Every finding on record at St James Place Nursing Care Center

Based on interviews and record review, the facility failed to maintain documentation and demonstrate evidence of their ongoing Quality Assurance and Performance Improvement (QAPI) Program. The QAPI committee failed to provide sufficient evidence of documented investigation, data analysis, monitoring, or evaluation of corrective actions put in place after identifying issues with inadequate documentation of resident's weights for 1 (#1) of 1 resident reviewed for weights. This deficient practice had the potential to affect a census of 55 residents. Findings: Review of the facility's policy with a revision date of 12/23/2020, and titled, Quality Assurance and Performance Improvement Plan, revealed the following, in part: Purpose: The purpose of the QAPI plan in our organization is to take a proactive approach to continually improve the way we care for and engage with our residents, caregivers, and other partners. Governance and Leadership: The governing body will be responsible for overseeing the QAPI committee. The Healthcare Services Administrator will have direct oversite for all functions of the QAPI committee and will report to the governing body. Feedback, Data and Monitoring: The QAPI committee will put systems in place to monitor care and services and review data from multiple sources. Performance indicators will be used to monitor care processes and facility outcomes. Action plans will be implemented to improve processes and prevent recurrences. The QAPI committee will use trending data to routinely monitor the following care items: Clinical Care. Review of the facility's policy with a review date of 10/2025, and titled, Weight Monitoring, revealed, in part, the following:Policy Summary and Objective:To establish a standardized process for obtaining, documenting, monitoring, and responding to resident weight changes in accordance with federal regulations, nursing facility requirements, physician orders, and accepted standards of practice.III. Physician-Ordered WeightsAdditional weights shall be obtained as ordered by the physician, nurse practitioner, or physician assistant.Examples include:Daily weights, weekly weights, weights following hospitalization, and weights related to CHF, renal disease, edema, diuretic therapy, nutritional concerns, or other clinical conditions. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included Abnormal Weight Loss and Parkinson's Disease. Review of Resident #1's current Physician Orders revealed, in part, an order dated 04/10/2025, for Resident #1 to be weighed every three days. Review of Resident #1's weight logs dated 03/01/2026 to present, revealed no documented evidence of being weighted on 03/21/2026, 04/14/2026, 04/21/2026, 05/11/2026, 05/17/2026, and 05/20/2026. On 06/17/2026 at 3:22 p.m., an interview was conducted with S2DON. The above mentioned incomplete documentation of Resident #1's weights were reviewed with S2DON. She stated nurses are responsible for obtaining daily weights and documenting the weights in the residents' electronic health record. S2DON also stated CNAs were responsible for obtaining weekly and monthly weights and documenting them on the Weekly Weights form. S2DON further stated it was her responsibility to review weights documented by CNAs and enter them into residents' electronic health record, as well as to review all resident weights to ensure they had been obtained as ordered and documented. S2DON confirmed Resident #1's weights should have been documented on the above mentioned dates and were not. Review of the facility's QAPI plan dated March 2026, as of 06/17/2026 at 4:00 p.m., revealed the following in part: In-service provided to nursing staff dated 03/10/2026 to include: ensure weights are performed as ordered and documented (daily, weekly, and monthly). Further review of the facility's QAPI plan as of 06/10/2026 at 4:00 p.m., revealed no evidence of documented investigation, data analysis, monitoring, or evaluation of corrective actions for the in-service provided to nursing staff on 03/10/2026. On 06/17/2026 at 4:00 p.m., an interview was conducted with S2DON. S2DON stated she had a QAPI on documenting weights which was open as of March 2026. S2DON stated she first identified an issue with staff documenting weights in February 2026 when she was documenting weights in the electronic health record and realized the weights were not correct or there was no baseline weight obtained during the resident's admission. S2DON stated there was a verbal in-service held for the nurses on 03/10/2026 pertaining to obtaining and documenting weights per physician orders. S2DON confirmed she had only completed the in-service on documenting weights with nursing staff, and had no documented evidence of investigation, data analysis, monitoring, or evaluation of the corrective actions. S2DON confirmed the verbal in service on documenting weights on 03/10/2026 was not effective since the survey team identified deficient practice regarding documenting resident weights. On 06/17/2026 at 4:05 p.m., an interview was conducted with S1ADM. S1ADM confirmed the QAPI on documenting weights was not effective, and should have included data analysis, documented evidence of monitoring weights per physician orders, and evaluation of corrective actions, and it did not.

Based on record reviews and interviews, the facility failed to report an injury of unknown origin to the State Survey Agency immediately, but no later than 24 hours after discovery, for 1 (#32) of 3 residents reviewed for hospitalizations. Findings:Review of the facility policy dated 07/2015 and titled, Incidents in Healthcare Reporting revealed the following: Policy Guidelines and Procedures: B. Facility shall report to State Agency any incidents suspected of involving: 4. Injuries of unknown originInjuries of unknown origin are defined as:a. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident; orc. the initial report of the incident or accident is due within 24 hours of occurrence or discovery of the incident.Review of Resident #32's Clinical Record revealed she was admitted to the facility on [DATE].Review of Resident #32's Quarterly MDS with an ARD of 03/18/2026 revealed a BIMS could not be conducted due to Resident #32 being rarely/never understood.Review of the Facility's Emergency Transfer log revealed Resident #32 was transferred to a local area hospital on [DATE] due to arm swelling.Review of Resident #32's Nurses' Notes revealed on 05/24/2026 at 2:31 p.m., S3LPN, wrote the following, in part: Skin/body audit completed. Bruising noted to right upper extremity above and below elbow with skin intact and no open areas observed. Review of Resident #32's Event Report revealed S2DON completed a Skin Integrity Investigation on 05/26/2026 at 5:12 p.m. and determined the following, in part: Event details: BruisePhysical Observation: 2 Discolorations noted to RUE (Right Upper Extremity). One dark purple in color with fading to exterior, noted to posterior RUE and measuring 12 cm x 8 cm. Second discoloration noted to elbow measuring approximately 5 cm x 5 cm. No open areas noted. Swelling noted to RUE.Activity during Bruise Occurrence: No activity selectedInterventions: Notified NP. New orders received for x-ray and labs. On 06/17/2026 at 2:48 p.m., an interview was conducted with S3LPN. She stated she had completed Resident #32's weekly body audit on 05/24/2026 and discovered mild swelling and speckled, purple bruising on and above Resident #32's right elbow. She stated she notified nursing management of Resident #32's RUE injury via text on 05/24/2026 at 5:32 p.m. She stated Resident #32 was non-verbal during the skin assessment and unable to communicate the cause of the injury. She stated she did not receive any reports from the CNAs regarding a fall or an incident during transfer. On 06/16/2026 at 1:34 p.m., an interview was conducted with S2DON. She stated S3LPN discovered Resident #32's RUE bruising on 05/24/2026 and notified management via text on 05/24/2026 at 5:32 p.m. She further stated she completed an investigation pertaining to Resident #32's RUE bruising and swelling on 05/26/2026 and was unable to determine the cause of the injury through physical observation and staff interviews. She confirmed due to the unknown source of the injury, Resident #32's injury should have been considered an injury of unknown origin and reported within 24 hours of discovery to State Agency and was not. On 06/17/2026 at 10:48 a.m., an interview was conducted with S1ADM. She stated she expected all injuries of unknown origin to be investigated immediately and reported to State Agency within the established time requirements. She confirmed the cause of Resident #32's injury was not determined through S2DON's investigation and should have been considered an injury of unknown origin. She confirmed a SIMs report should have been submitted within 24 hours and was not.

Based on observations, interviews and record review, the facility failed to ensure resident assessments accurately reflected the residents' status. The facility failed to ensure staff accurately coded:The use of restraints and alarms for 1 of 1 (#7) residents reviewed for physical restraints; andThe Functional Limitation in Range of Motion for 1 of 1 (#32) residents reviewed for mobility.Findings: Review of the facility's policy dated 08/2018 and titled, Resident Assessment Instrument (MDS) revealed the following, in part: Policy Guidelines and Procedures:The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Each assessment should reflect each resident's current status to include clinical, functional and psychosocial status. 1.Review of Resident #7's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #7's Quarterly MDS with an ARD of 04/08/2026, revealed a BIMS score of 14, which indicated intact cognition. Further review revealed the following, in part: Section P0100. Physical Restraints; Chair prevents rising-Used less than dailySection P0200. Alarms; Bed Alarm-Used less than daily Review of Resident #7's current physician orders revealed no orders for the use of physical restraints or alarms. On 06/15/2026 at 9:45 a.m., an observation was made of Resident #7 in bed. No physical restraints observed and no alarms were heard when she moved in bed. On 06/15/2026 at 9:47 a.m., an interview was conducted with Resident #7. She stated she had never been restrained or heard an alarm when she got out of bed. On 06/17/2026 at 10:38 a.m., an interview was conducted with S5MDS. She stated she was responsible for coding Resident #7's MDS assessments. She reviewed Section P on Resident #7's MDS with an ARD of 04/08/2026. She confirmed Resident #7 was coded as utilizing a chair restraint and bed alarm less than daily and should not have been. She further confirmed the facility did not utilize physical restraints and alarms with any residents. 2.Review of Resident #32's clinical record revealed she was admitted to the facility on [DATE] and had diagnoses which included Cerebral Infarction and contracture of muscle, right and left upper arm. Review of Resident #32's Quarterly MDS with an ARD of 03/18/2026 revealed the following, in part:Section GG0115. Functional Limitation in Range of Motion (ROM); Upper Extremity (shoulder, elbow, wrist, hand)-No impairment On 06/17/2026 at 10:38 a.m., an interview was conducted with S5MDS. She stated she was responsible for coding Resident #32's MDS assessments. She reviewed Section GG on Resident #32's MDS with an ARD of 03/18/2026. She confirmed Resident #32 was coded as having no impairment in her Upper extremity ROM and should not have been. She confirmed Resident #32's had bilateral arm and hand contractures that caused limitation in her upper extremity ROM. On 06/17/2026 at 11:02 a.m., an interview was conducted with S2DON. She stated she expected each residents' MDS assessments to be coded accurately to reflect their status.

Based on record review and interviews, the facility failed to ensure resident weights were accurately documented for 1 of 1 (#1) resident reviewed for weights.Review of the facility's policy Weight Monitoring, with a reviewed date of 10/2025, revealed, in part, the following:Policy Summary and Objective:To establish a standardized process for obtaining, documenting, monitoring, and responding to resident weight changes in accordance with federal regulations, nursing facility requirements, physician orders, and accepted standards of practice.III. Physician-Ordered WeightsAdditional weights shall be obtained as ordered by the physician, nurse practitioner, or physician assistant.Examples include:Daily weights, weekly weights, weights following hospitalization, and weights related to CHF, renal disease, edema, diuretic therapy, nutritional concerns, or other clinical conditions.Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE] with diagnoses, which included Abnormal Weight Loss.Review of Resident #1's current Physician's Orders revealed, in part, an order dated 04/10/2025, for Resident #1 to be weighed every three days.Review of Resident #1's weight logs dated 03/01/2026 to present, revealed no documentation of weights on 03/21/2026, 04/14/2026, 04/21/2026, 05/11/2026, 05/17/2026, and 05/20/2026.On 06/17/2026 at 3:22 p.m., an interview was conducted with S2DON. The above mentioned incomplete documentation of Resident #1's weights were reviewed with S2DON. She stated nurses were responsible for obtaining daily weights and documenting the weights in the residents' electronic health records. S2DON stated CNAs were responsible for obtaining weekly and monthly weights and documenting them on the Weekly Weights form. S2DON further stated it was her responsibility to review weights documented by CNAs and to enter them into residents' electronic health record, as well as to review all resident weights to ensure they had been obtained as ordered and documented. S2DON confirmed Resident #1's weights should have been documented on the above mentioned dates and were not.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards for 3 (#1, #2 and #3) of 3 sampled residents reviewed for baths/showers. Findings:Review of the Facility's Policy titled, Documentation in Clinical Record, revised in October 2025, revealed the following, in part:Procedure:Documentation on skilled residents is required every shift with evidence supporting the skilled service.Documentation must be completed every shift for assistance with activities of daily living (ADL) by assigned CNA.Ensure documentation provides an accurate reflection of nursing care and ADL assistance for each resident, including assessments, treatments, changes in clinical status, pertinent information, which supports deliverance of quality resident care by the multidisciplinary team. Resident #1Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #1's Physician Orders revealed the following, in part: bath on Tuesday, Thursday, and Saturday Days 6:30 a.m. - 6:30 p.m. Review of Resident #1's bath log dated 12/11/2025 through 01/06/2026 revealed the following, in part: no documentation a bath/ shower was given on the following dates: 12/13/2025, 12/16/2025, 12/23/2025, 12/25/2025, and 01/06/2026. An interview was conducted on 01/07/2026 at 2:34 p.m. with S2CNA. S2CNA confirmed she bathed Resident #1 on 12/16/2025 and 12/25/2025, but did not document it, and should have. Resident #2Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #2's Physician Orders revealed the following, in part: bath on Tuesday, Thursday, and Saturday Nights 6:30 p.m. - 6:30 a.m. Review of Resident #2's bath log dated 11/02/2025 through 01/03/2026 revealed the following, in part: no documentation a bath/ shower was given on the following dates: 11/05/2025, 11/14/2025, 11/16/2025, 11/19/2025, 11/23/2025, 11/28/2025, 11/30/2025, 12/03/2025, 12/07/2025, 12/10/2025, 12/12/2025, 12/17/2025, 12/19/2025, 12/21/2025, 12/26/2025, 12/28/2025, 12/31/2025, and 01/02/2026. An interview was conducted on 01/08/2026 at 10:32 a.m. with S3CNA. S3CNA stated she worked with Resident #2 on 01/02/2026, 12/28/2025, and 12/19/2025. S3CNA stated she remembered giving Resident #2 a shower on 01/02/2026 but did not remember if she documented the shower was given. She further confirmed a shower given should be documented in the resident's record. Resident #3Review of Resident #3's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Physician Orders revealed the following, in part: bath on Tuesday, Thursday, and Saturday Days 6:30 a.m. - 6:30 p.m. Review of Resident #3's bath log dated 11/01/2025 through 01/07/2026 revealed: no documentation a bath/ shower was given on the following dates: 11/01/2025, 11/06/2025, and 11/13/2025. An interview was conducted on 01/07/2026 at 2:20 p.m. with S4CNA. S4CNA confirmed she worked with Resident #3 on 11/13/2025, but could not remember if Resident #3 received her bath. S4CNA further confirmed she did not document if the bath was given, but should have. An interview was conducted on 01/08/2026 at 10:45 a.m. with S1DON. S1DON confirmed there was no documentation on the aforementioned dates for completion of baths or showers for Resident #1, Resident #2, and Resident #3 and there should have been.

Based on observations, interviews, and policy review, the facility failed to store serving dishes and prepare food under sanitary conditions by failing to ensure ceiling vents in two kitchen locations remained free of thick fluffy gray substance. The deficiency had the potential to affect 58 residents who were served meals from the kitchen. Findings: Review of Policy, dated 05/2012, DS Cleaning and Maintenance of Kitchen revealed: Policy Guidelines and Procedures: Ceilings, Vents, and Lights, Ceiling tiles, vents, and lights must be cleaned monthly and maintained in good condition. Ceiling tiles and vents must be dust free . When ceiling tiles, vents, and lights require cleaning, a work order will be placed with Environmental Services. Findings: On 06/23/2025 at 11:40 a.m., an observation was made with S8CS of Kitchen A which revealed ceiling vent covering above the sanitation machine had excessive fluffy gray substance visible above the clean dish rack. S8CS stated she did not know when vents were cleaned last. On 06/23/25 at 12:00 p.m., an interview and observation of Kitchen B was conducted with S7DS. S7D verified observations of ceiling vent covering with large amount of fluffy gray substance and stated the vent did not appear to be clean. She stated she did not know who was responsible or when kitchen vent coverings were last cleaned or replaced. On 06/24/25 at 08:31 a.m., an observation was made of Kitchen B vent directly above clean dish rack completely covered with thick clumps of fluffy gray substance and unable to view openings of vent due to excessive debris. On 06/24/25 at 09:55 a.m., an interview and observation of Kitchen A and Kitchen B ceiling vents was conducted with S5DM. He verified and confirmed both Kitchen A and Kitchen B ceiling vent coverings were completely covered with thick fluffy gray substance, unable to visualize vent holes due to excessive debris and not clean. He stated he was not sure when vents were last cleaned or if monitored by Maintenance Department, nor who was responsible to clean them. On 06/24/2025 at 01:30 p.m., an interview was conducted with S6PSM. After observing Kitchen A and Kitchen B ceiling vents, he confirmed observations of vent coverings completely covered with thick fluffy gray substance and were not clean. He stated he was responsible for monitoring of all ceiling vent coverings in the facility. He further stated that the kitchen vents were not on a regular cleaning, maintenance check schedule and had not been monitored for cleaning or vent covering change needs. He confirmed he had no documentation of when the ceiling vent coverings were last cleaned or changed and he should have.

Based on record reviews and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards and practices for 1 (#32) of 3 (#1, #10, and #32) residents reviewed for Pressure Ulcer/Injury. The facility failed to ensure nursing staff accurately documented Resident #32's weekly body audits. Findings: Review of the facility's policy Documentation in Clinical Record, revised 10/2024, revealed the following, in part: Procedure: Ensure documentation provides an accurate reflection of nursing care and activities of daily living assistance for each resident, including assessments, treatments, changes in clinical status, pertinent information, which supports deliverance of quality resident care by the multidisciplinary team. Review of Resident #32's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #32's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/14/2025, revealed he had one unhealed Stage II pressure ulcer/injury. Review of the facility's Wound Log dated March 2025 to June 2025 revealed Resident #32 had a right heel pressure ulcer, Stage III, identified on 11/11/2024 and healed on 05/02/2025. Further review revealed Resident #32 had a left heel pressure ulcer, Stage II, identified 03/06/2025, with most recent documentation dated 06/17/2025 as stable, with measurements 1.3 x 0.5 x 0.3 (Length x Width x Depth) centimeters (cm). Review of the Resident #32's current Physician Orders revealed Resident #32 should receive weekly body audits every Saturday. Further review revealed an order to discontinue wound care to the right heel on 05/14/2025, with note right heel has resolved. Review of Nurses' Note dated 05/10/2025, 05/24/2025, 06/07/2025, and 06/21/2025 revealed weekly body audits documenting the presence of pressure ulcer/injury to both the right and left heel as follows: 05/10/2025 10:11 a.m., weekly body audit . He does have a right heel stage II pressure wound, with no drainage at this time, and a left heel stage II. Will continue to use cleanser, pat dry, and wrap with kerlix daily. Signed S10LPN. 05/24/2025 2:52 p.m., weekly body audit . He does have a right heel stage II pressure wound with scant brownish drainage at this time, and a left heel scab. Will continue to use cleanser, pat dry, calcium alginate and wrap with kerlix daily. Signed S10LPN. 06/07/2025 10:11 a.m., weekly body audit . He does have a right heel stage II pressure wound with scant brownish drainage at this time, and a left heel scab. Will continue to use cleanser, pat dry, calcium alginate and wrap with kerlix daily. Signed S10LPN. 06/21/2025 01:44 p.m., weekly body audit . He does have a right heel stage II pressure wound with scant brownish drainage at this time, and a left heel scab. Will continue to use cleanser, pat dry, calcium alginate and wrap with kerlix daily. S10LPN. Between the dates of 06/23/2025 and 06/25/2025, multiple attempts made via telephone to contact S10LPN were unsuccessful. On 06/24/2025 at 3:03 p.m., an interview was conducted with S9CNA. S9CNA stated Resident #32 no longer had any pressure injuries on his heels. On 06/25/2025 at 9:17 a.m., an interview was conducted with S2DON. S2DON stated the facility's wound care nurse was unavailable. S2DON confirmed she was familiar with Resident #32's care. S2DON reviewed Resident #32's medical record and confirmed Resident #32 had a Stage III pressure ulcer/injury to his right heel healed on 05/02/2025. S2DON confirmed any documentation past 05/02/2025 noting Resident #32 to have a pressure ulcer/injury to his right heel was inaccurate. S2DON confirmed she expected staff's documentation to reflect an accurate picture of the resident's current condition.

Based on interviews and record review, the facility failed to implement policies and procedures for COVID-19 immunizations for 1 (#11) of 5 (#1, #10, #11, #16 and #254) resident's records reviewed for immunizations. The facility failed to ensure the residents' medical records included documentation that indicated: 1. Residents or resident representatives received education regarding the benefits and potential side effects of COVID-19 immunization; and 2. Residents either received the COVID-19 immunization or did not receive the COVID-19 immunization due to medical contraindication or refusal. The deficient practice had the potential to affect any of the 58 Residents residing in facility who required education and consents for immunizations. Findings: Review of Resident #11's medical record revealed he was admitted to the facility on [DATE]. Further review revealed Resident #11 was not vaccinated with the COVID-19 vaccine nor any documentation of a rationale for the resident not receiving the COVID-19 vaccine and no documentation of education regarding the benefits and potential side effects related to the COVID-19 vaccine for year 2024. On 06/24/2025 at 11:55 a.m., an interview was conducted with S2DON. She stated she was responsible for infection control program since March 20205. She confirmed the COVID-19 vaccinations were available for the facility to administer. She further confirmed Resident #11 was offered the COVID-19 vaccination in 2023. She confirmed there was no COVID-19 vaccination consent declination nor documentation in Resident #11's record of education provided to resident or resident's representative regarding benefits or side effects related to COVID-19 vaccinations, and should have been.

Based on interviews and record review, the facility failed ensure 1 (#11) of 5 (#1, #10, #11, #16, and #254) residents' records reviewed for immunizations had documentation indicating: 1. Resident or resident representative received education regarding the benefits and potential side effects of Pneumococcal and Influenza immunization; and 2. Resident either received, did not receive, or refused the Pneumococcal and Influenza immunization due to medical contraindication. Findings: Review of the facility's policy, titled Infection Control Policies And Procedures, reviewed on 06/24/2024, revised 04/11/2025, revealed, in part: Policy: The Advisory Committee on Immunizations Practices (ACIP) recommends that an Influenza vaccine be provided annually to all residents of nursing communities, prior to Influenza season. Procedure: B. If the resident/authorized representative refuses the vaccine, this will be documented .in the Electronic Health Record. C. If the resident consents to the vaccine, the procedure will be explained .the resident or resident representative will sign and date in the Electronic Health Record. Review of Resident #11's clinical record from 10/01/2024 to 06/24/2025 revealed no documentation of pneumococcal and influenza immunization status. On 06/24/2025 at 11:55 a.m., an interview was conducted with S2DON. She stated she was responsible for the infection control program since 03/2025.She stated the most recent vaccine consent form for Resident #11 was dated 11/01/2023. She confirmed she was responsible for ensuring complete documentation of obtaining consents, education was provided, and administration of pneumococcal and influenza vaccines for all residents beyond admission process. She reported the pneumococcal and influenza vaccines were available for administration if requested. S2DON confirmed all pneumococcal and influenza immunization administration and documentation was not complete for Resident #11 at this time and she had no evidence annual immunization process was followed for Resident #11.

Based on observations, interviews, and record review, the facility failed to implement and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 (#254) of 2 (#48 and #254) residents observed with catheters. The facility failed to ensure Resident #254's catheter bag and tubing remained off of the floor. Findings: Review of the facility's policy titled, Catheter Insertion and Removal with a revision date of 07/2024 revealed the following, in part: Catheter Placement: Check placement of drainage bag to ensure bag does not touch floor and is below bladder level. Secure drainage bag when applicable to prevent accidental contamination. Avoid allowing any part of urinary catheter system to touch floor. Review of Resident #254's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #254's current Physician Orders revealed Foley Catheter care every shift with a start date of 06/18/2025. Review of Resident #254's current Care Plan revealed the following, in part: Problem: Resident requires an external catheter related to urinary retention. Approach: Do not allow tubing or any part of the drainage system to touch the floor. On 06/23/2025 at 9:50 a.m., an observation was made of Resident #254 in her room sitting in her wheelchair, catheter tubing was observed resting on the floor. On 06/24/2025 at 2:45 p.m., an observation was made of Resident #254's indwelling catheter bag and tubing resting on the floor. On 06/24/2025 at 3:40 p.m., an observation and interview was conducted with S3LPN. Upon entering Resident #254's room, S3LPN observed Resident #254's indwelling catheter bag and tubing on the floor. S3LPN confirmed the indwelling catheter bag and tubing were lying on the floor and should not have been. On 06/25/2025 at 12:10 p.m., an interview was conducted with S2DON. S2DON confirmed indwelling catheter bags and tubing should be kept off of the floor as it can increase the risk of infection.

Based on interviews and record review, the facility failed to meet the following Hospice requirements by failing to maintain a system to ensure a resident's Hospice Binder contained the most recent Hospice Plan of Care for 1(#8) of 2 (#8 and #41) residents reviewed for Hospice care. Findings: A review of Resident #8's Clinical Record revealed she was admitted to the facility on [DATE]. Further review revealed Resident #8 was a patient of a local Hospice agency with an admission Date of [DATE]. A review of Resident #8's Hospice Plan of Care on file revealed the most current Plan of Care present in the Hospice Binder was from previous certification period dated [DATE] thru [DATE]. An interview was conducted on [DATE] at 1:50 p.m. with S2DON. S2DON stated she was responsible for working with hospice representatives to coordinate care to the resident provided by the facility. S2DON reviewed Resident #8 Hospice Binder. S2DON confirmed the current Plan of Care on file was expired with certification period date of [DATE] thru [DATE]. She confirmed Resident #8 Hospice Binder should contain the most current and up to date Plan of Care and did not.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the resident's status for 1 (#41) of 15 sampled residents reviewed for MDS. Findings: Review of Resident #41's Clinical Record revealed an admission date of 05/21/2024 with diagnoses which included Bipolar, Depression, and Anxiety. Review of Resident #41's Annual MDS with an Assessment Reference Date (ARD) of 05/21/2025 revealed in part, the following: Section N0415: Medications: Antipsychotic: No. Review of Resident #41's current Physician Orders revealed in part, the following: Start date: 04/01/2025, Risperidone 0.5mg tablet, give 1 tablet by mouth every night. An interview was conducted on 06/24/2025 at 2:00 p.m. with S4MDS. She reviewed Resident #41's Annual MDS with ARD of 05/21/2025. She confirmed Section N0415 was coded as Resident #41 not taking an antipsychotic, which was coded inaccurately. An interview was conducted on 06/25/2025 at 12:45 p.m. with S2DON. She confirmed all residents' MDS should be accurately coded for the medications they received.

Based on record review and interviews, the facility failed to maintain accurate records in accordance with accepted professional standards for 3 of 3 (#1, #2, and #3) sampled residents reviewed for baths. Findings: Review of the Facility's Policy titled, Documentation in Clinical Record, dated October 2023, revealed the following, in part: Procedure: Documentation on skilled residents is required every shift with evidence supporting the skilled service. Documentation must be completed every shift for assistance with activities of daily living (ADL) by assigned CNA. Ensure documentation provides an accurate reflection of nursing care and ADL assistance for each resident, including assessments, treatments, changes in clinical status, pertinent information, which supports deliverance of quality resident care by the multidisciplinary team. Resident #1 Review of Resident #1's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #1's Care Plan revealed Resident #1 should be offered a bath of choice at least three days a week. Review of Resident #1's September 2024 Bath/Shower Logs revealed no documentation for a bath or shower given on 09/05/2024, 09/10/2024, 09/14/2024, 09/19/2024, 09/24/2024, and 09/28/2024. An interview was conducted on 10/04/2024 at 10:59 a.m. with S2FCNA. S2FCNA stated she gave Resident #1 a shower on 09/05/2024 and did not document the care. An interview was conducted on 10/04/2024 at 10:40 a.m. with S3CNA. S3CNA confirmed she gave Resident #1 a shower on 09/14/2024 and did not document the care. An interview was conducted on 10/04/2024 at 10:27 a.m. with S4CNA. S4CNA confirmed she gave Resident #1 a bed bath on 09/19/2024 and 09/28/2024 and did not document the bed bath. Resident #2 Review of Resident #2's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #2's Care Plan revealed Resident #2 should be offered a bath of choice at least three days a week. Review of Resident #2's September 2024 Bath/Shower Logs revealed no documentation for a bath or shower given on 09/10/2024, 09/14/2024, 09/19/2024, 09/24/2024, 09/26/2024, and 09/28/2024. An interview was conducted on 10/04/2024 at 10:37 a.m. with S3CNA. S3CNA confirmed she gave Resident #2 a bath on 09/14/2024 and did not document the bath. An interview was conducted on 10/04/2024 at 10:27 a.m. with S4CNA. S4CNA confirmed she gave Resident #2 a shower on 09/19/2024 and did not document the care. S4CNA stated Resident #2 refused a shower on 09/28/2024 and confirmed she did not document the refusal. Resident #3 Review of Resident #3's Clinical Record revealed the resident was admitted to the facility on [DATE]. Review of Resident #3's Care Plan revealed Resident #3 should be offered a bath of choice at least three days a week. Review of Resident #3's September 2024 Bath/Shower Logs revealed no documentation for a bath or shower given on 09/10/2024, 09/12/2024, 09/14/2024, 09/17/2024, 09/19/2024, 09/21/2024, 09/24/2024, and 09/28/2024. An interview was conducted on 10/04/2024 at 9:22 a.m. with S5CNA. S5CNA confirmed she gave Resident #3 a bath on 09/12/2024 and did not document the bath. An interview was conducted on 10/04/2024 at 10:00 a.m. with S6CNA. S6CNA confirmed she gave Resident #3 a bath on 09/24/2024 and did not document the bath. An interview was conducted on 10/04/2024 at 10:17 a.m. with S7CNA. S7CNA confirmed she gave Resident #3 a bath on 09/28/2024 and did not document the bath. An interview was conducted on 10/04/2024 at 12:51 p.m. with S1DON. She confirmed there was no documentation for the aforementioned dates for baths or showers for Resident #1, Resident #2, and Resident #3 and there should have been.

Based on interviews and record reviews, the facility failed to ensure licensed nurses had the necessary competencies and skill sets to care for a resident's needs. The facility failed to ensure: 1. S4LPN and S5LPN implemented the hypoglycemic protocol for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes; and 2. S5LPN assessed an unresponsive resident with gurgled breathing for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. Upon rechecking Resident #48's blood glucose level, the reading was 53 mg/dL. S4LPN did not notify the physician of the low readings. On [DATE] at 6:00 a.m., S5LPN observed Resident #48 and found the resident had gurgled breathing and was unable to be aroused. S5LPN failed to notify Resident #48's physician or assess vital signs to include a blood glucose reading at that time. At 6:30 a.m., S5LPN found Resident #48 unresponsive, without a pulse or breath sounds. S1ADM and S2DON were notified of the Immediate Jeopardy situation on [DATE] at 12:50 p.m. The Immediate Jeopardy was removed on [DATE] at 3:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the remaining 49 residents residing in the facility. Findings: Review of the facility policy titled Diabetes Mellitus Resident Care revised ,d+[DATE] revealed the following, in part: Policy Guidelines and Procedures: Monitoring of blood sugar levels is done as ordered by MD, and PRN per nursing judgement. MD is notified for any change in condition. In the event of emergency or acute change in status, assess the resident for the following: Not able to awaken, Personality Change, Unconsciousness and obtain a blood glucose reading. In the event of low blood sugar, follow physician standing order. If the resident who has low blood sugar remains unresponsive after initiation of standing order, activate EMS system and transfer to the emergency room . Notify MD and obtain order for transfer. Repeat blood glucose testing as indicated to monitor efficacy of emergency treatments. Notify MD of any initiation of standing order for low blood sugar, including resident response to treatment. Review of the facility policy titled Physician Contact, revised ,d+[DATE], revealed the following, in part: Policy Summary and Objective: Effective communication with the resident's MD is necessary in order to plan for and deliver high quality resident service. Policy Guidelines and Procedures: Prior to calling a MD to report a change in condition or status update, you should have: A complete set of vital signs and any follow up vital signs to show response to interventions to this point Chief complaint of the resident including signs and symptoms Nursing assessment of resident complaint Results of lab work Report any outstanding issues to on-coming shift for continued assessment/intervention Notify the Director of Nursing or Nurse Manager on call for any unstable residents Review of Resident #48's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #48's Physician's Orders revealed the following, in part: [DATE] Hypoglycemia Protocol: follow hypoglycemia protocol as listed then notify MD if CBG is less than 74 mg/dL or unless otherwise instructed by physician. Review of the facility document presented as the Hypoglycemic Protocol titled Signs and Symptoms of Hypoglycemia In Adults signed by S16MD on [DATE] revealed the following, in part: Whenever hypoglycemia is suspected the following steps are to be taken: 1. Verify results by repeated CBG 2. Follow hypoglycemia treatment, notify physician of CBG value unless otherwise ordered. 3. Treat according to appropriate level or protocol Level II: CBG ,d+[DATE] mg/dl with or without mild/moderate symptoms Give 8 oz of juice. If juice is not tolerated, give 16oz Skim or Low Fat milk; go to #4 4. Retest CBG after ,d+[DATE] minutes after treatment. If CBG less than 74 mg/dl, give another 4 ounces juice or 8 oz of milk. Review of Resident #48's Nurse's Notes revealed the following, in part: On [DATE] at 7:06 a.m. by S4LPN: [DATE] 5:15 a.m. routine blood sugar checked, initial result was 49 fasting and resident was given sweetener on sponge to tongue and cheeks. Blood sugar rechecked after 30 minutes results 53 will alert a.m. nurse to result again in 30 minutes. On [DATE] at 6:43 a.m. by S5LPN: 6:30 a.m. Upon entering resident's room, resident was found lying in her bed. Resident was not breathing, resident had no pulse, O2 sats unobtainable. No heart sounds upon auscultation. On [DATE] at 9:01 a.m., an interview was conducted with S20CNA. S20CNA stated her shift started at 6:00 p.m. on [DATE]. S20CNA stated Resident #48 did not have gurgled breathing during her shift. On [DATE] at 2:42 p.m., an interview was conducted with S4LPN. S4LPN confirmed Resident #48 was a Diabetic. S4LPN stated on [DATE] at approximately 5:15 a.m., Resident #48's blood glucose reading was 49 and she administered about a teaspoon of sugar on and under the tongue and placed the remaining sugar in approximately 2 ounces of water and administered about ,d+[DATE] of the solution to the resident's mouth using a pink sponge stick. S4LPN stated she rechecked Resident #48's blood sugar 20 - 25 minutes later and it was 53. S4LPN stated once the blood sugar came up to 53, Resident #48 was more alert. S4LPN stated she administered Resident #48 three additional sponges of sugar water from the same cup to the resident. S4LPN stated she did not consider administering glucagon. S4LPN stated she did not notify the doctor because the blood glucose was not super low, and she was attempting to get it up with sugar water. S4LPN stated there were standing orders to notify the doctor if a blood glucose was under a certain value but she did not know the value. S4LPN stated she did not look at the standing order for hypoglycemia. S4LPN confirmed blood glucose readings of 49 and 53 were abnormal. On [DATE] at 8:59 a.m., an interview was conducted with S5LPN. S5LPN confirmed Resident #48 was a Diabetic. S5LPN stated she observed Resident #48 on [DATE] at approximately 6:00 a.m. and again around 6:15 a.m. S5LPN said Resident #48 was unresponsive with gurgled breathing. She stated the resident would not wake up to verbal stimulation when her name was called or when she physically shook her. She confirmed she did not assess the residents vital signs or check blood glucose levels at either 6:00 a.m. or 6:15 a.m. S5LPN stated she received report that Resident #48 was declining, so she was not concerned when the resident was unresponsive with gurgled breathing. S5LPN stated when she next observed Resident #48 at 6:30 a.m., the resident was unresponsive, without a pulse, and stopped breathing. She explained she did not call the doctor to notify them of Resident #48's status at either 6:00 a.m. or 6:15 a.m. because the resident expired before she got a chance to. S5LPN stated she did not know the resident had low blood glucose readings beginning at 5:15 a.m. On [DATE] at 10:35 a.m., an interview was conducted with S16MD. S16MD stated there was a Hypoglycemic Protocol in place for nurses to follow when a blood glucose reading was less than 60. S16MD stated the nurse should have called the on-call physician immediately when Resident #48's blood glucose reading of 49 was received. S16MD stated if Resident #48 was unable to drink the sugar water, then Glucagon would have been the better option to treat Resident #48's hypoglycemia. On [DATE] at 11:13 a.m., an interview was conducted with S2DON. S2DON stated she expected nurses to follow the Hypoglycemic Protocol. S2DON stated the Hypoglycemic Protocol was the standing doctor's orders for a Diabetic resident and was located at the nurse's station. S2DON stated this information is included in orientation. S2DON stated if Resident #48 was unable to drink enough sugar water, Glucagon should have been administered. S2DON confirmed S4LPN did not follow the Hypoglycemic Protocol. S2DON confirmed the physician should have been notified as soon as there was a change in Resident #48's condition. S2DON stated the physician should have been notified upon receipt of the 49 blood glucose reading. S2DON stated when Resident #48 was unresponsive to verbal and physical stimuli and had gurgled respirations, S5LPN should have assessed the resident, obtained vital signs and notified the physician. S2DON stated S5LPN should have automatically sent the resident to the hospital and notified the physician of the reason. Review of the document titled RN / LPN Skills Orientation Check List revealed no documentation of the Hypoglycemic Protocol.

The facility failed to ensure a resident received treatment and care according to the resident's plan of care and physician's orders in accordance with professional standards of practice by failing to provide needed services. The facility failed to ensure: 1. S4LPN and S5LPN implemented the hypoglycemic protocol for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes; and 2. S5LPN assessed an unresponsive resident with gurgled breathing for 1 (#48) of 3 (#32, #46, and #48) residents reviewed with Diabetes. This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. Upon rechecking Resident #48's blood glucose level, the reading was 53 mg/dL. S4LPN did not notify the physician of the low readings. On [DATE] at 6:00 a.m., S5LPN observed Resident #48 and found the resident had gurgled breathing and was unable to be aroused. S5LPN failed to notify Resident #48's physician or assess vital signs to include a blood glucose reading at that time. At 6:30 a.m., S5LPN found Resident #48 unresponsive, without a pulse or breath sounds. S1ADM and S2DON were notified of the Immediate Jeopardy situation on [DATE] at 5:37 p.m. The Immediate Jeopardy was removed on [DATE] at 3:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the remaining 49 residents residing in the facility. Findings: Review of the facility policy titled Diabetes Mellitus Resident Care revised ,d+[DATE] revealed the following, in part: Policy Guidelines and Procedures: Monitoring of blood sugar levels is done as ordered by MD, and PRN per nursing judgement. MD is notified for any change in condition. In the event of emergency or acute change in status, assess the resident for the following: Not able to awaken, Personality Change, Unconsciousness and obtain a blood glucose reading. In the event of low blood sugar, follow physician standing order. If the resident who has low blood sugar remains unresponsive after initiation of standing order, activate EMS system and transfer to the emergency room . Notify MD and obtain order for transfer. Repeat blood glucose testing as indicated to monitor efficacy of emergency treatments. Notify MD of any initiation of standing order for low blood sugar, including resident response to treatment. Review of Resident #48's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #48's Physician's Orders revealed the following, in part: [DATE] Hypoglycemia Protocol: follow hypoglycemia protocol as listed then notify MD if CBG is less than 74 mg/dL or unless otherwise instructed by physician. Review of the facility document presented as the Hypoglycemic Protocol titled Signs and Symptoms of Hypoglycemia In Adults signed by S16MD on [DATE] revealed the following, in part: Whenever hypoglycemia is suspected the following steps are to be taken: 1. Verify results by repeated CBG 2. Follow hypoglycemia treatment, notify physician of CBG value unless otherwise ordered. 3. Treat according to appropriate level or protocol Level II: CBG ,d+[DATE] mg/dl with or without mild/moderate symptoms Give 8 oz of juice. If juice is not tolerated, give 16oz Skim or Low Fat milk; go to #4 4. Retest CBG after ,d+[DATE] minutes after treatment. If CBG less than 74 mg/dl, give another 4 ounces juice or 8 oz of milk. Review of Resident #48's Care Plan revealed the following, in part: Problem: Nutrition - Resident #48 has a diagnosis of Diabetes. Interventions: Notify MD of abnormal and treat as ordered. Problem: Metabolism-Diabetes- Resident #48 has a diagnosis of Diabetes and is at risk for unstable blood sugar levels. Interventions: Evaluate, assess, and monitor hypoglycemia signs and symptoms. Review of Resident #48's Nurse's Notes revealed the following, in part: On [DATE] at 7:06 a.m. by S4LPN: [DATE] 5:15 a.m. routine blood sugar checked, initial result was 49 fasting and resident was given sweetener on sponge to tongue and cheeks. Blood sugar rechecked after 30 minutes results 53 will alert a.m. nurse to result again in 30 minutes. On [DATE] at 6:43 a.m. by S5LPN: 6:30 a.m. Upon entering resident's room, resident was found lying in her bed. Resident was not breathing, resident had no pulse, O2 sats unobtainable. No heart sounds upon auscultation. On [DATE] at 9:01 a.m., an interview was conducted with S20CNA. S20CNA stated her shift started at 6:00 p.m. on [DATE]. S20CNA stated Resident #48 did not have gurgled breathing during her shift. On [DATE] at 2:42 p.m., an interview was conducted with S4LPN. S4LPN confirmed Resident #48 was a Diabetic. S4LPN stated on [DATE] at approximately 5:15 a.m., Resident #48's blood glucose reading was 49 and she administered about a teaspoon of sugar on and under the tongue and placed the remaining sugar in approximately 2 ounces of water and administered about ,d+[DATE] of the solution to the resident's mouth using a pink sponge stick. S4LPN stated she rechecked Resident #48's blood sugar 20 - 25 minutes later and it was 53. S4LPN stated once the blood sugar came up to 53, Resident #48 was more alert. S4LPN stated she administered Resident #48 three additional sponges of sugar water from the same cup to the resident. S4LPN stated she planned to recheck the resident's blood sugar again in ,d+[DATE] minutes but never did. S4LPN stated the resident did not have a hypoglycemic protocol to follow in her record. S4LPN explained she thought about giving the resident juice but had received report that the resident was not eating. S4LPN stated she did not consider administering glucagon. S4LPN stated she did not notify the doctor because the blood glucose was not super low, and she was attempting to get it up with sugar water. S4LPN stated there were standing orders to notify the doctor if a blood glucose was under a certain value but she did not know the value. S4LPN stated she had not looked at the standing order for hypoglycemia. On [DATE] at 8:59 a.m., an interview was conducted with S5LPN. S5LPN confirmed Resident #48 was a Diabetic. S5LPN stated she observed Resident #48 on [DATE] at approximately 6:00 a.m. and again around 6:15 a.m. S5LPN said Resident #48 was unresponsive with gurgled breathing. She stated the resident would not wake up to verbal stimulation when her name was called or when she physically shook her. She confirmed she did not assess the residents vital signs or check blood glucose levels at either 6:00 a.m. or 6:15 a.m. S5LPN stated she received report that Resident #48 was declining, so she was not concerned when the resident was unresponsive with gurgled breathing. S5LPN stated when she next observed Resident #48 at 6:30 a.m., the resident was unresponsive, without a pulse, and stopped breathing. She explained she did not call the doctor to notify them of Resident #48's status at either 6:00 a.m. or 6:15 a.m. because the resident expired before she got a chance to. She further confirmed she did not notify EMS. S5LPN stated she did not know the resident had low blood glucose readings beginning at 5:15 a.m. and would have checked her blood sugar and followed the hypoglycemic protocol if she did. On [DATE] at 10:35 a.m., an interview was conducted with S16MD. S16MD stated there was a Hypoglycemic Protocol in place for nurses to follow when a blood glucose reading was less than 60. S16MD stated the nurse should have called the on-call physician immediately when Resident #48's blood glucose reading of 49 was received. S16MD stated if Resident #48 was unable to drink the sugar water, then Glucagon would have been the better option to treat Resident #48's hypoglycemia. On [DATE] at 11:13 a.m., an interview was conducted with S2DON. S2DON stated she expected nurses to follow the Hypoglycemic Protocol. S2DON stated the Hypoglycemic Protocol was the standing doctor's orders for a Diabetic resident and was located at the nurse's station. S2DON stated if Resident #48 was unable to drink enough sugar water, Glucagon should have been administered. S2DON confirmed S4LPN did not follow the Hypoglycemic Protocol. S2DON confirmed the physician should have been notified as soon as there was a change in Resident #48's condition. S2DON stated the physician should have been notified upon receipt of the 49 blood glucose reading. S2DON stated when Resident #48 was unresponsive to verbal and physical stimuli and had gurgled respirations, S5LPN should have assessed the resident, obtained vital signs and notified the physician. S2DON stated S5LPN should have automatically sent the resident to the hospital and notified the physician of the reason.

Based on interviews and record reviews, the facility failed to ensure nursing staff communicated a significant change in status to the resident's physician or family for 2 (#48, #46) of 4 (#6, #32, #46, and #48) residents reviewed for notification of change. The facility failed to ensure: 1. Nursing staff notified Resident #48's physician after low blood glucose readings were obtained, a change in breath sounds was noted, or a change in level of consciousness occurred; and 2. Nursing staff notified Resident # 46's family after a low blood glucose readings were obtained This deficient practice resulted in an Immediate Jeopardy situation on [DATE] at 5:15 a.m., when S4LPN failed to implement the standing orders for Hypoglycemic Protocol when Resident #48's blood glucose level was 49 mg/dL. S4LPN administered approximately 2 ounces of sugar water via oral swab to the resident. Upon rechecking Resident #48's blood glucose level, the reading was 53 mg/dL. S4LPN did not notify the physician of the low readings. On [DATE] at 6:00 a.m., S5LPN observed Resident #48 and found the resident had gurgled breathing and was unable to be aroused. S5LPN failed to notify Resident #48's physician or assess vital signs to include a blood glucose reading at that time. At 6:30 a.m., S5LPN found Resident #48 unresponsive, without a pulse or breath sounds. S1ADM and S2DON were notified of the Immediate Jeopardy situation on [DATE] at 5:37 p.m. The Immediate Jeopardy was removed on [DATE] at 3:53 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. The deficient practice continued at more than minimal harm for the remaining 49 residents residing in the facility. Findings: 1. Resident #48 Review of the facility document presented as the Hypoglycemic Protocol titled Signs and Symptoms of Hypoglycemia In Adults signed by S16MD on [DATE] revealed the following, in part: Whenever hypoglycemia is suspected the following steps are to be taken: 2. Follow hypoglycemia treatment, notify physician of CBG value unless otherwise ordered. Review of the facility policy titled Diabetes Mellitus Resident Care revised ,d+[DATE] revealed the following, in part: Policy Guidelines and Procedures: Monitoring of blood sugar levels is done as ordered by MD, and PRN per nursing judgement. MD is notified for any change in condition. Review of Resident #48's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #48's Physician orders revealed the following, in part: [DATE] Hypoglycemia Protocol: follow hypoglycemia protocol as listed then notify MD if CBG is less than 74 mg/dL or unless otherwise instructed by physician. Review of Resident #48's Care Plan revealed the following, in part: Problem: Nutrition - Resident #48 has a diagnosis of Diabetes. Interventions: accu checks as ordered, notify MD of abnormals and treat as ordered Review of Resident #48's Nurse's Notes revealed the following, in part: [DATE] at 7:06 a.m. by S4LPN: [DATE] at 05:15 a.m. routine blood sugar checked initial result was 49 fasting resident was given sweetener on sponge to tongue and cheeks. Blood sugar rechecked after 30 minutes results 53 will alert AM nurse to result again in 30 minutes. [DATE] at 6:43 a.m. by S5LPN: 6:30 a.m.: Upon entering resident's room, resident was found lying in her bed. O2 via nasal cannula at 2 Liters/min. Resident was not breathing, resident had no pulse, O2 sats unobtainable. No heart sounds upon auscultation. On [DATE] at 9:01 a.m., an interview was conducted with S20CNA. S20CNA stated her shift started at 6:00 p.m. on [DATE]. S20CNA stated Resident #48 did not have gurgled breathing during her shift. On [DATE] at 2:42 p.m., an interview was conducted with S4LPN. S4LPN confirmed Resident #48 was a Diabetic. S4LPN stated on [DATE] at approximately 5:15 a.m., Resident #48's blood glucose reading was 49 and she administered about a teaspoon of sugar on and under the tongue and placed the remaining sugar in approximately 2 ounces of water and administered about ,d+[DATE] of the solution to the resident's mouth using a pink sponge stick. S4LPN stated she rechecked Resident #48's blood sugar 20 - 25 minutes later and it was 53. S4LPN stated once the blood sugar came up to 53, Resident #48 was more alert. S4LPN stated she did not notify the doctor because the blood glucose was not super low, and she was attempting to get it up with sugar water. S4LPN stated there were standing orders to notify the doctor if a blood glucose was under a certain value but she did not know the value. S4LPN stated she had not looked at the standing order for hypoglycemia. S4LPN confirmed blood glucose readings of 49 and 53 were abnormal. On [DATE] at 8:59 a.m., an interview was conducted with S5LPN. S5LPN confirmed Resident #48 was a Diabetic. S5LPN stated she observed Resident #48 on [DATE] at approximately 6:00 a.m. and again around 6:15 a.m. S5LPN said Resident #48 was unresponsive with gurgled breathing. She stated the resident would not wake up to verbal stimulation when her name was called or when she physically shook her.S5LPN stated she received report that Resident #48 was declining, so she was not concerned when the resident was unresponsive with gurgled breathing. S5LPN stated when she next observed Resident #48 at 6:30 a.m., the resident was unresponsive, without a pulse, and stopped breathing. She explained she did not call the doctor to notify them of Resident #48's status at either 6:00 a.m. or 6:15 a.m. because the resident expired before she got a chance to. On [DATE] at 10:35 a.m., an interview was conducted with S16MD. S16MD stated there was a Hypoglycemic Protocol in place for nurses to follow when a blood glucose reading was less than 60. S16MD stated the nurse should have called the on-call physician immediately when Resident #48's blood glucose reading of 49 was received. On [DATE] at 11:13 a.m., an interview was conducted with S2DON. S2DON confirmed S4LPN did not follow the Hypoglycemic Protocol. S2DON confirmed the physician should have been notified as soon as there was a change in Resident #48's condition. S2DON stated the physician should have been notified upon receipt of the 49 blood glucose reading. S2DON stated when Resident #48 was unresponsive to verbal and physical stimuli and had gurgled respirations, S5LPN should have assessed the resident, obtained vital signs and notified the physician. S2DON stated S5LPN should have automatically sent the resident to the hospital and notified the physician of the reason. 2. Resident #46 Review of Resident #46's clinical record revealed Resident #46 was admitted to the facility on [DATE] with diagnoses, which included Type 2 Diabetes Mellitus. Review of Resident #46's Nurse's Notes revealed the following, in part: [DATE] at 4:20 a.m. Resident #46's blood glucose was noted to be 24 mg/dL. Further review revealed there was no documentation Resident #46's family was notified of the blood glucose level. A telephone interview was conducted on [DATE] at 11:54 a.m. with Resident #46's Responsible Party. He stated he was not notified when Resident #46 had a low blood sugar. An interview was conducted on [DATE] at 11:28 a.m. with S2DON. S2DON stated family should be notified of low blood sugar levels once treatment was provided and the blood sugar was stable. A telephone interview was conducted on [DATE] at 12:07 p.m. with S18LPN. S18LPN stated on [DATE] when Resident #46's blood sugar was 24 mg/dL and she did not call the family. 47500

Based on observations and interviews, the facility failed to post the required nurse staffing information on a daily basis for 4 of 4 (Nurse's Station a, b, c, and d) Nurse's Stations reviewed for nurse staffing information. Findings: An observation of the staffing data posted at Nursing Station a revealed it did not include the resident census, the total number and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on the following dates and times: 05/28/2024 at 8:45 a.m., 05/28/2024 at 1:40 p.m., and 05/29/2024 at 8:25 a.m. An observation of the staffing data posted at Nursing Station b revealed it did not include the resident census, the total number and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on the following dates and times: 05/28/2024 at 11:15 a.m., 05/28/2024 at 3:20 p.m., and 05/29/2024 at 11:15 a.m. An observation of the staffing data posted at Nursing Station c revealed it did not include the resident census, the total number and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on the following dates and times: 05/28/2024 at 9:00 a.m., 05/28/2024 at 1:43 p.m., and 05/29/2024 at 9:00 a.m. An observation of the staffing data posted at Nursing Station d revealed it did not include the resident census, the total number and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and Certified Nursing Assistants on the following dates and times: 05/28/2024 at 9:05 a.m., 05/28/2024 at 1:45 p.m., and 05/29/2024 at 9:20 a.m. An interview was conducted on 05/31/2024 at 11:05 a.m. with S8SD. S8SD stated she was responsible for posting the staffing assignment sheet. S8SD confirmed she did not include the resident census, the total number and the actual hours worked for resident care per shift for Registered Nurses, Licensed Practical Nurses, and CNAs when she posted the staffing assignment sheet. An interview was conducted on 05/31/2024 at 11:08 a.m. with S1ADM. S1ADM stated he was not aware of the required data that should have been posted regarding the staffing assignment sheet.

Based on interview and record review, the facility failed to ensure residents' drug regimens were free from unnecessary psychotropic medications by failing to ensure an antipsychotic medication was used only when there was an acceptable diagnosis; and ensure adequate monitoring for effectiveness and side effects of psychotropic medication was completed for 2 (#32 and #250) of 5 (#11, #32, #36, #47, and #250) residents reviewed for unnecessary medications. Findings: Resident #32 Review of Resident #32's clinical record revealed, in part, Resident #32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Cognitive Communication Deficit, Type 2 Diabetes, Vascular Dementia, and Chronic Embolism. Review of Resident #32's MDS with an ARD of 05/14/2024 revealed, in part, Resident #32 received antipsychotic medication, antianxiety medication, and antidepressant medication in the previous 7 days. Review of Resident #32's physician orders dated May 2024 revealed, in part, an order dated 05/08/2024 for Clonazepam 2mg tablet at bedtime for Radiculopathy, Quetiapine 25 mg twice daily for Vascular Dementia, and Viibryd 20mg every morning before breakfast for Depressive Episode. Review of Resident #32's MAR dated May 2024 revealed, in part, Resident #32 received the above medications as ordered. There was no documentation of monitoring for target behaviors or side effects of psychotropic medication for Resident #32 and the facility failed to provide documentation since the medication was started on 05/08/2024. Resident #250 Review of Resident #250's medical record revealed, Resident #250 was admitted to the facility on [DATE] with diagnoses, in part, Bipolar Disorder. Review of Resident #250's physician orders revealed, in part, an order dated 05/21/2024 for Fluoxetine 10 mg capsule by mouth daily for Depressive Disorder; Clonazepam 0.5mg by mouth hour of sleep for Spondylosis; and Risperdal 0.5 mg by mouth hour of sleep for Spondylosis. Review of Resident #250's MAR dated May 2024 revealed, in part, Resident #250 received the above medication as ordered. There was no documentation of monitoring for target behaviors or side effects of psychotropic medication for Resident #250 and the facility failed to provide documentation. An interview was conducted on 5/31/2024 at 10:18 a.m. with S2DON. S2DON confirmed Vascular Dementia was not an appropriate indication for use of Quetiapine, Radiculopathy and Spondylosis was not an appropriate indication for use of Clonazepam, and Spondylosis was not an appropriate indication for use of Risperdal. She also confirmed there was no monitoring of target behaviors or monitoring of side effects for the above medications for Resident #32 and Resident #250 and there should have been.

Based on record review and interview, the facility failed to ensure adequate monitoring for side effects with the use of anticoagulant medication was completed for 2 (#32 and #250) of 5 (#11, #32, #36, #47, and #250) residents reviewed for unnecessary medications. Findings: Resident #32 Review of Resident #32's clinical record revealed, in part, Resident #32 was admitted to the facility on [DATE] with diagnoses of Metabolic Encephalopathy, Cognitive Communication Deficit, Type 2 Diabetes, Vascular Dementia, and Chronic Embolism. Review of Resident #32's MDS with an ARD of 05/14/2024 revealed, in part, Resident #32 received anticoagulant medication in the previous 7 days. Review of Resident #32's physician orders dated May 2024 revealed, in part, an order dated 05/08/2024 for Xarelto 15 mg at dinner for acute embolism. There was no documentation of monitoring for anticoagulant side effects for Resident #32 and the facility failed to provide documentation. Resident #250 Review of Resident #250's medical record revealed, Resident #250 was admitted to the facility on [DATE] with diagnoses, in part, bipolar disorder and heart condition. Review of Resident #250's physician orders revealed, in part, an order dated 05/21/2024 for Eliquis 5 mg by mouth twice daily for unspecified atrial fibrillation. Review of Resident #250's MAR dated 05/2024 revealed, in part, Eliquis administered as ordered for atrial fibrillation. Further review revealed there was no documentation of monitoring for side effects of Eliquis. An interview was conducted on 5/31/2024 at 10:18 a.m. with S2DON. S2DON confirmed there was no documentation of monitoring for side effects of the anticoagulant medication for Resident #32 and Resident #250. She confirmed monitoring for side effects of the anticoagulant medication should have been completed every shift.

Based on interviews and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences by failing to respond to call lights in an appropriate time frame for 2 of 2 (#27 and #33) residents reviewed for call light response. Findings: Resident #27 Review of Resident #27's clinical record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Parkinson's Disease, Muscle Weakness (Generalized), and Unsteadiness on Feet. Review of Resident #27's Annual MDS with an ARD of 03/27/2024 revealed the resident had a BIMS of 15 which indicated the resident had intact cognition. Further review revealed Resident #27 required partial/moderate to substantial/maximum assistance with ADLs with the exception of eating. Review of the call light log for Resident #27 from 03/28/2024 to 05/28/2024 revealed the following, in part: 03/28/2024 Occurred: 4:31p.m. Responded: 5:20 p.m. Response Time: 48 minutes 04/01/2024 Occurred: 10:23 p.m. Responded: 11:42 p.m. Response Time: 78 minutes 04/05/2024 Occurred: 12:44 p.m. Responded: 1:29 p.m. Response Time: 44 minutes 05/16/2024 Occurred: 10:22 p.m. Responded: 10:59 p.m. Response Time: 37 minutes 05/17/2024 Occurred: 6:27 p.m. Responded: 7:06 p.m. Response Time: 39 minutes 05/17/2024 Occurred: 9:06 p.m. Responded: 9:54 p.m. Response Time: 48 minutes 05/19/2024 Occurred: 7:58 p.m. Responded: 8:44 p.m. Response Time: 45 minutes On 05/28/2024 at 9:54 a.m., an interview was conducted with Resident #27. Resident #27 stated sometimes she has to wait up to an hour for a call light response. Resident #27 stated this has happened several times a day. Resident #33 Review of Resident #33's clinical record revealed the resident was admitted to the facility on [DATE] and had diagnoses which included Repeated Falls, Personal History of TIA, and CVA. Review of Resident #33's Quarterly MDS with an ARD of 04/10/2024 revealed a BIMS of 11 which indicated the resident had moderate cognitive impairment. Further review revealed Resident #33 was dependent or required substantial/maximum assistance with all ADLs with the exception of eating. Review of Resident #33's current Care Plan revealed the following, in part: Problem: ADL Function and Rehab: Mobility, Impaired physical Interventions: Instruct Resident #33 frequently to use the pull cord for assistance. Review of the call light log for Resident #33 from 03/28/2024 to 05/28/2024 revealed the following, in part: 03/29/2024 Occurred: 5:53 p.m. Responded: 6:56 p.m. Response Time: 62 minutes 04/01/2024 Occurred: 4:00 p.m. Responded: 4:45 p.m. Response Time: 45 minutes 04/01/2024 Occurred: 9:41 p.m. Responded: 11:43 p.m. Response Time: 121 minutes 04/02/2024 Occurred: 1:51 p.m. Responded: 2:33 p.m. Response Time: 41 minutes 04/12/2024 Occurred: 8:32 p.m. Responded: 9:14 p.m. Response Time: 41 minutes 04/15/2024 Occurred: 6:33 p.m. Responded: 7:17 p.m. Response Time: 44 minutes 04/26/2024 Occurred: 5:36 p.m. Responded: 6:13 p.m. Response Time: 37 minutes 04/27/2024 Occurred: 10:25 a.m. Responded: 11:20 a.m. Response Time: 54 minutes 04/28/2024 Occurred: 9:01 a.m. Responded: 9:37 a.m. Response Time: 36 minutes 04/28/2024 Occurred: 10:21 a.m. Responded: 11:39 a.m. Response Time: 77 minutes 05/04/2024 Occurred: 11:24 a.m. Responded: 12:34 p.m. Response Time: 70 minutes 05/05/2024 Occurred: 4:47 a.m. Responded: 5:52 a.m. Response Time: 65 minutes 05/11/2024 Occurred: 8:52 p.m. Responded: 9:57 p.m. Response Time: 64 minutes 05/14/2024 Occurred: 3:57 a.m. Responded: 5:23 a.m. Response Time: 85 minutes 05/17/2024 Occurred: 12:21 p.m. Responded: 1:23 p.m. Response Time: 61 minutes 05/17/2024 Occurred: 8:16 p.m. Responded: 9:14 p.m. Response Time: 58 minutes 05/21/2024 Occurred: 4:29 a.m. Responded: 5:16 a.m. Response Time: 47 minutes 05/28/2024 Occurred: 8:22 p.m. Responded: 9:16 p.m. Response Time: 54 minutes On 05/28/2024 at 11:13 a.m., an interview was conducted with Resident #33. Resident #33 stated the call light wait is more than 30 minutes for response. On 05/31/2024 at 12:23 p.m., an interview was conducted with S2DON. S2DON stated call lights should be answered timely and within 15 minutes. S2DON stated a 20 minute response time would be unreasonable but things happen. S2DON reviewed and confirmed the aforementioned findings for Resident #27 and #33. S2DON confirmed the call light response was horrible and the response times were not appropriate.

Based on record review and interviews, the facility failed have a quality assessment and assurance committee that identified and implemented effective plans of action for quality related deficiencies (cross reference F281, F490, F498). The facility had a census of 48 residents. Residents #24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, and #38 were placed in Immediate Jeopardy on 12/7/12 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for a resident(#22) with a positive stool culture on 12/7/12 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the 3rd floor. The deficient practice remains in place for all other residents at a level of more than minimum harm. The Administrator was notified of the Immediate Jeopardy on 1/15/13 at 4:00 p.m. A Plan of Removal was presented by the S2DON which read: The facility shall continue an infection control program in order to prevent, to the extent possible, the onset and spread of infection. Appropriate transmission-based precautions shall be utilized when indicated. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Corrections put in place: Contact precautions continue for resident who tested positive for [MEDICAL CONDITION]. Transmission precautions shall remain in effect until physician gives order to remove contact precautions, considering asymptomatic status and CDC guidelines. Personal protective equipment, which includes gloves and gowns, is placed in room for staff use. All blood pressure cuffs that had the potential to exposure discarded. The rolling up BP machine was appropriately disinfected with Dispatch, Bleach Germicidal Cleaner. Resident roommate was moved to another room to avoid possible transmission of infection. Resident was educated on appropriate hand hygiene. Signage was placed on door to alert staff or visitors to see nurse at care base before entering room so that he/she/they may be educated on transmission precautions. Staff has been educated on HIPPA violation regarding signage on resident doors. Biohazard sanitation set-up is in resident bathroom. Soiled linens and personal clothing items are bagged in melt-a-way bags and again in yellow bag for transport to laundry. Melt-a-way bag is removed from yellow bag, placed in washing machine and washed with disinfectant appropriate for[DIAGNOSES REDACTED] control. Random checks shall be performed by nursing management to ensure compliance with transmission based precautions. Mandatory Infection Control meeting held 1/16/2013, educating 60 plus employees. Education continues. Environmental services shall perform in-service regarding the use of appropriate chemical to control infection. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Revision of Infection Control policy and procedure complete. The Immediate Jeopardy was lifted on 1/17/13 at 10:00 a.m. when surveyors determined the facility had implemented its plan of removal. Findings: 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 facility's Infection Control Policy effective July 2012 revealed the following in part: Policy Summary and Objective: To help prevent, recognize, and control, to the extent possible, the onset and spread of infection. Policy Guidelines and Procedures: High Risk meetings, which include Infection Control, shall be held, at the minimum, bimonthly, to identify any onset or spread of infection. Director of Nursing, or his/her designee, shall track and trend infection control, completing an infection control report monthly. If any significant trend is noted, necessary measures shall be taken to identify and correct, to the extent possible, to prevent further infection. To prevent and control infection, appropriate transmission precautions shall be put in place. Standard precautions, (Universal Precautions), shall be infection prevention practice for all residents. To avoid the potential negative impact a resident may experience as of result of the implementation of special precautions, signage shall be posted on resident apartment for extreme precautions only. All direct care staff shall receive, at the minimum, annual infection control training. Soiled bed linens and towels shall be contained in melt-a-way bag and yellow bagged before sending to laundry via laundry chute. Personal clothing items shall be contained in melt-a-way bag and washed in laundry on care area floor, utilizing Auto Chlor Solution QA dispensed with wash cycle. Resident #22 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimal Data Set(MDS) with an Assessment Review Date(ARD) date of 12/12/12 in Section C; Cognitive Patterns the resident's Brief Interview of Mental Status(BIMS) revealed the resident's total score to be a 14; Cognitively Intact. Section G: Functional Status G0110. Activities of Daily Living(ADL) Assistance revealed E. Locomotion on unit (2) Limited assistance; (2) One person physical assist. F. Locomotion off unit (2) Limited assistance (2) One person physical assist. Review of Resident #22's December 2012's physician's orders [REDACTED]. 12/5/12 Order for stool study x 3 stool samples 12/7/12 [MEDICATION NAME] 500 milligrams(mg) by mouth(po) twice(bid) times 7 days 12/25/12 For Diarrhea (loose stools). Check for impaction. If negative [MEDICATION NAME] 2 po now, then 2 po after each loose stools. 12/26/12 Check stool for [MEDICAL CONDITION] Review of the facility's Facsimile Transmission Cover Sheet revealed the following in part: 12/5/12 Resident complaints of 3 loose stool episodes during the day. Resident has a history of [MEDICAL CONDITION]. 12/7/12 Resident have had 2 soft stools, not watery today. 12/10/12 Resident positive for [MEDICAL CONDITION] on [MEDICATION NAME] 500 mg po bid times 7 days. 12/12/12 Resident on ABT for [MEDICAL CONDITION]. Family wants stool culture after ABT is complete. Is this ok? 12/19/12 Family concerned resident with watery stool times 3 this day and resident complaint of tired of feeling. Completed [MEDICATION NAME] on 12/14. 12/25/12 S.O. initiated for loose stools times 2. resident had a history of [REDACTED]. Is on Flora Q and yogurt. Review of Resident #22's Nursing Home Progress Note dated 12/10/12 revealed the following in part: Treated on ... for[DIAGNOSES REDACTED]. Review of Resident #22's Laboratory documentation revealed the following in part: 12/6/12[DIAGNOSES REDACTED]icile Positive [MEDICATION NAME] started. 12/28/12[DIAGNOSES REDACTED]icile Positive Review of Resident #22's Comprehensive Plan of Care for Recurrent [DIAGNOSES REDACTED]icile dated 12/7/12 revealed the following: Goal: Resident #22 will have no further complications through the next 90 days 3/7/13 Approaches: 1) Administer medication as ordered 2) Contact precautions as ordered 3) Encourage resident and staff to practice good handwashing before and after care 4) Obtain stool specimens as ordered and notify MD of results 5) Monitor for signs/symptoms of abdominal cramping; foul odor to stools; frequent watery diarrhea; pus in stool and decrease appetite. On 1/16/12 at 1:51 p.m. an interview was conducted with S6Medicare Nurse Coordinator. She stated Resident #22 was diagnosed with [REDACTED]. She said the resident was asymptomatic and was not taking medications. She said she did not revise the resident's Comprehensive Plan of Care to reflect such; because she wanted to see if the resident was going to develop[DIAGNOSES REDACTED] again before the 90 days. Review of Resident #22's Nurses' Progress Notes revealed the following in part: 12/29/12 6 p.m.-6 a.m. Loose stool times 1 with odor noted. Lab results received 1:30 a.m. positive for[DIAGNOSES REDACTED] of stool. Contact Precautions implemented. 1/3/13 History of[DIAGNOSES REDACTED]. Review of Resident #22's Interdisciplinary Notes revealed the following in part: 12/29/12 11:03 12/29/12 10p-6a. Resident positive for[DIAGNOSES REDACTED] of stool at this time. No antibiotic(ABT) therapy ordered per physician. 1 loose stool today. Report given. Doctor was notified. No new orders given. On contact precautions. 12/25/12 2:50 a.m. 12/25/12 2:50 a.m. CNA to report loose stools x 2 episodes. 12/20/12 5:24 p.m. Resident complained of 2 episodes of loose stool. Resident has an order for [REDACTED]. 12/19/12 5:00 p.m. Resident complained of 3 episodes of loose stool. 12/11/12 12/10/12 5:27 a.m. ABT in use for positive[DIAGNOSES REDACTED] in stool. Contact isolation in progress. 12/10/12 2:04 p.m. No diarrhea noted throughout the shift. 12/09/12 2:00 a.m. Contact Isolation implemented. 12/9/12 12/8/12 1:29 a.m. at 10:40 p.m. Resident is currently on [MEDICATION NAME] for[DIAGNOSES REDACTED]. 12/8/12 Resident on antibiotic therapy for[DIAGNOSES REDACTED]. Contact Precautions taken during resident care. 12/5/12 12/5/12 6:17 p.m. Resident up in chair. Complain of 3 episodes of loose stool. Doctor office called to report resident complaint. 12/4/12 Resident lying in bed AAO x 3. Decided to stay in bed due to diarrhea. She had throughout the night. States, she feel weak. Will continue to monitor while taking meds this am. 12/4/12 12/3/12 2:05 a.m. AAO x 3. at 1:50 a.m. Resident complains of having 3 loose stools. Checked for impaction. Negative. [MEDICATION NAME] x 2 given po now, then 2 po after each loose stool x 24 hours per physician standing orders. On 1/14/13 at 1:14 p.m. an interview was conducted with S7LPN. She said she was informed Resident #22 had[DIAGNOSES REDACTED] and was on Contact Precautions. She stated the facility trained her that with a resident with[DIAGNOSES REDACTED] she was to wear gloves and use proper handwashing. S7LPN said the facility staff who trained her showed her where to get the boxes and where the yellow and red bags were, how to place them and how to dispose of them. She said the resident became asymptomatic after 12/29/12. She said she and others voiced concerns about a resident being on[DIAGNOSES REDACTED] and not instituting Contact Precautions of PPE(personal protective equipment) and Administration told them it was not a nursing home and they was not going to institute all that. She said the facility does not put signage on resident's door to alert staff or visitors of transmission precautions. She said they did not disinfect blood pressure cuffs when the resident was infectious before they used it on other residents. She said the resident was admitted on [DATE]. She started having diarrhea on 12/4/12. An order was obtained on 12/5/12 to check stool times 3. She said on 12/7/12 the resident was positive for[DIAGNOSES REDACTED] and was placed on [MEDICATION NAME]. She stated that the resident did not have a roommate at that time. She said on 12/10/12 a resident was admitted to the room. She said a yellow bag and a red bag was supposed to be placed in 2 card board boxes in the resident's room. She said the resident's clothing and her linen went in a melt a way bag that was placed in a yellow bag. She said the linen was sent down the "shoot" to the laundry in a melt a way bag inside a yellow bag and her personal clothes were also put in a melt a way bag and washed on the 3rd floor. She confirmed there was no yellow bag in 1 of the resident's card board boxes in the bathroom and there was a melt away bag with linen in it and a clear bag with clothing items in it. She said the clear bag with the linen was not processed correctly. She acknowledged it should have been in a melt a way bag inside a yellow bag to alert the laundry staff the linens were contaminated. She said the resident took showers in her room and her roommate was bed bound. She verified the roommate's sitter went in the bathroom; because she gave the resident a bed bath and took care of the resident. On 1/14/13 at 2:58 p.m. an observation was made that Resident #22 had no signage on her door or above her bed. Further observation revealed 2 brown card board boxes in the resident #22's bathroom. One card board box had a red biohazard bag filled with disposable diapers and the other card board box had a clear melt a way bag with linen in it and a clear trash bag with linen in it. Further observation noted no yellow bag was in 1 of the card board boxes. On 1/14/13 at 3:24 p.m. an interview was conducted with S11CNA. She said she had been working at the facility for 2 months and had not been trained to wear personal protective equipment in taking care a person who had[DIAGNOSES REDACTED] on Contact Precautions. She said she wore gloves and washed her hands. On 1/15/12 at 10:06 a.m. an interview was conducted with S12CNA. She stated when she worked with Resident #22, she put her personal clothing in a water soluble bag and washed them at the end of her shift. She stated she send the resident's linen down the "shoot" in a melt a way bag. She said the Biohazard boxes were picked up from the Biohazard people. S12CNA said sometimes a yellow bag was in the cardboard box and sometimes they had to put one in. She said she couldn't remember whether she placed a yellow bag in the cardboard box the prior day when she worked with the resident. On 1/15/13 at 10:52 a.m. an interview was conducted with S2DON. She stated when the resident had[DIAGNOSES REDACTED] and was on Contact Precautions, appropriate precautions were put in place. She said the staff discussed Infection Control weekly and she tracked and trended infections to make sure there was no outbreak. She stated they don't isolate residents on[DIAGNOSES REDACTED], because she didn't consider it to be "highly contagious" like the flu. S2DON said the facility was not going to place any kind of signage at the resident's door notifying staff or visitors to see the nurse because of "cultural diversity". She confirmed they had no specific policy regarding what precautions the staff would specifically implement for a resident on[DIAGNOSES REDACTED]. She stated it was at the facility's discretion as far as what protocol they would use. She said she got reports from CDC guidelines all the time and was aware of what precautions were recommended for residents with[DIAGNOSES REDACTED]. She acknowledged she did not train staff to wear personal protective equipment or to properly disinfect equipment after use on a[DIAGNOSES REDACTED] resident. She said she only informed them to wear gloves and exercise good handwashing. She verified a yellow and red bag was supposed to be placed in the separate card board boxes in the resident's room and the CNA staff was supposed to place a melt a way bag inside the yellow bag and send the laundry down the shoot. She said the resident's personal clothes was also to be placed in a melt a way bag and washed on the resident's floor by the CNA staff. On 1/15/13 at 1:11 p.m. an interview was conducted with S10CNA. She stated she started working at the facility on December 20, 2012. She said she had not been trained on what to wear besides gloves in taking care of a resident with[DIAGNOSES REDACTED] on Contact Precautions. She stated they told her to wear gloves and practice good handwashing. She said they never wore gowns, gloves or mask when providing care. On 1/15/13 at 1:39 p.m. an interview was conducted with S7LPN. She stated nursing staff did weekly vital signs on residents who were not skilled and daily on skilled residents. She said when Resident #22 was diagnosed with [REDACTED]. She said the resident was continent, but also had incontinent episodes when she couldn't make it to the bathroom. S7LPN stated staff had to assist with incontinent care. She said the resident wore briefs and did soil her clothes occasionally. She said the resident did not remain in her room when she was infectious nor did staff wear gowns, masks or shoe covers. On 1/16/13 at 8:56 a.m. an interview was conducted with S13CNA. She stated Resident #22 had[DIAGNOSES REDACTED], but "Don't quote me exactly on what precautions I'm supposed to be use". She said she thought it was contact precautions. She said she was trained to wear gloves and exercise good handwashing precautions, but was never told to wear protective equipment like a gown or a mask. On 1/16/13 at 9:07 a.m. an interview was conducted with S9LPN. She stated Resident #22 was on Contact Precautions and she used gloves, soap and water to wash her hands. She said they took vitals weekly for non skilled residents and daily on skilled residents. She said they had 1 rolling blood pressure cuff machine on the 3rd floor and 1 hand held blood pressure cuff in each cart on the floor and they did not disinfect the blood pressure machines after using it on Resident #22 before use on other residents. On 1/16/13 at 9:13 a.m. an interview was conducted with S8LPN. She stated she had 3 skilled residents that she took daily vital signs on and the weekly vitals on her non-skilled residents. Review of the facility's training logs revealed the LPN and CNA staff received the following training in part: 12/12 Monthly Nursing Meeting.[DIAGNOSES REDACTED] Report any increase in signs and symptoms 4/26/12 on Ergonomics, Bloodborne Pathogens, Fall Incidents, MSDS and Workplace Violence. 4/24/12 Bloodborne Pathogens and other Microorganisms. MDRO (multi-drug resistant organism) including[DIAGNOSES REDACTED]. Further review of the training documentation revealed no mention of wearing personal protective equipment for taking care a resident with[DIAGNOSES REDACTED] or how to properly store and transport linen for a resident wit[DIAGNOSES REDACTED]. Review of the facility's Weekly Management Environmental Services Meeting Agenda dated May 14, 2012 revealed the following in part: Items for Discussion: In-Service Cleaning Procedure for Resident Rooms when infectious condition exists. May 11, 2012 Special Instructions to staff cleaning on Health and Wellness Second floor: This is the result of a surface bacteria call [MEDICAL CONDITION] or [MEDICAL CONDITION] that will only respond to the Dispatch Bleach Germicidal Cleaner provided for you. When preparing your cart for the day, be certain that you have a bottle of Dispatch Bleach Disinfectant with you. All surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the residents touched or will touch must be sprayed with Dispatch Bleach Disinfectant and left on for thirty seconds before wiping down. The entire bathroom, commode in and out, the shower, the floor, doors and door frames should be disinfected. Anything the resident might have touched, phones, bed rails, remotes, everything. Please use a very small amount in your mop bucket to mop these floors so they don't get sticky. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag or rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. (Please note: The disinfecting foam provided for waterless cleaning will not kill this bacteria.) Proceed to your next resident room, using universal precautions, in our case, put on fresh gloves, and proceed as usual using fresh clean rags, and mops for each room. Review of the In-Service: Cleaning procedure for Resident Rooms When Infectious Surfaces Condition exists revealed the following in part:. This is the result of surface bacteria that is spread around by the resident or other individuals in the resident's room or area, and that will only respond to the Blue Skies II Quaternary disinfectant. When preparing your cart for the day, be certain that your Blue Skies II Quaternary Disinfectant bottle is full of the chemical. ALL surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the resident has touched or will touch must be wiped down with the Blue Skies II Quaternary disinfectant. The entire bathroom, commode in and out, the shower, the floor should be disinfected. Please use rain-dance in your mop bucket to mop the floors so they don't get sticky as they will with Blue Skies II Quaternary disinfectant. The Raindance is a disinfectant cleaner. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. However, in these types of situations, clean the mirror with the Blue Skies II. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag of rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. Then you may proceed to your next resident room. On 1/16/13 at 9:27 a.m. an interview was conducted with S5Environmental Services Coordinator and S15Environmental Services Lead Tech. They both verified staff used Raindance Neutral Floor cleaner for the floors; Bathmate for the toilets and shower area, disinfectant for the bathrooms and Ringo Blue occasionally or Soft Cream if the toilets had a ring in it. They said the staff also use Dispatch if a resident was on[DIAGNOSES REDACTED] or had a yellow or red bag in their room that killed[DIAGNOSES REDACTED]. On 1/16/13 at 9:41 a.m. an interview was conducted with S14Housekeeper. She confirmed she cleaned all the rooms on 3rd floor. She said she used Disinfectant to spray the toilet and the sinks and Bathmate to clean the tub and shower. She said she sprayed Raindance on a Doodle pad and cleaned the floor and disposed of it afterwards. S14Housekeeper said she also used Breakdown which was an odor eliminator and Dispatch if she saw a yellow or red bag in the room. She said she only used her mop bucket to clean staff bathrooms. Review of the facility's Material Safety Data Sheet for Raindance Low Foam Neutral Floor Cleaner revealed the following in part: Recommended use: Cleaning product. This product is intended to be diluted prior to use. Composition/Information on Ingredients: [MEDICATION NAME] Alcohol ethoxylates On 1/16/13 at 9:45 a.m. an interview was conducted with S15Environmental Services Lead Tech. She confirmed that Raindance did not kill[DIAGNOSES REDACTED] and S14Housekeeper was supposed to be using Dispatch and cleaning the floors following the above noted in-service on floors. On 1/17/13 at 3:47 p.m. an interview was held with S3ADON regarding Quality Assurance and Assessment (QAA) of [MEDICAL CONDITION] (C. Difficile) as a QAA issue. She stated that the QAA committee met quarterly and as needed when QAA issues were identified. She said they had not identified C.Difficile as a quality assurance problem. She further stated that the facility did not have a contact isolation policy regarding C.Difficile specifically. She said the staff was educated on C.Difficile through in-services. She stated that there was no tool in place for monitoring correct staff performance of contact isolation precautions/procedures covered in staff in-services regarding C.Difficile. She said the cleaning frequency of medical equipment (such as blood pressure cuffs) used for multiple residents was not monitored. When asked which cleaning agents were used by housekeeping to reduce C.Difficile transmission, she responded that she was not sure. She further stated that S4EnvironmentalServicesManager would be the department that would monitor the type of cleaning agents used for [DIAGNOSES REDACTED]icile. On 1/17/13 at 4:18 p.m. a telephone interview was conducted with S4Environmental ServicesManager regarding chemicals used by housekeeping and the laundry staff for disinfection related to C.Difficile. She said the housekeeping staff was instructed to use Dispatch to clean resident ' s rooms who were positive for [DIAGNOSES REDACTED]icile. She was asked if Raindance Neutral Floor Cleaner was an appropriate cleaner for [DIAGNOSES REDACTED]icile and she said it was not. She was also questioned regarding handling of C.Difficile contaminated linens and she said C.Difficile contaminated linens should come down the laundry chute in a bio-degradable bag, within a yellow bag. She said the yellow bag determined what personal protective equipment (PPE) the staff would use to launder the potentially infectious linens. She said the staff should wear gloves at all times and they should wear additional PPE (goggles, facemask, and an apron) when handling potentially infectious linens. She said Autochlor is the cleanser dispensed by the washing machines in the laundry (chlorine base 7-8%).

Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well being for 28 (#24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, #38) of 29 (#22,#24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, #38) residents reviewed for Infection Control. The facility further failed to be administered in a manner to ensure that the other 28 residents on the 3rd floor (#24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, #38 ) from a total skill nursing census of 48 residents were not subjected to staff who did not follow proper isolation precautions, before entering their rooms, after leaving Resident #22's room with a known infectious organism. The facility failed to: 1) Have a system of supervision and monitoring in place to ensure the housekeepers were using the proper disinfective agent to clean the room and environment of a resident)#22) infected with[DIAGNOSES REDACTED]. 2) Provide clinical supervision and monitoring to ensure staff follow CDC guidelines for Contact Isolation Precautions when providing care for a resident with[DIAGNOSES REDACTED] infection. 3) Ensure staff properly stored and transported contaminated linen for a resident(22) with [MEDICAL CONDITION] on Contact Precautions. 4) Ensure Contact Isolation precautions was followed for a resident (#22) diagnosed with [REDACTED]. 5) Ensure staff cleaned reusable equipment with an appropriate disinfective agent after use on a resident with positive[DIAGNOSES REDACTED] infection prior to use on other residents. Residents #24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, and #38 were placed in Immediate Jeopardy on 12/7/12 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for a resident(#22) with a positive stool culture on 12/7/12 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the 3rd floor. The deficient practice remains in place for all other residents at a level of more than minimum harm. The Administrator was notified of the Immediate Jeopardy on 1/15/13 at 4:00 p.m. A Plan of Removal was presented by the S2DON which read: The facility shall continue an infection control program in order to prevent, to the extent possible, the onset and spread of infection. Appropriate transmission-based precautions shall be utilized when indicated. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Corrections put in place: Contact precautions continue for resident who tested positive for [MEDICAL CONDITION]. Transmission precautions shall remain in effect until physician gives order to remove contact precautions, considering asymptomatic status and CDC guidelines. Personal protective equipment, which includes gloves and gowns, is placed in room for staff use. All blood pressure cuffs that had the potential to exposure discarded. The rolling up BP machine was appropriately disinfected with Dispatch, Bleach Germicidal Cleaner. Resident roommate was moved to another room to avoid possible transmission of infection. Resident was educated on appropriate hand hygiene. Signage was placed on door to alert staff or visitors to see nurse at care base before entering room so that he/she/they may be educated on transmission precautions. Staff has been educated on HIPPA violation regarding signage on resident doors. Biohazard sanitation set-up is in resident bathroom. Soiled linens and personal clothing items are bagged in melt-a-way bags and again in yellow bag for transport to laundry. Melt-a-way bag is removed from yellow bag, placed in washing machine and washed with disinfectant appropriate for[DIAGNOSES REDACTED] control. Random checks shall be performed by nursing management to ensure compliance with transmission based precautions. Mandatory Infection Control meeting held 1/16/2013, educating 60 plus employees. Education continues. Environmental services shall perform in-service regarding the use of appropriate chemical to control infection. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Revision of Infection Control policy and procedure complete. The Immediate Jeopardy was lifted on 1/17/13 at 10:00 a.m. when surveyors determined the facility had implemented its plan of removal. Findings: 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 facility's Infection Control Policy effective July 2012 revealed the following in part: Policy Summary and Objective: To help prevent, recognize, and control, to the extent possible, the onset and spread of infection. Policy Guidelines and Procedures: High Risk meetings, which include Infection Control, shall be held, at the minimum, bimonthly, to identify any onset or spread of infection. Director of Nursing, or his/her designee, shall track and trend infection control, completing an infection control report monthly. If any significant trend is noted, necessary measures shall be taken to identify and correct, to the extent possible, to prevent further infection. To prevent and control infection, appropriate transmission precautions shall be put in place. Standard precautions, (Universal Precautions), shall be infection prevention practice for all residents. To avoid the potential negative impact a resident may experience as of result of the implementation of special precautions, signage shall be posted on resident apartment for extreme precautions only. All direct care staff shall receive, at the minimum, annual infection control training. Soiled bed linens and towels shall be contained in melt-a-way bag and yellow bagged before sending to laundry via laundry chute. Personal clothing items shall be contained in melt-a-way bag and washed in laundry on care area floor, utilizing Auto Chlor Solution QA dispensed with wash cycle. Resident #22 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimal Data Set(MDS) with an Assessment Review Date(ARD) date of 12/12/12 in Section C; Cognitive Patterns the resident's Brief Interview of Mental Status(BIMS) revealed the resident's total score to be a 14; Cognitively Intact. Section G: Functional Status G0110. Activities of Daily Living(ADL) Assistance revealed E. Locomotion on unit (2) Limited assistance; (2) One person physical assist. F. Locomotion off unit (2) Limited assistance (2) One person physical assist. Review of Resident #22's December 2012's physician's orders [REDACTED]. 12/5/12 Order for stool study x 3 stool samples 12/7/12 [MEDICATION NAME] 500 milligrams(mg) by mouth(po) twice(bid) times 7 days 12/25/12 For Diarrhea (loose stools). Check for impaction. If negative [MEDICATION NAME] 2 po now, then 2 po after each loose stools. 12/26/12 Check stool for [MEDICAL CONDITION] Review of the facility's Facsimile Transmission Cover Sheet revealed the following in part: 12/5/12 Resident complaints of 3 loose stool episodes during the day. Resident has a history of [MEDICAL CONDITION]. 12/7/12 Resident have had 2 soft stools, not watery today. 12/10/12 Resident positive for [MEDICAL CONDITION] on [MEDICATION NAME] 500 mg po bid times 7 days. 12/12/12 Resident on ABT for [MEDICAL CONDITION]. Family wants stool culture after ABT is complete. Is this ok? 12/19/12 Family concerned resident with watery stool times 3 this day and resident complaint of tired of feeling. Completed [MEDICATION NAME] on 12/14. 12/25/12 S.O. initiated for loose stools times 2. resident had a history of [REDACTED]. Is on Flora Q and yogurt. Review of Resident #22's Nursing Home Progress Note dated 12/10/12 revealed the following in part: Treated on ... for[DIAGNOSES REDACTED]. Review of Resident #22's Laboratory documentation revealed the following in part: 12/6/12[DIAGNOSES REDACTED]icile Positive [MEDICATION NAME] started. 12/28/12[DIAGNOSES REDACTED]icile Positive Review of Resident #22's Comprehensive Plan of Care for Recurrent [DIAGNOSES REDACTED]icile dated 12/7/12 revealed the following: Goal: Resident #22 will have no further complications through the next 90 days 3/7/13 Approaches: 1) Administer medication as ordered 2) Contact precautions as ordered 3) Encourage resident and staff to practice good handwashing before and after care 4) Obtain stool specimens as ordered and notify MD of results 5) Monitor for signs/symptoms of abdominal cramping; foul odor to stools; frequent watery diarrhea; pus in stool and decrease appetite. On 1/16/12 at 1:51 p.m. an interview was conducted with S6Medicare Nurse Coordinator. She stated Resident #22 was diagnosed with [REDACTED]. She said the resident was asymptomatic and was not taking medications. She said she did not revise the resident's Comprehensive Plan of Care to reflect such; because she wanted to see if the resident was going to develop[DIAGNOSES REDACTED] again before the 90 days. Review of Resident #22's Nurses' Progress Notes revealed the following in part: 12/29/12 6 p.m.-6 a.m. Loose stool times 1 with odor noted. Lab results received 1:30 a.m. positive for[DIAGNOSES REDACTED] of stool. Contact Precautions implemented. 1/3/13 History of[DIAGNOSES REDACTED]. Review of Resident #22's Interdisciplinary Notes revealed the following in part: 12/29/12 11:03 12/29/12 10p-6a. Resident positive for[DIAGNOSES REDACTED] of stool at this time. No antibiotic(ABT) therapy ordered per physician. 1 loose stool today. Report given. Doctor was notified. No new orders given. On contact precautions. 12/25/12 2:50 a.m. 12/25/12 2:50 a.m. CNA to report loose stools x 2 episodes. 12/20/12 5:24 p.m. Resident complained of 2 episodes of loose stool. Resident has an order for [REDACTED]. 12/19/12 5:00 p.m. Resident complained of 3 episodes of loose stool. 12/11/12 12/10/12 5:27 a.m. ABT in use for positive[DIAGNOSES REDACTED] in stool. Contact isolation in progress. 12/10/12 2:04 p.m. No diarrhea noted throughout the shift. 12/09/12 2:00 a.m. Contact Isolation implemented. 12/9/12 12/8/12 1:29 a.m. at 10:40 p.m. Resident is currently on [MEDICATION NAME] for[DIAGNOSES REDACTED]. 12/8/12 Resident on antibiotic therapy for[DIAGNOSES REDACTED]. Contact Precautions taken during resident care. 12/5/12 12/5/12 6:17 p.m. Resident up in chair. Complain of 3 episodes of loose stool. Doctor office called to report resident complaint. 12/4/12 Resident lying in bed AAO x 3. Decided to stay in bed due to diarrhea. She had throughout the night. States, she feel weak. Will continue to monitor while taking meds this am. 12/4/12 12/3/12 2:05 a.m. AAO x 3. at 1:50 a.m. Resident complains of having 3 loose stools. Checked for impaction. Negative. [MEDICATION NAME] x 2 given po now, then 2 po after each loose stool x 24 hours per physician standing orders. On 1/14/13 at 1:14 p.m. an interview was conducted with S7LPN. She said she was informed Resident #22 had[DIAGNOSES REDACTED] and was on Contact Precautions. She stated the facility trained her that with a resident with[DIAGNOSES REDACTED] she was to wear gloves and use proper handwashing. S7LPN said the facility staff who trained her showed her where to get the boxes and where the yellow and red bags were, how to place them and how to dispose of them. She said the resident became asymptomatic after 12/29/12. She said she and others voiced concerns about a resident being on[DIAGNOSES REDACTED] and not instituting Contact Precautions of PPE(personal protective equipment) and Administration told them it was not a nursing home and they was not going to institute all that. She said the facility does not put signage on resident's door to alert staff or visitors of transmission precautions. She said they did not disinfect blood pressure cuffs when the resident was infectious before they used it on other residents. She said the resident was admitted on [DATE]. She started having diarrhea on 12/4/12. An order was obtained on 12/5/12 to check stool times 3. She said on 12/7/12 the resident was positive for[DIAGNOSES REDACTED] and was placed on [MEDICATION NAME]. She stated that the resident did not have a roommate at that time. She said on 12/10/12 a resident was admitted to the room. She said a yellow bag and a red bag was supposed to be placed in 2 card board boxes in the resident's room. She said the resident's clothing and her linen went in a melt a way bag that was placed in a yellow bag. She said the linen was sent down the "shoot" to the laundry in a melt a way bag inside a yellow bag and her personal clothes were also put in a melt a way bag and washed on the 3rd floor. She confirmed there was no yellow bag in 1 of the resident's card board boxes in the bathroom and there was a melt away bag with linen in it and a clear bag with clothing items in it. She said the clear bag with the linen was not processed correctly. She acknowledged it should have been in a melt a way bag inside a yellow bag to alert the laundry staff the linens were contaminated. She said the resident took showers in her room and her roommate was bed bound. She verified the roommate's sitter went in the bathroom; because she gave the resident a bed bath and took care of the resident. On 1/14/13 at 2:58 p.m. an observation was made that Resident #22 had no signage on her door or above her bed. Further observation revealed 2 brown card board boxes in the resident #22's bathroom. One card board box had a red biohazard bag filled with disposable diapers and the other card board box had a clear melt a way bag with linen in it and a clear trash bag with linen in it. Further observation noted no yellow bag was in 1 of the card board boxes. On 1/14/13 at 3:24 p.m. an interview was conducted with S11CNA. She said she had been working at the facility for 2 months and had not been trained to wear personal protective equipment in taking care a person who had[DIAGNOSES REDACTED] on Contact Precautions. She said she wore gloves and washed her hands. On 1/15/12 at 10:06 a.m. an interview was conducted with S12CNA. She stated when she worked with Resident #22, she put her personal clothing in a water soluble bag and washed them at the end of her shift. She stated she send the resident's linen down the "shoot" in a melt a way bag. She said the Biohazard boxes were picked up from the Biohazard people. S12CNA said sometimes a yellow bag was in the cardboard box and sometimes they had to put one in. She said she couldn't remember whether she placed a yellow bag in the cardboard box the prior day when she worked with the resident. On 1/15/13 at 10:52 a.m. an interview was conducted with S2DON. She stated when the resident had[DIAGNOSES REDACTED] and was on Contact Precautions, appropriate precautions were put in place. She said the staff discussed Infection Control weekly and she tracked and trended infections to make sure there was no outbreak. She stated they don't isolate residents on[DIAGNOSES REDACTED], because she didn't consider it to be "highly contagious" like the flu. S2DON said the facility was not going to place any kind of signage at the resident's door notifying staff or visitors to see the nurse because of "cultural diversity". She confirmed they had no specific policy regarding what precautions the staff would specifically implement for a resident on[DIAGNOSES REDACTED]. She stated it was at the facility's discretion as far as what protocol they would use. She said she got reports from CDC guidelines all the time and was aware of what precautions were recommended for residents with[DIAGNOSES REDACTED]. She acknowledged she did not train staff to wear personal protective equipment or to properly disinfect equipment after use on a[DIAGNOSES REDACTED] resident. She said she only informed them to wear gloves and exercise good handwashing. She verified a yellow and red bag was supposed to be placed in the separate card board boxes in the resident's room and the CNA staff was supposed to place a melt a way bag inside the yellow bag and send the laundry down the shoot. She said the resident's personal clothes was also to be placed in a melt a way bag and washed on the resident's floor by the CNA staff. On 1/15/13 at 1:11 p.m. an interview was conducted with S10CNA. She stated she started working at the facility on December 20, 2012. She said she had not been trained on what to wear besides gloves in taking care of a resident with[DIAGNOSES REDACTED] on Contact Precautions. She stated they told her to wear gloves and practice good handwashing. She said they never wore gowns, gloves or mask when providing care. On 1/15/13 at 1:39 p.m. an interview was conducted with S7LPN. She stated nursing staff did weekly vital signs on residents who were not skilled and daily on skilled residents. She said when Resident #22 was diagnosed with [REDACTED]. She said the resident was continent, but also had incontinent episodes when she couldn't make it to the bathroom. S7LPN stated staff had to assist with incontinent care. She said the resident wore briefs and did soil her clothes occasionally. She said the resident did not remain in her room when she was infectious nor did staff wear gowns, masks or shoe covers. On 1/16/13 at 8:56 a.m. an interview was conducted with S13CNA. She stated Resident #22 had[DIAGNOSES REDACTED], but "Don't quote me exactly on what precautions I'm supposed to use". She said she thought it was contact precautions. She said she was trained to wear gloves and exercise good handwashing precautions, but was never told to wear protective equipment like a gown or a mask. On 1/16/13 at 9:07 a.m. an interview was conducted with S9LPN. She stated Resident #22 was on Contact Precautions and she used gloves, soap and water to wash her hands. She said they took vitals weekly for non skilled residents and daily on skilled residents. She said they had 1 rolling blood pressure cuff machine on the 3rd floor and 1 hand held blood pressure cuff in each cart on the floor and they did not disinfect the blood pressure machines after using it on Resident #22 before use on other residents. On 1/16/13 at 9:13 a.m. an interview was conducted with S8LPN. She stated she had 3 skilled residents that she took daily vital signs on and the weekly vitals on her non-skilled residents. Review of the facility's training logs revealed the LPN and CNA staff received the following training in part: 12/12 Monthly Nursing Meeting.[DIAGNOSES REDACTED] Report any increase in signs and symptoms 4/26/12 on Ergonomics, Bloodborne Pathogens, Fall Incidents, MSDS and Workplace Violence. 4/24/12 Bloodborne Pathogens and other Microorganisms. MDRO (multi-drug resistant organism) including[DIAGNOSES REDACTED]. Further review of the training documentation revealed no mention of wearing personal protective equipment for taking care a resident with[DIAGNOSES REDACTED] or how to properly store and transport linen for a resident wit[DIAGNOSES REDACTED]. Review of the facility's Weekly Management Environmental Services Meeting Agenda dated May 14, 2012 revealed the following in part: Items for Discussion: In-Service Cleaning Procedure for Resident Rooms when infectious condition exists. May 11, 2012 Special Instructions to staff cleaning on Health and Wellness Second floor: This is the result of a surface bacteria call [MEDICAL CONDITION] or [MEDICAL CONDITION] that will only respond to the Dispatch Bleach Germicidal Cleaner provided for you. When preparing your cart for the day, be certain that you have a bottle of Dispatch Bleach Disinfectant with you. All surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the residents touched or will touch must be sprayed with Dispatch Bleach Disinfectant and left on for thirty seconds before wiping down. The entire bathroom, commode in and out, the shower, the floor, doors and door frames should be disinfected. Anything the resident might have touched, phones, bed rails, remotes, everything. Please use a very small amount in your mop bucket to mop these floors so they don't get sticky. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag or rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. (Please note: The disinfecting foam provided for waterless cleaning will not kill this bacteria.) Proceed to your next resident room, using universal precautions, in our case, put on fresh gloves, and proceed as usual using fresh clean rags, and mops for each room. Review of the In-Service: Cleaning procedure for Resident Rooms When Infectious Surfaces Condition exists revealed the following in part:. This is the result of surface bacteria that is spread around by the resident or other individuals in the resident's room or area, and that will only respond to the Blue Skies II Quaternary disinfectant. When preparing your cart for the day, be certain that your Blue Skies II Quaternary Disinfectant bottle is full of the chemical. ALL surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the resident has touched or will touch must be wiped down with the Blue Skies II Quaternary disinfectant. The entire bathroom, commode in and out, the shower, the floor should be disinfected. Please use rain-dance in your mop bucket to mop the floors so they don't get sticky as they will with Blue Skies II Quaternary disinfectant. The Raindance is a disinfectant cleaner. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. However, in these types of situations, clean the mirror with the Blue Skies II. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag of rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. Then you may proceed to your next resident room. On 1/16/13 at 9:27 a.m. an interview was conducted with S5Environmental Services Coordinator and S15Environmental Services Lead Tech. They both verified staff used Raindance Neutral Floor cleaner for the floors; Bathmate for the toilets and shower area, disinfectant for the bathrooms and Ringo Blue occasionally or Soft Cream if the toilets had a ring in it. They said the staff also use Dispatch if a resident was on[DIAGNOSES REDACTED] or had a yellow or red bag in their room that killed[DIAGNOSES REDACTED]. On 1/16/13 at 9:41 a.m. an interview was conducted with S14Housekeeper. She confirmed she cleaned all the rooms on 3rd floor. She said she used Disinfectant to spray the toilet and the sinks and Bathmate to clean the tub and shower. She said she sprayed Raindance on a Doodle pad and cleaned the floor and disposed of it afterwards. S14Housekeeper said she also used Breakdown which was an odor eliminator and Dispatch if she saw a yellow or red bag in the room. She said she only used her mop bucket to clean staff bathrooms. Review of the facility's Material Safety Data Sheet for Raindance Low Foam Neutral Floor Cleaner revealed the following in part: Recommended use: Cleaning product. This product is intended to be diluted prior to use. Composition/Information on Ingredients: [MEDICATION NAME] Alcohol ethoxylates On 1/16/13 at 9:45 a.m. an interview was conducted with S15Environmental Services Lead Tech. She confirmed that Raindance did not kill[DIAGNOSES REDACTED] and S14Housekeeper was supposed to be using Dispatch and cleaning the floors following the above noted in-service on floors.

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 #22 who was diagnosed with [REDACTED]. The facility further failed to ensure that the other 28(#22,#24, #25, #26, #1, #2, #3, #4, #85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, #38) residents from a total census of 48 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(#22) who was on contact precautions for [MEDICAL CONDITION]. 2) Ensure nursing staff implemented appropriate isolation precautions for a resident (#22) 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 #24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, and #38 were placed in Immediate Jeopardy on 12/7/12 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for a resident(#22) with a positive stool culture on 12/7/12 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the 3rd floor. The deficient practice remains in place for all other residents at a level of more than minimum harm. The Administrator was notified of the Immediate Jeopardy on 1/15/13 at 4:00 p.m. A Plan of Removal was presented by the S2DON which read: The facility shall continue an infection control program in order to prevent, to the extent possible, the onset and spread of infection. Appropriate transmission-based precautions shall be utilized when indicated. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Corrections put in place: Contact precautions continue for resident who tested positive for [MEDICAL CONDITION]. Transmission precautions shall remain in effect until physician gives order to remove contact precautions, considering asymptomatic status and CDC guidelines. Personal protective equipment, which includes gloves and gowns, is placed in room for staff use. All blood pressure cuffs that had the potential to exposure discarded. The rolling up BP machine was appropriately disinfected with Dispatch, Bleach Germicidal Cleaner. Resident roommate was moved to another room to avoid possible transmission of infection. Resident was educated on appropriate hand hygiene. Signage was placed on door to alert staff or visitors to see nurse at care base before entering room so that he/she/they may be educated on transmission precautions. Staff has been educated on HIPPA violation regarding signage on resident doors. Biohazard sanitation set-up is in resident bathroom. Soiled linens and personal clothing items are bagged in melt-a-way bags and again in yellow bag for transport to laundry. Melt-a-way bag is removed from yellow bag, placed in washing machine and washed with disinfectant appropriate for[DIAGNOSES REDACTED] control. Random checks shall be performed by nursing management to ensure compliance with transmission based precautions. Mandatory Infection Control meeting held 1/16/2013, educating 60 plus employees. Education continues. Environmental services shall perform in-service regarding the use of appropriate chemical to control infection. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Revision of Infection Control policy and procedure complete. The Immediate Jeopardy was lifted on 1/17/13 at 10:00 a.m. when surveyors determined the facility had implemented its plan of removal. Findings: 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..." Review of the facility's Infection Control Policy effective July 2012 revealed the following in part: Policy Summary and Objective: To help prevent, recognize, and control, to the extent possible, the onset and spread of infection. Policy Guidelines and Procedures: High Risk meetings, which include Infection Control, shall be held, at the minimum, bimonthly, to identify any onset or spread of infection. Director of Nursing, or his/her designee, shall track and trend infection control, completing an infection control report monthly. If any significant trend is noted, necessary measures shall be taken to identify and correct, to the extent possible, to prevent further infection. To prevent and control infection, appropriate transmission precautions shall be put in place. Standard precautions, (Universal Precautions), shall be infection prevention practice for all residents. To avoid the potential negative impact a resident may experience as of result of the implementation of special precautions, signage shall be posted on resident apartment for extreme precautions only. All direct care staff shall receive, at the minimum, annual infection control training. Soiled bed linens and towels shall be contained in melt-a-way bag and yellow bagged before sending to laundry via laundry chute. Personal clothing items shall be contained in melt-a-way bag and washed in laundry on care area floor, utilizing Auto Chlor Solution QA dispensed with wash cycle. Resident #22 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimal Data Set(MDS) with an Assessment Review Date(ARD) date of 12/12/12 in Section C; Cognitive Patterns the resident's Brief Interview of Mental Status(BIMS) revealed the resident's total score to be a 14; Cognitively Intact. Section G: Functional Status G0110. Activities of Daily Living(ADL) Assistance revealed E. Locomotion on unit (2) Limited assistance; (2) One person physical assist. F. Locomotion off unit (2) Limited assistance (2) One person physical assist. Review of Resident #22's December 2012's physician's orders [REDACTED]. 12/5/12 Order for stool study x 3 stool samples 12/7/12 [MEDICATION NAME] 500 milligrams(mg) by mouth(po) twice(bid) times 7 days 12/25/12 For Diarrhea (loose stools). Check for impaction. If negative [MEDICATION NAME] 2 po now, then 2 po after each loose stools. 12/26/12 Check stool for [MEDICAL CONDITION] Review of the facility's Facsimile Transmission Cover Sheet revealed the following in part: 12/5/12 Resident complaints of 3 loose stool episodes during the day. Resident has a history of [MEDICAL CONDITION]. 12/7/12 Resident have had 2 soft stools, not watery today. 12/10/12 Resident positive for [MEDICAL CONDITION] on [MEDICATION NAME] 500 mg po bid times 7 days. 12/12/12 Resident on ABT for [MEDICAL CONDITION]. Family wants stool culture after ABT is complete. Is this ok? 12/19/12 Family concerned resident with watery stool times 3 this day and resident complaint of tired of feeling. Completed [MEDICATION NAME] on 12/14. 12/25/12 S.O. initiated for loose stools times 2. resident had a history of [REDACTED]. Is on Flora Q and yogurt. Review of Resident #22's Nursing Home Progress Note dated 12/10/12 revealed the following in part: Treated on ... for[DIAGNOSES REDACTED]. Review of Resident #22's Laboratory documentation revealed the following in part: 12/6/12[DIAGNOSES REDACTED]icile Positive [MEDICATION NAME] started. 12/28/12[DIAGNOSES REDACTED]icile Positive Review of Resident #22's Comprehensive Plan of Care for Recurrent [DIAGNOSES REDACTED]icile dated 12/7/12 revealed the following: Goal: Resident #22 will have no further complications through the next 90 days 3/7/13 Approaches: 1) Administer medication as ordered 2) Contact precautions as ordered 3) Encourage resident and staff to practice good handwashing before and after care 4) Obtain stool specimens as ordered and notify MD of results 5) Monitor for signs/symptoms of abdominal cramping; foul odor to stools; frequent watery diarrhea; pus in stool and decrease appetite. On 1/16/12 at 1:51 p.m. an interview was conducted with S6Medicare Nurse Coordinator. She stated Resident #22 was diagnosed with [REDACTED]. She said the resident was asymptomatic and was not taking medications. She said she did not revise the resident's Comprehensive Plan of Care to reflect such; because she wanted to see if the resident was going to develop[DIAGNOSES REDACTED] again before the 90 days. Review of Resident #22's Nurses' Progress Notes revealed the following in part: 12/29/12 6 p.m.-6 a.m. Loose stool times 1 with odor noted. Lab results received 1:30 a.m. positive for[DIAGNOSES REDACTED] of stool. Contact Precautions implemented. 1/3/13 History of[DIAGNOSES REDACTED]. Review of Resident #22's Interdisciplinary Notes revealed the following in part: 12/29/12 11:03 12/29/12 10p-6a. Resident positive for[DIAGNOSES REDACTED] of stool at this time. No antibiotic(ABT) therapy ordered per physician. 1 loose stool today. Report given. Doctor was notified. No new orders given. On contact precautions. 12/25/12 2:50 a.m. 12/25/12 2:50 a.m. CNA to report loose stools x 2 episodes. 12/20/12 5:24 p.m. Resident complained of 2 episodes of loose stool. Resident has an order for [REDACTED]. 12/19/12 5:00 p.m. Resident complained of 3 episodes of loose stool. 12/11/12 12/10/12 5:27 a.m. ABT in use for positive[DIAGNOSES REDACTED] in stool. Contact isolation in progress. 12/10/12 2:04 p.m. No diarrhea noted throughout the shift. 12/09/12 2:00 a.m. Contact Isolation implemented. 12/9/12 12/8/12 1:29 a.m. at 10:40 p.m. Resident is currently on [MEDICATION NAME] for[DIAGNOSES REDACTED]. 12/8/12 Resident on antibiotic therapy for[DIAGNOSES REDACTED]. Contact Precautions taken during resident care. 12/5/12 12/5/12 6:17 p.m. Resident up in chair. Complain of 3 episodes of loose stool. Doctor office called to report resident complaint. 12/4/12 Resident lying in bed AAO x 3. Decided to stay in bed due to diarrhea. She had throughout the night. States, she feel weak. Will continue to monitor while taking meds this am. 12/4/12 12/3/12 2:05 a.m. AAO x 3. at 1:50 a.m. Resident complains of having 3 loose stools. Checked for impaction. Negative. [MEDICATION NAME] x 2 given po now, then 2 po after each loose stool x 24 hours per physician standing orders. On 1/14/13 at 1:14 p.m. an interview was conducted with S7LPN. She said she was informed Resident #22 had[DIAGNOSES REDACTED] and was on Contact Precautions. She stated the facility trained her that with a resident with[DIAGNOSES REDACTED] she was to wear gloves and use proper handwashing. S7LPN said the facility staff who trained her showed her where to get the boxes and where the yellow and red bags were, how to place them and how to dispose of them. She said the resident became asymptomatic after 12/29/12. She said she and others voiced concerns about a resident being on[DIAGNOSES REDACTED] and not instituting Contact Precautions of PPE(personal protective equipment) and Administration told them it was not a nursing home and they was not going to institute all that. She said the facility does not put signage on resident's door to alert staff or visitors of transmission precautions. She said they did not disinfect blood pressure cuffs when the resident was infectious before they used it on other residents. She said the resident was admitted on [DATE]. She started having diarrhea on 12/4/12. An order was obtained on 12/5/12 to check stool times 3. She said on 12/7/12 the resident was positive for[DIAGNOSES REDACTED] and was placed on [MEDICATION NAME]. She stated that the resident did not have a roommate at that time. She said on 12/10/12 a resident was admitted to the room. She said a yellow bag and a red bag was supposed to be placed in 2 card board boxes in the resident's room. She said the resident's clothing and her linen went in a melt a way bag that was placed in a yellow bag. She said the linen was sent down the "shoot" to the laundry in a melt a way bag inside a yellow bag and her personal clothes were also put in a melt a way bag and washed on the 3rd floor. She confirmed there was no yellow bag in 1 of the resident's card board boxes in the bathroom and there was a melt away bag with linen in it and a clear bag with clothing items in it. She said the clear bag with the linen was not processed correctly. She acknowledged it should have been in a melt a way bag inside a yellow bag to alert the laundry staff the linens were contaminated. She said the resident took showers in her room and her roommate was bed bound. She verified the roommate's sitter went in the bathroom; because she gave the resident a bed bath and took care of the resident. On 1/14/13 at 2:58 p.m. an observation was made that Resident #22 had no signage on her door or above her bed. Further observation revealed 2 brown card board boxes in the resident #22's bathroom. One card board box had a red biohazard bag filled with disposable diapers and the other card board box had a clear melt a way bag with linen in it and a clear trash bag with linen in it. Further observation noted no yellow bag was in 1 of the card board boxes. On 1/15/13 at 1:39 p.m. an interview was conducted with S7LPN. She stated nursing staff did weekly vital signs on residents who were not skilled and daily on skilled residents. She said when Resident #22 was diagnosed with [REDACTED]. She said the resident was continent, but also had incontinent episodes when she couldn't make it to the bathroom. S7LPN stated staff had to assist with incontinent care. She said the resident wore briefs and did soil her clothes occasionally. She said the resident did not remain in her room when she was infectious nor did staff wear gowns, masks or shoe covers. Review of the facility's training logs revealed the LPN staff received the following training in part: 12/12 Monthly Nursing Meeting.[DIAGNOSES REDACTED] Report any increase in signs and symptoms 4/26/12 on Ergonomics, Bloodborne Pathogens, Fall Incidents, MSDS and Workplace Violence. 4/24/12 Bloodborne Pathogens and other Microorganisms. MDRO (multi-drug resistant organism) including[DIAGNOSES REDACTED]. Further review of the training documentation revealed no mention of wearing personal protective equipment for taking care a resident with[DIAGNOSES REDACTED] or how to properly store and transport linen for a resident wit[DIAGNOSES REDACTED]. On 1/15/13 at 10:52 a.m. an interview was conducted with S2DON. She stated when the resident had[DIAGNOSES REDACTED] and was on Contact Precautions, appropriate precautions were put in place. She said the staff discussed Infection Control weekly and she tracked and trended infections to make sure there was no outbreak. She stated they don't isolate residents on[DIAGNOSES REDACTED], because she didn't consider it to be "highly contagious" like the flu. S2DON said the facility was not going to place any kind of signage at the resident's door notifying staff or visitors to see the nurse because of "cultural diversity". She confirmed they had no specific policy regarding what precautions the staff would specifically implement for a resident on[DIAGNOSES REDACTED]. She stated it was at the facility's discretion as far as what protocol they would use. She said she got reports from CDC guidelines all the time and was aware of what precautions were recommended for residents with[DIAGNOSES REDACTED]. She acknowledged she did not train the LPN staff to wear personal protective equipment or to properly disinfect equipment after use on a[DIAGNOSES REDACTED] resident. She said she only informed them to wear gloves and exercise good handwashing.

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 disease and infection for 1(#22) of 29(#22,#24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, #38), residents who residing on the 3rd floor from a total census of 48 residents listed on the Resident Census and Condition document by failing to: 1) Ensure staff wore proper protective clothing before entering a room to provide care for a resident(#22) who was on Contact Precautions for Clostridium Difficile. 2) Ensure housekeeping staff disinfected a resident's(#22) bathroom according to Centers for Disease Control(CDC) Standards with a agent effective in killing Clostridium Difficile(C Diff). 3) Ensure Certified Nursing Assistant(CNA) staff properly stored and transported contaminated linen for a resident with[DIAGNOSES REDACTED]. 4) Implement appropriate contact precautions for a resident(#22) whose stool culture was reported positive for[DIAGNOSES REDACTED] on 12/7/12. 5) Ensure the facility's policy and procedure for infection control contained measures staff would implement to prevent spread of[DIAGNOSES REDACTED] infection. 6) Ensure the Licensed Practical Nurses(LPN) and CNA staff were trained on and implemented Contact Precautions for a resident(#22) with for[DIAGNOSES REDACTED]. 7) Ensure blood pressure cuffs were appropriately disinfected after use for a resident(#22) with[DIAGNOSES REDACTED] before use on other residents. Residents #24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, and #38 were placed in Immediate Jeopardy on 12/7/12 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for a resident(#22) with a positive stool culture on 12/7/12 for Clostridium Difficile(C Diff). This presented an exposure for all other residents who resided on the 3rd floor. The deficient practice remains in place for all other residents at a level of more than minimum harm. The Administrator was notified of the Immediate Jeopardy on 1/15/13 at 4:00 p.m. A Plan of Removal was presented by the S2DON which read: The facility shall continue an infection control program in order to prevent, to the extent possible, the onset and spread of infection. Appropriate transmission-based precautions shall be utilized when indicated. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Corrections put in place: Contact precautions continue for resident who tested positive for[DIAGNOSES REDACTED]. Transmission precautions shall remain in effect until physician gives order to remove contact precautions, considering asymptomatic status and CDC guidelines. Personal protective equipment, which includes gloves and gowns, is placed in room for staff use. All blood pressure cuffs that had the potential to exposure discarded. The rolling up BP machine was appropriately disinfected with Dispatch, Bleach Germicidal Cleaner. Resident roommate was moved to another room to avoid possible transmission of infection. Resident was educated on appropriate hand hygiene. Signage was placed on door to alert staff or visitors to see nurse at care base before entering room so that he/she/they may be educated on transmission precautions. Staff has been educated on HIPPA violation regarding signage on resident doors. Biohazard sanitation set-up is in resident bathroom. Soiled linens and personal clothing items are bagged in melt-a-way bags and again in yellow bag for transport to laundry. Melt-a-way bag is removed from yellow bag, placed in washing machine and washed with disinfectant appropriate for[DIAGNOSES REDACTED] control. Random checks shall be performed by nursing management to ensure compliance with transmission based precautions. Mandatory Infection Control meeting held 1/16/2013, educating 60 plus employees. Education continues. Environmental services shall perform in-service regarding the use of appropriate chemical to control infection. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Revision of Infection Control policy and procedure complete. The Immediate Jeopardy was lifted on 1/17/13 at 10:00 a.m. when surveyors determined the facility had implemented its plan of removal. Findings: 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 facility's Infection Control Policy effective July 2012 revealed the following in part: Policy Summary and Objective: To help prevent, recognize, and control, to the extent possible, the onset and spread of infection. Policy Guidelines and Procedures: High Risk meetings, which include Infection Control, shall be held, at the minimum, bimonthly, to identify any onset or spread of infection. Director of Nursing, or his/her designee, shall track and trend infection control, completing an infection control report monthly. If any significant trend is noted, necessary measures shall be taken to identify and correct, to the extent possible, to prevent further infection. To prevent and control infection, appropriate transmission precautions shall be put in place. Standard precautions, (Universal Precautions), shall be infection prevention practice for all residents. To avoid the potential negative impact a resident may experience as of result of the implementation of special precautions, signage shall be posted on resident apartment for extreme precautions only. All direct care staff shall receive, at the minimum, annual infection control training. Soiled bed linens and towels shall be contained in melt-a-way bag and yellow bagged before sending to laundry via laundry chute. Personal clothing items shall be contained in melt-a-way bag and washed in laundry on care area floor, utilizing Auto Chlor Solution QA dispensed with wash cycle. Resident #22 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimal Data Set(MDS) with an Assessment Review Date(ARD) date of 12/12/12 in Section C; Cognitive Patterns the resident's Brief Interview of Mental Status(BIMS) revealed the resident's total score to be a 14; Cognitively Intact. Section G: Functional Status G0110. Activities of Daily Living(ADL) Assistance revealed E. Locomotion on unit (2) Limited assistance; (2) One person physical assist. F. Locomotion off unit (2) Limited assistance (2) One person physical assist. Review of Resident #22's December 2012's physician's orders [REDACTED]. 12/5/12 Order for stool study x 3 stool samples 12/7/12 [MEDICATION NAME] 500 milligrams(mg) by mouth(po) twice(bid) times 7 days 12/25/12 For Diarrhea (loose stools). Check for impaction. If negative [MEDICATION NAME] 2 po now, then 2 po after each loose stools. 12/26/12 Check stool for[DIAGNOSES REDACTED] Review of the facility's Facsimile Transmission Cover Sheet revealed the following in part: 12/5/12 Resident complaints of 3 loose stool episodes during the day. Resident has a history of[DIAGNOSES REDACTED]. 12/7/12 Resident have had 2 soft stools, not watery today. 12/10/12 Resident positive for[DIAGNOSES REDACTED] on [MEDICATION NAME] 500 mg po bid times 7 days. 12/12/12 Resident on ABT for[DIAGNOSES REDACTED]. Family wants stool culture after ABT is complete. Is this ok? 12/19/12 Family concerned resident with watery stool times 3 this day and resident complaint of tired of feeling. Completed [MEDICATION NAME] on 12/14. 12/25/12 S.O. initiated for loose stools times 2. resident had a history of [REDACTED]. Is on Flora Q and yogurt. Review of Resident #22's Nursing Home Progress Note dated 12/10/12 revealed the following in part: Treated on ... for[DIAGNOSES REDACTED]. Review of Resident #22's Laboratory documentation revealed the following in part: 12/6/12[DIAGNOSES REDACTED]icile Positive [MEDICATION NAME] started. 12/28/12[DIAGNOSES REDACTED]icile Positive Review of Resident #22's Comprehensive Plan of Care for Recurrent [DIAGNOSES REDACTED]icile dated 12/7/12 revealed the following: Goal: Resident #22 will have no further complications through the next 90 days 3/7/13 Approaches: 1) Administer medication as ordered 2) Contact precautions as ordered 3) Encourage resident and staff to practice good handwashing before and after care 4) Obtain stool specimens as ordered and notify MD of results 5) Monitor for signs/symptoms of abdominal cramping; foul odor to stools; frequent watery diarrhea; pus in stool and decrease appetite. On 1/16/12 at 1:51 p.m. an interview was conducted with S6Medicare Nurse Coordinator. She stated Resident #22 was diagnosed with [REDACTED]. She said the resident was asymptomatic and was not taking medications. She said she did not revise the resident's Comprehensive Plan of Care to reflect such; because she wanted to see if the resident was going to develop[DIAGNOSES REDACTED] again before the 90 days. Review of Resident #22's Nurses' Progress Notes revealed the following in part: 12/29/12 6 p.m.-6 a.m. Loose stool times 1 with odor noted. Lab results received 1:30 a.m. positive for[DIAGNOSES REDACTED] of stool. Contact Precautions implemented. 1/3/13 History of[DIAGNOSES REDACTED]. Review of Resident #22's Interdisciplinary Notes revealed the following in part: 12/29/12 11:03 12/29/12 10p-6a. Resident positive for[DIAGNOSES REDACTED] of stool at this time. No antibiotic(ABT) therapy ordered per physician. 1 loose stool today. Report given. Doctor was notified. No new orders given. On contact precautions. 12/25/12 2:50 a.m. 12/25/12 2:50 a.m. CNA to report loose stools x 2 episodes. 12/20/12 5:24 p.m. Resident complained of 2 episodes of loose stool. Resident has an order for [REDACTED]. 12/19/12 5:00 p.m. Resident complained of 3 episodes of loose stool. 12/11/12 12/10/12 5:27 a.m. ABT in use for positive[DIAGNOSES REDACTED] in stool. Contact isolation in progress. 12/10/12 2:04 p.m. No diarrhea noted throughout the shift. 12/09/12 2:00 a.m. Contact Isolation implemented. 12/9/12 12/8/12 1:29 a.m. at 10:40 p.m. Resident is currently on [MEDICATION NAME] for[DIAGNOSES REDACTED]. 12/8/12 Resident on antibiotic therapy for[DIAGNOSES REDACTED]. Contact Precautions taken during resident care. 12/5/12 12/5/12 6:17 p.m. Resident up in chair. Complain of 3 episodes of loose stool. Doctor office called to report resident complaint. 12/4/12 Resident lying in bed AAO x 3. Decided to stay in bed due to diarrhea. She had throughout the night. States, she feel weak. Will continue to monitor while taking meds this am. 12/4/12 12/3/12 2:05 a.m. AAO x 3. at 1:50 a.m. Resident complains of having 3 loose stools. Checked for impaction. Negative. [MEDICATION NAME] x 2 given po now, then 2 po after each loose stool x 24 hours per physician standing orders. On 1/14/13 at 1:14 p.m. an interview was conducted with S7LPN. She said she was informed Resident #22 had[DIAGNOSES REDACTED] and was on Contact Precautions. She stated the facility trained her that with a resident with[DIAGNOSES REDACTED] she was to wear gloves and use proper handwashing. S7LPN said the facility staff who trained her showed her where to get the boxes and where the yellow and red bags were, how to place them and how to dispose of them. She said the resident became asymptomatic after 12/29/12. She said she and others voiced concerns about a resident being on[DIAGNOSES REDACTED] and not instituting Contact Precautions of PPE(personal protective equipment) and Administration told them it was not a nursing home and they was not going to institute all that. She said the facility does not put signage on resident's door to alert staff or visitors of transmission precautions. She said they did not disinfect blood pressure cuffs when the resident was infectious before they used it on other residents. She said the resident was admitted on [DATE]. She started having diarrhea on 12/4/12. An order was obtained on 12/5/12 to check stool times 3. She said on 12/7/12 the resident was positive for[DIAGNOSES REDACTED] and was placed on [MEDICATION NAME]. She stated that the resident did not have a roommate at that time. She said on 12/10/12 a resident was admitted to the room. She said a yellow bag and a red bag was supposed to be placed in 2 card board boxes in the resident's room. She said the resident's clothing and her linen went in a melt a way bag that was placed in a yellow bag. She said the linen was sent down the "shoot" to the laundry in a melt a way bag inside a yellow bag and her personal clothes were also put in a melt a way bag and washed on the 3rd floor. She confirmed there was no yellow bag in 1 of the resident's card board boxes in the bathroom and there was a melt away bag with linen in it and a clear bag with clothing items in it. She said the clear bag with the linen was not processed correctly. She acknowledged it should have been in a melt a way bag inside a yellow bag to alert the laundry staff the linens were contaminated. She said the resident took showers in her room and her roommate was bed bound. She verified the roommate's sitter went in the bathroom; because she gave the resident a bed bath and took care of the resident. On 1/14/13 at 2:58 p.m. an observation was made that Resident #22 had no signage on her door or above her bed. Further observation revealed 2 brown card board boxes in the resident #22's bathroom. One card board box had a red biohazard bag filled with disposable diapers and the other card board box had a clear melt a way bag with linen in it and a clear trash bag with linen in it. Further observation noted no yellow bag was in 1 of the card board boxes. On 1/14/13 at 3:24 p.m. an interview was conducted with S11CNA. She said she had been working at the facility for 2 months and had not been trained to wear personal protective equipment in taking care a person who had[DIAGNOSES REDACTED] on Contact Precautions. She said she wore gloves and washed her hands. On 1/15/12 at 10:06 a.m. an interview was conducted with S12CNA. She stated when she worked with Resident #22, she put her personal clothing in a water soluble bag and washed them at the end of her shift. She stated she send the resident's linen down the "shoot" in a melt a way bag. She said the Biohazard boxes were picked up from the Biohazard people. S12CNA said sometimes a yellow bag was in the cardboard box and sometimes they had to put one in. She said she couldn't remember whether she placed a yellow bag in the cardboard box the prior day when she worked with the resident. On 1/15/13 at 10:52 a.m. an interview was conducted with S2DON. She stated when the resident had[DIAGNOSES REDACTED] and was on Contact Precautions, appropriate precautions were put in place. She said the staff discussed Infection Control weekly and she tracked and trended infections to make sure there was no outbreak. She stated they don't isolate residents on[DIAGNOSES REDACTED], because she didn't consider it to be "highly contagious" like the flu. S2DON said the facility was not going to place any kind of signage at the resident's door notifying staff or visitors to see the nurse because of "cultural diversity". She confirmed they had no specific policy regarding what precautions the staff would specifically implement for a resident on[DIAGNOSES REDACTED]. She stated it was at the facility's discretion as far as what protocol they would use. She said she got reports from CDC guidelines all the time and was aware of what precautions were recommended for residents with[DIAGNOSES REDACTED]. She acknowledged she did not train staff to wear personal protective equipment or to properly disinfect equipment after use on a[DIAGNOSES REDACTED] resident. She said she only informed them to wear gloves and use exercise good handwashing. She verified a yellow and red bag was supposed to be placed in the separate card board boxes in the resident's room and the CNA staff was supposed to place a melt a way bag inside the yellow bag and send the laundry down the shoot. She said the resident's personal clothes was also to be placed in a melt a way bag and washed on the resident's floor by the CNA staff. On 1/15/13 at 1:11 p.m. an interview was conducted with S10CNA. She stated she started working at the facility on December 20, 2012. She said she had not been trained on what to wear besides gloves in taking care of a resident with[DIAGNOSES REDACTED] on Contact Precautions. She stated they told her to wear gloves and practice good handwashing. She said they never wore gowns, gloves or mask when providing care. On 1/15/13 at 1:39 p.m. an interview was conducted with S7LPN. She stated nursing staff did weekly vital signs on residents who were not skilled and daily on skilled residents. She said when Resident #22 was diagnosed with [REDACTED]. She said the resident was continent, but also had incontinent episodes when she couldn't make it to the bathroom. S7LPN stated staff had to assist with incontinent care. She said the resident wore briefs and did soil her clothes occasionally. She said the resident did not remain in her room when she was infectious nor did staff wear gowns, masks or shoe covers. On 1/16/13 at 8:56 a.m. an interview was conducted with S13CNA. She stated Resident #22 had[DIAGNOSES REDACTED], but "Don't quote me exactly on what precautions I'm supposed to be use". She said she thought it was contact precautions. She said she was trained to wear gloves and exercise good handwashing precautions, but was never told to wear protective equipment like a gown or a mask. On 1/16/13 at 9:07 a.m. an interview was conducted with S9LPN. She stated Resident #22 was on Contact Precautions and she used gloves, soap and water to wash her hands. She said they took vitals weekly for non skilled residents and daily on skilled residents. She said they had 1 rolling blood pressure cuff machine on the 3rd floor and 1 hand held blood pressure cuff in each cart on the floor and they did not disinfect the blood pressure machines after using it on Resident #22 before use on other residents. On 1/16/13 at 9:13 a.m. an interview was conducted with S8LPN. She stated she had 3 skilled residents that she took daily vital signs on and the weekly vitals on her non-skilled residents. Review of the facility's training logs revealed the LPN and CNA staff received the following training in part: 12/12 Monthly Nursing Meeting.[DIAGNOSES REDACTED] Report any increase in signs and symptoms 4/26/12 on Ergonomics, Bloodborne Pathogens, Fall Incidents, MSDS and Workplace Violence. 4/24/12 Bloodborne Pathogens and other Microorganisms. MDRO (multi-drug resistant organism) including[DIAGNOSES REDACTED]. Further review of the training documentation revealed no mention of wearing personal protective equipment for taking care a resident with[DIAGNOSES REDACTED] or how to properly store and transport linen for a resident wit[DIAGNOSES REDACTED]. Review of the facility's Weekly Management Environmental Services Meeting Agenda dated May 14, 2012 revealed the following in part: Items for Discussion: In-Service Cleaning Procedure for Resident Rooms when infectious condition exists. May 11, 2012 Special Instructions to staff cleaning on Health and Wellness Second floor: This is the result of a surface bacteria call[DIAGNOSES REDACTED] or Clostridium Difficile that will only respond to the Dispatch Bleach Germicidal Cleaner provided for you. When preparing your cart for the day, be certain that you have a bottle of Dispatch Bleach Disinfectant with you. All surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the residents touched or will touch must be sprayed with Dispatch Bleach Disinfectant and left on for thirty seconds before wiping down. The entire bathroom, commode in and out, the shower, the floor, doors and door frames should be disinfected. Anything the resident might have touched, phones, bed rails, remotes, everything. Please use a very small amount in your mop bucket to mop these floors so they don't get sticky. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag or rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. (Please note: The disinfecting foam provided for waterless cleaning will not kill this bacteria.) Proceed to your next resident room, using universal precautions, in our case, put on fresh gloves, and proceed as usual using fresh clean rags, and mops for each room. Review of the In-Service: Cleaning procedure for Resident Rooms When Infectious Surfaces Condition exists revealed the following in part:. This is the result of surface bacteria that is spread around by the resident or other individuals in the resident's room or area, and that will only respond to the Blue Skies II Quaternary disinfectant. When preparing your cart for the day, be certain that your Blue Skies II Quaternary Disinfectant bottle is full of the chemical. ALL surfaces, door frames, light switches, telephone, remotes, table tops, bed rails, ANYTHING the resident has touched or will touch must be wiped down with the Blue Skies II Quaternary disinfectant. The entire bathroom, commode in and out, the shower, the floor should be disinfected. Please use rain-dance in your mop bucket to mop the floors so they don't get sticky as they will with Blue Skies II Quaternary disinfectant. The Raindance is a disinfectant cleaner. As a reminder, Glass cleaner is not a disinfectant, and should not be used for anything else but glass cleaning. However, in these types of situations, clean the mirror with the Blue Skies II. When you leave the room, place your cleaning cloths, mops etc. in the soiled bag of rags on your housekeeping cart, remove your gloves, and go to a public bathroom to wash your hands with soap and water. Then you may proceed to your next resident room. On 1/16/13 at 9:27 a.m. an interview was conducted with S5Environmental Services Coordinator and S15Environmental Services Lead Tech. They both verified staff used Raindance Neutral Floor cleaner for the floors; Bathmate for the toilets and shower area, disinfectant for the bathrooms and Ringo Blue occasionally or Soft Cream if the toilets had a ring in it. They said the staff also use Dispatch if a resident was on[DIAGNOSES REDACTED] or had a yellow or red bag in their room that killed[DIAGNOSES REDACTED]. On 1/16/13 at 9:41 a.m. an interview was conducted with S14Housekeeper. She confirmed she cleaned all the rooms on 3rd floor. She said she used Disinfectant to spray the toilet and the sinks and Bathmate to clean the tub and shower. She said she sprayed Raindance on a Doodle pad and cleaned the floor and disposed of it afterwards. S14Housekeeper said she also used Breakdown which was an odor eliminator and Dispatch if she saw a yellow or red bag in the room. She said she only used her mop bucket to clean staff bathrooms. Review of the facility's Material Safety Data Sheet for Raindance Low Foam Neutral Floor Cleaner revealed the following in part: Recommended use: Cleaning product. This product is intended to be diluted prior to use. Composition/Information on Ingredients: [MEDICATION NAME] Alcohol ethoxylates On 1/16/13 at 9:45 a.m. an interview was conducted with S15Environmental Services Lead Tech. She confirmed that Raindance did not kill[DIAGNOSES REDACTED] and S14Housekeeper was supposed to be using Dispatch and cleaning the floors following the above noted in-service on floors.

Based on record review and interviews, the facility failed to ensure CNAs(Certified Nursing Assistant) carried out appropriate infection control precautions. The facility failed to: 1) Ensure staff wore proper protective clothing before entering a room for a resident who was on Contact Isolation Precautions. (#22) 2) Ensure staff stored and transported contaminated linen for a resident(#22) with [MEDICAL CONDITION] on Contact Precautions. Residents #24, #25, #26, #1, #2, #3, #4,#85, #13, #82, #19, #58, #31, #47, #23, #43, #40, #75, #67, #61, #39, #90, #68, #62, #45, #8, #32, and #38 were placed in Immediate Jeopardy on 12/7/12 when the facility failed to have a system in place to ensure contact isolation precautions were maintained for a resident(#22) with a positive stool culture on 12/7/12 for [MEDICAL CONDITION](C Diff). This presented an exposure for all other residents who resided on the 3rd floor. The deficient practice remains in place for all other residents at a level of more than minimum harm. The Administrator was notified of the Immediate Jeopardy on 1/15/13 at 4:00 p.m. A Plan of Removal was presented by the S2DON which read: The facility shall continue an infection control program in order to prevent, to the extent possible, the onset and spread of infection. Appropriate transmission-based precautions shall be utilized when indicated. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Corrections put in place: Contact precautions continue for resident who tested positive for [MEDICAL CONDITION]. Transmission precautions shall remain in effect until physician gives order to remove contact precautions, considering asymptomatic status and CDC guidelines. Personal protective equipment, which includes gloves and gowns, is placed in room for staff use. All blood pressure cuffs that had the potential to exposure discarded. The rolling up BP machine was appropriately disinfected with Dispatch, Bleach Germicidal Cleaner. Resident roommate was moved to another room to avoid possible transmission of infection. Resident was educated on appropriate hand hygiene. Signage was placed on door to alert staff or visitors to see nurse at care base before entering room so that he/she/they may be educated on transmission precautions. Staff has been educated on HIPPA violation regarding signage on resident doors. Biohazard sanitation set-up is in resident bathroom. Soiled linens and personal clothing items are bagged in melt-a-way bags and again in yellow bag for transport to laundry. Melt-a-way bag is removed from yellow bag, placed in washing machine and washed with disinfectant appropriate for[DIAGNOSES REDACTED] control. Random checks shall be performed by nursing management to ensure compliance with transmission based precautions. Mandatory Infection Control meeting held 1/16/2013, educating 60 plus employees. Education continues. Environmental services shall perform in-service regarding the use of appropriate chemical to control infection. Resident's record shall be assessed upon admission, hospital return, and as necessary to identify infection control risk. Revision of Infection Control policy and procedure complete. The Immediate Jeopardy was lifted on 1/17/13 at 10:00 a.m. when surveyors determined the facility had implemented its plan of removal. Findings: 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 facility's Infection Control Policy effective July 2012 revealed the following in part: Policy Summary and Objective: To help prevent, recognize, and control, to the extent possible, the onset and spread of infection. Policy Guidelines and Procedures: High Risk meetings, which include Infection Control, shall be held, at the minimum, bimonthly, to identify any onset or spread of infection. Director of Nursing, or his/her designee, shall track and trend infection control, completing an infection control report monthly. If any significant trend is noted, necessary measures shall be taken to identify and correct, to the extent possible, to prevent further infection. To prevent and control infection, appropriate transmission precautions shall be put in place. Standard precautions, (Universal Precautions), shall be infection prevention practice for all residents. To avoid the potential negative impact a resident may experience as of result of the implementation of special precautions, signage shall be posted on resident apartment for extreme precautions only. All direct care staff shall receive, at the minimum, annual infection control training. Soiled bed linens and towels shall be contained in melt-a-way bag and yellow bagged before sending to laundry via laundry chute. Personal clothing items shall be contained in melt-a-way bag and washed in laundry on care area floor, utilizing Auto Chlor Solution QA dispensed with wash cycle. Resident #22 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimal Data Set(MDS) with an Assessment Review Date(ARD) date of 12/12/12 in Section C; Cognitive Patterns the resident's Brief Interview of Mental Status(BIMS) revealed the resident's total score to be a 14; Cognitively Intact. Section G: Functional Status G0110. Activities of Daily Living(ADL) Assistance revealed E. Locomotion on unit (2) Limited assistance; (2) One person physical assist. F. Locomotion off unit (2) Limited assistance (2) One person physical assist. Review of Resident #22's December 2012's physician's orders [REDACTED]. 12/5/12 Order for stool study x 3 stool samples 12/7/12 [MEDICATION NAME] 500 milligrams(mg) by mouth(po) twice(bid) times 7 days 12/25/12 For Diarrhea (loose stools). Check for impaction. If negative [MEDICATION NAME] 2 po now, then 2 po after each loose stools. 12/26/12 Check stool for [MEDICAL CONDITION] Review of the facility's Facsimile Transmission Cover Sheet revealed the following in part: 12/5/12 Resident complaints of 3 loose stool episodes during the day. Resident has a history of [MEDICAL CONDITION]. 12/7/12 Resident have had 2 soft stools, not watery today. 12/10/12 Resident positive for [MEDICAL CONDITION] on [MEDICATION NAME] 500 mg po bid times 7 days. 12/12/12 Resident on ABT for [MEDICAL CONDITION]. Family wants stool culture after ABT is complete. Is this ok? 12/19/12 Family concerned resident with watery stool times 3 this day and resident complaint of tired of feeling. Completed [MEDICATION NAME] on 12/14. 12/25/12 S.O. initiated for loose stools times 2. resident had a history of [REDACTED]. Is on Flora Q and yogurt. Review of Resident #22's Nursing Home Progress Note dated 12/10/12 revealed the following in part: Treated on ... for[DIAGNOSES REDACTED]. Review of Resident #22's Laboratory documentation revealed the following in part: 12/6/12[DIAGNOSES REDACTED]icile Positive [MEDICATION NAME] started. 12/28/12[DIAGNOSES REDACTED]icile Positive Review of Resident #22's Comprehensive Plan of Care for Recurrent [DIAGNOSES REDACTED]icile dated 12/7/12 revealed the following: Goal: Resident #22 will have no further complications through the next 90 days 3/7/13 Approaches: 1) Administer medication as ordered 2) Contact precautions as ordered 3) Encourage resident and staff to practice good handwashing before and after care 4) Obtain stool specimens as ordered and notify MD of results 5) Monitor for signs/symptoms of abdominal cramping; foul odor to stools; frequent watery diarrhea; pus in stool and decrease appetite. On 1/16/12 at 1:51 p.m. an interview was conducted with S6Medicare Nurse Coordinator. She stated Resident #22 was diagnosed with [REDACTED]. She said the resident was asymptomatic and was not taking medications. She said she did not revise the resident's Comprehensive Plan of Care to reflect such; because she wanted to see if the resident was going to develop[DIAGNOSES REDACTED] again before the 90 days. Review of Resident #22's Nurses' Progress Notes revealed the following in part: 12/29/12 6 p.m.-6 a.m. Loose stool times 1 with odor noted. Lab results received 1:30 a.m. positive for[DIAGNOSES REDACTED] of stool. Contact Precautions implemented. 1/3/13 History of[DIAGNOSES REDACTED]. Review of Resident #22's Interdisciplinary Notes revealed the following in part: 12/29/12 11:03 12/29/12 10p-6a. Resident positive for[DIAGNOSES REDACTED] of stool at this time. No antibiotic(ABT) therapy ordered per physician. 1 loose stool today. Report given. Doctor was notified. No new orders given. On contact precautions. 12/25/12 2:50 a.m. 12/25/12 2:50 a.m. CNA to report loose stools x 2 episodes. 12/20/12 5:24 p.m. Resident complained of 2 episodes of loose stool. Resident has an order for [REDACTED]. 12/19/12 5:00 p.m. Resident complained of 3 episodes of loose stool. 12/11/12 12/10/12 5:27 a.m. ABT in use for positive[DIAGNOSES REDACTED] in stool. Contact isolation in progress. 12/10/12 2:04 p.m. No diarrhea noted throughout the shift. 12/09/12 2:00 a.m. Contact Isolation implemented. 12/9/12 12/8/12 1:29 a.m. at 10:40 p.m. Resident is currently on [MEDICATION NAME] for[DIAGNOSES REDACTED]. 12/8/12 Resident on antibiotic therapy for[DIAGNOSES REDACTED]. Contact Precautions taken during resident care. 12/5/12 12/5/12 6:17 p.m. Resident up in chair. Complain of 3 episodes of loose stool. Doctor office called to report resident complaint. 12/4/12 Resident lying in bed AAO x 3. Decided to stay in bed due to diarrhea. She had throughout the night. States, she feel weak. Will continue to monitor while taking meds this am. 12/4/12 12/3/12 2:05 a.m. AAO x 3. at 1:50 a.m. Resident complains of having 3 loose stools. Checked for impaction. Negative. [MEDICATION NAME] x 2 given po now, then 2 po after each loose stool x 24 hours per physician standing orders. On 1/14/13 at 1:14 p.m. an interview was conducted with S7LPN. She said she was informed Resident #22 had[DIAGNOSES REDACTED] and was on Contact Precautions. She stated the facility trained her that with a resident with[DIAGNOSES REDACTED] she was to wear gloves and use proper handwashing. S7LPN said the facility staff who trained her showed her where to get the boxes and where the yellow and red bags were, how to place them and how to dispose of them. She said the resident became asymptomatic after 12/29/12. She said she and others voiced concerns about a resident being on[DIAGNOSES REDACTED] and not instituting Contact Precautions of PPE(personal protective equipment) and Administration told them it was not a nursing home and they was not going to institute all that. She said the facility does not put signage on resident's door to alert staff or visitors of transmission precautions. She said they did not disinfect blood pressure cuffs when the resident was infectious before they used it on other residents. She said the resident was admitted on [DATE]. She started having diarrhea on 12/4/12. An order was obtained on 12/5/12 to check stool times 3. She said on 12/7/12 the resident was positive for[DIAGNOSES REDACTED] and was placed on [MEDICATION NAME]. She stated that the resident did not have a roommate at that time. She said on 12/10/12 a resident was admitted to the room. She said a yellow bag and a red bag was supposed to be placed in 2 card board boxes in the resident's room. She said the resident's clothing and her linen went in a melt a way bag that was placed in a yellow bag. She said the linen was sent down the "shoot" to the laundry in a melt a way bag inside a yellow bag and her personal clothes were also put in a melt a way bag and washed on the 3rd floor. She confirmed there was no yellow bag in 1 of the resident's card board boxes in the bathroom and there was a melt away bag with linen in it and a clear bag with clothing items in it. She said the clear bag with the linen was not processed correctly. She acknowledged it should have been in a melt a way bag inside a yellow bag to alert the laundry staff the linens were contaminated. She said the resident took showers in her room and her roommate was bed bound. She verified the roommate's sitter went in the bathroom; because she gave the resident a bed bath and took care of the resident. On 1/14/13 at 2:58 p.m. an observation was made that Resident #22 had no signage on her door or above her bed. Further observation revealed 2 brown card board boxes in the resident #22's bathroom. One card board box had a red biohazard bag filled with disposable diapers and the other card board box had a clear melt a way bag with linen in it and a clear trash bag with linen in it. Further observation noted no yellow bag was in 1 of the card board boxes. On 1/14/13 at 3:24 p.m. an interview was conducted with S11CNA. She said she had been working at the facility for 2 months and had not been trained to wear personal protective equipment in taking care a person who had[DIAGNOSES REDACTED] on Contact Precautions. She said she wore gloves and washed her hands. On 1/15/12 at 10:06 a.m. an interview was conducted with S12CNA. She stated when she worked with Resident #22, she put her personal clothing in a water soluble bag and washed them at the end of her shift. She stated she send the resident's linen down the "shoot" in a melt a way bag. She said the Biohazard boxes were picked up from the Biohazard people. S12CNA said sometimes a yellow bag was in the cardboard box and sometimes they had to put one in. She said she couldn't remember whether she placed a yellow bag in the cardboard box the prior day when she worked with the resident. On 1/15/13 at 1:11 p.m. an interview was conducted with S10CNA. She stated she started working at the facility on December 20, 2012. She said she had not been trained on what to wear besides gloves in taking care of a resident with[DIAGNOSES REDACTED] on Contact Precautions. She stated they told her to wear gloves and practice good handwashing. She said they never wore gowns, gloves or mask when providing care. On 1/16/13 at 8:56 a.m. an interview was conducted with S13CNA. She stated Resident #22 had[DIAGNOSES REDACTED], but "Don't quote me exactly on what precautions I'm supposed to be use". She said she thought it was contact precautions. She said she was trained to wear gloves and exercise good handwashing precautions, but was never told to wear protective equipment like a gown or a mask. Review of the facility's training logs revealed the CNA staff received the following training in part: 12/12 Monthly Nursing Meeting.[DIAGNOSES REDACTED] Report any increase in signs and symptoms 4/26/12 on Ergonomics, Bloodborne Pathogens, Fall Incidents, MSDS and Workplace Violence. 4/24/12 Bloodborne Pathogens and other Microorganisms. MDRO (multi-drug resistant organism) including[DIAGNOSES REDACTED]. Further review of the training documentation revealed no mention of wearing personal protective equipment for taking care a resident with[DIAGNOSES REDACTED] or how to properly store and transport linen for a resident wit[DIAGNOSES REDACTED]. On 1/15/13 at 10:52 a.m. an interview was conducted with S2DON. She stated when the resident had[DIAGNOSES REDACTED] and was on Contact Precautions, appropriate precautions were put in place. She said the staff discussed Infection Control weekly and she tracked and trended infections to make sure there was no outbreak. She stated they don't isolate residents on[DIAGNOSES REDACTED], because she didn't consider it to be "highly contagious" like the flu. S2DON said the facility was not going to place any kind of signage at the resident's door notifying staff or visitors to see the nurse because of "cultural diversity". She confirmed they had no specific policy regarding what precautions the staff would specifically implement for a resident on[DIAGNOSES REDACTED]. She stated it was at the facility's discretion as far as what protocol they would use. She said she got reports from CDC guidelines all the time and was aware of what precautions were recommended for residents with[DIAGNOSES REDACTED]. She acknowledged she did not train CNA staff to wear personal protective equipment or to properly disinfect equipment after use on a[DIAGNOSES REDACTED] resident. She said she only informed them to wear gloves and exercise good handwashing. She verified a yellow and red bag was supposed to be placed in the separate card board boxes in the resident's room and the CNA staff was supposed to place a melt a way bag inside the yellow bag and send the laundry down the shoot. She said the resident's personal clothes was also to be placed in a melt a way bag and washed on the resident's floor by the CNA staff.