**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews with staff, Medical Director (MD) and Physician Assistant (PA), the facility failed to notify the physician when a resident had signs of Clostridium Difficile (C. difficile) that included persistent loose, watery, mushy, and odorous stool. From 2/9/24 through 2/27/24 the resident experienced these abnormal stools. The physician was notified on 2/13/24 of the abnormal stools, but was not made aware of the ongoing issue until 2/27/24 when it was brought to the nurse's attention by the resident's family member. Upon discharge from the facility on 2/28/2024, the resident was immediately transported by a family member directly to her Primary Care Physician's office where she was tested for C. Difficile, and the lab test was positive for C. Difficile on 2/29/2024. This deficient practice placed Resident #86 at risk for developing complications from C. difficile such as dehydration, skin breakdown, and death. The facility also failed to notify the physician when a resident was receiving insulin outside the parameters to administer insulin. This deficient practice was for 2 of 2 residents reviewed for notification (Residents #86 and #59). Immediate Jeopardy began on 2/15/2024 when the physician was not notified that Resident #86 was continuing to have multiple loose and watery stools for more than 48 hours. Immediate Jeopardy was removed on 7/27/2024 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lesser scope and severity of E (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure education was completed and monitoring systems put in place are effective. Resident #59 was cited at scope and severity D. Findings included: 1. The CDC indicates the following : C. difficile is a highly contagious bacteria that causes diarrhea and inflammation of the colon and can be life-threatening; symptoms include 3 or more foul smelling watery stools a day lasting longer than 1 day, and abdominal cramping. Common complications include dehydration and inflammation of the colon. One in 11 people over age [AGE] diagnosed with a healthcare-associated C. diff infection die within one month. The facility's Physician's Standing Orders (Standing Orders are a means for physician or Advanced Practice Provider to legally convey to a nurse, the ability to provide routine medical interventions to a resident based on subjective and objective findings) revealed the following: bismuth subsalicylate (antidiarrheal medication) 15 cc (cubic centimeters) after each diarrhea stool. Check for impaction before giving. Notify Physician if no improvement after 8 hours or in the morning if stable. Resident #86 was admitted to the facility on [DATE]. The medical record indicated Resident #86 was [AGE] years old in February of 2024. Resident #86's bowel movement documentation and medication administration record (MAR) revealed the following: - 2/9/2024 Nurse Aide (NA) #9 documented 1 large and loose and watery stool at 1:49 PM and 1 medium loose and watery stool at 5:40 PM. No medication was documented as given for loose stools per the MAR. - 2/10/2024 NA #9 documented 1 large and formed/normal stool at 1:16 PM, 1 large loose and mushy stool at 4:16 PM, and NA #11 documented one large loose and watery stool at 11:49 PM. No medication was documented as given for loose stools per the MAR. - 2/11/2024 NA #12 documented 1 large loose and mushy stool at 12:26 PM, 1 large loose and watery stool at 3:18 PM, and NA #11 documented 1 medium loose and watery stool at 11:39 PM. No medication was documented as given for loose stools per the MAR. - 2/12/2024 NA #12 documented 1 medium loose and mushy stool at 11:30 AM and NA #13 documented 1 small and putty like stool at 7:57 PM. No medication was documented as given for loose stools per the MAR. A nurse's note written by Minimum Data Set (MDS) Nurse #2 for Resident #86 revealed the following secure conversation text messages (secure text message from the nurse to the provider that is saved and uploaded to the progress notes in the electronic medical record) from MDS Nurse #2 to the Medical Director on 2/13/2024 at 11:44 AM which read in part, Resident has had diarrhea since admitting and we have no [brand name of medication-bismuth subsalicylate, an antidiarrheal medication] on hand. Can we have an order for loperamide [antidiarrheal medication]? Please advise. Thanks. The Medical Director responded back on 2/13/2024 at 11:46 AM with an order for loperamide hydrochloride (HCL) 2 milligrams (mg) three times a day as needed for diarrhea. The physician's orders for Resident # 86 revealed an order for loperamide hydrochloride (HCL) 2mg tablets; give 1 tablet by mouth three times a day as needed (prn) for diarrhea was ordered on 2/13/2024. An interview with MDS Nurse #2 was completed on 7/25/2024 at 9:44 AM. MDS Nurse #2 stated she was unable to recall Resident #86 or why she was the nurse that sent the text message to the Medical Director on 2/13/2024 regarding her diarrhea. MDS #2 stated that the nurse working that hall must have told her about the diarrhea and that the facility was out of the medication bismuth subsalicylate that were on the Physician's Standing Orders. MDS Nurse #2 stated that if a resident was having diarrhea and loperamide was given and it was ineffective, the nurses should have assessed them for signs and symptoms of C. difficile. She further stated that she was positive that none of the staff members reported that Resident #86's stools had a foul odor, because that would have been a sign that she might have a C. difficile infection. She indicated that if C. difficile was left untreated it could lead to skin breakdown and dehydration. On 2/13/2024 NA #13 documented 1 large and loose and watery stool at 6:10 AM, 1 large loose and watery stool 10:56 AM, and NA #9 documented 1 large loose and watery stool at 6:44 PM. Loperamide HCL oral tablet 2 mg was administered by Nurse #8 at 8:07 PM and it was documented as having been effective. A telephone interview was completed with Nurse #8 on 7/25/2024 at 8:21 AM. Nurse #8 stated Resident #86's name sounded familiar, but she was not able to recall any information about her. She indicated if she administered loperamide HCL to Resident #86 on 2/13/2024 at 8:07 PM., then the NA or the resident must have reported the resident having diarrhea to her. Resident #86's bowel movement documentation and MAR revealed the following: - 2/14/2024 at NA #9 documented 1 large loose and watery stool at 11:04 AM, 1 medium loose and watery stool 5:26 PM, and NA #14 documented 1 small loose and watery stool at 11:34 PM. No medication was documented as given for loose stools per the MAR. - 2/15/2024 NA #10 documented 1 medium formed/normal stool at 10:42 AM and 1 large loose and mushy stool and at 3:24 PM. No medication was documented as given for loose stools per the MAR. On 2/16/24 Nurse #9 initiated the standing physician's order for Resident #86 for bismuth subsalicylate oral suspension 262 milligrams mg/15 ml; give 15 ml by mouth as needed (prn) for diarrhea. Give 15 ml after each loose stool. Check for impaction first. Notify the physician if there is no improvement after 8 hours or in the morning if stable. On 2/16/24 the bowel movement record and the MAR indicated NA #13 documented 1 medium loose and mushy stool at 3:26 AM, 1 medium loose and mushy stool at 8:58 PM, and NA #9 documented 1 medium loose and mushy stool at 11:58 AM. Bismuth subsalicylate prn 15 ml was administered by Nurse #9 at 5:05 PM and was documented as effective. Nurse #9 was unable to be interviewed during the survey. Resident #86's bowel movement documentation and MAR revealed the following: - 2/17/24 the bowel movement record and the MAR indicated NA #13 documented 1 medium loose and mushy stool at 4:44 AM and NA #10 documented 1 large formed/normal stool at 5:15 PM. No medication was documented as given for loose stools per the MAR. - 2/18/2024 NA #15 documented 1 small putty like stool at 2:53 PM, 1 medium loose and watery stool at 12:14 PM, and NA #9 documented 1 large loose and watery stool at 3:19 PM. No medication was documented as given for loose stools per the MAR. - 2/19/2024 NA #15 documented 1 large loose and watery stool at 6:27 AM. NA #15 documented 1 large loose and mushy stool and 1 large and formed/normal stool at 11:33 AM. Bismuth subsalicylate prn 15 ml was administered by Nurse #10 at 9:14 PM and was documented as effective. A telephone interview was completed with Nurse #10 on 7/25/2024 at 4:00 PM. She stated that she did not recognize Resident #86's name or recall anything about her. Nurse #10 explained that she was just not familiar with Resident #86 and didn't know if she was having diarrhea or not or if the physician was notified. Resident #86's bowel movement documentation and MAR revealed the following: - 2/20/2024 at 4:43 AM NA #13 documented 1 large loose and watery stool, at 11:44 AM NA #1 documented 1 large loose and watery stool, at 9:05 PM NA #13 documented 1 large loose and mushy stool, and at 11:14 PM NA #13 documented 1 small loose and mushy stool. Loperamide HCL 2 mg tablet prn was administered by Nurse #10 at 5:09 AM and was documented as effective; bismuth subsalicylate prn 15 ml was administered by Nurse #11 at 8:47 AM and was documented as effective; and loperamide HCL 2 mg tablet prn was administered by Nurse #11 at 1:48 PM and was documented as effective. - 2/21/2024 NA #1 documented 1 large loose and watery stool and 1 large loose and mushy stool at 9:15 AM. NA #13 documented and 1 medium loose and mushy stool at 11:11 PM. Loperamide HCL 2 mg tablet prn was administered by Nurse #12 at 6:13 AM and was documented as effective. - 2/22/2024 NA #9 documented 1large loose and watery stool at 2:59 PM and one large loose and watery stool at 5:03 PM. Loperamide HCL 2 mg tablet prn was administered by Nurse #13 at 3:01 PM and was documented as effective. A telephone interview was conducted with Nurse #13 on 7/25/2024 at 1:28 PM. Nurse #13 stated she worked at the facility prn (as needed) and had not worked in at least 3-4 months. Nurse #13 indicated that she was unable to recall anything about Resident #86 and did not remember if she was having diarrhea or was taking antidiarrheal medication. Resident #86's bowel movement documentation and MAR revealed the following: - 2/23/2024 NA #13 documented 1 medium loose and mushy stool at 12:08 AM, 1 large loose and watery stool at 12:03 PM, and NA #9 documented 1 large loose and mushy stool at 4:57 PM. No medication was documented as given for loose stools per the MAR. - 2/24/2024 NA #9 documented 1 large loose and mushy stool at 10:48 AM and NA #19 documented 1 large loose and watery stool at 9:53 PM. Loperamide 2 mg tablet prn was administered by Nurse #14 at 2:00 PM and was documented as effective. A telephone interview was completed with Nurse #14 on 7/25/2024 at 3:00 PM. Nurse #14 stated that she worked at the facility as needed, and she could not remember anything about Resident #86. Resident #86's bowel movement documentation and MAR revealed the following: - 2/25/2024 NA #9 documented 1 medium loose and mushy stool at 2:59 PM and NA #1 documented 1 large loose and mushy stool. No medication was documented as given for loose stools per the MAR. - 2/26/2024 NA #9 documented 1 large loose and watery stool at 10:37 AM and NA #1 large loose and mushy stool at 8:26 PM. Two doses of loperamide 2mg tablet prn were administered by the Staff Development Coordinator (SDC) Nurse one dose at 8:37 AM and was documented as effective and the dose at 7:06 PM the effectiveness was documented as unknown. - 2/27/2024 NA #13 documented 1 medium formed/normal stool at 1:32 AM. NA #1 documented 1 large loose and watery stool at 11:05 AM and 1 large loose and mushy stool at 9:18 PM. Two doses of loperamide 2 mg tablet prn were administered by the Staff Development Coordinator (SDC) Nurse at 8:29 AM and 4:38 PM and they were documented as effective. A nurse's note for Resident #86 revealed the following secure conversation text message from Nurse #15 to the Medical Director dated 2/27/2024 at 3:33 PM which read in part, Daughter is concerned that resident is having a lot of loose BMs [bowel movements]. I looked through her chart and she does have a lot of watery stools but also a lot of mushy stools. May we have an order to test for C. difficile? The daughter also wants to know what else could be causing it if it were not C. difficile because her medications are the same as they were at home. Please advise. The Medical Director responded back to Nurse #15 on 2/27/2024 at 4:35 PM with the following message, if not watery they will not do a C. diff. Nurse #14 responded back that she would inform the daughter. A telephone interview was conducted with Nurse #15 on 7/24/2024 at 9:13 AM. Nurse #15 stated that she was a unit manager at the facility in February 2024, but that she was no longer currently employed by the facility. She stated she was unable to recall messaging the Medical Director or the reason she had contacted him. An interview was completed with the Staff Development Coordinator (SDC) Nurse on 7/23/2024 at 8:29 AM. The SDC Nurse reported Resident #86 was only in the facility for 20 days and that she could not recall anything about her. She stated she was unable to recall if a nurse aide (NA) had reported the diarrhea to her or if Resident #86 had requested the antidiarrheal medication herself. The SDC Nurse indicated she was unable to remember if Resident #86 was having a lot of loose stools or if it had any foul odors. The bowel movement record and the MAR for 2/28/2024 indicated NA #13 documented 1 medium loose and mushy stool at 12:06 AM and NA #9 documented 1 large formed/normal stool. No medication was documented as given for loose stools per the MAR. Resident #86 was discharged to the community on 2/28/2024. A telephone interview was completed with the PA at Resident #86's Primary Care Physician's office on 7/25/2024 3:40 PM. The PA stated that on 2/28/2024 the family had called requesting Resident #86 be seen in the office due to having diarrhea when she was in the facility. She further stated that when Resident #86 was discharged from the facility her family had brought her straight to her office. The PA stated that a stool sample was obtained and sent to the lab and the results were positive for C. difficile infection on 2/29/2024. The lab results for Resident #86 dated 2/29/2024 revealed she was positive for C. difficile infection. Resident #86's bowel movement documentation sheets from the date of admission, 2/8/24, through the date of discharge, 2/28/24, revealed she was coded as having 23 loose and watery stools, 19 loose and mushy stools, 1 putty like stool and 5 normal stools. Resident #86's MAR for February 2024 revealed she was administered 3 doses of bismuth subsalicylate and 10 doses of loperamide HCL from 2/13/2024 through 2/27/2024. The bowel movement documentation sheets and the daily assignment sheet revealed NA #9 was assigned to care for Resident #86 on 2/9/2024, 2/10/2024, 2/14/2024, 2/16/2024, 2/22/2024, 2/24/2024, 2/25/2024, 2/26/2024, and 2/28/2024. An interview was conducted with NA #9 on 7/23/2024 at 1:50 PM. NA #9 stated she was frequently assigned to care for Resident #86 when Resident #86 was residing in the facility. She further stated Resident #86 was having frequent loose and mushy/watery stools with a foul odor and the resident kept asking why she was having so many bowel movements. NA #9 indicated she did report the frequent stools to the nurse, but she was unable to remember which one, because there was usually a different agency nurse assigned to the unit. The bowel movement documentation sheets and the daily assignment sheet revealed Resident #86 was assigned to NA #10 on 2/15/2024, 2/17/2024, and 2/24/2024. An interview was conducted with NA #10 on 7/23/2024 at 2:00 PM. NA #10 stated she was able to remember Resident #86 and the resident was incontinent of her bowels and was having frequent large loose foul-smelling stools when the resident was at the facility. NA #10 reported that while the bowel movements did have a terrible odor, she did not believe it smelt like the C. difficile odor she had smelled before when a resident had C. difficile. She indicated she did report the diarrhea to the nurse, but she was not able to remember which one. Review of the bowel movement documentation sheets and daily assignment sheet revealed NA #1 was assigned to care for Resident #86 on 2/19/2024, 2/20/2024, 2/21/2024, 2/25/2024, and 2/26/2024. An interview was conducted with NA #1 on 7/25/2024 at 12:05 PM. NA #1 stated Resident #86 was incontinent of stool and was having very frequent and large loose bowel movements with a foul odor when she was a resident in the facility and the odor was even identifiable in the hallway outside her room. NA #1 stated anytime a resident had more than 1 bowel movement during the shift he would notify the nurse. NA #1 indicated Nurse #16 had been informed Resident #86 was having loose foul-smelling bowel movements but could not recall the date. A telephone interview was completed with Nurse #16 on 7/25/2024 at 2:34 PM. Nurse #16 stated she was no longer working at the facility, and she could not recall Resident #86 or anything about her. She indicated she was unable to recall if NA #1 reported to her that Resident #86 was having diarrhea. An interview was conducted with the Medical Director (MD) on 7/24/2024 at 10:31 AM. The Medical Director stated that whenever he was informed by the nursing staff that a resident was having loose stools, he typically did not immediately order a C. difficile test. He further stated he would first look at the medications they were taking to see if they could be having an effect on the bowels, such as laxatives or stool softeners, and stop them for a couple of days to see if the diarrhea stopped. The Medical Director reported that constipation with overflow was the most common cause of loose stools in a nursing facility, so a C. difficile test and precautions would not be indicated, unless they had other symptoms. He stated that he was first informed Resident #86 was having diarrhea on 2/13/2024 when MDS Nurse #2 requested an order for loperamide HCL. The Medical Director indicated that if the resident was continuing to have loose stools and antidiarrheal medications were ineffective, he would have expected the nursing staff to contact him within 24-48 hours (2/14/24 or 2/15/24). He further indicated that part of the diarrhea protocol was if the antidiarrheal medication was ineffective then he would order an abdominal x-ray to check for constipation with overflow. The Medical Director stated that there was clearly a communication problem because he had no idea that she was having so many loose and watery stools and that the antidiarrheal medications were ineffective. He further stated that just by looking at Resident #86's bowel movement documentation sheets and the amount and frequency of loose and watery stools she was having, that this was a clear indication that she had C. difficile infection. A follow-up telephone interview was completed with the Medical Director on7/25/2024 at 10:36 AM. The Medical Director stated that he depended on the nursing staff to make him aware of any changes or concerns involving the residents. The Medical Director indicated that this was clearly a communication problem because Resident #86 was having a lot of stools, and he wasn't made aware of this by the nursing staff. He indicated that he would have expected to have multiple messages from multiple nurses in the 2 weeks between the notifications on 2/13/2024 and 2/27/2024. The Medical Director stated if he was unaware she was having any problems there would be no reason to see her and assess her. An interview was completed with the Director of Nursing (DON)/Infection Control Preventionist (ICP) on 7/24/2024 at 1:51 PM. The DON/ICP stated that she was unfamiliar with Resident #86 and was not aware that she was having loose stools when she was residing in facility. The DON/ICP indicated she expected the nursing staff to provide the Medical Director with an accurate description of the situation, such as the number and amount of loose watery stools and that the antidiarrheal medications were ineffective. A follow-up interview was conducted with the DON/IPC Nurse on 7/25/2024 at 9:55 AM. She stated the information the nursing staff provided the Medical Director was not sufficient to accurately describe or paint a clear picture of the situation, and they should have told him the amount and frequency of the stools. The Administrator was notified of the Immediate Jeopardy on 7/25/2024 at 4:45 PM. The Administrator submitted the following credible allegation of immediate jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. The facility failed to notify the physician when a resident (Resident #86) repeatedly had loose watery stools or mushy stools from 2/9/24 through 2/27/24 despite the administration of anti-diarrhea medication. The facility did not implement effective systems to ensure the physician is notified of significant changes. The physician revealed he was not notified that the resident was having loose stools until 2/27/24. He further revealed when he was notified on 2/27/24 he was not made aware there were repetitive loose stools for greater than 2 weeks with anti-diarrheal medication being ineffective. He indicated this was indicative of c-diff and he would have initiated the diarrhea protocol to include reviewing the medications and discontinue any medications that could contribute to diarrhea, order bismuth subsalicylate if that was ineffective, he would obtain an abdominal x-ray and if x-ray was negative, he would obtain a stool sample to check for C-diff. Resident #86 was discharged to home 02/28/2024 and is no longer a resident of the facility. No further corrective action could be completed specific to Resident #86 All residents are at risk for harm related to the deficient practice requiring a comprehensive assessment for signs and symptoms of C. difficile (Clostridium difficile). Signs and symptoms for C. difficile include: watery diarrhea, fever, loss of appetite, nausea, malodorous stool and abdominal pain/tenderness. On 07/25/2024 the Director of Nursing met with all direct care nurses who were working to initiate an assessment of 100% of current residents. Beginning on 07/25/2024, the Registered Nurse Managers and Licensed Practical Support Nurses completed an audit of all residents. This audit consisted of an assessment of each resident for the following signs and symptoms: watery diarrhea, fever, loss of appetite, nausea, malodorous stool and abdominal pain/tenderness in the last 7 days. Included in this assessment was a review of each resident's bowel movement documentation for the last 7 days to identify symptoms of watery diarrhea. If a resident had 3 or more loose watery stools in 24 hours the MD/Nurse Practitioner (NP)/PA will be notified for evaluation of C. difficile. If any residents were identified with any signs and symptoms of C. difficile the medical record was reviewed to identify if the MD/NP/PA had been notified. If the MD/NP/PA had not been notified, the nurse would then make the notification to the MD/NP/PA. This audit was completed on 07/25/2024. The audit identified that 2 of 80 residents had signs or symptoms of C. difficile which are: watery diarrhea, fever, loss of appetite, nausea, malodorous stool and abdominal pain/tenderness. On 07/25/2024, a corrective action was completed for 2 of 80 residents identified as having signs and symptoms of C. difficile when the provider was notified of the change in condition and orders for the change in condition were carried out by the direct care staff. Specify the actions the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or reoccurring and when the action will be completed. On 07/25/2024 the Director of Nursing and the Registered Nurse Managers began in servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants (CNA) (full time, part time, and prn including agency) on signs and symptoms of C. difficile including watery diarrhea, fever, loss of appetite, nausea, abdominal pain/tenderness. The above staff were educated on the importance of documenting bowel movements including consistency of bowel movements accurately. In addition, the CNA's were educated to report any changes in condition including diarrhea to the nurse when noted. RN's and LPN's were additionally educated on if a resident has 3 or more loose watery stools in 24 hours then notify the MD for evaluation of C. difficile, initiate Enteric Contact Isolation when C. difficile is known or suspected, when to report changes in condition, completing an assessment, and notifying the MD/NP/PA when interventions are not effective. The DON will ensure that all licensed nurses, RN's, LPN's, and CNA's (full time, part time, and prn including agency) who do not complete the in-service training by 07/26/2024 will not be allowed to work until the training is completed. This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants (full time, part time, and prn including agency.) Alleged date of IJ removal 07/27/2024 The immediate jeopardy removal plan of 7/26/2024 was validated on 7/26/2024. The audit of 100% of current residents for signs and symptoms of C. difficile was conducted by the nursing staff on 7/25/2024. The education sign in sheets were reviewed for the in-services conducted on 7/25/2024 for all nursing staff (NA's and nurses) regarding the signs and symptoms of C. difficile. In addition, the licensed nursing staff were educated regarding checking the clinical dashboard in the electronic medical record for alerts, initiating Enteric Contact Isolation when C. difficile is known or suspected, and assessing residents for signs and symptoms of C. difficile and notifying the physician. Staff interviews confirmed education was received on recognizing the signs and symptoms of C. difficile, assessing the residents for signs and symptoms, enteric isolation precautions, and the clinical dashboard alerts. Staff interviews with the nurses confirmed that education was received regarding signs and symptoms of C. difficile and notifying the physician. The facility's immediate jeopardy removal date of 7/27/2024 was validated. 2) Resident #59 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident 359 was cognitively intact and she received insulin and hypoglycemic (medications to treat diabetes) medications. A review of the physician's order revealed an order was written for Novolog Insulin, inject 10 units subcutaneously with meals and hold if glucose is less than 120 mg/dl. A review of the June 2024 Medication Administration Record revealed Resident #59's blood sugar reading was 109 mg/dl on 06/22/24. The medication administration record revealed Resident #59 received the Novolog Insulin on 06/22/24 as evidenced by a checkmark and nursing initials. A review of the July 2024 Medication Administration Record revealed Resident #59's blood sugar reading was 107 mg/dl on 07/01/24, 113 mg/dl on 07/03/24, and 109 mg/dl on 07/06/24, 114 on 07/10/24, 117 on 07/21/24, 100 on 07/22/24, and 116 on 07/24/24. The medication administration record revealed Resident #59 received the Novolog Insulin on 07/01/24, 07/03/24, 07/10/24, and 07/24/24 as evidenced by a checkmark and nursing initials. An interview was conducted with Nurse #1 on 07/24/24 at 9:45 AM. Nurse #1 confirmed the initials on the Medication Administration Record on 06/22/24, 07/01/24, 07/03/24, 07/10/24, and 07/24/24 were hers. She stated the checkmark under each of the dates meant that the medication was administered. Nurse #1 stated she administered the Novolog Insulin even though the order read to hold the insulin if the blood sugar level was less than 120 mg/dl because the resident stated she wanted it. Nurse #1 stated the resident had rights and if she wanted the medication, then she would administer it. Nurse #1 stated she did not notify the physician that the resident was requesting to receive the 10 units of insulin even though her blood sugar was less than 120 mg/dl. An interview was conducted with the facility Physician on 07/24/24 at 10:17 AM. The Physician stated he had the parameter for administering the insulin in place because he did not want Resident #59's blood sugar level to get too low. He stated he was not notified that Resident #59 was requesting to receive her insulin even though her blood sugar level was below 120 mg/dl. He stated had he been notified he would have changed the parameter to hold the insulin to a lower number. Additionally, the Physician stated if nursing had notified him he could follow the resident's blood sugar results to determine if he needed to change the order or discontinue the order. An interview with the Director of Nursing (DON) on 07/26/24 at 3:00 PM revealed she would have expected the nursing staff to notify the physician and that it was not up to nursing to decide whether or not to administer a medication if it was not ordered without discussing the order with the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and family, staff, Medical Director, and Physician Assistant interviews, the facility failed to comprehensively assess a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention (CDC): C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon and can be life-threatening; symptoms include 3 or more foul smelling watery stools a day lasting longer than 1 day, and abdominal cramping), to determine the cause of the watery stools, identify the seriousness of the symptoms, and implement effective interventions to treat repeat watery stools which started on 2/09/2024. Resident #86's bowel movement documentation sheets from the date of admission, 2/8/24, through the date of discharge, 2/28/24, revealed she was coded as having 23 loose and watery stools, 19 loose and mushy stools, 1 putty like stool and 5 normal stools. The resident was administered 13 doses of anti-diarrheal medication through the 20 days the resident was at the facility despite administration of anti-diarrheal medication being contra-indicated for C. Difficile or when C. Difficile symptoms persist. On 2/27/2024 Nurse #15 notified the Medical Director the resident's family member was requesting a C. difficile test for loose, watery, mushy stools, and a test was not ordered. Resident #86 was discharged on 2/28/2024 and was transported by a family member directly to her Primary Care Physician's office where she was tested for C. Difficile, and the lab test was positive for C. Difficile on 2/29/2024. This deficient practice placed Resident #86 at risk for developing complications from C. difficile such as dehydration, skin breakdown, and in extreme cases death. This deficient practice was discovered for 1 of 3 residents reviewed for professional standards (Resident #86); and the nursing staff failed to perform complete neurological checks for 1 of 1 resident reviewed for falls (Resident #2) which was cited at a lower scope and severity. Immediate Jeopardy began on 02/15/2024 when Resident #86 was not assessed to determine possible cause or effective interventions for continued loose and watery stools after the administration of an anti-diarrheal medication. Immediate Jeopardy was removed on 7/27/2024 when the facility implemented an acceptable plan of Immediate Jeopardy removal. The facility remains out of compliance at a lesser scope and severity of E (no harm with the potential for more than minimal harm that is not Immediate Jeopardy) to ensure education was completed and monitoring systems put in place are effective. Resident #2 was cited at scope and severity E. Findings included: Per an article by the National Institute in Health (NIH), from the Mayo Clinic, dated November 2012: The use of antimotility agents such as narcotics and loperamide in active C difficile infection is discouraged because use of these agents may result in more severe colitis. The facility's Clostridium Difficile policy last reviewed on 12/2023 read in part, The following measures are guidelines to prevent the spread of C. difficile infection, clinical features include watery diarrhea, fever, loss of appetite, nausea, abdominal pain/tenderness. General diagnostic testing ordered by the MD [Medical Director] involves 3 or more watery diarrhea in 24 hours. Suspect C. difficile if the resident has symptoms and has been in the hospital and/or recently received antibiotics. The facility's Physician's Standing Orders (Standing Orders are a means for physician or Advanced Practice Provider to legally convey to a nurse, the ability to provide routine medical interventions to a resident based on subjective and objective findings) revealed the following: bismuth subsalicylate (antidiarrheal medication) 15 cc (cubic centimeters) after each diarrhea stool. Check for impaction before giving. Notify Physician if no improvement after 8 hours or in the morning if stable. The hospital history and physical dated 2/1/2024 revealed Resident #86 was admitted to the hospital with diagnoses to include right hip pain, rhabdomyolysis (a rare life-threatening muscle injury where muscles breakdown and lead to muscle death. When this occurs, toxic components of the muscle fibers enter the blood circulation system and kidneys, resulting in kidney damage; this dangerous muscle condition can result from overexertion, trauma (such as fall), or medications), a ground-level fall at home, and acute kidney injury superimposed on chronic kidney disease, and generalized muscle weakness. According to the hospital medication list Resident #86 was not administered any antibiotics while she was in the hospital. She was discharged from the hospital on 2/8/2024 to the facility. Resident #86 was admitted to the facility on [DATE], with diagnoses to include Type 2 diabetes mellitus with chronic kidney disease, muscle weakness, and urinary retention. She had a planned discharge to home on [DATE]. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 was cognitively intact, had an indwelling catheter, and was frequently incontinent of bowels. The baseline Care Plan initiated on 2/8/2024 for Resident #86 revealed a plan of care for activities of daily living (ADL) self-care performance deficit. Interventions included allowing plenty of time to complete tasks, providing incontinence care as needed, and monitoring/documenting/reporting to the nurse as needed any changes in ADL abilities and reasons for self-care deficit/decline. Resident #86's bowel movement documentation and medication administration record (MAR) revealed the following: 2/9/2024 NA #9 documented1 large and loose and watery stool at 1:49 PM and 1 medium loose and watery stool at 5:40 PM. No medication was documented as given for loose stools per the MAR. 2/10/2024 NA #9 documented 1 large and formed/normal stool at 1:16 PM, 1 large loose and mushy stool at 4:16 PM, and NA #11 documented one large loose and watery stool at 11:49 PM. No medication was documented as given for loose stools per the MAR. 2/11/2024 NA #12 documented 1 large loose and mushy stool at 12:26 PM, 1 large loose and watery stool at 3:18 PM, and NA #11 documented 1 medium loose and watery stool at 11:39 PM. No medication was documented as given for loose stools per the MAR. 2/12/2024 NA #12 documented 1 medium loose and mushy stool at 11:30 AM and NA #13 documented 1 small and putty like stool at 7:57 PM. No medication was documented as given for loose stools per the MAR. A nurse's note written by MDS Nurse #2 for Resident #86 revealed the following secure conversation text messages (secure text message from the nurse to the provider that is saved and uploaded to the progress notes in the electronic medical record) from MDS Nurse #2 to the Medical Director on 2/13/2024 at 11:44 AM which read in part, Resident has had diarrhea since admitting and we have no [brand name of medication-bismuth subsalicylate, an antidiarrheal medication] on hand. Can we have an order for loperamide [antidiarrheal medication]? Please advise. Thanks. The Medical Director responded back on 2/13/2024 at 11:46 AM with an order for loperamide hydrochloride (HCL) 2 milligrams (mg) three times a day as needed for diarrhea. The physician's orders for Resident # 86 revealed an order for loperamide (HCL) 2mg tablets; give 1 tablet by mouth three times a day as needed (prn) for diarrhea was initiated by MDS Nurse #2 on 2/13/2024. An interview with MDS Nurse #2 was completed on 7/25/2024 at 9:44 AM. MDS Nurse #2 stated she was a unit manager at the facility in February of 2024. She further stated she was not Unit Manager for the hall where Resident #86 resided. MDS Nurse #2 stated she was unable to recall Resident #86 or why she was the nurse that sent the text message to the Medical Director on 2/13/2024 regarding her diarrhea. MDS #2 stated that the nurse working that hall must have told her about the diarrhea and that the facility was out of bismuth subsalicylate the medication on the Physician's Standing Orders. MDS Nurse #2 explained that loperamide hydrochloride 2 mg was not on the facility's Standing Orders sheet and if the facility was out of bismuth subsalicylate that must have been the reason she contacted the Medical Director. MDS Nurse #2 stated that if a resident was having diarrhea and loperamide was given and it was ineffective, the nurses should have assessed them for signs and symptoms of C. difficile. She further stated that she was positive that none of the staff members reported that Resident #86's stools had a foul odor, because that would have been a sign that she might have a C. difficile infection. MDS Nurse #2 reported that if a resident was positive for C. difficile, they were to be placed on enteric precautions, and placed in a private room because it was very contagious. She indicated that if C. difficile was left untreated it could lead to skin breakdown and dehydration. 2/13/2024 NA #13 documented 1 large and loose and watery stool at 6:10 AM, 1 large loose and watery stool 10:56 AM, and NA #9 documented 1 large loose and watery stool at 6:44 PM. Loperamide HCL oral tablet 2 mg was administered by Nurse #8 at 8:07 PM and it was documented as having been effective. A telephone interview was completed with Nurse #8 on 7/25/2024 at 8:21 AM. Nurse #8 stated Resident #86's name sounded familiar, but she was not able to recall any information about her. She indicated if she administered loperamide HCL to Resident #86 on 2/13/2024 at 8:07 PM., then the NA or the resident must have reported the resident having diarrhea to her. She stated if a NA reported a resident was having loose stools, she would administer an antidiarrheal medication and follow-up to make sure it was effective. Nurse #8 stated if a NA reported a resident's stool had a foul odor, she would assess them for C. difficile. Nurse #8 further stated the facility's protocol for C. difficile was to collect a stool specimen and request an order for a lab culture from the Medical Director because it was a serious infection. She indicated she was unable to remember administering loperamide HCL to Resident #86 on 2/13/2024 at 8:07 PM or recall NA # 9 informing her of the diarrhea. Further review of Resident #86's bowel movement documentation and MAR revealed the following: 2/14/2024 at NA #9 documented 1 large loose and watery stool at 11:04 AM, 1 medium loose and watery stool 5:26 PM, and NA #14 documented 1 small loose and watery stool at 11:34 PM. No medication was documented as given for loose stools per the MAR. 2/15/2024 NA #10 documented 1 medium formed/normal stool at 10:42 AM and 1 large loose and mushy stool and at 3:24 PM. No medication was documented as given for loose stools per the MAR. Resident #86's physician's orders further revealed a standing order for bismuth subsalicylate oral suspension 262 mg/15 milliliters (ml) was initiated by Nurse #9 on 2/16/2024. Bismuth subsalicylate oral suspension 262 mg/15 ml; give 15 ml by mouth as needed (prn) for diarrhea. Give 15 ml after each loose stool. Check for impaction first. Notify the physician if there was no improvement after 8 hours or in the morning if stable. Further review of Resident #86's bowel movement documentation and MAR revealed the following: 2/16/2024 NA #13 documented 1 medium loose and mushy stool at 3:26 AM, 1 medium loose and mushy stool at 8:58 PM, and NA #9 documented 1 medium loose and mushy stool at 11:58 AM. Bismuth subsalicylate prn 15 ml was administered by Nurse #9 at 5:05 PM and was documented as effective. 2/17/2024 NA #13 documented 1 medium loose and mushy stool at 4:44 AM and NA #10 documented 1 large formed/normal stool at 5:15 PM. No medication was documented as given for loose stools per the MAR. 2/18/2024 NA #15 documented 1 small putty like stool at 2:53 PM, 1 medium loose and watery stool at 12:14 PM, and NA #9 documented 1 large loose and watery stool at 3:19 PM. No medication was documented as given for loose stools per the MAR. 2/19/2024 NA #15 documented 1 large loose and watery stool at 6:27 AM. NA #15 documented 1 large loose and mushy stool and 1 large and formed/normal stool at 11:33 AM. Bismuth subsalicylate prn 15 ml was administered by Nurse #10 at 9:14 PM and was documented as effective. 2/20/2024 at 4:43 AM NA #13 documented 1 large loose and watery stool, at 11:44 AM NA #1 documented 1 large loose and watery stool, at 9:05 PM NA #13 documented 1 large loose and mushy stool, and at 11:14 PM NA #13 documented 1 small loose and mushy stool. Loperamide HCL 2 mg tablet prn was administered by Nurse #10 at 5:09 AM and was documented as effective; bismuth subsalicylate prn 15 ml was administered by Nurse #11 at 8:47 AM and was documented as effective; and loperamide HCL 2 mg tablet prn was administered by Nurse #11 at 1:48 PM and was documented as effective. A telephone interview was completed with Nurse #10 on 7/25/2024 at 4:00 PM. Nurse # 10 stated she usually did not work on the unit where Resident #86 resided when she was at the facility. She further stated she did not recognize Resident #86's name or recall anything about her. Nurse #10 explained she was just not familiar with Resident #86 and didn't know if she was having diarrhea or not. She stated she did not remember administering bismuth subsalicylate on 2/19/2024 or loperamide HCL 2 mg tablet on 2/20/2024 to Resident #86. 2/21/2024 NA #1 documented 1 large loose and watery stool and 1 large loose and mushy stool at 9:15 AM. NA #13 documented and 1 medium loose and mushy stool at 11:11 PM. Loperamide HCL 2 mg tablet prn was administered by Nurse #12 at 6:13 AM and was documented as effective. 2/22/2024 NA #9 documented 1 large loose and watery stool at 2:59 PM and one large loose and watery stool at 5:03 PM. Loperamide HCL 2 mg tablet prn was administered by Nurse #13 at 3:01 PM and was documented as effective. A telephone interview was conducted with Nurse #13 on 7/25/2024 at 1:28 PM. Nurse #13 stated she worked at the facility as needed. She further stated that she did not typically work the unit where Resident #86 resided and only worked 1 day every couple of weeks. Nurse #13 indicated that she had been assigned the unit where Resident #86 resided a few times but did not recall anything about Resident #86 and did not recall administering loperamide HCL 2 mg tablet to her on 2/22/2024 for diarrhea. 2/23/2024 NA #13 documented 1 medium loose and mushy stool at 12:08 AM, 1 large loose and watery stool at 12:03 PM, and NA #9 documented 1 large loose and mushy stool at 4:57 PM. No medication was documented as given for loose stools per the MAR. 2/24/2024 NA #9 documented 1 large loose and mushy stool at 10:48 AM and NA #19 documented 1 large loose and watery stool at 9:53 PM. Loperamide 2 mg tablet prn was administered by Nurse #14 at 2:00 PM and was documented as effective. A telephone interview was completed with Nurse #14 on 7/25/2024 at 3:00 PM. Nurse #14 stated she worked at the facility as needed, and she could not remember anything about Resident #86. She further stated she couldn't recall the resident's name. Nurse #14 stated she was unable to recall administering loperamide HCL 2 mg tablet to Resident #86 for diarrhea on 2/24/2024. 2/25/2024 NA #9 documented 1 medium loose and mushy stool at 2:59 PM and NA #1 documented 1 large loose and mushy stool. No medication was documented as given for loose stools per the MAR. 2/26/2024 NA #9 documented 1 large loose and watery stool at 10:37 AM and NA #1 large loose and mushy stool at 8:26 PM. Two doses of loperamide 2mg tablet prn were administered by the Staff Development Coordinator (SDC) Nurse one dose at 8:37 AM and was documented as effective and the dose at 7:06 PM the effectiveness was documented as unknown. 2/27/2024 NA #13 documented 1 medium formed/normal stool at 1:32 AM. NA #1 documented 1 large loose and watery stool at 11:05 AM and 1 large loose and mushy stool at 9:18 PM. Two doses of loperamide 2 mg tablet prn were administered by the SDC Nurse at 8:29 AM and 4:38 PM and they were documented as effective. An interview was completed with the Staff Development Coordinator (SDC) Nurse on 7/23/2024 at 8:29 AM. The SDC Nurse stated she was working the 7 AM to 7 PM shift on the hall where Resident #86 resided on 2/26/2024 and 2/27/2024. The SDC Nurse reported Resident #86 was only in the facility for 20 days and that she could not recall anything about her. She stated she was unable to recall if a nurse aide (NA) had reported the diarrhea to her or if Resident #86 had requested the antidiarrheal medication herself. The SDC Nurse explained the electronic medical record the facility used for documentation had an alert system on the residents' dashboard (screen with pertinent information), it would display a red bell if the resident was having diarrhea or constipation, but she was unable to recall if the alert had been on the screen. The SDC Nurse indicated she was unable to remember if Resident #86 was having a lot of loose stools or if it had any foul odors. The SDC Nurse was unable to recall why Nurse #15 had contacted the Medical Director instead of her on 2/27/2024, because she was the charge nurse on the hall. She stated she was certain Resident #86's family member had never informed her she thought her mother had C. difficile, and she had not requested her to contact the Medical Director for a C. difficile test. A follow-up interview was completed with the SDC Nurse on 7/25/2024 at 9:10 AM. The SDC Nurse indicated if she administered the loperamide HCL to Resident #86 on 2/26/2024 and 2/27/2024, the NA must have told her she was having loose stools, or the resident requested it. She stated Nurse #15 was the unit manager in February and if Nurse #15 spoke to Resident #86's daughter regarding a C. difficile test, she was not made aware. The SDC Nurse explained if she suspected a resident was positive for C. difficile, she would first contact the Medical Director and get an order to obtain a stool specimen for a stool test. She further explained since C. difficile was highly contagious, she would place the resident in a private room and initiate enteric precautions. The SDC Nurse stated if the stool test was positive the Medical Director would order antibiotics, and the resident would remain on isolation precautions until they completed the course of antibiotics and was not having loose watery stools. 2/28/2024 NA #13 documented 1 medium loose and mushy stool at 12:06 AM and NA #9 documented 1 large formed/normal stool. No medication was documented as given for loose stools per the MAR. Resident #86's bowel movement documentation sheets from the date of admission, 2/8/24, through the date of discharge, 2/28/24, revealed she was coded as having 23 loose and watery stools, 19 loose and mushy stools, 1 putty like stool and 5 normal stools. The bowel movement documentation sheets and the daily assignment sheet revealed Resident #86 was assigned to NA #10 on 2/15/2024, 2/17/2024, and 2/24/2024. An interview was conducted with NA #10 on 7/23/2024 at 2:00 PM. NA #10 stated she was able to remember Resident #86 and the resident was incontinent of her bowels and was having frequent large loose foul-smelling stools when the resident was at the facility. NA #10 reported that while the bowel movements did have a terrible odor, she did not believe it smelt like the C. difficile odor she had smelled before when a resident had C. difficile. She indicated she did report the diarrhea to the nurse, but she was not able to remember which one. The bowel movement documentation sheets and the daily assignment sheet revealed NA #9 was assigned to care for Resident #86 on 2/9/2024, 2/10/2024, 2/14/2024, 2/16/2024, 2/22/2024, 2/24/2024, 2/25/2024, 2/26/2024, and 2/28/2024. An interview was conducted with NA #9 on 7/23/2024 at 1:50 PM. NA #9 stated she was frequently assigned to care for Resident #86 when Resident #86 was residing in the facility. She reported Resident #86 was unable to ambulate and was receiving physical therapy. NA #9 stated Resident #86 was incontinent of bowels and had an indwelling catheter. She further stated Resident #86 was having frequent loose and mushy/watery stools with a foul odor and the resident kept asking why she was having so many bowel movements. NA #9 indicated she did report the frequent stools to the nurse, but she was unable to remember which one, because there was usually a different agency nurse assigned to the unit. Review of the bowel movement documentation sheets and daily assignment sheet revealed NA #1 was assigned to care for Resident #86 on 2/19/2024, 2/20/2024, 2/21/2024, 2/25/2024, and 2/26/2024. An interview was conducted with NA #1 on 7/25/2024 at 12:05 PM. NA #1 stated Resident #86 was incontinent of stool and was having very frequent and large loose bowel movements with a foul odor when she was a resident in the facility and the odor was even identifiable in the hallway outside her room. NA #1 stated anytime a resident had more than 1 bowel movement during the shift he would notify the nurse. NA #1 indicated Nurse #16 had been informed Resident #86 was having loose foul-smelling bowel movements but could not recall the date. A telephone interview was completed with Nurse #16 on 7/25/2024 at 2:34 PM. Nurse #16 stated she was no longer working at the facility, and she could not recall Resident #86 or anything about her. She further stated when she was employed at the facility, she had worked on different halls all the time and she just could not remember the resident or if she was having any issues with diarrhea. Nurse #16 indicated she was unable to recall if NA #1 reported to her that Resident #86 was having diarrhea, because she just couldn't remember that far back. Resident #86's MAR for February 2024 revealed she was administered 3 doses of bismuth subsalicylate and 10 doses of loperamide HCL from 2/13/2024 through 2/27/2024. A nurse's note for Resident #86 revealed the following secure conversation text message from Nurse #15 to the Medical Director dated 2/27/2024 at 3:33 PM which read in part, [family member] is concerned that resident is having a lot of loose BMs [bowel movements]. I looked through her chart and she does have a lot of watery stools but also a lot of mushy stools. May we have an order to test for C. difficile? The daughter also wants to know what else could be causing it if it were not C. difficile because her medications are the same as they were at home. Please advise. The Medical Director responded back to Nurse #15 on 2/27/2024 at 4:35 PM with the following message, if not watery they will not do a C. difficile test. Nurse #15's responded back to the Medical Director she would inform the family member. A telephone interview was conducted with Nurse #15 on 7/24/2024 at 9:13 AM. Nurse #15 stated she was a unit manager at the facility in February 2024, but that she was no longer employed by the facility. She further stated Resident #86's name sounded familiar, but she was unable to recall any information about her. Nurse #15 indicated she did not recall Resident #86's family member asking her to request a C. difficile test or recall Resident #86 having frequent loose stools. She stated she was unable to recall messaging the Medical Director or the reason she had contacted him. Nurse #15 stated she did not remember anything about Resident #86. Review of the EMR revealed no documentation in the nurses' progress notes regarding Resident #86's diarrhea for the duration of her stay at the facility. There was also no discovered mention of a family member expressing concern about the resident's diarrhea and inquiring about a test for C. difficile. An interview was completed with the Director of Nursing (DON)/Infection Control Preventionist (ICP) on 7/24/2024 at 1:51 PM. The DON/ICP stated she was unfamiliar with Resident #86 and was not aware that Resident #86 was having loose stools when she was residing in facility. She further stated the facility's standing order for diarrhea was for bismuth subsalicylate and that loperamide HCL required an order from the Medical Director. The DON/ICP indicated after examining the bowel movement documentation sheet, the nursing progress notes, and the MAR for Resident #86, the nursing staff should have assessed the resident for other symptoms of C. difficile infection such as cramping, abdominal pain, and foul-smelling stools. The DON/ICP indicated she expected the nursing staff to provide the Medical Director with an accurate description of the situation, such as the number and amount of loose watery stools and that the antidiarrheal medications were ineffective. A follow-up interview was conducted with the DON/IPC on 7/25/2024 at 9:55 AM. The DON/IPC stated it appeared Resident #86 was having diarrhea from the time she was admitted to the facility, and the nursing staff might have thought that was her normal routine. She further stated MDS Nurse #2, and Nurse #15 were the unit managers at the time, and they were also the staff members that were communicating with the Medical Director. The DON/IPC explained if she was made aware of the loose watery stools, she would have assessed the resident for other signs and symptoms of a C. difficile infection such as abdominal pain and cramping, fever, and foul-smelling stools. The DON/IPC stated the nursing staff had not followed the facility's Clostridium. Difficile Infection Control Policy by not assessing her for other symptoms such as fever, abdominal pain/tenderness, recent hospitalization or antibiotic use, and by not contacting the Medical Director for testing order after she had 3 or more watery stools in 24 hours. She further stated Resident #86's risk factors for C. difficile included she was recently discharged from the hospital, and she was having loose and watery stools. The DON indicated alerts for diarrhea and constipation light up a red bell on the residents' dashboard in the facility's electronic medical record and should have triggered the nursing staff to assess the resident for more information. She stated the text message sent by the MDS Nurse #2, and Nurse #15 to the Medical Director should have been more detailed and informed him of the number of stools she was having, and the antidiarrheal medication was ineffective. Resident #86's electronic medical record (EMR) revealed an admission History and Physical which was completed by the Medical Director on 2/9/2024 and a progress noted dated 2/23/2024 regarding discharge. There was no mention of diarrhea in the History and Physical or progress note for discharge. There were no other progress notes written by the Medical Director or another health care provider. An interview was conducted with the Medical Director on 7/24/2024 at 10:31 AM. The Medical Director stated that whenever he was informed by the nursing staff that a resident was having loose stools, he would not usually immediately order a C. difficile test. He further stated he would first look at the medications they were taking to see if they could be having an effect on the bowels, such as laxatives or stool softeners, and he would stop the medications for a couple of days to see if the loose stools would clear up. The Medical Director confirmed Resident #86 was not administered any medications that could cause diarrhea during her stay at the facility. The Medical Director reported that constipation with overflow was the most common cause of loose stools in a nursing facility, so a C. difficile test and precautions would not be indicated, unless they had other symptoms. He stated that he was first informed Resident #86 was having diarrhea on 2/13/2024 when MDS Nurse #2 requested an order for loperamide HCL. The Medical Director indicated that if the resident was continuing to have loose stools and antidiarrheal medications were ineffective, he would have expected the nursing staff to contact him within 24-48 hours. He further indicated that part of the diarrhea protocol was if the medication were ineffective then he would order an abdominal x-ray to check for constipation with overflow. The Medical Director stated that there was clearly a communication problem because he had no idea that she was having so many loose and watery stools and the antidiarrheal medications were ineffective. He further stated that just by looking at Resident #86's bowel movement documentation sheets and the amount and frequency of loose and watery stools she was having, that this was a clear indication that she had C. difficile infection. The Medical Director stated that he was unaware that Resident #13 was continuing to have diarrhea after 2/13/ 2024 when he had ordered the loperamide HCL, because the nursing staff had not contacted him until 2/27/2024. A follow-up telephone interview was completed with the Medical Director on 7/25/2024 at 10:36 AM. The Medical Director stated he depended on the nursing staff to make him aware of any changes or concerns involving the residents. He further stated he would have expected the nursing staff to assess the resident for signs of infection if she was continuing to experience diarrhea and the antidiarrheal medications were ineffective. The Medical Director further stated that his protocol for diarrhea was to discontinue any medications that could be contributing to loose stools, and then the next step would be to order antidiarrheal medications, and if they were ineffective, he would order an abdominal x-ray to rule out constipation with overflow. The Medical Director further stated that if the x-ray was negative for constipation, he would then order a C. difficile test. He reported that people with healthy immune systems were usually able eradicate C. difficile infection on their own, and that most C. difficile infections were usually treated with a 10-day course of antibiotics. The Medical Director indicated the risk factors for developing a C. difficile infection was a recent hospitalization, post antibiotic use, and being immunocompromised. The Medical Director stated that if a C. difficile infection was left untreated, it could develop into pseudomembranous colitis and toxic megacolon (large), and in extreme cases rupture the colon and death. He further stated it just depends on whether the resident was immunocompromised with other comorbidities. The Medical Director indicated that isolation was not necessary unless they had other signs and symptoms of C. difficile infection. The facility's infection Tracking and Trending information for 2024 was reviewed with the DON on 7/24/2024 at 1:51 PM. The Tracking and Trending information revealed no record of residents who were diagnosed with C. difficile during the time of Resident #86 or after up through the date of the review. A telephone interview was completed with Resident #86's Responsible Party (RP) on 7/25/2024 at 3:23 PM. The RP stated when Resident #86 was at the facility the resident was having diarrhea. She further stated when Resident #86 was discharged on 2/28/2024 she had already made an appointment to take her straight to her Primary Care Physician's (PCP) office because of the continued diarrhea. The RP explained the Physician's Assistant (PA) at the PCP's office had ordered a C. difficile test based on the resident's report of diarrhea and the RP's report of the frequent stools with foul odor. She further stated at the appointment a stool sample was obtained and sent to the lab. She said the results were reported as positive on 2/29/2024 and the PA ordered 10 days of antibiotics for Resident #86. A telephone interview was completed with the PA at Resident #86's Primary Care Physician's office on 7/25/2024 3:40 PM. The PA stated that on 2/28/2024 the family had called on 2/27/2024 requesting Resident #86 be seen in the office due to having loose watery stools when she was in the facility. She further stated when Resident #86 was discharged from the facility her family had brought her straight to her office from the