7PysicalTherapy returned Resident # 303 to his room. S7PhysicalTherapy cleaned the porous clothe like material gait belt with a santi wipe-bleach wipe. She also cleaned a rolling walker. She discarded her gown and gloves in the clear garbage bag and failed to wash her hands in the resident's room. She exited the room, placed the walker against the wall of the hallway, and draped the gait belt over the walker then walked to the sink in front of the nursing station to wash her hands. An interview was conducted on 03/18/2013 at 3:28 pm with S7PhysicalTherapy. She stated that the gait belt was a washable item, and she wiped it down with a bleach wipe after using it with Resident # 303. She states that its possible spores could get into the belt and could not be properly cleaned with a bleach wipe. She confirmed she discarded her gown and gloves into a clear garbage bag. She stated she washed her hands in front of the nursing station and not in the Residents room. She further revealed that when the gait belt is used, it is placed in a pillow case and stored in the therapy department. An observation was conducted on 03/18/2013 at 3:15p.m. of Resident # 303 ' s room.The observation revealed two garbage cans with clear bags lining the cans . An observation was conducted on 03/18/2013 at 3:20 p.m. of S11PCA. S11PCA wheeled a portable blood pressure monitor and thermometer into Resident 303 ' s room. She then proceeded to take Resident 's #303 blood pressure and temperature with the portable blood pressure monitor. She cleaned the portable blood pressure machine with a germicidal agent that was not effective against [MEDICAL CONDITION]. She removed her gown and gloves and discarded them in the clear garbage bag. She failed to wash her hands in the Residents room. An interview was conducted on 03/18/2013 at 3:30 p.m. with S11PCA. She stated she knew Resident #303 was in Contact Isolation. She stated she cleaned the portable blood pressure machine with the germicidal wipes that was not indicated for [MEDICAL CONDITION]. She stated she knew that the portable blood pressure machine had to be cleaned with a bleach cleaner after taking it into a room with [MEDICAL CONDITION]. She further reveled no bleach wipes were located in the room and failed to disinfect the blood pressure machine with a bleach cleaner. She stated red bags were not located in the garbage cans in the room and gowns and gloves are discarded in the clear bags. She verified she removed her gown and gloves and placed these items into the clear plastic trash liners and failed to wash her hands in the Residents room.. An interview was conducted on 03/18/2013 at 5:45 p.m. with S5 Infection Control Practitioner. She stated that medicine carts, gait belts, and blood pressure machines should not be brought into a Residents room in Contact Isolation. She further revealed that in then event any equipment was taken into a room where the resident was on Contact Precautions, the equipment should be left in the room and then properly disinfected with a agent that kills [MEDICAL CONDITION] after the resident was discharged . She stated gowns and gloves should be discarded in clear plastic garbage bags.She confirmed that all staff should follow the policy and procedures for Residents in Contact Isolation. She stated staff should sanitize their hands prior to putting on gloves and wash their hands with soap and water prior to leaving a room. She confirmed that gowns, gloves and Sani-wipes should be located in the Residents room on Contact Isolation at all times. An interview was conducted on 03/18/2013 at 5:55 p.m. with S1Director of Quality. She stated that equipment should not be brought into a Residents room in Contact Isolation. She further revealed that in then event any equipment was taken into a room where the resident was on Contact Precautions, the equipment should be left in the room and then properly disinfected with a agent that kills [MEDICAL CONDITION] after the resident was discharged . She stated they have isolation kits with disposable thermometer and blood pressure kits that should be used in Contact Isolation rooms. On 3/19/13 at 10:42 a.m. an observation was made of S6Housekeeper exiting Resident #303's bathroom with a gown and a pair of gloves on. Further observation noted S6Housekeeper touched clean towels on her cart and returned to Resident #303's bathroom. At 10:44 a.m. an observation was made of S6Housekeeper coming out of Resident #303's bathroom; with the same gown and gloves, returned back to the housekeeping cart , retrieved a set of keys and opened up 1 side of cart and got a clean towel. At 10:46 a.m. S6Housekeeper returned back to the cart with her same gown and gloves and touched items on her cart a 3rd time. At 10:50 a.m. S6Housekeeper returned back to the housekeeping cart with the same gown and gloves on retrieving an item off the housekeeping cart. Further observation noted that S6Housekeeper removed the broom/sweeper used to clean Resident #303's room without properly disinfecting it with a sporacidal agent that killed [MEDICAL CONDITION]. S6Housekeeper pushed her cart to room [ROOM NUMBER] and began cleaning that room. On 3/19/13 at 11:30 a.m., an interview was conducted with S6Housekeeper. She confirmed she did not remove her gown and gloves or wash her hands neither of the 4 times she came out of Resident #303's bathroom into the hallway to her housekeeping cart. She also confirmed she did not disinfect the sweeper/broom used to clean the resident's bathroom before exiting the resident's room. She said, "To be honest, I really don't know what I should have done". On 3/20/13 at 1:42 p.m. S13LPN was observed putting a pair of gloves on and attemped to open a gown. The gown fell to the floor. S13LPN picked the gown up off the floor with the gloves she had on, put it in the trash can and kept the same gloves on. At 1:55 p.m. S13LPN came out of Resident #303's with a gown and a pair of gloves on, retrieved a medication cart in the hall and returned back to the room. On 3/20/12 at 1:50 p.m. an interview was conducted with S13LPN. She confirmed she didn't wash her hands when she picked up the gown that fell to the floor. She also acknowledged she came out Resident #303's room with a gown and a pair of gloves on, retrived a medication cart and returned to the room without removing the gown/gloves and washing her hands and acknowledged she should have.

Based on record review and interview, the facility failed to establish and maintain an Infection Control Program designed to prevent the development and transmission of[DIAGNOSES REDACTED]icile and infection for 1(#303) of 21(#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #303, #305, #306), residents who residing on the Skilled Nursing Facility(SNF) Unit from a total census of 21 residents listed on the Resident Census and Condition document by failing to: 1) Ensure staff disinfected a medication cart and rolling blood pressure cart with a agent effective in killing Clostridium Difficile(C Diff) according to Centers for Disease Control(CDC) Standards before exiting a resident's(#303) room. 2) Ensure staff performed proper hand washing measures before donning gloves/gown and after completion of resdident care, on resident (#303) on Contact Precautions for[DIAGNOSES REDACTED]. 3) Ensure staff properly discarded personal protective clothing in a red biohazard bag for a resident (#303) who was on Contact Precautions for Clostridium Difficile. 4) Ensure the facility's policy and procedure for infection control contained measures staff would implement to prevent spread of[DIAGNOSES REDACTED] infection. 6) Ensure S10RN was trained on and implemented Contact Precautions for disinfecting a medication cart for a resident (#303) diagnosed for[DIAGNOSES REDACTED]. 7) Ensure therapy staff properly disinfected a gait belt made of porous material after use for a resident (#303) with[DIAGNOSES REDACTED]. 8) Ensure a sporicidal agent was readily available to use by staff upon exiting a resident's(#303) room with[DIAGNOSES REDACTED] for cleaning equipment. Residents (#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #303, #305, #306 were placed in Immediate Jeopardy on 3/18/13 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for Resident(#303) who had a positive stool culture on 3/13/13 for Clostridium Difficile(C Diff). This presented an exposure for all other residents who resided on the SNF unit. The deficient practice remains in place for all other residents at a level 2. The Administrator was notified of the Immediate Jeopardy on 3/18/13 at 5:50 p.m. A Plan of Removal was presented by the S2Regulatory Coordinator which read: 1. The registered nurse, the physical therapist and the patient care attendant observed during the survey were counseled regarding the appropriate care of patients with Clostridium Difficile in Contact Precautions Hand Washing(Completed 3/18/13). 2. A. The policy IC-100 Patient Care Cleaning and Disinfecting was reviewed and revised to clearly articulate the requirement for equipment cleaning used on patients in contact precautions (e.g. Clostridium Difficile (Attachment A). Gait belts that are used by therapy will be cleaned in the same manner as other patient equipment if they are non-porous. If they are porous gait belts, they will be issued to the patient and left in the room; and disposed of upon discharge. B. The computer keyboards attached to the medication carts were replaced with Medigenic Cleaning required when flashing by Esterline Advanced Input Systems, which is a flat keyboard that can be wiped with a hospital approved bleach-based disinfectant (Completed 3/20/13). C. The policy IC-220 Infection Control: Isolation Precautions was revised to clarify that a bleach-based product will be used to clean equipment according to the manufacturer's guidelines. The requirement to wash hands with soap and water prior to leaving the patient's room was already in the policy. (Attachment B). D. The policy IC-230: Handling of Wastes, Sharps and Linens was reviewed and revised to require all waste for[DIAGNOSES REDACTED] patients to be discarded in a red biohazard bag. (Attachment C). E. The CDC guidelines 2007 Guideline for Isolation Precautions: Preventing Transmissions of Infectious Agents in Healthcare Settings were reviewed for the requirements of PPE equipment (e.g. gowns, gloves). BRG policy IC-215 Infection Control: Standard Precautions was revised to clarify proper disposal of PPE. (Attachment D). F. Accessibility of needed supplies (e.g. bleach-based disinfectant equipment. gowns) and equipment will be evaluated and replenished as needed daily on the night shift. G. The Infection Control Practitioner reviews the CDC Guidelines on an ongoing basis; reviews and revised the Infection Control Policies annually and PRN; and works with the SNF Administrative Staff to ensure the Infection Control Plan is implemented. H. The Housekeeping employee observed by the surveyor entering the patient's room in contact precautions has been counseled (Attachment E). 3. Staffs will be educated (Attachment F) on: Topic: Revised Policies: IC-100 Patient Care Cleaning and Disinfecting IC-215 Infection Control: Standard Precautions IC-220 Infection Control: Isolation Precautions IC-230 Infection Control: Handling of Wastes, Sharps and Linens Target Audience: The following direct care staff: SNF Nursing Staff to include RN's LPN's, PCA's. SNF PT, OT, speech, PTA, COTA, Rehab Technicians Education-"Just In Time" Instructions for patients for Isolation Precautions. A sign will be placed on the door of the patients in Contact Precautions instructing them to report to the nurse's station for instructions prior to entering the room. Targeted Audience: Direct and/or Indirect Support Patient Care staff (e.g. Housekeeping, Social Services, Dietary, etc.) Accessibility of supplies and equipment for patients with Clostridium Difficile. Targeted Audience: SNF Nursing Staff to include RN's, LPNs, PCA's. Education began on March 18, 2013 at 7:00 p.m. Effective at 7:00 p.m. on March 18, 2013 SNF staff to include RNs, LPNs, PCAs; and SNF PT, OT, Speech, PTA, COTA and Rehab Technicians will not be allowed to work on the SNF unit until the education is completed. Education as outlined above will be completed by all active SNF staff by March 20, 2013. Staff that have not completed the education due to PRN status, Leave of Absence or Vacation will not be allowed to accept a patient care assignment upon return until the education is completed. 3. Auditing and monitoring of the corrective action plan will be coordinated by the SNF Nurse Manager using the SNF Corrective Action Plan Audit Tool (Attachment G) to include the following: a. Beginning Monday March 25, 2013 100% of patients with[DIAGNOSES REDACTED] who are on Contact Precautions will be observed once daily at a random time of day until 100% compliance with appropriate care and precautions of the patient with[DIAGNOSES REDACTED] has been achieved for two weeks. b. The SNF Nurse Manager, or designee (e.g. Charge Nurse, Educator) will conduct an observation audit; provide immediate feedback to the staff; and coordinate with the staff' manager for any deficient practice. Once 100% compliance had been achieved for two weeks, weekly random audits will be conducted by the Nurse Manager, or designee until 100% compliance has been achieved for 4 months. During the observation audit, the room will be assessed for the availability of necessary supplies. c. Weekly reports will be provided by the SNF Nurse Manager to the SNF Director for discussion and further actions as needed. The Immediate Jeopardy was lifted on 3/20/13 at 5:35 p.m. when the facility had implemented its plan of removal. Findings: Review of the facility's policies received revealed the following in part: Number: IC-220 Title: Isolation Precautions Policy: dated 02/13 Purpose: Isolation Precautions will be implemented to reduce or eliminate the transmission of certain microorganisms including multidrug-resistant organisms. Procedure: 7. The Isolation Precautions Kit which contains a disposable blood pressure cuff, thermometer and stethoscope and will be used for patients in the following: b. Contact Precautions Hand Washing Procedure: Hand Hygiene 1. Hands hygiene will be performed: a. Immediately prior to putting on personal protective equipment. This should be done in the patient ' s room. Contact Precautions Hand Washing 1. Gloves and a long sleeve gown (personal protective equipment) will be worn: a. When providing care to the patient b. When contact with environmental surfaces or equipment in the patient ' s room is anticipated. 2. Personal protective equipment will be removed and hands will be washed with soap and water prior to leaving the patients room. 3. If disposable equipment cannot be used, reusable equipment will be cleaned and disinfected according to policy IC-100: Patient Care Equipment Cleaning and Disinfecting. a. Reusable equipment and environmental surfaces will be disinfected using a bleached -base disinfectant whenever feasible. 5. Everyone will be required to wash their hands with soap and water prior to leaving the patients room. Number IC-230 Title: Handling of Wasted, Sharp, Linen, and Reusable Pillows Policy: dated 01/11 Purpose: To outline the process for handling of waste, sharps, soiled linens, and reusable pillows that minimize exposure to bacteria and viruses that may be found in blood and other potentially infectious materials (OPIM), which includes body fluids. Policy: Medical waste, sharps and dirty linen are handled in accordance with Local, State and Federal guidelines, utilizing Standard Precautions. Definitions: 1. All wastes, sharps, soiled linens, and reusable pillows will be handled using Standard Precautions. A. Liquid or semi -liquid blood or " other potentially infectious material " (OPIM) C. Items caked with dried blood or OPIM that are capable of releasing these materials during handling. D. Pathological and microbiological waste containing blood or OPIM. Procedure: Medical or Biohazard Waste e. Pathological and biological waste containing blood or OPIM. 3. Place all medical waste, except sharps in a red biohazard bag. Resident #303 was a [AGE] year old male admitted to the SNF unit on 03/09/2013 with [DIAGNOSES REDACTED]. Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6... An observation was conducted on 03/18/2013 at 11:30 a.m. of Resident ' s # 303 Door. The Door was labeled with Pink Signage approximately 12 inches x 24 inches in size that revealed the following verbiage. Stop: Please See Nurse Before Entering The Room. Contact Precautions Hand Washing. 1. Clean hands immediately prior to putting on gloves and long- sleeve gown. 2. Wear gloves and a long-sleeve gown when providing any care to the patient. Discard immediately prior to leaving the room. 3. Everyone Must wash their hands with soap and warm water immediately prior to leaving the room. Review of Resident #303's March physician's orders [REDACTED]. 03/13/2013 [MEDICATION NAME] 125 milligrams (mg) by mouth 4 times a day for[DIAGNOSES REDACTED] Review of Resident #303's Laboratory documentation revealed the following in part: 03/12/13- Clostridium Difficile Positive Initiate Contact Precautions- Hand Washing for inpatients Review of Resident # 303's Plan of Care revealed no plan of care for Contact Precautions or[DIAGNOSES REDACTED]. Review of Resident # 303 ' s Nursing flow sheet revealed the following in part: 03/14/2013- 2 Stools: Bowel Control- Continent, Description: large liquid brown 03/15/2013-2 Stools: Bowel Control- Continent, Description: as reported by previous nurse and stated by the patient had loose stool large amount. 03/16/2013- 1 Stool: Bowel Control- Continent, No Description 03/17/2013- 1 Stool: Bowel Control- Continent, No Description 03/18/2013- 2 Stools: Bowel Control- Continent, No Description 03/19/2013-4 Stools: Bowel Control- Continent, No Description On 3/18/13 at 12:15 p.m. an observation was made of S10RN standing in the hallway putting on a gown and a pair of gloves. Further observation noted S10RN did not wash her hands before putting on a gown and gloves in Resident #303's room. S10RN was observed pushing a medication cart that contained other resident's medicines into Resident #303's room, who was on Contact Precautions for[DIAGNOSES REDACTED]. On 3/18/13 at 12:32 p.m. an observation was made of S10RN standing in the hall with her medication cart. Further observation revealed that she never properly disinfected the cart; with an agent that killed[DIAGNOSES REDACTED], before pushing it out of the resident's room. On 3/18/13 at 12:45 p.m. an interview was conducted with S10RN. She stated Resident #303 was on Contact Precautions for[DIAGNOSES REDACTED]. She said the facility's protocol was to wash your hands and put a gown and gloves on when entering a resident room on Contact Precautions. She verified she did not wash her hands immediately before downing gown and gloves. She said she washed her hands down the hall in front of the nurses station. She acknowledged she pushed a medication cart in Resident #303's room that contained other resident's medications. S10RN said she did not properly disinfected the medication cart with an agenct that killed[DIAGNOSES REDACTED] before removing it from the resident's room. She stated that she did not know the facility policy stated she was supposed to wash her hands in the resident's room before putting on the gown and gloves and said she would have to refresh herself on that policy. An interview was conducted with on 03/18/2013 at 3:00 p.m. with S4UnitManager. He states they use Sani- Wipes-Bleach that contains a bleach solution to clean the room and equipment of residents with[DIAGNOSES REDACTED]. He stated that they did not have any Sani-Wipes-Bleach on the unit,but they can order more from Environmental Services. He further reveled that every Resident who had[DIAGNOSES REDACTED] will have Sani-Wipes-Bleach in the room to clean equipment that was brought out of the room of a resident with[DIAGNOSES REDACTED]. He stated that each Contact Isolation room had bleach wipes in the room. He checked the room and verified that no Sani- Wipes-Bleach cleaning supplies were in the room. He exited the room and returned with 3 individual packs of Sani-clothes for the room and stated he would order more from Environmental Services. An observation was conducted on 03/18/2013 at 3:05 pm. S7PhysicalTherapy was gowned and gloved walking the resident in the hall with a gait belt around his waist. S7PysicalTherapy returned Resident # 303 to his room. S7PhysicalTherapy cleaned the porous clothe like material gait belt with a santi wipe-bleach wipe. She also cleaned a rolling walker. She discarded her gown and gloves in the clear garbage bag and failed to wash her hands in the resident's room. She exited the room, placed the walker against the wall of the hallway, and draped the gait belt over the walker then walked to the sink in front of the nursing station to wash her hands. An interview was conducted on 03/18/2013 at 3:28 pm with S7PhysicalTherapy. She stated that the gait belt was a washable item, and she wiped it down with a bleach wipe after using it with Resident # 303. She states that its possible spores could get into the belt and could not be properly cleaned with a bleach wipe. She confirmed she discarded her gown and gloves into a clear garbage bag. She stated she washed her hands in front of the nursing station and not in the resident's room. She further revealed that when the gait belt is used, it is placed in a pillow case and stored in the therapy department. She confirmed she removed her gown and gloves and placed these items into the clear plastic trash liners. An observation was conducted on 03/18/2013 at 3:15p.m. of Resident 303's room. The observation revealed two garbage cans with clear bags lining the cans . An observation was conducted on 03/18/2013 at 3:20 p.m. of S11PCA. S11PCA wheeled a portable blood pressure monitor and thermometer into Resident 303 ' s room. She then proceeded to take the blood pressure and temperature with the portable blood pressure monitor. She cleaned the portable blood pressure machine with a germicidal agent that was not an effective agent against[DIAGNOSES REDACTED]. She removed her gown and gloves and discarded them in the clear garbage bag. She failed to wash her hands in the resident's room. An interview was conducted on 03/18/2013 at 3:30 p.m. with S11PCA. She stated she knew Resident #303 was in Contact Isolation. She stated she cleaned the portable blood pressure machine with the germicidal wipes that was not indicated for[DIAGNOSES REDACTED]. She stated she knew that the portable blood pressure machine had to be cleaned with a bleach cleaner after taking it into a room with[DIAGNOSES REDACTED]. She further reveled no bleach wipes were located in the room and failed to disinfect the blood pressure machine with a bleach cleaner. She stated red bags were not located in the garbage cans in the room and gowns and gloves are discarded in the clear bags. She verified she removed her gown and gloves and placed these items into the clear plastic trash liners and failed to wash her hands in the Residents room.. An interview was conducted on 03/18/2013 at 5:45 p.m. with S5 Infection Control Practitioner. She stated that medicine carts, gait belts, and blood pressure machines should not be brought into a Residents room in Contact Isolation. She further revealed that in the event any equipment was taken into a room where the resident was on Contact Precautions, the equipment should be left in the room and then properly disinfected with a agent that kills[DIAGNOSES REDACTED] after the resident was discharged . She stated gowns and gloves should be discarded in clear plastic garbage bags.She confirmed that all staff should follow the policy and procedures for Residents in Contact Isolation. She stated staff should sanitize their hands prior to putting on gloves and wash their hands with soap and water prior to leaving a room. She confirmed that gowns, gloves and Sani-wipes should be located in the resident's on Contact Isolation at all times. An interview was conducted on 03/18/2013 at 5:55 p.m. with S1Director of Quality. She stated that equipment should not be brought into a Residents room in Contact Isolation. She further revealed that in the event any equipment was taken into a room where the resident was on Contact Precautions, the equipment should be left in the room and then properly disinfected with a agent that kills[DIAGNOSES REDACTED] after the resident was discharged . She stated they have isolation kits with disposable thermometer and blood pressure kits that should be used in Contact Isolation rooms. On 3/19/13 at 10:42 a.m. an observation was made of S6Housekeeper exiting Resident #303's bathroom with a gown and a pair of gloves on. Further observation noted S6Housekeeper touched clean towels on her cart and returned to Resident #303's bathroom. At 10:44 a.m. an observation was made of S6Housekeeper coming out of Resident #303's bathroom; with the same gown and gloves, returned back to the housekeeping cart , retrieved a set of keys and opened up 1 side of cart and got a clean towel. At 10:46 a.m. S6Housekeeper returned back to the cart with her same gown and gloves and touched items on her cart a 3rd time. At 10:50 a.m. S6Housekeeper returned back to the housekeeping cart with the same gown and gloves on retrieving an item off the housekeeping cart. Further observation noted that S6Housekeeper removed the broom/sweeper used to clean Resident #303's room without properly disinfecting it with a sporacidal agent that killed[DIAGNOSES REDACTED]. S6Housekeeper pushed her cart to room [ROOM NUMBER] and began cleaning that room. On 3/19/13 at 11:30 a.m., an interview was conducted with S6Housekeeper. She confirmed she did not remove her gown and gloves or wash her hands neither of the 4 times she came out of Resident #303's bathroom into the hallway to her housekeeping cart. She also confirmed she did not disinfect the sweeper/broom used to clean the resident's bathroom before exiting the resident's room. She said, "To be honest, I really don't know what I should have done". On 3/20/13 at 1:42 p.m. S13LPN was observed putting a pair of gloves on and attemped to open a gown. The gown fell to the floor. S13LPN picked the gown up off the floor with the gloves she had on, put it in the trash can and kept the same gloves on. At 1:55 p.m. S13LPN came out of Resident #303's with a gown and a pair of gloves on, retrieved a medication cart in the hall and returned back to the room. On 3/20/12 at 1:50 p.m. an interview was conducted with S13LPN. She confirmed she didn't wash her hands when she picked up the gown that fell to the floor. She also acknowledged she came out Resident #303's room with a gown and a pair of gloves on, retrived a medication cart and returned to the room without removing the gown/gloves and washing her hands and acknowledged she should have.

Based on record review and interview, the facility failed to provide professional standards of quality by failing to ensure that nursing staff implemented infection control procedures for Resident #303 who was diagnosed with [REDACTED]. The facility further failed to ensure that the other 20(#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #305, #306 ) residents from a total census of 21 residents were not subjected to staff who did not follow proper isolation precautions, before entering their rooms, after leaving a resident's room with a known infectious organism. The facility failed to: 1) Ensure nursing staff wore proper protective clothing before entering a room to provide care for a resident(#303) who was on contact precautions for [MEDICAL CONDITION]. 2) Ensure nursing staff implemented appropriate isolation precautions for a resident (#303) whose stool culture was reported positive for[DIAGNOSES REDACTED] on 12/7/13. 3) Ensure nursing staff followed MD orders for contact isolation on 11/26/12. 4) Ensure nursing staff implemented and followed CDC guidelines for infection control correctly to prevent spread of [MEDICAL CONDITION] infection. Residents (#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #303, #305, #306 were placed in Immediate Jeopardy on 3/18/13 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for Resident(#303) who had a positive stool culture on 3/13/13 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the SNF unit. The deficient practice remains in place for all other residents at a level 2. The Administrator was notified of the Immediate Jeopardy on 3/18/13 at 5:50 p.m. A Plan of Removal was presented by the S2Regulatory Coordinator which read: 1. The registered nurse, the physical therapist and the patient care attendant observed during the survey were counseled regarding the appropriate care of patients with [MEDICAL CONDITION] in Contact Precautions Hand Washing (Completed 3/18/13). 2. A. The policy IC-100 Patient Care Cleaning and Disinfecting was reviewed and revised to clearly articulate the requirement for equipment cleaning used on patients in contact precautions (e.g. [MEDICAL CONDITION] (Attachment A). Gait belts that are used by therapy will be cleaned in the same manner as other patient equipment if they are non-porous. If they are porous gait belts, they will be issued to the patient and left in the room; and disposed of upon discharge. B. The computer keyboards attached to the medication carts were replaced with Medigenic Cleaning required when flashing by Esterline Advanced Input Systems, which is a flat keyboard that can be wiped with a hospital approved bleach-based disinfectant (Completed 3/20/13). C. The policy IC-220 Infection Control: Isolation Precautions was revised to clarify that a bleach-based product will be used to clean equipment according to the manufacturer's guidelines. The requirement to wash hands with soap and water prior to leaving the patient's room was already in the policy. (Attachment B). D. The policy IC-230: Handling of Wastes, Sharps and Linens was reviewed and revised to require all waste for [MEDICAL CONDITION] patients to be discarded in a red biohazard bag. (Attachment C). E. The CDC guidelines 2007 Guideline for Isolation Precautions: Preventing Transmissions of Infectious Agents in Healthcare Settings were reviewed for the requirements of PPE equipment (e.g. gowns, gloves). BRG policy IC-215 Infection Control: Standard Precautions was revised to clarify proper disposal of PPE. (Attachment D). F. Accessibility of needed supplies (e.g. bleach-based disinfectant equipment. gowns) and equipment will be evaluated and replenished as needed daily on the night shift. G. The Infection Control Practitioner reviews the CDC Guidelines on an ongoing basis; reviews and revised the Infection Control Policies annually and PRN; and works with the SNF Administrative Staff to ensure the Infection Control Plan is implemented. H. The Housekeeping employee observed by the surveyor entering the patient's room in contact precautions has been counseled (Attachment E). 3. Staffs will be educated (Attachment F) on: Topic: Revised Policies: IC-100 Patient Care Cleaning and Disinfecting IC-215 Infection Control: Standard Precautions IC-220 Infection Control: Isolation Precautions IC-230 Infection Control: Handling of Wastes, Sharps and Linens Target Audience: The following direct care staff: SNF Nursing Staff to include RN's LPN's, PCA's. SNF PT, OT, speech, PTA, COTA, Rehab Technicians Education-"Just In Time" Instructions for patients for Isolation Precautions. A sign will be placed on the door of the patients in Contact Precautions instructing them to report to the nurse's station for instructions prior to entering the room. Targeted Audience: Direct and/or Indirect Support Patient Care staff (e.g. Housekeeping, Social Services, Dietary, etc.) Accessibility of supplies and equipment for patients with [MEDICAL CONDITION]. Targeted Audience: SNF Nursing Staff to include RN's, LPNs, PCA's. Education began on March 18, 2013 at 7:00 p.m. Effective at 7:00 p.m. on March 18, 2013 SNF staff to include RNs, LPNs, PCAs; and SNF PT, OT, Speech, PTA, COTA and Rehab Technicians will not be allowed to work on the SNF unit until the education is completed. Education as outlined above will be completed by all active SNF staff by March 20, 2013. Staff that have not completed the education due to PRN status, Leave of Absence or Vacation will not be allowed to accept a patient care assignment upon return until the education is completed. 3. Auditing and monitoring of the corrective action plan will be coordinated by the SNF Nurse Manager using the SNF Corrective Action Plan Audit Tool (Attachment G) to include the following: a. Beginning Monday March 25, 2013 100% of patients with [MEDICAL CONDITION] who are on Contact Precautions will be observed once daily at a random time of day until 100% compliance with appropriate care and precautions of the patient with [MEDICAL CONDITION] has been achieved for two weeks. b. The SNF Nurse Manager, or designee (e.g. Charge Nurse, Educator) will conduct an observation audit; provide immediate feedback to the staff; and coordinate with the staff' manager for any deficient practice. Once 100% compliance had been achieved for two weeks, weekly random audits will be conducted by the Nurse Manager, or designee until 100% compliance has been achieved for 4 months. During the observation audit, the room will be assessed for the availability of necessary supplies. c. Weekly reports will be provided by the SNF Nurse Manager to the SNF Director for discussion and further actions as needed. The Immediate Jeopardy was lifted on 3/20/13 at 5:35 p.m. when the facility implemented its plan of removal. Findings: Resident #303 was a [AGE] year old male admitted to the SNF unit on 03/09/2013 with [DIAGNOSES REDACTED]. Review of CDC Vital Signs March 2012 edition, Making Health Care Safer revealed the following in part: Stopping [DIAGNOSES REDACTED]icile Infections For Clinicians: 6 Steps to Prevention 1.. 2. Test for [DIAGNOSES REDACTED]icile when patients have diarrhea while on antibiotics or within several months of taking them. 3. Isolate patients with [DIAGNOSES REDACTED]icile immediately. 4. Wear gloves and gowns when treating patients with [DIAGNOSES REDACTED]icile, even during short visits. Hand sanitizer does not kill [DIAGNOSES REDACTED]icile, and hand washing may not be sufficient. 5. Clean room surfaces with bleach or another EPA-approved, spore-killing disinfectant after a patient with [DIAGNOSES REDACTED]icile has been treated there. 6... Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part. XLVII, Nurses: Practical Nurses and Registered Nurses Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part ..."3. development of those qualities and personal characteristics needed to practice practical nursing safely, effectively and with [MEDICATION NAME], including increased and ongoing development of self awareness, sound judgment, prudence, ethical thinking and behaviors, problem solving and critical thinking abilities...7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and working as a member of the interdisciplinary health care team..." Findings: Review of the facility's policies received revealed the following in part: Number: IC-220 Title: Isolation Precautions Policy: dated 02/13 Purpose: Isolation Precautions will be implemented to reduce or eliminate the transmission of certain microorganisms including [MEDICAL CONDITION]. Procedure: 7. The Isolation Precautions Kit which contains a disposable blood pressure cuff, thermometer and stethoscope and will be used for patients in the following: b. Contact Precautions Hand Washing Procedure: Hand Hygiene 1. Hands hygiene will be performed: a. Immediately prior to putting on personal protective equipment. This should be done in the patient ' s room. Contact Precautions Hand Washing 1. Gloves and a long sleeve gown (personal protective equipment) will be worn: a. When providing care to the patient b. When contact with environmental surfaces or equipment in the patient ' s room is anticipated. 2. Personal protective equipment will be removed and hands will be washed with soap and water prior to leaving the patients room. 3. If disposable equipment cannot be used, reusable equipment will be cleaned and disinfected according to policy IC-100: Patient Care Equipment Cleaning and Disinfecting. a. Reusable equipment and environmental surfaces will be disinfected using a bleached -base disinfectant whenever feasible. 5. Everyone will be required to wash their hands with soap and water prior to leaving the patients room. Number IC-230 Title: Handling of Wasted, Sharp, Linen, and Reusable Pillows Policy: dated 01/11 Purpose: To outline the process for handling of waste, sharps, soiled linens, and reusable pillows that minimize exposure to bacteria [MEDICAL CONDITION] that may be found in blood and other potentially infectious materials (OPM), which includes body fluids. Policy: 3. Place all medical waste, except sharps in a red biohazard bag. Review of Resident #303's Laboratory documentation revealed the following in part: 03/12/13- [MEDICAL CONDITION] Positive Initiate Contact Precautions- Hand Washing for inpatients. An observation was conducted on 03/18/2013 at 11:30 a.m. of Resident ' s # 303 Door. The Door was labeled with Pink Signage approximately 12 inches x 24 inches in size that revealed the following verbiage. Stop: Please See Nurse Before Entering The Room. Contact Precautions Hand Washing. 1. Clean hands immediately prior to putting on gloves and long- sleeve gown. 2. Wear gloves and a long-sleeve gown when providing any care to the patient. Discard immediately prior to leaving the room. 3. Everyone Must wash their hands with soap and warm water immediately prior to leaving the room. On 3/18/13 at 12:15 p.m. an observation was made of S10RN standing in the hallway putting on a gown and a pair of gloves. Further observation noted S10RN did not wash her hands before putting on a gown and gloves in Resident #303's room. S10RN was observed pushing a medication cart; that contained other resident's medicines, in Resident #303's room who was on Contact Precautions for [MEDICAL CONDITION]. On 3/18/13 at 12:32 p.m. an observation was made of S10RN standing in the hall with her medication cart. Further observation revealed that she never properly disinfected the cart; with an agent that killed [MEDICAL CONDITION], before pushing it out of the resident's room. On 3/18/13 at 12:45 p.m. an interview was conducted with S10RN. She stated Resident #303 was on Contact Precautions for [MEDICAL CONDITION]. She said the facility's protocol was to wash your hands and put a gown and gloves on when entering a resident room on Contact Precautions. She verified she did not wash her hands immediately before downing gown and gloves. S10RN said she washed her hands down the hall in front of the nurses station. She acknowledged she pushed a medication cart in Resident #303's room; that contained other resident's medications, and did not properly disinfected it with an agenct that killed [MEDICAL CONDITION] before removing it from the resident's room. She stated that she did not know the facility policy stated she was supposed to wash her hands in the resident's room before putting on the gown and gloves and said she would have to refresh herself on that policy. An interview was conducted with on 03/18/2013 at 3:00 p.m. with S4UnitManager. He stated staff should use Sani- Wipes-Bleach that contained a bleach solution to clean the room and equipment for residents with [MEDICAL CONDITION]. He stated they did not have any Sani-Wipes-Bleach on the unit and they could order more from Environmental Services. He further revealed every Resident who had [MEDICAL CONDITION] should have Sani-Wipes-Bleach in the room to clean equipment brought out of the room. He stated that each Contact Isolation room had bleach wipes in the room. He checked the room and verified that no Sani- Wipes-Bleach cleaning supplies was in the room. An interview was conducted on 03/18/2013 at 5:55 p.m. with S1 Director of Quality. She stated that equipment should not be brought into a Residents room in Contact Isolation. She further revealed that in the event any equipment was taken into a room where the resident was on Contact Precautions, then equipment should be left in the room and the properly disinfected with a agent that kills [MEDICAL CONDITION] after the resident was discharged . She stated they have isolation kits with disposable thermometer and blood pressure kits that should be used in Contact Isolation rooms. She further revealed S10RN had been instructed and counseled on the policy for Contact Isolation. On 3/20/13 at 1:42 p.m. S13LPN was observed putting a pair of gloves on and attemped to open a gown. The gown fell to the floor. S13LPN picked the gown up off the floor with the gloves she had on, put it in the trash can and kept the same gloves on. At 1:55 p.m. S13LPN came out of Resident #303's with a gown and a pair of gloves on, retrieved a medication cart in the hall and returned back to the room. On 3/20/12 at 1:50 p.m. an interview was conducted with S13LPN. She confirmed she didn't wash her hands when she picked up the gown that fell to the floor. She also acknowledged she came out Resident #303's room with a gown and a pair of gloves on, retrived a medication cart and returned to the room without removing the gown/gloves and washing her hands and acknowledged she should have.

Based on clinical record review and interview the facility failed to ensure an assessment of the resident's ability and desire to participate in activities or the resident's activity preferences was conducted for 1 (#309) of 2 (#309, #312) reviewed for activities. There were 32 residents reviewed in Stage II. Findings: Review of Resident # 309's clinical record revealed she was an [AGE] year old female with an admission date of [DATE]. Resident #309's [DIAGNOSES REDACTED]. Review of the MDS (Minimum Data Set), with an assessment reference date of 3/10/13, revealed there was no documentation of an assessment regarding the resident's Preferences for Customary Routine and Activities (Section F). Review of the Recreational Therapy notes revealed there was no documentation for recreation therapy (activities) visits related to assessments from 3/5/13-3/18/13. An interview was held with S8ActivitiesCoordinator on 3/19/13 at 2:48 p.m. S8ActivitiesCoordinator verified that she had not completed an initial evaluation for activities for Resident # 309 since her admission on 3/5/13. She also said that she had not spoken with the resident or her family to find out the residents likes or dislikes related to activities. An interview was held with the S9MDSCoordinator on 3/20/13 at 1:52 p.m. She verified there was no MDS worksheet for preferences for activities for Resident #309. She also said there was no documentation of an assessment in the Recreational Therapy (activities) visits for the resident from 3/5/13-3/18/13.

Based on record review, and interview the facility failed to develop a comprehensive care plan with measurable goals and interventions for 1 (#303) of 21 (#321, #320, #317, #316, #314, #304, #323, #322, #318, #315, #313, #312, #311, #310, #309, #308, #307, #305, #306) resident's to address care issues associated with contact isolation. Findings: Resident #303 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #303's Laboratory documentation revealed the following in part: 03/12/13- [MEDICAL CONDITION] Positive Initiate Contact Precautions- Hand Washing for inpatients. Review of Resident # 303's e-chart revealed no Plan of Care for Isolation or [MEDICAL CONDITION]. An interview was conducted on 03/20/2013 at 2:30 p.m. with S4Unit Manager. He stated the primary nurse was responsible for the Contact Isolation care plan. He further revealed that the care plans should be reviewed and revised for the Resident on each shift and appropriate changes made. He further revealed the resident was admitted to skilled nursing unit on 03/13/2013 and was placed on contact isolation. S4UnitManager viewed the e-care plan and verified Resident #303's care plan was first initiated for contact isolation on 03/20/2013 seven days after admit to the unit, and should have been initiated on 03/13/2013.

Based on observation and interview, the facility failed to ensure that food items were stored, distributed and served under sanitary conditions as evidenced by not ensuring the resident's food was covered when transporting on food carts from the 1st floor to the 5th floor . This deficiency had the potential to affect all 21 residents residing on the Skilled Nursing Facility Unit that received food items from the kitchen. Findings: On 3/18/13 at 11:30 a.m. an observation was made of an open metal cart with resident's trays on it without a covering. Further observation noted a plate with a lid cover partly off, exposing a resident's food. On 3/19/13 at 11:12 a.m. an observation was made of S11PCA exiting the elevator pushing an open metal cart with the resident's trays on it with the lid partly off several trays exposing bread and cheese cake. On 3/19/13 11:15 a.m. an interview was conducted with S23RNC. She verified several food lids were off of resident's trays with their bread and cheese cake exposed upon arrival to the SNF Unit.. On 3/19/13 at 11:24 a.m. an observation was made of a Dietary Staff pushing an open metal cart on the SNF unit with several lids partly covering the resident's food with bread and muffins exposed. On 3/19/13 at 11:26 a.m. an interview was conducted with S3Director of Nutritional Services. He confirmed there were several resident's trays on the open metal cart with lid covers off, exposing resident's food and said it should not have been.

Based on interviews and record reviews the facility failed to immediately notify the physician of a deep tissue injury for 1 (#59) of 3 (#59, #199, & #207) residents reviewed for pressure ulcers in the stage 2 sample. Review of the Census and Condition form dated 4/24/12 revealed there were 5 residents in the facility with pressure ulcers. Findings: Resident #59 Review of the nurse's notes revealed that Resident #59 was [AGE] years old and admitted on [DATE] with a stage 2 pressure ulcer to the coccyx. Review of the clinical record revealed that Resident #59 had the following Diagnoses: [REDACTED]. Review of the wound care notes dated 11/9/11 revealed 2 deep tissue injury pressure ulcers to the left ankle: left lateral 4.2 centimeters (cm) x 3.4 cm and left medial 1.5 cm x 1.6 cm. An interview was held with S7Director of Quality & Patient Safety on 4/26/12 at 12:32 p.m. After reviewing the chart she verified that the physician was made aware of the left ankle deep tissue injury wounds on 11/15/11. She explained anytime a patient's condition changes the physician should be notified immediately. She verified that the physician should have been notified on 11/9/11 when the 2 deep tissue injuries were first identified on Resident #59's left ankle. An interview was held with S1DON on 4/26/12 at 3:55 p.m. After reviewing the medical record, she verified there was no documentation that the physician was notified of the deep tissue injuries on the left ankle on 11/9/11. She verified that the documentation revealed the physician was notified of the deep tissue injuries to the left ankle on 11/15/11.

Based on observations and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions by failing to wear hair restraints to prevent their hair from contacting exposed food. There were 24 residents that were served food from the kitchen. Findings: An observation was made of S2DietaryStaff cooking meat on 4/24/12 at 9:10 a.m. He was noted to be wearing a cap. He had 3 inches of hair around the back of his head that was not contained by the cap. An interview was held with S2DietaryStaff at this time. He verified that he did not have a hair net on. He said that he did not usually wear a hair net. He explained that he just wore his cap. An interview was held with S3NutritionalSystemsDirector on 4/24/12 at 9:15 a.m. He verified that S2DietaryStaff did not have a hair net on and his hair was not contained. S3NutritionalSystemsDirector verified that S2DietaryStaff's hair should be contained. An observation was made of S4DietaryStaff on 4/24/12 at 9:20 a.m. He was working in the food prep area. He was noted to be wearing a baseball cap. He also had a mustache, and he did not have it covered. An interview was held with S4DietaryStaff at this time. He said that he did not wear hair nets because he wore a baseball cap. He also verified that he did not cover his mustache. An interview was held with S3NutritionalSystemsDirector at 9:25 a.m. on 4/24/12. He verified that S4DietaryStaff's hair and mustache were not contained. He verified it should be contained. An observation was made of S5DietarySupervisor working in the food prep area on 4/24/12 at 9:40 a.m. He was noted to have a mustache and beard, and he was not wearing anything to contain his beard and mustache. An interview was held with S5DietarySupervisor at this time. He verified that he did not have his beard or mustache covered. He said that his beard covering had gotten messed up that morning so he threw it away. He said that he did not have another one to replace it. An interview was held with S6DirectorofNutritionalCare on 4/24/12 at 9:50 a.m. He verified that S5DietarySupervisor did not have anything on to contain his beard or mustache.