**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 2 residents (R19, R32), reviewed for hospitalization. This had the potential to affect all residents transferred to hospital. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], indicated R19's diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure, and R19 was cognitively intact. R19's progress notes indicated R19 was hospitalized from [DATE] through 6/8/23. R19's medical record lacked evidence the Ombudsman for LTC was notified of R19's transfer to the hospital. R32's face sheet, undated, indicated the following diagnoses hemiplegia and hemiparesis of the right side (weakness and paralysis on the right side), osteoarthritis, right femur fracture, and cerebral vascular infarction (CVA-stroke). Progress notes indicated R32 was hospitalized from [DATE] until 9/20/23 and 10/22/23 until 10/24/23. R32's medical record lacked evidence a written notification of transfer was sent to the Ombudsman for long term care. The facility's Admission/Discharge To/From Report for 6/1/23 to 6/30/23, listed resident names, dates, and location for seven residents discharged to home or other facilities from 6/1/23 through 6/30/23. However, the report did not include the names and dates of residents transferred to the hospital. On 3/21/24 at 1:03 p.m., social services director (SSD) stated the ombudsman of LTC was not notified of transfers to the hospital and was only notified of discharges to home or other facilities. SSD acknowledged the ombudsman should have been notified of all discharges, including residents transferred to the hospital. On 3/21/24 at 1:11 p.m., administrator acknowledged the ombudsman of LTC had not been notified of resident transfers to hospital. Administrator stated the ombudsman of LTC should have been notified of all resident hospital transfers. The facility's Transfer or Discharge, Emergency policy, last approved 3/2024, indicated the procedures that would be implemented for emergency transfer or discharge to a hospital. However, the policy lacked information regarding notification to the ombudsman of LTC.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review, the facility failed to notify the physician and/or nurse practitioner (NP) for 1 of 3 residents (R34) reviewed for change of condition. Findings include: R34's quarterly minimum data set (MDS) dated [DATE], identified R34 had severe cognitive impairment and diagnoses which included dementia, Alzheimers, chronic kidney disease, edema and constipation. A review of R34's medical record revealed on 3/16/2024, at 4:41 a.m. a nursing progress note indicated Resident had small blood clots in her incontinent product. Further progress note on 3/16/2024 2:22 p.m. indicated resident had an emesis during lunch. After lunch, resident also had blood clots in her stool noted. Progress note on 3/18/2024, at 2:26 a.m. indicated R34 had a large blood clot and blood coming from her rectum that filled her incontinent pad. Further review of R34's medical record revealed the medical record lacked evidence R34's physician and/or NP had been notified. During interview on 3/21/24, at 11:07 a.m. registered nurse (RN)-B stated R34 had not had blood clots coming from the rectum prior to this and was not sure if the physician and/or NP were notified. On 3/21/24, at 11:13 a.m. RN-C stated it was not ordinary for R34 to have blood clots or blood coming from the rectum. RN-C stated the provider would be informed of a change in condition if there was a concern with R34's comfort or if there was something out of the ordinary. On 3/21/24, at 12:15 p.m. director of nursing (DON) reviewed the medical record and verified the record lacked evidence the provider had been notified of clots and blood coming from the rectum. The DON stated the provider should have been updated blood and clots from the rectum are definitely not ordinary. Facility policy Change in a Resident's Condition or Status dated 1/2024 identified our facility shall promptly notify the resident, his or her attending Physician, and representative of changes in the resident's medical/mental condition and /or status.

Based on observation, interview and document the review the facility failed to ensure the dishwashing machine temperatures reached adequate washing temperatures to clean and sanitize ddishware. This deficient practice had the potential to affect all 46 residents who received meals from the facility's kitchen. Findings include: On 3/20/24 at 8:22 a.m., while observing the dishwasher, the wash cycle was observed 4 times and the temperatures were as follows: Wash cycle #1 at 8:22 a.m. =147 degrees Fahrenheit (°F) Wash cycle #1 at 8:23 a.m. =148 °F Wash cycle #1 at 8:25 a.m. =149 °F Wash cycle #1 at 8:27 a.m. =152 °F On 3/20/24 at 8:27 a.m., the dietary dishwasher (DD)-A stated it was a common occurrence for the dishwasher wash cycle to not reach the required temperature of 150 °F, since date of hire (November 2023). The log for the dishwasher temperatures was reviewed and indicated wash cycle temperatures greater than 150°F. DD-A stated the machine had to run a few times before it got to the required temperature that morning. However, DD-A stated when/if the wash cycle did not reach the required temperature the dishes were put out for use and not rewashed. On 3/20/24 at 9:23 a.m., the dietary manager (DM)-A stated they had not been notified the dishwasher was not meeting required wash cycle temperature. DM-A confirmed the dishwasher used high heat and chemical to sanitize and the required temperatures were 150 °F for wash cycle and 180 °F for rinse cycle. The DM-A expected staff to rewash dishes if the dishwasher did not get to the required washing temperature and report occurrence to DM-A. On 3/21/24 at 4:15 p.m., the maintenance staff (MA)-A confirmed the required temperatures for the dishwasher was a wash cycle at 150 °F or higher, and sanitize cycle at 180 °F. Additionally, MA-A confirmed issues in the past with dishwasher temperatures had been addressed. On 3/21/24 at 4:22 p.m., the Ecolab technician who maintained the machine for the facility confirmed the wash cycle needed to reach 150 °F and the rinse cycle 180 °F. If the temperature did not reach 150°F, staff should have run a test strip to ensure the machine reached the required temperatures. Prior to washing dishes, approximately 20-30 cycles could be necessary to reach the required 150 °F. The facility policy Operation of the Dish Machine dated 03/2024, indicated the required ranges was >150 °F for the wash cycle and >180 °F for rinse cycle.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure an eternal (feeding) tube was consistently checked for placement prior to the administration of medications through for 1 of 1 residents (R1) whose medication administration was offered through a stomach tube. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had unspecified intracranial injury with loss of consciousness for unknown period of time (injury to the brain without being awake for an unknown length of time) with related diagnosis of dysphagia (difficulty swallowing), and use of an abdominal feeding tube (a type of tube going straight into the stomach). R1's current orders, dated 2/2/23, identified a G-tube (gastrostomy tube) (a type of tube going straight into the stomach) and received medications given directly into stomach. On 1/31/23 at 2:12 p.m. registered nurse (RN)-A was observed by 2 surveyors, performing medication administration in R1's room following medication review, gathering a marked syringe, and beaker with water. RN-A raised the head of the bed, donned clean gloves, connected syringe onto G-tube and using gravity flow method, poured 30 ml of water through the syringe. RN-A did not check the placement of the tube prior to the 30 ml pour of water, RN-A continued to administer crushed medications through G-tube, and then flushing again with a 30 ml pour of water before disconnecting, and capping G-tube line. On 1/31/23 immediately after exiting R1's room from completion of medication administration, RN-A was unable to explain the facilities policy for checking G-tube placement prior to giving medications. RN-A stated, I'm not sure, I would have to ask, I don't know how we check placement. On 1/31/23 at 3:27 p.m. licensed practical nurse (LPN)-A said her process for performing medication administration for R1 would be to review the rights of medication administration, crush medications, use proper hygiene, and PPE (personal protective equipment) with syringe, and check placement through auscultation. LPN-A said she generally does not check residual volume for R1 (pulling back with a syringe for gastric contents) but does do auscultation (using a stethoscope. placed over the stomach to listen for rushing air through a G-tube from a syringe). On 1/31/23 at 3:32 p.m. clinical manager (CM)-A Identified R1 as the only resident with a G-tube in the facility. CM-A explained her expectation of skilled nursing staff, before administering a medication for any resident through a G-tube was to perform the rights of medication administration, use proper hand hygiene with PPE, have necessary equipment, and to check placement by both auscultation, and residual volume prior to medication administration. On 1/31/23 at 4:13 p.m. director of nursing (DON) said her expectations of skilled nursing staff administering medications through a G-tube, review the MAR with rights of medication administration, do appropriate water flushes, have proper hand hygiene with PPE, having an awareness of infection control, and to check tube placement. The DON stated, I would expect placement be checked through a residual volume check. The DON continued, staff should be checking placement prior to putting any medications or flushes through a G-tube and should not rely on auscultation. I have been reviewing the facility policy for G-tube medication, and it does identify checking placement prior to administration. The DON continued, if the placement was incorrect, it could result in potential infection, respiratory issues, and failure of medication absorption. Facility policy titled Administering Medications through an Enteral Tube obtained on 1/31/23, with upcoming review of 11/23 identified purpose, preparation, general guideline, equipment and supplies, steps in the procedure, and documentation. Under steps in the procedure on step 18, the policy identified confirm placement of feeding tube. Step 25 stated administer medication by gravity flow.