**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report 1 of 3 residents' (R), R131, allegations of exploitation to the State Survey Agency via the State's Misconduct Incident Reporting (MIR) system immediately upon learning of the incident. Findings include: Facility policy titled Abuse Prevention Program, stated in part, -#1. Initial Reporting of Allegations. When an allegation of abuse, exploitation, neglect, mistreatment, or misappropriation of resident property has been made, the administrator, or designee, shall complete and submit a DQA form F-62617, notifying DQA that an occurrence of potential abuse, neglect, exploitation, mistreatment or misappropriation of a resident property has been reported to the administrator and is being investigated. This report shall be made immediately. On 03/13/25, Surveyor reviewed an anonymous complaint, dated 10/30/24, alleging that Certified Nursing Assistant (CNA) E took a picture of R131's private area from her personal cell phone to show another staff member, on AM shift, that they used the wrong cream on R131's bottom at the hospital. R131 cannot agree to this as she is not mentally capable of understanding what is going on. R131 was not in the facility at the time of the investigation. On 3/13/25, Surveyor reviewed R131's medical record. R131 was admitted on [DATE] with cerebral palsy and epilepsy. R131's care plan, dated 09/30/22, indicates R131 is dependent on staff for meeting emotional, intellectual, physical, and social needs due to inability to communicate and physical mobility. Care plan dated 08/10/22 states R131 has impaired cognitive function or impaired thought processes. On 03/13/25, Surveyor attempted to contact CNA E and CNA K via phone. Messages were left and there were no return calls. On 3/13/25 at 11:37 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and Director of Nursing (DON) B and asked if they were aware of an event on 10/28/24 - 10/29/24 that involved staff taking a picture of a resident's private part. Both agreed that they recalled the incident. NHA A stated the event was investigated. A night CNA took a picture to show the oncoming shift that the wrong cream was applied. Day shift staff immediately reported the incident to DON B. DON B stated that she observed the CNA delete the picture and completed a disciplinary action and completed all staff education regarding cell phone usage. DON B reported that CNA E admitted the error and was apologetic. Surveyor asked why a facility reported incident was not completed. NHA A stated they did not report because there was no ill intent, and she misinterpreted the regulation. On 03/13/25, Surveyor reviewed the investigation file for R131. Records indicated the incident as described above. NHA also provided the Disciplinary Action Report for CNA E. Surveyor could not find any facility documentation of this incident being reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 1 of 12 sampled residents (R) reviewed. (R18) -The MDS assessments are coded in error stating that a Preadmission Screening and Resident Review (PASARR) level 2 screen had not been completed when it was completed at the time of assessment for R18. Findings include: R18 was admitted to the facility on [DATE] with diagnoses including depression, anxiety, and PTSD. Record review identified R18 had a PASARR level 2 screen completed on 12/06/24 indicating R18 has a major mental disorder. R18's comprehensive MDS assessment, dated 12/08/24, indicated for question A 1500 that No PASARR level 2 had been completed. Section I of the MDS notes R18 has PTSD. On 03/12/25 at 2:02 PM, Surveyor interviewed Director of Nursing (DON) B who agrees that the discrepancy had occurred and question A 1500 should have been coded Yes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide interventions in the comprehensive care plan to mitigate re-traumatization for 1 of 1 resident (R18) reviewed for Post Traumatic Stress Disorder (PTSD). -Staff were not aware there was a resident with PTSD. R18's PTSD care plan did not indicate triggers and specific interventions related to loud noises. Findings include: R18 was admitted to the facility on [DATE] with diagnoses including anxiety, depression, and PTSD. R18's most recent quarterly Minimum Data Set (MDS), dated [DATE], stated a Brief Interview of Mental Status (BIMS) score of 15 indicating R18 is cognitively intact. R18 was independent with bed mobility, eating, transferring, and toileting. On 03/12/25 at 12:18 PM, Surveyor reviewed R18's medical record that indicated a Trauma Informed Care assessment, dated 12/02/24, noted loud noises trigger R18. Care plan dated 12/05/24 includes a plan for PTSD, however, does not include loud noise triggers R18, or interventions to loud noises that can result in potential for re-traumatization. On 03/12/25 at 12:22 PM, Surveyor interviewed R18 who clarified not wanting or needing any special therapy services related to PTSD, and that R18 will be discharged soon. On 03/12/25 at 12:57 PM, Surveyor interviewed Certified Nursing Assistant (CNA) L and asked if any residents in the facility have PTSD. CNA L stated, Nobody has PTSD. I have been employed here for almost a year. On 03/12/25 at 1:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN) M and asked if there are any residents that have PTSD. LPN M stated she works the floor and would have to check with the Director of Nursing (DON). On 03/12/25 at 1:05 PM, Surveyor interviewed LPN N and asked if any residents have PTSD. LPN N stated, I am the floor nurse to care for all residents today and when I work. I am not aware of anyone that has PTSD. On 03/12/25 at 2:02 PM, Surveyor interviewed DON B and asked about R18's trauma informed care assessment that identified loud noises trigger PTSD. DON B stated that R18's PTSD care plan should be more clear and would expect the staff to know about it and how to approach the issue.

Based on observation, record review and interview, the facility did not prepare, store or distribute foods in a sanitary manner. The facility practices had the potential to affect all 25 residents. Dietary Aide (DA) G did not allow the thermometer probe to air dry of alcohol prior to inserting into glasses of milk and juice intended to be served to residents for breakfast. Resident foods that were brought in were not labeled with resident names/dates and disposed of in a manner to prevent illness. DA G was observed with her shirt, which had been sprayed with water and food debris, putting away clean dishes in a manner that contaminated the clean dishes. DA G put the clean dishes away when still saturated with water. This is evidenced by: Example 1: Surveyor reviewed the facility policy titled, Thermometer, dated February 2020. The policy, in part, read: Procedure: ~Sanitize thermometer before and between testing of different foods. ~The thermometer may be stored in or dipped into sanitized solution to sanitize. The policy does not direct if using an alcohol preparation pad to sanitize the thermometer probe it should be allowed to air dry before inserting into foods/beverages. On 3/12/25 at 7:13 AM, Surveyor observed preparation for breakfast in the kitchen. Surveyor observed DA G taking temperatures of beverages that had been poured in glasses and removed from refrigeration. DA G wiped the thermometer probe with an alcohol prep pad and immediately inserted the thermometer into a glass of milk. DA G wiped the thermometer probe with another alcohol pad and immediately inserted into a glass of juice. Surveyor asked DA G if she has ever been instructed to wait and allow the thermometer probe to air dry of alcohol before inserting into foods or beverages. DA G indicated she has always wiped the thermometer probe and inserted right away to check temperatures and was never told to wait. Surveyor asked Dietary Manager (DM) H about the observation and expectations regarding air drying the thermometer probe prior to inserting into foods/beverages. DM H expressed he would expect staff to allow the thermometer probe to air dry of alcohol before inserting into foods or beverages to not contaminate the items with alcohol. Example 2: Surveyor reviewed the facility policy titled, Food from Outside Sources, dated April 13, 2020. The policy, in part, read: Policy: All residents have the right to accept food brought into the facility by family or other visitors, however, the food must be handled in a way to ensure safety to the resident. Procedure: All food items that are already prepared by the family or visitor brought in must: a. Be labeled with content, date (the date the item was brought into the facility) and the residents name. b.will be dated when accepted for storage and discarded after five days. On 3/12/25 at 7:33 AM, Surveyor and DM H observed the refrigerator where foods are brought in for residents. The refrigerator contained resident items that were dated with one set of dates or not dated. The refrigerator contained the following items: ~Muscle milk, chocolate milk and whole milk with no dates labeled with R19's name. ~Snack size jello and apple sauce which were not dated, limes dated 2/12/25, and pineapple juice which was not dated. Items were marked with R22's name. ~Protein drink tabled with initials D.S. and no date. ~Yogurt with no name or date ~Pickled eggs with no name or date ~Peanut butter and jelly sandwich with no dates. ~Grape juice dated 3/05/25. Surveyor noted refrigerator with sign that read: Can be kept up to 3 days. If food is not dated it will be thrown away, no exceptions. After the observation, Surveyor spoke with DM H about the expectation of labeling resident food/beverages brought in by visitors. DM H indicated the items should be labeled with resident names and date brought in. Items should be disposed of within 3 days to prevent residents from getting sick. Example 3: Surveyor reviewed the facility policy titled, Dishwashing Procedure, dated February 2020. The policy read, in part, Purpose: To ensure that dishes are properly washed and sanitized to prevent the spread of food borne illness. Procedure: ~All items must be air-dried after wash and rinse cycles are completed. ~Before any dish machine operator moves from soiled dishes to clean dishes, on of the following must occur: a. Hands shall be washed using proper hand washing procedures. b. If using gloves, soiled gloves shall be removed, hands shall be washed using hand washing procedures and clean, unused gloves shall be put on. The procedure did not address the need to don and doff an apron to ensure the clean dishes do not come into contact with any contaminated surfaces such as staff's clothing. On 3/12/25 at 9:35 AM, Surveyor observed DA G at dish machine spraying and scrubbing dirty dishes. DA G was not wearing an apron or gloves. DA G's shirt was sprayed with the spray from the dirty dishes. DA G's shirt was visibly wet and dirty of food particles. DA G loaded the dishes to the dishwasher rack and unloaded the dish rack from the machine. Surveyor observed DA G lean over the dish counter to obtain clean dishes to put away. DA G's shirt was in direct contact with the clean dishes that she immediately put away. Surveyor observed the plate covers taken from the dish rack across the kitchen to be put away. The plate covers were saturated with water, dripping to the kitchen floor. The plate covers were placed on a stack of clean covers. The plate covers were visibly wet. Following the observation, Surveyor asked DA G about the observation of her wet/dirty shirt coming into contact with clean dishes and if dishes should be put away wet. DA G responded she was never informed she should wear apron or gloves when washing dirty dishes and no aprons are available to be used when washing dirty dishes. DA G stated she understood how her dirty shirt coming into contact with the clean dishes could cause contamination. Surveyor asked about the wet dishes being put away and risk for bacterial growth. DA stated she understood the risk. DM H, who was present during the observation, indicated he would obtain aprons for dishwashing due to the potential for contamination of clean dishes as observed. DM H pulled the plate covers from the stack to be re-washed and informed DA G she needed to allow more time for dishes to air dry as he has told her in the past. DM H indicated he understood how putting away wet dishes poses a risk of contamination. DM H also indicated he understood how DA G's shirt contaminated the clean dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 6 On 3/11/25 at 10:04 AM, Surveyor observed CNA C in the hallway with surgical mask worn below her nose. On 03/11/25 at 10:09 AM, CNA C entered room [ROOM NUMBER] with her mask below nose. room [ROOM NUMBER] had posting indicating mask, gown, and gloves should be worn when entering room. On 03/11/25 at 12:05 PM, CNA C was observed passing resident lunch trays in their rooms with her mask below nose. On 3/12/25 at 4:05 PM, Surveyor interviewed CNA C about the observation of her surgical mask worn below her nose. CNA C indicated it is expected for staff to wear surgical masks in common areas during outbreaks. Staff should not wear masks below the nose. It is important to wear masks above the nose to keep yourself safe and prevent the spread of infection. Surveyor reviewed the facility line list of resident infections, and R23, who resides in room [ROOM NUMBER], presented with incontinence, liquid stool, and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F. ICP F has been on staff 2 weeks and is the facility's Infection Control Preventionist. Surveyor asked about the facility outbreak status. ICP F explained the facility was in respiratory, covid and GI outbreak when the survey team entered the building on 3/11/25. The last day of respiratory outbreak was 3/11/25. The facility remains in covid outbreak status. The covid outbreak started in November 2024. Per the facility policy, which is based on Centers for Disease Control, the facility remains in outbreak status 28 days post last positive test. The facility is also in a GI outbreak status with resident first symptoms noted 3/07/25 and 2 residents positive for norovirus on 3/08/25. Surveyor asked about expected staff PPE in common areas during the outbreaks and shared the observation. DON B expressed a standard surgical mask is expected to be worn in common areas. Wearing a mask below the nose is an ineffective use of a surgical mask during an outbreak. DON B explained it is important to wear the mask over the nose to prevent symptoms and the potential spread of the infection. Example 7 On 3/11/25 at 10:09 AM, Surveyor observed CNA C enter R23's room after donning a gown and gloves. CNA C did not perform hand hygiene prior to donning the gloves. R23's room has posting indicating mask, gown and gloves should be worn when entering room. On 3/12/25 at 4:05 PM, Surveyor spoke with CNA C about the observation of not performing hand hygiene prior to donning gloves to enter R23's room. CNA C indicated it is expected that staff perform hand hygiene prior to putting on gloves to help prevent the spread of infection. Surveyor reviewed the facility line list of resident infections, and R23 presented with incontinence, liquid stool and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F explained R23 presented on 3/09/25 with symptoms of incontinence of liquid stool and nausea and is on precautions. Staff should follow the posted sign on R23's door and don gown and gloves before entering the room. Hand hygiene is expected prior to donning PPE to help prevent the spread of infection. Example 8 On 03/11/25 at 10:09 AM, Surveyor observed CNA D enter R23's room with no gown or gloves donned. CNA D was wearing a surgical mask. Surveyor observed a cart with PPE outside R23's room and a posting on the room door for precautions of gown, gloves and mask to be worn. CNA D walked to R23 who was in bed and exited the room. Surveyor asked CNA D about the lack of PPE of gown and gloves when she entered room [ROOM NUMBER]. CNA D responded she should have worn a gown and gloves when entering R23's room to not spread infection. Surveyor reviewed the facility line list of resident infections, and R23 presented with incontinence, liquid stool and nausea on 3/09/25. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F explained R23 presented on 3/09/25 with symptoms of incontinence of liquid stool and nausea and is on precautions. Staff should follow the posted sign on R23's door and don gown and gloves before entering the room to help prevent the spread of infection. Example 9 Surveyor requested and received the facility policy titled Handling Linens and Laundry dated March 2020. The policy in part read: Purpose: To provide a process for the safe and aseptic handling .of linen. Procedure: Consider all soiled linen to be potentially infectious. ~In resident rooms: a. Do not allow linen, clean or soiled, to touch clothing or uniform. b. Handle all soiled linen as though it is potentially infectious. On 3/11/25 at 12:27 PM, Surveyor observed CNA E exit R24's room with dirty bed linens that had been removed from R24's bed. The linens were not bagged and were carried out of the room up the hallway against CNA E's upper body. CNA E was observed not wearing gloves. Surveyor asked CNA E if the linens were dirty and if it is normal to carry dirty linens from resident rooms without bagging them. CNA E indicated the linens were dirty and had been removed from R24's bed. CNA E further indicated it is normal to carry dirty linens out of rooms without bagging them. Surveyor asked CNA E if standard precautions would direct her to bag the dirty linens prior to exiting resident room and carrying them up the hallway. CNA E responded she has never been told the expectation of bagging dirty linens. On 3/13/25 at 10:21 AM, Surveyor spoke with DON B and ICP F about the observation. DON B and ICP F expressed staff are expected to have gloved hands when handling dirty linens. The dirty linens should be bagged before exiting resident rooms. All dirty linen is treated as potentially hazardous, and staff are expected to be handling the linens with gloves and bagging before leaving resident rooms to prevent the potential spread of infection. Based on observation, interview and record review, the facility did not establish and 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. This has the potential to affect all 25 residents (R). -Residents with infection symptoms not placed on proper precautions. -Observations of Certified Nursing Assistants (CNA) not donning Personal Protective Equipment (PPE) and providing proper hand hygiene prior to entering/exiting rooms for residents on precautions. Certified Nursing Assistant (CNA) C did not wear her surgical mask in a manner (above her nose) to prevent the spread of infection during a facility outbreak of respiratory illness, covid 19 and gastrointestinal illness (GI). CNA C did not perform hand hygiene before donning gown and gloves and entering R23's room who was on precautions for gastrointestinal illness (GI). CNA D did not don gown and gloves before entering R23's room who was on precautions for GI. CNA E did not handle dirty linens in a manner to prevent the potential spread of infection. Findings include: Surveyor requested and reviewed the facility policy titled, Personal Protective Equipment, dated January 2023. The policy, in part, read: Purpose: To provide guidance for the use and selection of appropriate personal protective equipment (PPE) based on risk of exposure to blood or body fluids in accordance with state and federal regulations. Procedure: 1. All staff who have contact with residents and/or their environments must wear personal protective equipment as appropriate during resident care activities and other times in which exposure to blood and body fluids, or potentially infectious materials is likely. Face Protection: Wear a mask to protect the face from contamination Gloves Perform hand hygiene before donning gloves and after removal. Gloves are not a substitute for hand hygiene. Example 1 On 03/11/25 at 10:05 AM, Surveyor observed R20 sitting in a chair with a basin next to her. R20 complained of feeling sick and throwing up all night, and said, I wouldn't even come in here if I was you. Roommate confirmed, Yeah, all night long. Outside the room was a sign for Enhanced Barrier Precautions (EBP) but not the required contact precautions. At 4:00 PM, contact precautions were still not initiated. On 03/12/25 at 7:10 AM, contact precaution sign was posted outside R20's room. Example 2 On 3/11/25 at 10:24 AM, Surveyor observed R130 lying in bed with a basin. R130 stated, I came in here a few weeks ago for 'breathing' and now I am sick with vomiting and diarrhea. The required contact precaution sign was not in place. At 4:00 PM, contact precautions were still not initiated. On 03/12/25 at 7:10 AM, contact precaution sign was posted outside R130's room. Nursing progress notes dated 03/11/25 at 4:36 PM stated, Note Text: Resident had large emesis early this AM and several times into this shift. Afebrile at 97.8 Resident attempted to eat breakfast but could not finish and refused lunch. Example 3 On 3/11/25 at 10:14 AM, Surveyor reviewed infection control surveillance and noted that R22's medical record indicated R22 developed symptoms of nausea, vomiting, and diarrhea on 03/08/25 and was removed from contact precautions on 03/11/25. Surveyor observed no signage outside R22's room alerting staff and visitors of contact precautions. At approximately 4:00 PM, required contact precaution sign still was not posted. The following day, 03/12/25 at 7:18 AM, Surveyor observed that contact precautions signage was posted. Example 4 On 03/12/25 at 7:32 AM, Surveyor observed CNA O set up R19 for morning cares. Contact precaution sign was posted outside R19's room stating, Everyone must: clean their hands, including before entering and when leaving the room. Providers and staff must also: put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. CNA O appropriately followed the signage until CNA O realized she forgot to retrieve washcloths and towels. At 7:38 AM, CNA O entered R19's room without proper PPE to give R19 washcloths and towels. Example 5 On 03/12/25 at 7:40 AM, CNA O entered R12's room to assist with toileting. Signage on door was posted for contact precautions and EBP. CNA O entered and exited R12's room without sanitizing hands or donning/doffing PPE. CNA O left room to gather supplies and entered room again without appropriate PPE except for wearing only surgical mask. CNA O assisted R12 in bathroom and after finishing, at 7:48 AM, brought bagged soiled items outside the room, down hallway, and behind the nurses station to the soiled utility room. Surveyor then asked CNA O what the process is for residents on contact precautions. CNA O said, [R12's] roommate is the resident that is ill. I don't know why there are no bins in there. I did not gown the second time in [R12's] room because it is the roommate that was ill. Surveyor reviewed the surveillance line list, nursing progress notes, and checked for signage outside the rooms and noted the following: 1. R20 had nausea, vomiting and diarrhea on the night shift between 03/10/25 and 03/11/25. Was not placed on precautions until 03/12/25. 2. R130 had nausea, vomiting and diarrhea on 03/11/25 and was not placed on precautions until 03/12/25. 3. R22 had nausea, vomiting and diarrhea on 03/08/25 and was not placed on precautions until 03/12/25. 4. R8 had nausea, vomiting and diarrhea on 03/10/25 and was not placed on precautions at all and had no resolve date on line list or documentation in nursing progress notes regarding precautions at all. On 03/12/25 at 11:44 AM, Surveyor interviewed Director of Nursing (DON) B and the Infection Control Preventionist (ICP) F and asked what the staff expectation is for hand hygiene and PPE for residents on precautions. DON B stated they would expect the staff to follow the signage on the door and that correct precautions are implemented timely.

Based on interview and record review, the facility did not ensure each resident receives adequate supervision to prevent accidents for 5 of 5 residents (R1, R2, R4, R5, and R6). R1 experienced a fall after staff did not appropriately place sling for mechanical lift transfer. The facility did not ensure all direct care staff were educated on proper sling placement to ensure all other residents requiring a mechanical lift transfer, did not sustain a fall or injury during a transfer. Findings: R1 was admitted to the facility in 07/19/24 for rehabilitation services, after a right below the knee amputation (BKA) on 07/12/24. Facility assessment of R1's transfer status indicated on 07/19/24, R1 was assessed for needing assistance of two with mechanical (Hoyer) lift transfers. On 08/03/24, R1 was in his wheelchair and the sling needed to be placed in order to transfer him into bed per his request. Two Certified Nursing Assistants (CNAs) were present and placed the sling but did not get the sling far enough underneath R1 in order to safely lift him. R1 began to slip out from the sling and one CNA reported helping R1's butt to the bed and then slid R1 to the floor. R1 denied pain, vital signs were taken, and these were within normal limits. R1 stated he was not upset and not hurt. This was a witnessed fall and R1 did not hit his head per the CNAs and R1. R1 was assisted with the Hoyer back to the bed. Root Cause: Staff did not properly place the sling all the way beneath his buttock and legs prior to lifting. Immediate Intervention: The involved staff were given immediate training on the lift and proper placement of sling. They then had to demonstrate back to the educator they can properly place sling on resident, which they completed and signed the 1:1 training/education. Primary care provider updated. On 08/26/24 at 1:32 p.m., Surveyor interviewed Nursing Home Administrator (NHA) A who indicated the facility scheduled a training for all direct care staff on 08/27/24, to provide education and repeat demonstration of proper sling placement and safe mechanical lift transfers. This training was scheduled 25 days after R1's fall from mechanical lift, placing R1, R2, R4, R5 and R6 at risk for accidents or injuries during transfers.

Based on observation, interview and record review, the facility failed to store prepare and distribute food under sanitary conditions this has the ability to affect 21 of the facility's 22 residents. Low temperature chemical sanitization dish machine is used but the facility has no monitoring system in place to monitor the machine to ensure proper chemical sanitization occurs. Beard restraints were not always worn during food preparation. Oscillating fan on kitchen wall is dirty and blows towards food preparation areas. This is evidenced by: The facility policy, entitled Dishwashing Temperature Log, dated February 2020, states in part: For low temperature (chemical sanitizing) machines, concentration of sanitizer must be recorded on form. The facility policy, entitled Personal Cleanliness and Hygienic Practices, dated February 2020, states in part: All dietary staff, including the dietary manager, and any person entering the kitchen, must wear an approved hair restraint* to keep hair and particles in the hair from falling into food. Hair restraints must entirely cover all hair. Food handlers with facial hair should also wear beard restraints. On 03/04/24 at 9:03 AM, Surveyor observed Maintenance Director (MD) C doing dishes following the breakfast meal. Surveyor asked what the facility does to ensure the dish machine is working appropriately. MD C stated that MD C checks the temperature and writes it on the log on the wall. MD C indicated the temperature should be between 120-150 degrees. MD C indicated this is a low temperature, chemical sanitization machine. Surveyor asked what is done to ensure the chemical sanitization occurs. MD C indicated MD C looks to ensure there are chemicals in the bottles on the wall that feed into the machine. MD C stated the company services the machine monthly and checks the machine for functioning. Surveyor asked about a procedure taped on the wall, which talks about test strips. MD C stated MD C is not sure how or when it is done, but Dietary Manager (DM) I surely knows. Observation of the dishwasher temperature log revealed no documentation of sanitizer monitoring. On 03/04/24 at 9:03 AM, Surveyor observed an oscillating fan mounted on the wall near the microwave and juice machine running and blowing toward food preparation areas. The cage around the fan was dirty with blackish gray debris on the bars encasing the fan blades. On 03/04/24 at 9:35 AM, Surveyor observed DM I in the kitchen near food preparation areas. On 03/05/24 at 9:18 AM, Surveyor observed DM I in the kitchen preparing food. On 03/06/24 at 8:45 AM, Surveyor observed DM I in the kitchen preparing food. DM I was noted to have a beard and was observed multiple times on all three days of survey to be in the kitchen without a beard net on. On 03/06/24 at 9:05 AM, Surveyor interviewed DM I related to the above concerns. Surveyor asked what monitoring system was in place to ensure the dishwasher is adequately sanitizing the dishes. DM I replied that they record temps for wash and rinse cycles with each meal. Surveyor asked if anything else is done. DM I stated that staff have stickers for plate surfaces, they monitor chemical levels, and they use test strips. Surveyor asked how often any of these things are done. DM I stated, It has not been done as often as it should be. Surveyor asked DM I to clarify. DM I stated, It has been done a few times in the past month, but it is not documented anywhere. Surveyor requested the facility policy and procedure related to this. After reviewing the policy, DM I stated that the policy states to Check sanitizing solution throughout the day. Surveyor requested the facility policy and procedure on hair restraints. Surveyor asked DM I about the facility's beard net policy. DM I stated the policy states, Beard nets should be worn. Surveyor asked if DM I has been wearing a beard net for the past 3 days. DM I stated DM I has not been wearing a beard restraint and has been working with food without one. Surveyor asked about the dirty oscillating fan. DM I stated that it is on a cleaning schedule, but maybe it needs to be cleaned more often.

Based on interviews and record review, the facility failed to submit complete and accurate data to the Centers for Medicare and Medicaid Services (CMS) mandatory Payroll Based Journal (PBJ) data for quarter four of 2023 (July 1 - September 30). This has the potential to affect all 22 residents. This is evidenced by: Surveyor noted during survey preparation that the facility triggered for failing to have licensed nursing coverage 24 hours each day for the dates of: 07/08/23 (Saturday), 07/09/23 (Sunday), 07/22/2023 (Saturday), 08/05/2023 (Saturday), 08/06/2023 (Sunday), 09/02/23 (Saturday), 09/03/23 (Sunday), 09/04/23 (Monday), 09/16/23 (Saturday), 09/30/23 (Saturday). On 03/05/24 at 11:18 AM, Surveyor spoke with Nursing Home Administrator (NHA) A and Corporate Human Resources Director (CHRD) H regarding the nursing coverage for the months of July, August, and September of the 2023 year. Neither NHA A nor CHRD H could think of a time when they did not have full nursing coverage. Surveyor then reviewed the staff schedules for the period of July 1 - September 30, 2023, specifically the dates in question and compared the data with the time punches provided. There were no concerns uncovered related to licensed staff coverage or certified nursing assistant coverage. However, it was noted that the dates in question did have only two registered nurses working a 12-hour shift each of those days. On 03/05/24 at 12:15 PM, Surveyor interviewed NHA A and CHRD H after they reviewed their PBJ submissions regarding the months with missing nursing coverage. NHA A and CHRD H had discovered that one registered nurse's hours were not being pulled into the PBJ report. Those hours were not being submitted in the PBJ report. Currently the facility has no issues with the PBJ accuracy. The facility had failed to submit accurate PBJ data for the fourth quarter (July 1 - September 30) of the 2023 year. Surveyor reviewed the PBJ submission for Fiscal Year 2024 Quarter 1 (October 1 - December 31). The facility was noted to have submitted the 1st quarter's data on 02/13/24, accurately. The facility is in compliance as of 12/31/23. The facility did not have any errors in the PBJ report for the first quarter of the 2024 year and the issue was corrected. This was cited as past noncompliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not establish and 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. The facility did not a have a clear water management process or plan in effect with control measures to prevent transmission of Legionella infection. This has potential to effect 22 of 22 residents (R). Findings include: Example 1 The facility policy entitled, Water Management Program, dated 08/02/23, states in part: The organization will follow guidance of ASHRAE and CDC guidelines in creating this Water Management Program. The purpose of this program is to ensure the facility is inhibiting microbial growth in the buildings water system that reduce risk of growth and spread of legionella and other opportunistic pathogen by properly maintaining water systems. The facility will create a flowsheet of the path the water takes and any points with potential for growth. Decide where control measures should be applied and how to monitor them. Water Management Program Log Sheet states in part Flush for 5 minutes. The Center for Disease Control and Prevention (CDC) toolkit, entitled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, dated June 24, 2021, states in part: Once you have developed your process flow diagram, identify where potentially hazardous conditions could occur in your building water systems. The Center for Disease Control and Prevention (CDC) guidelines, entitled Controlling Legionella in potable water systems, last reviewed February 3, 2021, states in part: Flush low-flow piping runs and dead legs at least weekly and flush infrequently used fixtures (e.g., eye wash stations, emergency showers) regularly as-needed to maintain water quality parameters within control limits. On 03/06/24 at 7:51 AM, Surveyor reviewed the facility's water flow diagram, which was generic and does not specify the path the water takes from the facility's water source to assure any distinguished locations or areas where Legionella could grow or spread. On 03/06/24 at 7:45 AM, Surveyor interviewed Director of Nursing (DON) B who is responsible for the facility infection control. DON B indicated unawareness of having a flow water chart to map the facility water flow. On 03/06/24 at 8:14 AM, Surveyor interviewed Maintenance Director (MD) C, asking if the facility has a water flow diagram from the source of water and how it flows through the facility. Surveyor asked if areas where Legionella could grow were identified. MD C stated this is not clear in the facility water management policy. On 03/06/24 at 7:51 AM, Surveyor observed 2 separate operatable water fountains accessible to all residents. On 03/06/24 at 7:35 AM, Surveyor interviewed MD C regarding the 2 water fountains being managed for Legionella. MD C stated that housekeeping flushes them every morning when cleaning and confirmed they were not addressed on the Water Management Program Log sheet. On 03/06/24 at 7:38 AM, Surveyor interviewed Housekeeper (HSK) F, regarding expectations of maintaining the 2 water fountains. HSK F stated they are wiped down every morning and flushed for about 5 seconds. HSK F indicated this procedure is not logged. HSK F stated nobody uses them and was not sure why facility still had them. On 03/06/24 at 7:45 AM, Surveyor interviewed DON B and made DON B aware of concern regarding 2 water fountains and facility practice of flushing them. DON B stated that staff utilize the water fountains and doesn't feel they are a source of risk for Legionella. On 03/06/24 at 7:55 AM, Surveyor interviewed Registered Nurse (RN) E regarding usage of the 2 water fountains. RN E indicated that no one uses them. On 03/16/24 at 7:56 AM, Surveyor interviewed Licensed Practical Nurse (LPN) D and Certified Nursing Assistant (CNA) G regarding the 2 water fountains; both indicated nobody uses them. Both LPN D and CNA G stated the facility has a [NAME] water system behind the nurses station and all staff and residents prefer water from there, including when filling the daily water pass because it tastes better. The water fountains are unused, with a high potential for stagnate water, where Legionella can grow. The facility does not have documentation of flushes for 5 minutes to ensure the control measures are being followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not develop and implement a comprehensive person centered care plan for colostomy care for 1 of 12 total residents (R) reviewed (R4). This is evidenced by: Facility policy titled Bowel and Bladder Management Policy with revision date of July 2020 stated in part: .A resident who requires colostomy, urostomy or ileostomy services, receives care in accordance with his or her care plan . On 1/11/23, Surveyor reviewed R4's diagnoses that include but are not limited to: Colostomy status, GERD. R4's admission date at the facility was 12/19/22. On 1/11/23, Surveyor reviewed R4's most current MDS (minimum data set) dated 12/19/22 and 12/26/22 states R4 with ostomy status. BIMS (brief interview for mental status) for R4 is 9. (8-12 moderately impaired). On 1/12/23, Surveyor reviewed R4's Orders include (related to current issue) but are not limited to the following: Change system every 3-7 days or PRN. Use ConvaTec sure fit barrier #404594 seal/ring 2 Pouch ConvaTec Closed end 2-1/4 Flange #416421 every evening shift every 3 day(s) for Colostomy care AND as needed. Start date 1/12/23 On 1/11/23, Surveyor reviewed R4's Care Plan. There was no care plan noted concerning colostomy. On 1/11/23, Surveyor reviewed R4's [NAME]. There was nothing noted concerning colostomy. On 1/12/23, Surveyor reviewed R4's Baseline Care Plan/ Evaluation dated 12/19/22 note that R4 has an ostomy in the bowel and bladder section under bowel and bladder appliances Nothing noted based on cares of colostomy. R4 head to toe evaluation dated 12/19/22 under section G. Digestive does include devices LLQ (left lower quadrant) ostomy, bowel sounds active in all quadrants, resident reports passing gas. Stool in ostomy appears brown and watery. Abdomen soft, nontender, rounded, denies nausea or any other discomfort. R4's bowel and bladder evaluation dated 12/23/22 does not discuss anything concerning colostomy. On 01/10/23 at 3:56 p.m., Surveyor interviewed R4 about colostomy. R4 stated she has a sore colostomy since coming here. Staff empties the colostomy bag but doesn't clean it good like R4 did at home. R4 wishes staff to care for the colostomy. There is no care plan in place for colostomy care. On 01/11/23 at 12:56 p.m., Surveyor interviewed RN C about R4's colostomy asking how does she know who cares for the colostomy or the wishes of the resident concerning the care of the colostomy. RN C stated she usually will help R4 to change the colostomy device. R4 is mostly independent in changing it. RN C stated R4 has not had any issues with stoma infection, soreness, or pain that she is aware of. RN C states the colostomy device last changed 1/3/23 and 1/10/23. This is changed every 3-7 days on the evening shift. On 01/12/23 at 9:00 a.m., Surveyor interviewed RN C asking how she would know if R4 has a colostomy. RN C states she knows this from R4's hospital information and that the information on R4's TAR (Treatment Administration Record) would be there to notify of need to change colostomy device.

Based on observation, interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice based on the comprehensive assessment, comprehensive person-centered care plan, and policy and procedure of the facility for 1 of 12 total residents (R) reviewed (R14). The facility did not do a thorough comprehensive assessment for R14. R14's care plan does not address the risk of gastrointestinal issues or assessment of the gastrointestinal system. The facility did not routinely assess R14's gastrointestinal system to assess for bowel obstruction, when R14 had a history of ileus. This is evidenced by: Facility policy titled Bowel and Bladder Management Policy with Revision date of July 2020 only includes information on incontinence care and treatment. Nothing is noted concerning assessment of gastrointestinal system or bowel assessments. Bowel Protocol: Milk of Magnesia Suspension 400mg/5ml give 30ml (milliliters) by mouth as needed for constipation in evening of 3rd day of no BM (bowel movement). Bisacodyl Suppository, insert 1 suppository rectally as needed for constipation in afternoon of 4th day of no BM. Enema Sodium Phosphates, insert 1 dose rectally as needed for constipation in afternoon of 4th day of no BM. If no results from bowel protocol, notify primary physician or NP (nurse practitioner). On 01/10/23, Surveyor reviewed R14's diagnoses that include, but are not limited to: Cerebral Palsy, Lennox-Gastaut syndrome, intractable, with status epilepticus, localization related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus, symptoms and signs involving cognitive functions and awareness, adrenomedullary hyperfunction, gastrostomy status, GERD (Gastroesophageal reflux disease), dysphagia, ileus, abnormal posture, dependence on wheelchair. R14's admit date to the facility was on 4/20/21. On 01/10/23, Surveyor reviewed R14's most current MDS (minimum data set) dated 10/25/22 documents that R14 is unable to make needs known and is fully dependent on staff and is always incontinent of bowel and bladder. Tube feeding initiation of 4/21/21: Focus: R14 requires tube feeding Jevity with fiber r/t (related to) Chewing problem, Swallowing problem. Date Initiated: 04/21/2021 Revision on: 07/27/2021 Goal: R14 will remain free of side effects or complications related to tube feeding through review date. R14 will maintain adequate nutritional and hydration status and weight stable, no s/sx (signs/symptoms) of malnutrition or dehydration through review date. R14 will be free of aspiration through the review date. Bowel obstruction initiation of 1/11/23: Focus: R14 has actual bowel obstruction Date Initiated: 01/11/2023 Revision on: 01/11/2023 Goals: R14 will remain free from discomfort, complications or s/sx related to gastrointestinal alterations through review date. Date Initiated: 01/11/2023 Target Date: 12/20/2022 Interventions: o Give medications as ordered. Monitor/document side effects and effectiveness. Date Initiated: 01/11/2023 o Monitor bowel sounds q shift (every shift) update MD/ NP with any concerns Date Initiated: 01/11/2023 o Monitor vital signs (specify frequency). Notify MD of significant abnormalities. Notify MD of significant abnormalities (rapid pulse, shallow, rapid, or labored respirations, low blood pressure) Date Initiated: 01/11/2023 Revision on: 01/11/2023 o Obtain and monitor lab/ diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 01/11/2023 Nothing noted in R14's Care plan concerning risk of gastrointestinal issues or assessment of gastrointestinal system such as bowel sounds, palpation of abdomen, prior to 01/11/23. Survey team onsite starting 01/10/23. On 01/12/23, Surveyor reviewed R14's Orders include (related to current issue) but are not limited to the following: 1/12/23: Hold TF (tube feeding) and medication except Dilantin until NP (nurse practitioner) can review XR (x-ray) per on call provider. 1/11/23: Monitor bowel sounds q-shift (every shift) update MD/ NP (medical doctor/nurse practitioner) with any abnormal changes three times a day 1/11/23: MiraLax Powder 17 GM/SCOOP (Polyethylene Glycol 3350) Give 1 scoop via G-Tube (gastro tube) in the morning for constipation until 01/20/2023 1/4/23: On call provider states send to ER (emergency room) for tube replacement and vomiting 4/20/21: Bowel protocol per facility policy On 01/12/23, Surveyor reviewed R14's MAR (Medication Administration Record) and TAR (Treatment Administration Record): Per review, staff are charting care of R14's G tube, residual checks, flushes, holding feeding for Dilantin. Noted no documentation of bowel sounds or abdominal assessment. Surveyor reviewed R14's bowel records from 12/30/22 through 01/12/23. R14 averaged 2 to 3 bowel movements (BMs) per day with loose to normal consistency. No BMs recorded for 01/07/23 or 01/08/23. 5 BMs recorded on 01/09/23: 3 loose and 2 normal. 3 loose BMs recorded on 1/10/23, 1 normal BM recorded on 1/11/23, and 2 loose BMs recorded on 1/12/23. Surveyor reviewed R14's record for assessment of gastrointestinal system and identified a bowel and bladder evaluation completed on 10/21/22. The only other documentation of gastrointestinal status was the following Nursing Summary dated 01/06/23, which included the following: 1 emesis 1/4/23. Tube has been becoming dislodged. Active bowel. No other bowel assessment items noted. On 1/12/23, Surveyor reviewed R14's recent radiology reports with results as follows: 1) XR (x-ray) ABD (abdominal) KUB (kidneys, ureter, bladder) completed 1/5/23 by ER MD at Sacred Heart Hospital that states for finding: The patient's indwelling gastrostomy tube was injected with approximately 50 milliliters of Gastrografin. The injected contrast is contained within the gastric fundus. There is bowel distension which is largely colonic but with some loops of small bowel suggestive. This raises concern for ileus. Impression: 1. Appropriate G-tube positioning. 2) X-ray Chest 2 View ordered by facility provider was completed 1/11/23. This report was received 1/11/23 at 4:51 p.m. Results: . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragms . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragms. 3) Abdominal x-ray completed 1/12/23 at [hospital] for indication of abdominal distention and ileus. Findings: Post operative changes at the proximal left femur. G tube injecting over the central left lateral abdomen. IVC filter in good position. No substantial change in few mild to moderately dilated loops of large bowel along with multiple upper limits normal size gas filled loops of small bowel .1. Persistent mild to moderately diluted loops of large bowel consistent with mild more likely chronic ileus. On 01/11/23 at 11:32 a.m., Surveyor observed RN C administer medications to R14 through PEG tube. Procedure was performed correctly. RN C did not check for bowel sounds or assess R14's gastrointestinal status. On 1/12/23, Surveyor reviewed R14's Progress note dated 1/10/23 at 0900 written by nurse practitioner that stated the following: Services are being provided at [name of facility] History of present illness: Resident is seen today at staff request. They tell me that she is simply not looking right and is tachycardic. review of systems: blood pressure 149 / 93, pulse 117, respiratory rate 16, temperature 97.2 degrees Fahrenheit, SPO2 (oxygenation saturation) 93%. Physical exam: General: Resident looks at me when I greet her but does not verbalize which is her baseline. Respiratory effort is increased respiratory rate 24 per minute. mouth is open. Pharynx somewhat dry. Heart rhythm is regular. Posteriorly there are rhonchi on the left scattered rhonchi anteriorly as well. Normal bowel tones. G tube site is intact. Extremities are warm. Impression/Plan: 1) Recurrent aspiration pneumonia. She has a history of aspiration pneumonia and has had a change in her vital signs so I'm going to start empiric treatment. Augmentin 875 milligrams / 125 milligrams tablet via enteral tube twice daily for 10 days. Chest X-ray. CBC / CRP / BMP. nasal swab for COVID 19/ RSV / Influenza. 2) Epilepsy with complex partial seizure, seizures not intractable, without status epilepticus. She has a history of seizure disorder and has had multiple breakthrough seizures. I ordered a Dilantin level to be checked today. She is also on Keppra. I will have staff arranged for her to be seen by her neurology team for follow up and medication management. 3) PEG status. Patient has had multiple issues with her g-tube in the past couple of weeks. At this time, it is functioning well. 4) intellectual functioning disability. She has two guardians in place for health care decision making. On 1/12/23, Surveyor reviewed R14's Progress note dated 1/12/23 at 0950 written by Emergency department doctor at the hospital. History of presenting illness: Patient who is nonverbal with cerebral palsy and indwelling peg tube that presents today for bowel obstruction. patient is unable to provide history. Per nursing she reportedly has been having bowel movements, but it is unclear when her last one is. radiology report made available to us via paper handoff states in part, . Diffuse abdominal bowel obstruction with elevation of the hemidiaphragm. The osseous structures are unremarkable .ED course/medical decision making: Patient was brought to the hospital with suspicion of bowel obstruction as noted on imaging obtained from outside facility. We are unable to see the imaging only the report which states diffuse abdominal bowel obstruction with elevation of the hemidiaphragm. Patient reportedly still having flatulence and bowel movements last one unknown. CBC CMP lactic acid all ordered. General surgery consulted for further recommendations and on chart review he noted she has episodes of ileus which he suspects this is. No additional recommendations at this time consulted hospitalist services for admission obtained additional KUB imaging for evaluation. KUB pending. Admit to hospital service admit diagnosis bowel obstruction and ileus. On 1/16/23 an email sent to Surveyor from the CNO (Chief Nursing Officer) L at the facility concerning R14 stated, On 1/13/23 the resident returned to the facility for continuation of care and follow up KUB. CNO L states, .has the diagnosis of ileus with the summary states the following: Physical examination states the following: resting on cot no acute distress. GI: Rounded and soft. Active bowel sounds in all four quadrants. High pitched tiny sounds in left and right upper quadrants. No apparent guarding. PEG tube present to left abdomen, dressing clean dry and intact. Assessment: Ileus. Abdominal KUB on 1/5/23 shows bowel distention which is largely colonic but with some loops of small bowel which is suggestive of ileus. Repeat KUB on 1/12/23 shows continued moderately dilated large bowel. Plan: hold tube feeding overnight with repeat KUB and labs in the morning. Plan for nursing to give fleet enema times two tonight along with 120 milligrams simethicone for gas relief. General surgeon has been consulted. Patient seen and examined labs and chart reviewed I agree with the above note. At this point the patient appears to have decent bowel sounds, just received an enema, and has some liquid stool. Will await surgery recommendations . should be able to start some tube feeds on her tomorrow. I did change her fluids to supply with some dextrose since she is NPO. It is noted on the MAR (medication administration record) R14 received IVF (intravenous fluids) during this hospital stay. Sodium chloride 9.0% infusion rate 75ml/hr continuous. Start 1/12/23 1400 end 1/12/23 1706. Dextrose 5% and 0.9% NaCl (sodium chloride) with KCL (potassium chloride) 20 mEq (milliequivalents) infusion rate 75ml/hr continuous. Start 1/12/23 1730. Surveyor reviewed R14's progress notes from 12/31/22 through 1/12/23 to find no documentation of bowel sounds / gastrointestinal assessment except for the following: 1/12/2023 02:43 Nursing Progress Note: Note Text: R14 CXR (chest x-ray) returned noting diffuse abdominal bowel obstruction. Call placed to on call provider to update. Advises to hold TF (tube feeding) and medications, except Dilantin, until provider can review and advise. TF stopped immediately. TO (telephone order) faxed to on call provider for signature. R14 continues to have normoactive bowel sounds, multiple BMs (bowel movements) throughout yesterday, 1/11. Abdomen is soft, flat and nontender. PEG (percutaneous endoscopic gastrostomy) tube is patent, and Dilantin can be administered. R14 is afebrile, no vomiting. Will continue to monitor and await orders from PCP (primary care provider). There were no bowel assessments from 1/5/23 - 1/12/23, when ileus had been identified on the hospital report 1/5/23. 1/12/2023 08:39 Nursing Progress Note: Note Text: On call provider called this morning requesting that R14 be sent out to the ER for evaluation. Message left for POA (power of attorney) with no return call. 911 called and R14 left the facility at this time. Nurse report called to [hospital]. 1/12/2023 12:38 Nursing Progress Note: Note Text: This nurse called [hospital] and spoke with the ER (emergency room) nurse. ER Nurse states that R14 was not admitted with aspiration pneumonia but admitted with the X-ray report bowel obstruction that was sent with R14. ER Nurse also states that R14's increased gas may have caused an ileus causing this current problem. On 01/12/23 at 8:40 a.m., Surveyor was informed R14 was being sent to the hospital via ambulance to rule out bowel obstruction per Med Tech D. On 1/12/23 at 12:45 p.m., Surveyor interviewed RN C about R14's status and RN C stated R14 has been having consistent formed bowel movements with last ones yesterday that were formed. R14 had bowel sounds last night. RN C spoke with hospital RN just before this interview, who stated R14 is being admitted with x-ray indicated bowel obstruction. No new x-ray has been performed yet at the hospital, they are going off the x-ray report sent with R14. Hospital RN told RN C that it is possible increased gas could have caused an ileus causing this current problem. On 1/12/23 at 1:15 p.m., Surveyor interviewed DON B asking what the bowel protocol means as this was an order for R14. DON B stated this is a standing order that would start day three with no bowel movement. DON B provided the bowel protocol orders. Surveyor asked DON B what the expectations for bowel assessments were. DON B stated bowels would not really be assessed unless there is a concern. Nurses chart by exception. DON B told this Surveyor that she has started a PIP (Performance Improvement Project) for alert charting. On 1/12/23 at 1:30 p.m., Surveyor interviewed RN C about when bowel assessments would be done by nurses. RN C stated we chart by exception. If there is an issue, we assess the resident, chart, and notify the provider, DON, and POA if applicable. Follow up on orders if ordered and continue monitoring the resident. We have a 24-hour report log to report to the oncoming shift. Asked if this surveyor could see the report log and RN C stated, she was unsure where it is at that time. Based on standards of practice found on the Wisconsin Technical College System website nursing skills of assessment related to enteral tubes states, When caring for patients with enteral tubes, it is important for the nurse to routinely assess and document the patient's condition. Objective assessments for patients with enteral tubes include Bowel sounds should be present in all four quadrants, and the abdomen should be soft and nondistended .https://wtcs.pressbooks.pub/nursingskills/chapter/17-3-assessments-related-to-enteral-tubes/ American Nurse Official Journal of the American Nursing Association. Enteral Feeding: Indications, complications, and nursing care states the following: To identify complications of enteral feeding, thoroughly assess the patient before tube feeding begins and monitor closely during feedings. When beginning enteral feedings, Assess the abdomen by auscultating for bowel sounds and palpating for rigidity, distention, and tenderness. Know that patients who complain of fullness or nausea after a feeding starts may have higher a GRV (gastric residual volume). https://www.myamericannurse.com/enteral-feeding-indications-complications-and-nursing-care/

Based on observation, interview and record review, the facility did not ensure that residents who require colostomy services receive care consistent with the resident centered comprehensive care plan and address the goals and preferences of the resident for 1 of 12 total residents (R) reviewed (R4). The facility did not do a thorough comprehensive assessment for R4's colostomy status. The facility did not address the desires of R4 to have the colostomy cared for as she did at home. This is evidenced by: Facility policy titled Colostomy/Ileostomy Care Policy with revision date of March 2020 stated in part: .19. Observe stoma / peristomal area and measure stoma with guide. The normal stoma is bright red. Poor circulation suggested of if pale, black or purple report to physician . Suggested documentation: Condition of stoma and peristomal area. Amount and character of fecal drainage. Tolerance of procedure, self-care performed, and any education provided. Unusual observations and or complaints and subsequent interventions including communication with physician. Facility policy titled Bowel and Bladder Management Policy with revision date of July 2020 stated a resident who requires colostomy, urostomy or ileostomy services, receives care in accordance with his or her care plan. Surveyor reviewed R4's diagnoses that include but are not limited to: Colostomy status, GERD. Surveyor reviewed R4's most current MDS (minimum data set) dated 12/19/22 and 12/26/22 states R4 with ostomy status. BIMS (brief interview for mental status) for R4 is 9. (8-12 moderately impaired). R4's admission date at the facility was 12/19/22. On 01/10/23 at 3:56 p.m., Surveyor interviewed R4 about colostomy. R4 stated she has a sore colostomy since coming here. Staff empties the colostomy bag but doesn't clean it good like R4 did at home. On 1/12/23, Surveyor reviewed R4's Orders include (related to current issue) but are not limited to the following: Change system every 3-7 days or PRN. Use ConvaTec sure fit barrier #404594 seal/ring 2 Pouch ConvaTec Closed end 2-1/4 Flange #416421 every evening shift every 3 day(s) for Colostomy care AND as needed. Start date 1/12/23 On 1/11/23, Surveyor reviewed R4's Care Plan and Kardex; there is nothing noted concerning resident's preference of care for colostomy, nor assessment of stoma. On 1/12/23, Surveyor reviewed R4's Baseline Care Plan/ Evaluation dated 12/19/22 does have the box checked next to ostomy in the bowel and bladder section under bowel and bladder appliances. R4's head to toe evaluation dated 12/19/22 under section G. Digestive does include devices LLQ (left lower quadrant) ostomy, bowel sounds active in all quadrants, resident reports passing gas. Stool in ostomy appears brown and watery. Abdomen soft, nontender, rounded, denies nausea or any other discomfort. R4's bowel and bladder evaluation dated 12/23/22 does not discuss anything concerning colostomy. Reviewed the progress notes related to colostomy, no documentation noted on stoma assessment, nothing concerning pain to stoma and no documentation on R4's preference concerning care of colostomy. On 01/11/23 at 12:40 p.m., Surveyor observed CNA (Certified Nursing Assistant) K empty R4's colostomy. Hand hygiene completed with use of gloves. Privacy and explanation of what is being done. Bag was not very full of stool. During the observation R4 stated the stoma was hurting. Surveyor asked R4 if she had told staff of this before and R4 stated she has. Bag and site care not done at this time. The dressing and bag look good, no signs or symptoms of infection noted on outside, unable to really see the stoma due to stool residue left in bag. R4 stated she used to care for the colostomy at home. R4 stated the staff are not doing this how she took care of changing the bag daily. R4 states she would wash out the bag every time. On 01/11/23 at 12:56 p.m., Surveyor interviewed RN C about R4's colostomy asking how does she know who cares for the colostomy or the wishes of the resident concerning the care of the colostomy. RN C stated she usually will help R4 to change the colostomy device. R4 is mostly independent in changing it. RN C stated R4 has not had any issues with stoma infection, soreness, or pain that she is aware of. RN C states the colostomy device last changed 1/3/23 and 1/10/23. This is changed every 3-7 days on the evening shift. On 01/12/23 at 9:00 a.m., Surveyor interviewed RN C asking how she would know if R4 has a colostomy. RN C states she knows this from R4's hospital information and that the information on R4's TAR (Treatment Administration Record) would be there to notify of need to change colostomy device. R4 had a colostomy on admission, reported it has been sore since admission and staff was not caring for it as R4 desired. No initial, or routine comprehensive assessments documented on stoma condition. No determination on R4's preference of care were initiated. No comprehensive care plan directing staff of care for R4's colostomy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 2 On 1/11/23, Surveyor reviewed R4's diagnoses that include but are not limited to: Anxiety and major depressive disorder. R4 was admitted to the facility on [DATE]. On 1/12/23, Surveyor reviewed R4's Orders to include (related to current issue) but are not limited to the following: Citalopram Hydrobromide Tablet 20 MG Give 1 tablet by mouth one time a day for depression Nursing order: Antidepressant medication - monitor for sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle tremor, agitation, headache, skin rash, photosensitivity (skin) excess weight gain Document: 'Y' if monitored and none of the above observed. 'N' if monitored and any of the above was observed, select chart code 'Other/ See Nurses Notes' and progress note findings two times a day On 1/12/23, Surveyor reviewed R4's care plan which states nothing related to mood or behavior, targeted behaviors, non-pharmacological interventions. On 1/12/23, Surveyor reviewed R4's record and did not identify any behavior assessments, nor behavior monitoring to assess for levels of depression. On 1/12/23, Surveyor reviewed R4's [NAME] that states under behavior/mood: behaviors - verbally aggressive. On 1/12/23, Surveyor reviewed R4's Progress Notes since admission to find three nursing progress notes that discuss R4's behaviors. Two notes stated R4 was confused and became agitated, cursing at staff, difficult to redirect. One note stated R4 has been pleasant and appropriate this shift. Resident reviewed in behavioral meeting by IDT (interdisciplinary team) and pharmacist. Resident is on Citalopram due to depression, no changes recommended at this time. Will continue to monitor. Based on record review and interview, the facility did not develop a care plan with behavioral non-pharmacological approaches or have a system in place for monitoring the effectiveness of psychotropic medications prescribed. This has the potential to affect 2 of 5 residents reviewed for unnecessary medications (R19 and R4). R19 is prescribed Duloxetine an Antidepressant for depression, Trazodone an Antidepressant at bedtime for sleep and Escitalopram for depression. R19 has no care planned approaches for her depressive symptoms or to promote sleep. R19 has no system in place to monitor the effectiveness of the medications. R4 is prescribed Citalopram an antidepressant for depression. R4 has no care planned approaches for mood and behavior with no system in place to monitor the effectiveness of this medication This is evidenced by: Example 1 Surveyor reviewed R19's record and noted the following: R19's diagnosis included adjustment disorder with depressed mood. R19's most recent admission Minimum Data Set (MDS) dated [DATE] notes R19 took antidepressant medication 7/7 days evaluated, she had no behavioral concerns and had depressive symptoms of feeling down, depressed or hopeless, trouble falling or staying asleep or sleeping too much, feeling tired or having little energy. R19's Physician orders included: 11/06/22: Duloxetine (Antidepressant) 60 mg bid (twice daily) for depression 11/03/22: Trazadone (Antidepressant) 25 mg by mouth daily at bedtime for sleep 11/04/22: Escitalopram (Antidepressant) 20 mg QD (every day) for depression R19's care plan was reviewed by Surveyor. Surveyor noted no care planned goal or individual care planned approaches to address R19's indicators of depression or sleep disturbance. R19's record was reviewed by Surveyor. Surveyor noted system in place to monitor R19's depressive symptoms or sleep. There was no system in place to evaluate the effectiveness of R19's psychotropic medications. On 01/12/23 at 1:20 PM, Surveyor spoke with Director of Nursing (DON) B regarding R19's psychotropic medications, care plan and system to monitor the effectiveness of the medications. DON B indicated she has been on staff since 11/22. DON B expressed she would expect a care plan be developed after a comprehensive sleep study. The care plan should contain a focus of insomnia and depressive symptoms with a specific goal and individualized approaches. DON B explained the facility is aware there are concerns with the facility's behavior program. The facility has held one meeting to discuss the facility processes but due to other priorities in the building the system has not yet been developed and R19 has not yet been reviewed by team. Should have some type of charting to show how she is doing. DON B indicated she would check R19's record and get back to the surveyor. On 01/12/23 at 3:32 PM, DON B informed Surveyor R19 had no behavior monitoring or charting in place for her depressive symptoms or sleep. The facility just began looking at their processes and R19 has not yet been reviewed.

Based on observation, interview and record review, the facility did not prepare, distribute or store foods in a sanitary manner. This has the potential to affect 25 of 27 residents who eat foods orally. Dietary staff observed in the kitchen did not have their hair fully restrained. The Dietary Manager (DM) F repeatedly removed her reading glasses from the top of her head to place on her face. The glasses were presumably dirty. DM proceeded to touch clean items in the kitchen without washing her hands. The dry storage rooms floors were visibly dirty with a staff break area in the middle of the upstairs dry storage room and staff coats hanging on hooks in the storage area. The refrigerator and freezer that is used for foods brought into the facility for residents does not have a thermometer or system to monitor safe temperatures for storing foods. This is evidenced by: Example 1 On 1/10/23 at 9:35 AM, Surveyor conducted and initial tour of the kitchen. Dietary Manager (DM) F accompanied Surveyor on the tour. Surveyor observed DM F with her hair bangs and hair curls on both sides of her face not restrained with the hair net she was wearing. DM F continued the tour throughout the storage areas and kitchen with her hair not properly restrained. Surveyor also observed Dietary Aide (DA) G and (DA) H working in the kitchen and the kitchen's dish room. Both DA G and DA H had visible hair that was not restrained with the hair nets they were wearing. Following the tour Surveyor spoke with DM F about her expectation regarding staff hair restraint in the kitchen. DM F responded she would expect all hair be restrained in the kitchen. Surveyor requested the facility policy regarding expected dress code in the kitchen. Surveyor was provided a policy titled Uniform Information, which is not dated. Surveyor reviewed the policy which does not address hair restraint in the kitchen. Example 2 On 1/10/23 at 9:35 AM, Surveyor conducted an initial tour of the kitchen and the kitchen storage areas. Surveyor observed DM F repeatedly removing her glasses from the top of her head to place on her face to read various food labels and logs. DM F placed the glasses back to the top of her head after reading the food labels and logs for the refrigerator/freezer temperature logs and dish machine log. DM F continued the tour, touching various items in the kitchen without performing hand hygiene. After the observation, Surveyor spoke with DM F about the observation. DM F expressed it is normal for her to place her reading glasses on her head and place them on when she needs to read small print. DM F further expressed she had not realized she was touching her glasses as it is a habit and how her glasses are worn. DM F indicated she now realizes her glasses are dirty and hand washing should occur before touching clean items in the kitchen. Surveyor requested the facility policy regarding hand washing when going from dirty to clean items in the kitchen. Surveyor was provided a policy titled Handwashing section: Safe Food Handling with a revised date of January 2021. The policy in part reads ~Purpose: Proper hand washing promotes safe food handling practices and infection control. Guidelines: The following list includes, but is not limited to, when hands are washed .after engaging in any other activities that contaminate the hands. Example 3 On 1/10/23 at 9:35 AM, during the initial tour of the kitchen and the storage areas Surveyor noted the dry storage area in the basement with visibly dirty floors and debris on floor. The dry storage area upstairs near the kitchen had a dirt pathway down center of the room. DM F indicated the floor was dirty as the area has high staff traffic due to the area being a staff break area. Surveyor observed coats on hooks on the wall and a table and chairs in the middle of the storage area. Surveyor asked DM F about kitchen cleaning schedules. DM F responded the kitchen cleaning schedules are outdated and not currently being used. Surveyor asked DM F about the staff break area in the area where dry goods are stored. DM F responded the break area in the storage area creates a potential for contamination of foods and should not be there. Dietary staff coats from outside are not clean and staff eat and drink in the area. DM F further expressed the break area was placed there a few months ago; it should not be there and will be removed. Surveyor requested the kitchen sanitation policy. The policy titled Sanitation and Cleaning Schedule with section noted as: Food Services is dated as revised on April 2020. The policy in part reads: Purpose: ~The purpose of the policy is to maintain regulatory compliance under F812 which states that a facility must store, prepare, distribute and serve foods under sanitary conditions . ~The dietary department shall be responsible for maintaining sanitary conditions in the kitchen, all storage and dining areas, including all equipment located in/or utilized in these areas. ~All dry storage areas must be clean and free of clutter, including personal items, so dry goods, canned goods, packaged goods and disposables are free from contamination. Example 4 On 01/11/23 at 2:05 PM, Surveyor and DM F observed the refrigerator and freezer in the activity room. The refrigerator and freezer is used for food and drink brought into the facility for residents. Surveyor observed no thermometer in the refrigerator or freezer. Surveyor noted no log in place for monitoring the temperatures of the refrigerator or freezer. Surveyor noted tomato juice with resident name dated 1/11. Resident foods brought in from family discussed with DM F. DM F indicated foods brought in for residents are not stored in the kitchen and are stored in activity room refrigerator. DM F expressed she is not sure if the 1/11 date on the tomato juice is an open by or use by date. DM F further expressed there is no system in place to monitor temperatures of the refrigerator or freezer to ensure foods are stored at safe temperatures. Surveyor requested and received the facility policy titled Foods from Outside Sources section: Food Services dated as revised on April 13, 2020. The policy in part reads: ~Family members or other visitors may bring the resident food of their choosing. ~All refrigeration units will have internal thermometers to monitor temperatures. All units must be maintained at internal temperatures that are deemed safe for food storage according to state and federal standards.