**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to promptly notify the resident's physician, physician's assistant, nurse practitioner, or clinical nurse specialist of results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physicians' orders for one of three residents (Resident #1) reviewed for notification. 1. The facility failed to notify Resident #1's primary Physician and Infectious Disease Nurse Practitioner for three days when Resident #1 tested positive for C. Diff on 04/19/24. (Per CDC website: C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon). Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. Some of the C. Diff risk factors included: long term use of antibiotics, older age (65 and older), recent stay at a hospital or nursing home, a weakened immune system, or previous infection with C. diff or known exposure to the germs.) An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM and the Plan or Removal was requested. The IJ was removed on 04/25/24 at 11:03 AM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record Review of Resident #1's Face Sheet dated 2/27/2024 reflected a re-admission date of 02/27/24 to the facility. Record review of Resident #1's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admission date of 02/27/24. The resident had a BIMS of 14 which indicated she was cognitively intact. She was always urinary and bowel incontinent. Active diagnoses included Heart Failure, Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Parkinson's Disease ( brain disorder that caused uncontrolled movements) , and seizure disorder. Record review of Resident #1's care plan dated 04/14/2024, and revised on 04/24/2024 reflected, [Resident #1] Focus: Has infection of UTI- ESBL (Extended-spectrum beta-lactamase (ESBL) is an enzyme found in some strains of bacteria that makes them harder to treat with antibiotics. Urinary tract infections (UTIs) caused by ESBL-producing bacteria are a serious concern for adults), C. diff and requires Contact isolation. Resident and [family member] request that keep door open. She gets anxious and start yelling if door is closed. Family refuses for her to be moved, educated on risks. GOAL: Will be free from complications related to infection through the review date. INTERVENTION: Administer antibiotic as per MD orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain standard precautions when providing resident care. Record Review of LVN K's Progress Note dated 4/19/2024 reflected, [Resident #1] is yelling about pain in her rectum due to hemorrhoids, [Resident #1] is also noted to have diarrhea and pain with urination. New orders for CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Stool and Urine sample have been collected. Samples are in the fridge pending pick up. Lab was called and notified of STAT labs. Record Review of Physician order for Resident #1 dated 4/19/2024 reflected, STAT: CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Record review of the laboratory result for Resident #1 dated 4/19/2024 reflected the following: Sample Collection Date: 04/19/2024 16:51; Received Date: 04/19/2024 18:54; Reported Date: Date: 04/19/2024 at 19:40 , Positive C. Difficile Toxin EIA Positive (Positive C. diff Toxin Enzyme Immunoassay (EIA) test can indicate that resident's diarrhea and other symptoms are caused by toxin-producing C. diff.) was flagged as Abnormal (An abnormal C. diff lab test result indicates that toxins produced by C. difficile bacteria are present in the stool and causing diarrhea.) Record Review of the LVN K's progress note dated 4/22/2024 reflected [Resident #1] tested positive for C-DIFF. Infectious Disease NP in facility at this time. Received orders for Vancomycin (Antibiotic) 250mg by mouth Four times a day x 14 days related to C. Diff, Lactobacillus (probiotic) 1 capsule by mouth twice a day; push fluids and a CBC and BMP need to be collected every Thursday. Pt to be on isolation related to C. diff. Record Review of the RN progress notes revealed there were no notes charted for 4/20/22 and 4/21/24 for Resident #1. Record Review of the Infectious Disease NP note date 4/22/2024 reflected [Resident #1] reported to have elevated white Blood cells and lot diarrhea. Stool sample was sent for c-diff test and was tested positive. Pt. denies any dysuria (painful or uncomfortable urination) and denies any fever, chills, sweat, sob, cough. Record Review of the Physician's Order for Resident #1 dated 4/23/24 reflected , Contact Isolation for a Diagnosis of ESBL and C-Diff every shift related to ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT. Record review of the Physician's Order for Resident #1 dated 4/4/2024 reflected, Contact Isolation for a Diagnosis of ESBL every shift for ESBL IN URINE with end date of 04/14/2024. Record review of the Nursing Schedule for 4/19/24, 4/20/24 and 4/21/24 revealed LVN K, LVN L , LVN M, and LVN N were assigned to Resident #1. In an observation and interview with Resident #1 on 04/23/24 11:02 AM revealed Resident #1 was in an isolation room. Resident #1 was in bed with a scoop mattress; fall mats on either side of the bed and looked physically weak with muscle wasting. Resident #1's room had a foul smell. Resident #1 stated that she was having diarrhea multiple times for last few days, [could not tell the writer exact time frame] and was told on 4/22/24 that she had infection that caused diarrhea by the nurse. Resident #1 stated she was started on an antibiotic on 4/22/24 and had some relief in diarrhea on the day of this interview. Resident #1 stated it would have helped to start the antibiotic medication earlier. She stated staff were not wearing isolation gowns before entering her room since 4/22/24. Resident #1 also stated that she was incontinent of urine and stool and wore briefs. In an interview with LVN K on 4/24/24 at 9:23 AM revealed she worked on 6 am - 2 pm shift on 4/19/2024 and 4/22/2024. She stated that she had received stat orders to send Resident #1's stool sample for C. Diff testing. LVN K stated during her shift, she called the lab services to let them know to collect the stool sample, and it was noted on the 24-hour shift nursing report and communicated with the incoming nurse. She stated when she returned to work on Monday 4/22/24 6-2 shift, she checked the labs that were posted on the EHR and notified the Infectious Disease NP who was rounding the facility. She stated that Infectious Disease NP gave orders for Resident #1 to be on isolation and antibiotics. She stated that it was responsibility of the nurses to check labs and notify the physician about any abnormal significant lab result or change in condition immediately and the risk of not doing so could lead to delay in providing care to the resident. In a phone interview with LVN N on 4/24/24 at 12:01 PM revealed she worked on 4/20/24 and 4/21/24 6 am - 2 pm and 2 pm -10 pm shift on the Resident #1's hall. She stated that Resident #1 was not on isolation on 4/20/24 and 4/21/24. She stated that she did not check the C. Diff laboratory results or nursing progress notes in the EHR since she was not made aware on the 24-hour shift nursing report. She stated the physician was not informed about Resident#1's positive C. Diff lab results since she was not aware herself. LVN N stated that there was no mention of pending labs on the 24-hour shift report. She stated the risk to residents for not informing physician about significant abnormal lab results or change in resident condition was delayed treatment and increased risk of infection throughout the facility. In a phone interview with the Infectious Disease NP on 4/24/24 at 12:09 PM revealed the facility made her aware of Resident #1's of positive C. Diff lab result on 4/22/24 when she was rounding in the facility. The Infectious Disease NP stated once she learned about the positive C. Diff result for Resident #1, she gave orders to start Resident #1 on isolation and treated with antibiotics. She also stated if she would have known about the C. Diff results earlier, she would have started the antibiotics earlier. She stated the risk to residents for not informing the physician earlier was delayed treatment to the residents, lapses in infection control and quality of care could be decreased. In an interview with the ADON 04/24/24 at 12:28 PM revealed that she started working in the facility 3 weeks ago. She stated she thinks Resident #1 tested positive for C. Diff on 4/22/24 or 4/23/24 but she was not sure about the timeframe. She added her expectation was that any change in a resident's condition or significant lab change should be communicated to the physician immediately without any delay. ADON stated that nurses communicated with the on-coming shift Nurses for any pending labs or outstanding results via a 24-hour report and EHR. She stated the risk to residents for not notifying physician regarding residents change in condition can lead to delay in treatment and decreased quality of care. In an interview with LVN L on 4/24/24 at 1:02 PM revealed she worked 2 pm - 10 pm Shift on 4/19/22 and was assigned to Resident #1. LVN L stated that she had received 24-hour shift report from LVN K regarding a stat stool sample testing for C. Diff for Resident #1 and confirmed that laboratory personnel had picked up Resident #1's stool sample for testing. She further added, she thought C. Diff labs often took 2-3 days to get results and was not well versed with checking labs on the EHR, hence she did not check C. Diff labs on her entire shift, nor did she notify the physician about abnormal labs or change in condition. LVN L noted that she did not sought help from other staff member for checking lab results. She became aware that Resident #1 tested positive for C. Diff when she came back for her shift on 4/22/24. She stated Resident #1 was put on isolation on 4/22/24 per the shift 24- hour shift report she was given. She stated it was the nurses' responsibility to check for resident lab results and inform any change in condition for residents including abnormal labs to the physician immediately; and failure to do so could lead to delayed care and decreased quality of care. In a phone interview with LVN M on 4/24/24 at 1:08 PM revealed she worked 10 pm - 6 am shift on 4/19/24 and was assigned to Resident #1. She stated that Resident #1 was on isolation until 4/14/24 for ESBL but she did not remember if Resident #1 was on isolation on 4/19/24. LVN M further stated she did not check Resident #1's lab results or nursing progress notes on her shift because she had 40 residents to take care and did not have time to check the resident's EHR. She stated she only paid attention to the 24-hour nursing report, but she did not remember what was mentioned in the report. LVN M was not aware that Resident #1 had positive C. Diff lab until the time of this interview. LVN M stated she was not aware of the pending lab during the shift change. She stated she did not inform the physician about Resident #1's positive C. Diff report since she herself was not aware about it. LVN M stated she did not want to answer any further questions and the interview was ended. In an interview with the DON on 04/24/24 at 1:31 PM revealed she started at the facility about a month ago. She stated Resident #1 was having diarrhea and hence the stat stool testing was ordered and collected on 4/19/24 and resulted in a positive result for C. Diff on 4/19/24. The DON looked at the EHR and stated per physician's orders Resident #1 was started on isolation on 4/22/24. The DON stated that she became aware of the positive C. Diff lab on the morning of 4/22/24 during a clinical meeting. The DON also mentioned that Resident #1 was in isolation prior for ESBL which ended on 4/14/2024. She stated that they did not have a weekend supervisor and she was the point of contact for any nursing related concerns. The DON stated that she did not get any phone calls or messages notifying her about the positive C Diff result. The DON verbalized that usually the lab company will call the facility with any abnormal labs, but the facility did not get a call from the lab company. The DON also stated that all labs were available online and facility nurses knew how to access labs from the online portal. The DON stated that Resident #1's C. Diff labs results were available on the evening of 4/19/24 around 7 PM and added that the nurses for the 4/19/24 afternoon and night shift as well as nurses on 4/20/24 and 4/21/24 on all shifts failed to notify the physician about critical labs. The DON stated that typically nurses were responsible for checking lab results and notifying the Medical Director for any change in condition or abnormal labs immediately. She stated that she will need to speak with the nurses to identify the failure to communicate with the physician about a significant abnormal C. Diff lab for Resident #1. The DON stated her expectation was that any change of condition for a resident should be communicated to the physician immediately and the risk of not doing so can result in delayed treatment to the resident. The DON also stated that C. Diff is highly contagious disease and should have been started on appropriate treatment earlier. In a phone interview with the Medical Director (MD) on 04/30/24 at 3:13 PM revealed that she was not informed about Resident#1's Positive C. Diff lab until 4/22/24. The MD reviewed Resident #1's EHR during the interview and stated that she noted the C. Diff Toxin Enzyme Immunoassay lab was positive on 4/19/24. The MD stated a positive C. Diff Toxin Enzyme Immunoassay (EIA) test result indicated that diarrhea and other symptoms that Resident #1 was exhibiting were caused by toxin-producing C. Diff bacteria and was sufficient to start C. Diff treatment. The MD stated she should have been notified about positive C. Diff results immediately on the day it was resulted and not doing so exposed the residents to increased infections and a delay in treatment. She also stated if she was informed regarding Resident #1's significant results earlier, she would have started isolation protocols and other treatment earlier for Resident #1. In an interview with the Administrator on 04/24/24 03:16 PM revealed that Resident #1 was on isolation already, started earlier in the month with ESBL. The Administrator added that he was not aware that ESBL isolation orders had ended on 4/14/24. He further added that he became aware that Resident #1 was positive for C. Diff on 4/22/24 since it was brought up in the morning meeting. The Administrator added he will need to check the 24- hour nursing report to see what was said. The Administrator added that change of condition for a resident including significant lab result should be immediately communicated to the physician by the nursing team and failure to do so can result in delay in treatment. In an interview with Clinical Resource RN on 4/25/24 at 10:02 AM revealed that the facility was not able to locate the 24-hour nursing report paper copy dated 4/19/24. She added that there were no electronic copies of the report. Record review of facility's revision date December 2023, titled Significant change of condition, Response reflected, 1. If, at any time, it is recognized by any one of the team members that the condition or care needs of the resident have changed, the Licensed Nurse or Nurse Supervisor should be made aware. Examples would be the following (but not limited to): Any signs or symptoms of infection . Change in output (bowel or bladder) including amount, color, consistency, odor, or frequency .5. There will be certain circumstances where immediate attention will be warranted, and nursing will be responsible for notifying the appropriate department for evaluation. The nurse shall use his / her clinical judgment and shall contact the physician based on the urgency of the situation. The Medical Director shall be notified in the event that the Attending Physician or on-call Physician cannot be reached. The resident/ resident representative will be notified of the change of condition and any changes in the resident's medical or nursing care. Review of the Center for Disease Control (CDC) Website: Nursing Homes and Assisted Living (Long-term care facilities) https://www.cdc.gov/longtermcare/prevention/index.html reflected , C. difficile infection (CDI) is a common cause of acute diarrhea in nursing homes. Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. Contamination of a resident's skin and environment is greatest when a resident has diarrhea from CDI but hasn't started on appropriate treatment. Early identification of CDI can limit the spread of C. difficile by reducing the time from symptom onset to starting therapy. Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM and the Plan or Removal was requested. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM. The Plan of Removal reflected the following: Action: 1. The Medical Director was notified of the IJ on 04/24/24 at 4:11 PM. 2. The resident's physician was notified of positive C-diff lab result on 04/22/24. 3. A facility lab results review of total census was initiated by nursing admin and will be completed on 04/24/24. 4. A facility review of all infectious diseases/lab orders was initiated by nursing admin and will be completed by 04/24/24. 5. On 04/24/24 the facility Clinical Resource who is an RN, completed train the trainer in-servicing for the DON, ADON and Cluster Partners. The training includes obtaining, reporting, and documenting labs and physician notification of resident change in condition. 6. In-service training for licensed nurses was initiated by DON/ADON/Clinical Resource on 04/24/24 related to obtaining, reporting, and documenting labs. Training to be completed by 04/24/24. Any staff who are unable to complete training on 04/24/24, will be required to complete training prior to the beginning of their next scheduled shift. 7.In-service training for licensed nurses was initiated by DON/ADON/Clinical Resource on 04/24/24 related to physician notification of change in resident condition. Training to be completed by 04/24/24. Any staff who are unable to complete training on 04/24/24, will be required to complete training prior to the beginning of their next scheduled shift. 8.A member of management will be at the facility at each change of shift to ensure all staff get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. 9.DON or designee will review changes in condition daily to ensure that the resident's physician has been notified. Executive Director or designee will monitor to ensure reviews are completed. Findings during review will be reported at the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance and continue monthly for 90 days to ensure ongoing compliance. 10.An ad hoc meeting regarding items in the IJ template was completed on 4/24/24. Attendees included the Medical Director, DON/Infection Preventionist, ADON and other IDT members. Meeting was led by facility Executive Director. Facility will complete weekly QA meeting to review corrective measures for four weeks or until substantial compliance is established. 11.Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for four weeks beginning 4/24/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 04/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: IJ Monitoring process: Record Review of the in-service dated 4/24/24 Change of Condition and Physician Notification reflected Nurses were in-serviced. The Surveyors attempted interviews for all the nurses that were in-serviced for Change of condition and Physician notification. In an interview with LVN Z on 4/25/24 at 12:52 pm revealed that per in-services provided on 4/24/24 every nurse, every shift would be checking on-coming and out-going lab results. LVN Z stated they needed to notify the physician about any change of condition including significant lab results. She also stated that she would contact the physician immediately regarding significant abnormal labs. In an interview with LVN R on 4/25/24 at 1:20 pm revealed she received an in-service on infection control and physician notification today. LVN R stated she understood to report any change in condition including abnormal labs to the physician immediately. She also stated that she understood to check the labs on her shift and report any lab changes that are abnormal to the physician and the DON. In an interview with LVN A on 4/25/24 at 1:29 PM revealed each nurse was responsible for requesting and sending out labs. If the labs came back positive or abnormal, the nurse would inform the physician immediately. She also stated that all labs, pending or confirmed, must be communicated to the next nurse during rounds. She also stated that any kind of change in condition, change in orientation, change in vital signs, notify MD immediately, notify the family as well. LVN A stated she will report to the DON, MD, ADON and family. She stated that for all transmission-based precautions on a resident with a positive diagnosis, they need to call the Infectious Doctor immediately to obtain orders, if any. In a phone interview with LVN T on 4/25/24 at 2:35 PM revealed she received an in-service regarding notification of change to the physician immediately that includes abnormal critical labs. LVN R stated that any labs that are pending or resulted should be communicated with the incoming nurses and documented as well so the residents can be taken care of. She also stated that any resident with C. Diff or Covid should be on isolation protocol immediately upon diagnosis and symptoms and the physician orders to be followed promptly. In an interview with LVN S on 04/25/24 02:56 PM revealed he was working at the facility for 2 years. He stated that nurses were responsible for checking labs and needed to communicate with the incoming nurses and documented on the 24-hour nursing report. He stated that any change in the resident's condition including abnormal critical lab should be communicated to the physician immediately. He also stated that abnormal labs should be communicated to the DON and ADON as needed. He stated that for any resident with transmission-based precautions such as Covid, C. Diff, should be started on isolation immediately upon diagnosis and symptoms. In an interview with LVN L on 04/25/24 at 03:18 PM revealed she had been working in the facility for about 4 months. She stated that every nurse, on every shift, will check labs that were outgoing or resulted; and notify the physician immediately about any abnormal results. She stated any change of condition in a resident should be communicated to the physician immediately, including the significant abnormal labs. She also stated that for any resident with transmission-based precautions with a positive diagnosis they need to be placed on isolation immediately. In a phone interview with LVN N on 4/25/24 at 4:16 PM revealed that she received in-services about physician notification. LVN N stated that she understood all changes in condition for a resident should be reported to the physician immediately. She also stated that nurses were responsible for checking labs, any abnormal critical labs will be communicated to the physician and DON immediately as well as with the incoming nurses and documented. In a phone interview with LVN K on 4/25/24 at 4:20 PM revealed that she received in-services about physician notification in change in condition including significant labs. She also stated that she understood that any lab results either pending or resulted should be communicated with the oncoming nurses, the DON and the physician. She stated that any resident on transmission-based protocol with a positive diagnosis should be placed on isolation immediately and the physician orders should be carried out immediately. An interview via phone was attempted for RN DD on 4/25/24 at 3:45 PM. The surveyor did not receive a return call until the time of exit. In an interview with ADON on 4/25/24 at 3:03 PM revealed the cause of failure was C Diff, which was a very infectious disease and was not reported to the physician in timely manner. She also stated that the labs were not followed up by the incoming nurses which caused breakdown of the communication failure. She also stated that as an ADON she will ensure that nurses were responsible for reporting labs and the physician would be notified about critical labs daily. She also stated that she planned to pull a lab report on all residents daily, checking the lab portal daily, the lab tracker form will be given to the nursing team, and she will follow-up on that. She also stated that there will be no break in the audit on the weekend; and the ADON or designee will follow-up. She stated that the failure affected the resident because of the delay in getting adequate care, her relief of symptoms would be sooner. She also stated that the risk to other residents because of potential spread of infection. In an interview with the DON on 4/25/24 at 3:19 PM revealed that failure occurred because the positive C. Diff labs came back on the 2-10 PM Shift on 4/19/24 and the nurses on the weekend failed to check labs on the following weekend,4/20/24 and 4/21/24. She stated that nurses were responsible for checking and reporting labs. She also stated that there was a communication breakdown regarding critical lab value such as positive C. Diff lab should have been reported promptly to the physician since C. Diff was a highly contagious disease. The DON stated that in-services for this failure were completed by the clinical Resource RN and the DON. As the DON, her role will be to improve communication between nursing and the incoming and outgoing shifts so that such failures about abnormal lab reporting can be prevented. She also stated that as the DON, she would be monitoring labs daily, increase frequency of skill checks, and monitoring of staff. She also stated that she would increase education with nurses to implement the new processes. She also stated with help of QAPI, they have created a lab tracker form and the DON or designee will oversee it daily. She also stated that Resident #1 was affected by the failure since she received delayed care and chances of infection spreading in the facility increased. In an interview with the Administrator on 4/25/24 at 3:37 PM revealed that the failure occurred because results of stat lab for Positive C. Diff results was not communicated with the physician immediately. He also stated that since various shifts were involved, there was a communication breakdown specially between nursing staff to convey lab results and notification to physician. He also stated that for any resident with transmission-based precautions, isolation protocols should be in place immediately. He stated via the QAPI process all nurses were in-serviced, they will conduct ongoing and as needed IDT meetings to discuss resident labs and interventions needed. He also stated that lab results will be reviewed by the ADON, DON or designee, daily including weekends. He stated QAPI meetings to be held weekly for next 90 days to ensure ongoing compliance. He stated Resident #1 was affected because there was a delay in treatment because of the failure to notify the physician promptly. These failures resulted in the identification of an IJ on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM , the administrator was notified .The facility remained out of compliance at a scope of pattern due to the facility's need to complete inservice training and evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #1 and Resident #6) of four residents observed for infection control. 1. The facility failed to place Resident #1 who tested positive Clostridioides difficile (C. Diff) on 4/19/2024 in isolation until 04/22/2024, three days after the positive C. Diff result were obtained. (Per CDC website : C. diff is a bacterium that causes diarrhea and colitis (an inflammation of the colon) .Most cases of C. diff infection occur when a resident is taking an antibiotic or not long after resident has finished taking antibiotics. C. diff can be life-threatening. Some of the C. Diff risk factors included: long term use of antibiotics, older age (65 and older), recent stay at a hospital or nursing home, a weakened immune system, or previous infection with C. diff or known exposure to the germs.) 2. LVN O and NA P failed to wear appropriate PPE while caring for Resident #6 and Resident #1; who were on contact isolation, on 4/23/24. An Immediate Jeopardy (IJ) was identified on 04/24/24 at 3:40 PM. The IJ template was provided to the facility Administrator on 04/24/24 at 3:50 PM. While the IJ was removed on 04/25/24 at 11:03 AM the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of pattern due to the facility still monitoring the effectiveness of their Plan of Removal. These deficient practices could place residents at risks for spread of infection through cross-contamination of pathogens and illness, which could lead to worsening of their condition, hospitalization, or death. Findings included: 1- Record Review of Resident #1's Face Sheet dated 2/27/2024 reflected a re-admission date of 02/27/24 to the facility. Record review of Resident #1's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admission date of 02/27/24. The resident had a BIMS of 14 which indicated she was cognitively intact. She was always urinary and bowel incontinent. Active diagnoses included Heart Failure, Hypertension (high blood pressure), Diabetes Mellitus (high blood glucose), Parkinson's Disease ( brain disorder that caused uncontrolled movements) , and seizure disorder. Record review of Resident #1's care plan dated 04/14/2024, and revised on 04/24/2024 reflected, [Resident #1] Focus: Has infection of UTI- ESBL (Extended-spectrum beta-lactamase (ESBL) is an enzyme found in some strains of bacteria that makes them harder to treat with antibiotics. Urinary tract infections (UTIs) caused by ESBL-producing bacteria are a serious concern for adults), C. diff and requires Contact isolation. Resident and [family member] request that keep door open. She gets anxious and start yelling if door is closed. Family refuses for her to be moved, educated on risks. GOAL: Will be free from complications related to infection through the review date. INTERVENTION: Administer antibiotic as per MD orders. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain standard precautions when providing resident care. Record Review of LVN K's Progress Note dated 4/19/2024 reflected, [Resident #1] is yelling about pain in her rectum due to hemorrhoids, [Resident #1] is also noted to have diarrhea and pain with urination. New orders for CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Stool and Urine sample have been collected. Samples are in the fridge pending pick up. Lab was called and notified of STAT labs. Record Review of the LVN K's progress note dated 4/22/2024 reflected [Resident #1] tested positive for C-DIFF. Infectious Disease NP in facility at this time. Received orders for Vancomycin (Antibiotic) 250mg by mouth Four times a day x 14 days related to C. Diff, Lactobacillus (probiotic) 1 capsule by mouth twice a day; push fluids and a CBC and BMP need to be collected every Thursday. Pt to be on isolation related to C. diff. Record Review of the RN progress notes revealed there were no notes charted for 4/20/22 and 4/21/24 for Resident #1. Record review of Physician's Order for Resident #1 dated 4/4/2024 reflected, Contact Isolation for a Diagnosis of ESBL every shift for ESBL IN URINE with end date of 04/14/2024. Record Review of Physician's order for Resident #1 dated 4/19/2024 reflected, STAT: CBC, BMP Urine Analysis with w Culture and Sensitivity and Stool with C. Diff sample. Record Review of Physician's Order for Resident #1 dated 4/23/24 reflected , Contact Isolation for a Diagnosis of ESBL and C-Diff every shift related to ENTEROCOLITIS DUE TO CLOSTRIDIUM DIFFICILE, NOT SPECIFIED AS RECURRENT. Record review of the laboratory result for Resident #1 dated 4/19/2024 reflected the following: Sample Collection Date: 04/19/2024 16:51; Received Date: 04/19/2024 18:54; Reported Date: Date: 04/19/2024 at 19:40 , Positive C. Difficile Toxin EIA Positive (Positive C. diff Toxin Enzyme Immunoassay (EIA) test can indicate that resident's diarrhea and other symptoms are caused by toxin-producing C. diff.) was flagged as Abnormal (An abnormal C. diff lab test result indicates that toxins produced by C. difficile bacteria are present in the stool and causing diarrhea.) Record Review of the Infectious Disease NP note date 4/22/2024 reflected [Resident #1] reported to have elevated white Blood cells and lot diarrhea. Stool sample was sent for c-diff test and was tested positive. Pt. denies any dysuria (painful or uncomfortable urination) and denies any fever, chills, sweat, sob, cough. In an observation and interview with Resident #1 on 04/23/24 11:02 AM observed Resident #1 was in an isolation room; cohorting with Resident #6. Resident #1 was in bed with scoop mattress; fall mats on either side of the bed and cachectic looking. Resident #1's room had a foul smell. Resident stated that she was having diarrhea multiple times for last few days, [could not tell the writer exact time frame] and was told on 4/22/24 that she had infection that caused diarrhea by the Nurse. Resident #1 stated she was started on antibiotic on 4/22/24 and had some relief in diarrhea on the day of this interview. Resident #1 stated it would have helped to start the antibiotic medication earlier. She stated staff were not wearing isolation gowns before entering her room since 4/22/24. Resident #1 also stated that she was incontinent of urine and stool and wore briefs that needed to be changed by staff members. 2-Record Review of Resident #6's Face Sheet dated 3/21/2022 with a readmission date 3/21/2022 to the facility. Record review of Resident #6's quarterly MDS, dated [DATE], reflected an [AGE] year-old female with an admission date of 3/21/2024. The resident had a BIMS of 9 which indicated she had moderate cognitive impairment. She was frequently incontinent of urine and bowel. Resident #6 needed substantial/maximal assistance with toileting and hygiene. Active diagnoses included Pneumonia (infection in lungs), Osteoporosis (decreased bone strength or bone density), Cerebral Palsy (a group of conditions that affect movement and posture), functional urinary incontinence (toileting difficulty), non-Alzheimer's dementia (memory loss) and anxiety disorder. Record review of Resident #6's care plan with revised date of 4/24/24 revealed, Focus: Has a new onset infection ESBL UTI and requires isolation. Goal: Will be free from complications related to infection through the review date. Interventions: Ensure all immunization are up to date. Follow facility policy and procedures for line listing, summarizing, and reporting infections. Maintain isolation status. Maintain standard precautions when providing resident care. Record Review of the Physician's Orders dated 4/23/24 reflected Resident #6 had and order for Contact Isolation for a diagnosis of ESBL every shift related to URINARY TRACT INFECTION. In an observation on 4/23/24 at 2:32 PM from the hallway revealed that Resident #6 and Resident #1 shared the same room. The room was an isolation room with two contact isolation signs that stated See nurse before entering room posted on the door. The room door was open, and Resident #6 was found to be sitting on the floor of her room near the wheelchair. The isolation cart including PPE such as gloves, masks, and hand sanitizer was observed outside the door. Observed NA P rushed to the room, without performing any hand hygiene or wearing PPE. Then observed LVN O entered the isolation room without performing any hand hygiene or wearing PPE. The 2 staff members, LVN O and NA P, then proceeded to pick-up Resident #6 and sat her into the wheelchair in the room. NA P proceeded to move Resident # 6's wheelchair to the restroom. Meanwhile, LVN O came out of the room without performing hand hygiene and walked to the nurse's station. She grabbed a hand cuff blood pressure monitor and rushed back to the isolation room. Observed NA P escorted Resident #6's back from the restroom into her room. LVN O then measured Resident#6's blood pressure and walked out of the room, without performing hand hygiene, to the nurses' station and set the blood pressure monitor on the desk of the nurse's station without sanitizing it. Observed NA P then proceeding to wash her hands with soap and water and exiting the room. In an interview with NA P on 4/23/24 at 2:43 PM, revealed that she was working in the facility as a nurse aide for the last 4 months. She stated that she was not sure that Resident #6 was on isolation and stated she did not see the isolation signage on the door. She stated that Resident #1 was on isolation since 4/22/24; but she did not wear the PPE since she was only going to help Resident #6 who was on the ground. NA P then added that she saw the isolation sign on the door at the time of this interview. NA P stated that she initially thought that Resident #6 had a fall on the ground and rushed to the isolation room but then realized that Resident #6 was on the ground to reach the wheelchair. She stated the risk to residents for not adhering to PPE and infection control guidelines was increased risk of infection and spreading it to other residents. In an Interview with LVN O on 4/23/24 at 2:51 PM revealed that she heard NA P call her to Resident #6's room. LVN O stated that she worked in a different hall than where Resident #6 was located and hence did not notice the two contact isolation signs and the see Nurse signage on the Resident #6's door. She stated she was not provided an in-service on isolation protocols. She stated that for any contact isolation room, she needed to don her gown and gloves and perform adequate hand hygiene before entering the room. She also stated it was a mistake on her part to enter a contact isolation room without performing hand hygiene or donning appropriate PPE. She stated she checked on Resident #6's blood pressure which was 147/100 and rushed out of the room again without performing hand hygiene to inform the nurse assigned to Resident #6. She then set the blood pressure monitor on the nursing station desk and stated she would be sanitizing it after some time. LVN O stated the risk to residents for not performing hand hygiene, not donning PPE, and not sanitizing medical equipment after use within an isolation room was very high risk of spread of infection. In an interview with Resident #6 on 4/23/24 at 2:58 PM, it was revealed that Resident #6 wanted to use the restroom and scooted out of her recliner to sit on the wheelchair. Since the wheelchair was a little away from the recliner, she sat on the floor to scoot towards the wheelchair to climb into it so she could use the restroom. Resident #6 stated she forgot to press the call light to alert the staff members. Resident #6 also stated that she had a urine infection and needed to use the restroom frequently. Resident # 6 stated one of the staff members [could not tell the name of the staff member to the surveyor] told her on 4/24/24 that she had an infection that required everyone entering the room wear isolation gowns and gloves so the infection would not spread to others. She stated that the LVN O and NA P that entered the room while she was on the floor sometime back, did not wear a gown or gloves while assisting her. In an interview with the ADON on 04/23/24 at 3:18 PM revealed that she had only started working at the facility 3 weeks ago. She stated she thinks Resident #6 was on isolation for ESBL on 4/23/24 and the staff were in-serviced about isolation protocols. She added her expectation was for the staff to wear PPE at all times in an isolation room; except when there was an emergency and a resident's safety takes precedence over isolation protocols. She stated that she was not aware of the incident with Resident #6 being on the ground and would investigate to find why NA P and LVN O failed to follow appropriate isolation protocols. She stated that as an ADON she was responsible for overseeing staff follow all isolation precaution guidelines. In an interview with CNA Q on 4/24/24 at 8:58 AM revealed that Resident #1 started isolation on 4/22/24 and Resident #6 started isolation on 4/23/24. CNA Q stated that Residents #1 and #6 were not on isolation on 4/19-4/21. CNA Q stated that for all isolation rooms, CNAs needed to wear a gown and gloves before entering the room and perform adequate hand hygiene. The risk of not doing so could lead to infections. In an interview with Housekeeper F on 4/24/24 at 9:02 AM revealed that she worked on 4/21/24 and 4/22/24 and was assigned to the hall where Resident #1 and Resident #6 resided. She stated that Resident #1 and Resident #6's room was not on isolation on those days. She came back to work on 4/24/24 and was told that room (where Resident # 1 and #6 stayed) was on contact isolation and she needed to wear gloves, gown, and perform hand hygiene before entering the room. In an interview with LVN K on 4/24/24 at 9:23 AM revealed she worked on 6 am - 2 pm shift on 4/19/24 and 4/22/24. She stated that she checked Resident #1's lab results for positive C. Diff that resulted on 4/19/24. She notified the Infectious Disease NP, who gave orders for Resident #1 to be on isolation on 4/22/24. LVN K stated that Resident #1 was not on isolation when she arrived at the facility for her 6 am -2 pm shift on 4/22/24. LVN K stated that the risk to residents for not providing contact isolation was infection control concerns. In a phone interview with LVN N on 4/24/24 at 12:01 PM revealed she worked on 4/20/24 and 4/21/24 6 am - 2 pm and 2 pm -10 pm shift on the Resident #1's hall. She stated that Resident #1 was not on isolation on 4/20/24 and 4/21/24 on those days. She stated that the risk of not isolating residents with positive C. Diff promptly, was increased spread of infection. In a phone interview with the Infectious Disease NP on 4/24/24 at 12:09 PM revealed the facility made her aware of Resident #1 positive C. Diff lab result on 4/22/24 and labs for C. Diff for Resident #1 resulted positive on 4/19/24. The Infectious Disease NP stated once she learned about the positive C. Diff result for Resident #1, she gave orders to start Resident #1 on isolation. She stated the risks to residents for not placing resident on isolation promptly once C. Diff was diagnosed were lapses in infection control and quality of care can be decreased. In an interview with LVN L on 4/24/24 at 1:02 PM revealed she worked 2 pm - 10 pm Shift on 4/22/22 and was assigned to Resident #1. She stated she was provided a shift report that stated Resident #1 started isolation on 4/22/24. LVN L stated that for any contact isolation room, staff needed to wear PPE and perform hand hygiene, and failure to do so could result in risk of spreading the infection. LVN L also stated that it was a nursing protocol to place a resident with infectious disease in prompt isolation to prevent further spread of the disease to other residents. In an interview with the DON on 04/24/24 at 1:31 PM revealed she started at the facility about a month ago. She stated Resident #1's was having diarrhea and hence stat stool testing was order and collected on 4/19/24 and resulted positive for C. Diff on 4/19/24. The DON referred to the EHR and answered that per physician's orders Resident #1 was started on isolation on 4/22/24. The DON stated that she became aware of the positive C. Diff lab results on the morning of 4/22/24 in a clinical meeting. The DON stated that there was a failure to start prompt contact isolation for Resident #1 after a C. Diff diagnosis on 4/19/24. The DON stated her expectation was staff members to follow all isolation protocols for infectious diseases and wear appropriate PPE and perform hand hygiene. The DON also stated that they had started in-services for all staff members on 4/23/24 about wearing appropriate PPE and performing adequate hand hygiene. She stated that LVN O was suspended pending investigation of the incident on 4/23/24. The DON added that LVN O was one of the staff members that entered the isolation room without performing adequate hand hygiene and without doffing appropriate PPE. The DON stated that the risk to residents for not wearing appropriate PPE or not placing residents with diagnosis of infectious disease was very high chances of spreading infections. In a phone Interview with the Medical Director (MD) on 04/30/24 at 3:13 PM revealed that she was not informed about Resident#1's Positive C. Diff lab until 4/22/24. The MD stated that it was her expectation that all staff members follow transmission-based precautions for isolation rooms that included wearing appropriate PPE, performing adequate hand hygiene, and placing residents on appropriate isolation promptly. She also stated that risk for not adhering to infection control guidelines for transmission-based precautions was increased risk of spread of infections throughout the facility. In an interview with the Administrator on 04/24/24 at 03:16 PM revealed that Resident #1 was on isolation already, started earlier in month with ESBL. The Administrator added that he was not aware that ESBL isolation orders had ended on 4/14/24. He further added that he became aware that Resident #1 was positive for C. Diff on 4/22/24 since it was brought up in the morning meeting. The Administrator stated it was his expectation to start contact isolation promptly and wear appropriate PPE before caring for a resident with diagnosis of an infectious disease. The Administrator also added that the DON and the Clinical Resource RN had started in-services with all staff to adhere to wearing PPE and hand hygiene before entering all isolation rooms and failure to do so would lead to lapses in infection control. In an interview with Clinical Resource RN on 4/25/24 at 10:02 am revealed it was her expectation that staff members follow transmission-based precautions including wearing PPE, hand hygiene, starting prompt isolation and failure to do so may potentially cause lapses in infection control though out the facility. Record Review of Facility's titled IPCP Standard and Transmission-Based Precautions Policy revised date October 2022 reflected, .b. Personal protective equipment (PPE): i. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. ii. DON PPE upon room entry, then doff and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens. C. Patient-care equipment (e.g., blood pressure cuffs). It is preferred dedicated or disposable patient-care equipment be used. If common use of equipment for multiple patients is unavoidable, clean and disinfect such equipment before use on another patient .6. Implementation: a. The facility will implement a system to alert staff, residents, and visitors that a resident is on TBP. Post clear signage on the door or wall outside of the resident room indicating the type of Precautions and required PPE (e.g., gown and gloves) . Review of the Center for Disease Control (CDC) Website: Nursing Homes and Assisted Living (Long-term care facilities) https://www.cdc.gov/longtermcare/prevention/index.html dated December 28, 2016, reflected , C. difficile infection (CDI) is a common cause of acute diarrhea in nursing homes. Individuals with CDI serve as a source for bacterial spread to others, through the contamination of caregiver hands and shared equipment. Contamination of a resident's skin and environment is greatest when a resident has diarrhea from CDI but hasn't started on appropriate treatment. Early identification of CDI can limit the spread of C. difficile by reducing the time from symptom onset to starting therapy. Rapid containment through implementation of contact precautions for symptomatic residents can reduce contamination. Contact precautions include use of gowns/gloves and dedicated equipment during care of residents with new diarrhea Review of the CDC website, review date October 25, 2022, reflected: https://www.cdc.gov/cdiff/clinicians/faq.html reflected, Any surface, device, or material (such as commodes, bathtubs, and electronic rectal thermometers) that becomes contaminated with feces could serve as a reservoir for the C. diff spores. C. diff spores can also be transferred to patients via the hands of healthcare personnel who have touched a contaminated surface or item . Isolate patients with possible C. diff immediately, even if you only suspect CDI. Wear gloves and a gown when treating patients with C. diff, even during short visits. Gloves are important because hand sanitizer doesn't kill C. diff and handwashing might not be sufficient alone to eliminate all C. diff spores. As no single method of hand hygiene will eliminate all C. Diff spores, using gloves to prevent hand contamination remains at the cornerstone for preventing C. Diff transmission via the hands of healthcare personnel. These failures resulted in the identification of an IJ on 04/24/24 at 3:40 PM. The Administrator was notified and provided with the IJ template on 04/24/24 at 3:50 PM. The Plan of Removal was submitted by the facility and accepted on 04/25/24 at 11:03 AM The Plan of Removal reflected the following: Action: 1. The Medical Director was notified of the IJ on 04/24/24 at 4:11 PM 2. Charge nurse who failed to wear appropriate PPE was provided education counseling 4/23/24 and was removed from her shift. Nurse aide that entered room without donning and doffing PPE was provided education counseling by Facility Administrator and DON on 04/23/24. 3. Resident's physician was notified of resident's positive C. diff status and the resident was placed in isolation on 04/22/24. 4. On 04/23/24 the facility Clinical Resource who is an RN, completed train the trainer in-servicing for the DON/Infection Preventionist, ADON and Cluster Partners. The training includes donning/doffing PPE, transmission-based precautions, and discontinuation of precautions based on CDC guidance. 5. Training and competency for all staff on donning and doffing PPE, handwashing, transmission-based precautions, and discontinuation of precautions will be completed based on CDC guidance. Training will be completed by the DON, ADON, Clinical Resources, and Clinical Cluster Partners. Initiation of this training began on 4/23/24 will be completed on 4/24/24. Any staff who were unable to complete the training on 4/24/24, will be required to complete the training prior to the start of their next shift. 6. In-service training initiated on 4/24/24 for licensed nursing staff by DON/ADON/Clinical resource related to obtaining, reporting, and documenting labs. Training to be completed by 4/24/24. Any staff who are unable to complete training on 4/24/24 will be required to complete training prior to beginning their next scheduled shift. 7. A member of management will be at the facility at each change of shift to ensure all staff get trained prior to going to work on the floor. Staff will not be allowed to work unless they have completed the training and competency checks. This training will also be included in the new hire orientation and will be included for agency staff/PRN staff prior to starting work on the floor. 8. An ad hoc meeting regarding items in the IJ template was completed on 4/24/24. Attendees included the Medical Director, DON/Infection Preventionist, ADON and other IDT members. Meeting was led by facility Executive Director. Facility will complete weekly QA meeting to review corrective measures for four weeks or until substantial compliance is established. 9. Resident lab results will be reviewed Monday to Friday in daily morning clinical meeting by nursing administration or designee to ensure proper infection control practices are initiated as warranted. Lab results will be reviewed by weekend supervisor or designee on weekends for the same purpose. Facility Director or designee will ensure labs are reviewed as stated. 10. Isolation residents will be reviewed by nursing administration during weekly clinical meeting and the Medical Director will be consulted for any recommendations or suggestions as necessary. Meetings attendees to include but not limited to DON, ADON, Infection Preventionist, and Executive Director. The DON and Executive Director will be responsible for ensuring this meeting is held weekly and isolation residents are reviewed. This meeting will begin on 4/25/24. 11. Meeting minutes related to lab results and isolated residents will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance and continue monthly for 90 days to ensure ongoing compliance. 12. The DON or designee will verify staff competency with 10 staff weekly for 4 weeks or until substantial compliance is established. PPE and handwashing competency checklists will be utilized for to determine competency. This will be completed weekly after the initial training and competency began on 4/24/24. Executive Director or designee will ensure staff competencies are completed. 13. DON or designee will review 24hr report daily for potential changes in condition related to signs and symptoms of infection. Executive Director or designee will ensure daily review is completed. Findings related to review will be reported to the weekly QAPI committee meeting for 4 weeks or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. 14. Summary of IJ and corrective action to be reviewed by QAPI Committee weekly for four weeks beginning 4/24/2024 or until substantial compliance established and continue monthly for 90 days to ensure ongoing compliance. On 04/25/24 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: IJ Monitoring process: Record Review of the in-service dated 4/23/24 Infection Control: Observing and following Isolation precautions reflected facility staff were in-serviced. In-services included proper sequencing on donning and doffing PPE; appropriate hand washing techniques. The Surveyors attempted interviewed for all the nurses that were in-serviced for Infection Control: Observing and following Isolation precautions. Record Review of the Inservice, dated 4/23/24 , Infection Control: Standard and Transmission Based precautions reflected facility staff were in-serviced. In-service's included transmission-based precautions and discontinuation of precautions based on CDC guidance. The surveyor attempted interviewed for all the staff that were in-serviced for Infection Control: Standard and Transmission Based precautions. In an interview with LVN Z on 4/25/24 at 12:52 pm revealed, that per in-services provided on 4/24/24 regarding appropriate PPE use, PPE donning and doffing sequence, types of isolation, TBP protocols. LVN Z also stated that all staff members caring for residents on isolation will need to follow all TBP protocols. She verbalized that residents should be placed in isolation promptly following diagnosis of an infectious disease such as C. Diff. In an interview with CNA X on 4/25/24 at 12:54 PM revealed CNA X was observed entering the room after she donned gown and gloves. She stated she received an in-service on morning of 4/24/24 on different kind of isolations, PPE, hand hygiene. She stated that for a resident on enhanced barriers, she needed to use gown and gloves, and mask was not required. For the resident on contact isolation or droplet she should use the mask. CNA X also stated that she needed to Wash her hands before entering the isolation room and after she was done with care and between change of gloves. In an interview with CNA AA on 4/25/24 at 1:01 pm revealed she received in-services on 4/24/24 and verbalized the types of precautions such as contact, droplet and others. Verbalized the PEE to use according to the type of precaution. She stated that there was an isolated signage on the door that alerted the staff members regarding isolation protocols. Verbalized hand hygiene according to the in-service done by the facility this week, and if the resident was in contact isolation for C. Diff, she had to wash hands with soap and water. In an interview with CNA Y on 4/25/24 at 1:04 PM revealed he had been working at the facility for 4 months. He stated that he received an in-service on infection control: PPE to use when going to the residents' rooms, CNAs needed to wear PPE according to the signage at the door. He verbalized different kinds of precautions: contact, droplet, enhanced precaution, donning and doffing PPE. If a resident was on the floor in an isolation room, staff must wear PPE before she assisted the resident on the floor. He stated that all staff need to perform Hand hygiene: before and after they finished providing care and frequently and when they changed gloves. In an interview with CNA C on 4/25/24 at 1:06 PM revealed different types of precaution such as contact, droplet, other. She stated that all staff should be wearing appropriate PPE and perform hand hygiene for all residents on isolation. She also verbalized hand hygiene according to the in-service done by the facility this week, and if the resident was in contact isolation for C. Diff, staff had to wash hands with soap and water. In an interview with LVN R on 4/25/24 at 1:20 pm revealed they received an in-service on infection control regarding proper way of putting PPE; donning the proper PPE for appropriate isolation, hand washing (before and after done with care and as needed), precaution could be contact, droplet or enhanced. If a resident was on the floor in an isolation room, PPE must be donned before assisting the resident on the floor. LVN R also stated that isolation protocols for TBP residents need to be done promptly. In an interview with CNA BB on 04/25/24 at 1:21 PM revealed different types of isolations were contact precaution (touch), droplets (spitting), airborne (breathing). She stated that staff needed to wear PPE and perform hand hygiene during every contact with resident on isolation. She stated that she was in-serviced about proper sequence for[TRUNCATED]