The Estates At Greeley Llc

F-F604.

During observation on 8/7/24 at 8:13 a.m., Resident R37's fall mat was located on the floor in Resident R37's room and Resident R37 was in the dining room.

During interview and observation on 8/7/24 at 8:14 a.m., licensed practical nurse (LPN)-A verified the mat was on the floor by Resident R37's bed and stated the mat was not a hindrance for Resident R37 and added it was there because Resident R37 tries to get in and out of bed constantly and the mat was kept there to prevent Resident R37 from falling. LPN-A further stated wheelchairs were not locked because it was considered a restraint and stated it did not matter if Resident R37's wheelchair was locked and added Resident R37 was at a very high risk for falling.

During interview on 8/7/24 at 8:21 a.m., registered nurse (RN)-E stated Resident R37 was at risk for falling and stated fall interventions included a soft touch call light and a floor mat while in bed, a toileting schedule and keep Resident R37 in high traffic areas. RN-E further stated locking the wheelchair would be considered a restraint and could cause more of a safety risk because Resident R37 was not able to move and not able to back up.

During interview on 8/7/24 at 9:22 a.m., the director of nursing (DON) stated they always try to follow the care plan and planned to talk with the aides to see why the mat was on the floor and further, housekeeping did not have access to the care plan and stated Resident R37 could unlock the chair and stated it would be important to provide education to housekeeping.

During interview on 8/7/24 between 10:27 a.m., and 10:37 a.m., nursing assistant (NA)-D stated they had a sheet that indicated the cares a resident required and stated she could look at the documentation in the electronic medical record (EMR). NA-D stated Resident R37 could propel her wheelchair and further stated Resident R37 would not be able to think to know how to unlock and lock her wheelchair and stated Resident R37's wheelchair had been locked before such as in the bathroom and when Resident R37 first sits down in the chair and NA-D stated Resident R37 thinks

the wheelchair is stuck and does not know how to unlock it. NA-D further stated Resident R37's mat was supposed to be on the floor at all times and verified the mat was on the floor and Resident R37 was in the wheelchair. At 10:37 a.m. , NA-D viewed the [NAME] CNA Report sheet form and verified the form lacked fall prevention interventions including whether the mat was supposed to be off the floor when Resident R37 was in the chair.

During interview on 8/7/24 at 10:43 a.m., the DON was notified Resident R37 was in her room and the mat was located on the floor and staff were going down to Resident R37's room to follow up.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 An email sent on 8/7/24 at 1:02 p.m., from the DON indicated the facility did not have a policy on restraints because they did not use restraints. Level of Harm - Minimal harm or potential for actual harm A policy, Fall Prevention and Management revised 2/2024, indicated the purpose of the protocol was to identify residents at risk for falls, implement fall prevention interventions, provide guidelines for assessing a Residents Affected - Few resident after a fall and to assist staff in identifying causes of the fall. After an observed or probable fall staff will clarify the details of the fall, when the fall occurred, where, and what the individual was trying to do at the time the fall occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46885 minimal harm Based on observation, interview, and document review, the facility failed to ensure complete required nurse Residents Affected - Many staffing information was posted and was timely on a daily basis. This had the potential to affect all 48 residents, staff, and visitors who could wish to review this information.

Findings include:

On 8/6/24 at 1:57 p.m., form, Estates at [NAME], dated 8/6/24, was located next to the adminstartor's office.

The form identified an area to document the census, however, the census number was undocumented. Additionally, the form identified some staff and their titles, but did not identify all staff and their titles and lacked information on the total number and actual hours worked by registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants (NAs).

During interview on 8/6/24 at 2:00 p.m., the administrator verified the form, Estates at [NAME], was the staff posting and stated it usually included the census and verified the census was not added on the form and proceeded to write the census number on the form. When asked about the total hours worked, the administrator stated after the shift was worked it was broken down on how many hours were worked.

During interview on 8/7/24 at 9:34 a.m., the director of nursing (DON), verified staff posting forms reviewed from 7/26/24, through 8/6/24, lacked tallied hours. Further, the DON stated she corrected the posting for 8/7/24, and going forward to include the tally for the total number and actual hours worked. A policy was requested, but not received.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42586

Residents Affected - Few Based on interview and document review the facility failed to provide menu's and alternate food choices to 2 of 2 residents (Resident R14, Resident R98) reviewed for food.

Resident R14's quarterly Minimum Data Set (MDS) dated [DATE REDACTED], indicated intact cognition and diagnoses of congestive heart disease (CHF), type II diabetes. and required setup/clean up assistance with eating.

Resident R14's physician's orders dated 6/30/24, indicated a consistent carbohydrate diet, regular texture, regular (thin) consistency, no added salt. Offer assistance cutting foods, related to type II diabetes mellitus.

Resident R14's care plan dated 7/24/24, indicated a potential for alteration in nutrition related to diabetes mellitus type II (DMII), obesity, and history of COVID 19, iron deficiency anemia, depression, dementia, dysphagia, and hypertension (HTN) with an intervention to offer substitute for dislikes or when not eating.

During interview on 8/5/24 at 1:35 p.m., Resident R14 stated he never knows what he's going to get to eat for each meal and he hadn't received a menu. He also stated staff do not come in and ask him what he would like to eat before each meal, therefore he doesn't feel he get's a choice stating I just have to eat what they give me.

During a follow up interview on 8/7/24 at 8:40 a.m., the surveyor showed Resident R14 the weekly menu and a Bistro (alternate) menu. He stated he had never been given a menu up until a week ago and he had to ask for it.

He further stated he had never been given or seen the alternate menu and didn't know he had a choice of those items.

Resident R98's admission Minimal Data Set (MDS) report dated 8/2/24, indicated intact cognition, diagnoses of Resident R98's of enterocolitis due to c-diff, sepis, urinary tract infection (UTI), and was independent with eating.

Resident R98's physician's orders dated 8/1/24, indicated a 2 gram (gm) sodium diet, regular texture, regular (thin) consistency.

Resident R98's care plan dated 8/2/24, indicated Resident R98 had a potential alteration in nutrition related to C-Diff, sepsis, urinary tract infection (UTI), DMII, depression, HLD, and HTN. Decreased sodium/saturated fat needs related to HTN, HLD as evidenced by therapeutic diet order. Diet: 2 grams (gm) no added salt diet, regular texture, regular (thin) consistency. It further indicated an intervention to offer a substitute for dislikes or when not eating.

During interview on 08/05/24, at 5:40 p.m. Resident R98 stated she didn't know what she was going to get to eat each meal until it showed up in her room and there were a lot of things she didn't like. She further stated she hadn't received a menu and didn't know their were alternative menu items she could choose from.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 During a follow up interview on 8/7/24 at 8:43 a.m., surveyor showed Resident R98 the weekly menu and the alternate menu, in which she stated she'd never been given one and she didn't know their were alternate food items Level of Harm - Minimal harm or she could choose from, she just eats what she get's and theirs been things she didn't want to eat, for potential for actual harm example the green beans had all kinds of other stuff in them and I couldn't eat it.

Residents Affected - Few During interview on 8/6/24 at 8:37 a.m., the cook (C)-A stated the resident's know what they are having for each meal because the menu was posted on each end of the the dining halls. Also during activities often times the resident's will ask what was on the menu for that day. When a resident was admitted they received

a menu. Staff do not go in the resident's room and ask what they would like for each meal. The resident's don't get two choices It's more of a fixed menu. I think they get menu's or they can ask if they want to get a menu.

During interview on 8/6/24 at 12:02 p.m., the dietary manager stated their menu was a 5 week fixed menu which only included one food option unless they're serving fish or pork. They also provide a Bistro menu which lists alternative options the residents can choose from. The Bistro menu was not passed out to residents or posted on the wall with the weekly menu but was located in a hanging file on the wall next to the kitchen. The kitchen manager further stated he feels the dietary staff would make the residents anything they wanted even if it wasn't listed on the menu.

During interview on 8/7/24 at 8:28 a.m., nursing assistant (NA)-E stated each resident get's a weekly menu and an alternate menu every week so they can choose what they would like to eat.

During interview on 8/7/24 at 8:48 a.m. NA-G stated residents know what they are going to eat each day by looking at the menu's that are posted at the end of the each hallway. NA-G further stated the residents can ask for a menu or ask a staff member what the meal was going to be. It was the responsiblity of the resident to ask for a menu or tell a staff member if they don't like what was being served.

During interview on 8/7/24 at 8:53 a.m., registered nurse (RN)-A stated the nursing assistants were responsible for passing out menu's to the residents but anyone can do it. RN-A stated he didn't know if staff passed out the Bistro (alternate) menu to residents or not or if it was posted.

During interview on 8/7/24 at 9:53 a.m., licensed practical nurse (LPN)-C stated staff provide menu's to the residents who are conscious and those that aren't don't receive menu's because it doesen't matter. They don't pass out the alternate menu because if the resident wants something different they will ask for i

The facility's policy regarding menus dated 10/2017 indicated, menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy. Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and

posted in the kitchen at least one (1) week in advance. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 42586 potential for actual harm Based on observation, interview and record review the facility failed to ensure transmission-based Residents Affected - Many precautions (TBP) were utilized for 1 of 1 residents (Resident R98) who required contact precautions for clostridium difficile (C. diff, a highly contagious infection). Furthermore, the facility failed to ensure enhanced barrier precautions (EBP) and appropriate hand hygiene was used for 1 of 1 residents (Resident R20) observed during personal cares.

Findings include:

Resident R98's admission Minimum Data Set (MDS) report dated 8/2/24, indicated intact cognition and a diagnoses of enterocolitis due to c-diff, sepis, and urinary tract infection (UTI).

Resident R98's physician's orders lacked indication Resident R98 required contact precautions.

Resident R98's care plan dated 8/2/24, lacked indication Resident R98 required contact precautions.

Resident R98's progress note dated 8/6/24, indicated Resident R98 was receiving Vancomycin oral solution 250 mg/5 milliliters (ml) and had one large loose stool.

During observation on 8/6/24 at 2:31 p.m., Resident R98's room had a sign on the door indicating contact precautions: everyone must clean hands before entering and leaving the room. Providers and staff: put on gloves and a gown before room entry, discard before exiting. Resident R98 was sitting in her wheelchair in the dining room with certified occupational therapy assistant (COTA)-A. After a few minutes COTA-A assisted Resident R98 to stand up and was walking behind Resident R98 in the hallway holding onto her gait belt with one hand and pulling the wheelchair behind her with the other. They stopped at her room and went inside. COTA-A removed Resident R98's gait belt and assisted her to sit down in her recliner. Then she picked up two water pitchers and exited the room, walked down the hallway to the water cooler in the common/television area, filled up the water pitchers, and brought them back to Resident R98's room. Then exited the room. COTA-A was not wearing a gown or gloves during this process and did not wash or sanitize her hands upon entering/exiting the room.

During interview on 8/6/24 at 2:34 p.m., COTA-A stated Resident R98 was on contact precautions for C-diff, verified not donning appropriate personal protective equipment (PPE), and stated another therapist (unknown) said a gown and gloves only needed to be worn if they were performing cares.

During interview on 8/6/27 at 3:00 p.m., licensed practical nurse (LPN)-B stated staff working with residents who are on contact precautions should wear gloves and a gown upon entering the room and performing cares. They should also be washing their hands with soap and water as opposed to hand sanitizer.

During interview on 8/7/24 at 9:55 a.m., the director of nursing (DON) stated staff working with residents on contact precuations (specifically Resident R98) should be wearing a gowns, gloves, and washing their hands with soap and water, when entering the room to provide cares. The DON further stated therapy was considered to be providing cares and if staff don't wear the appropriate PPE, C-diff can spread very easily throughout the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 44647

Level of Harm - Minimal harm or Resident R20's quarterly MDS dated [DATE REDACTED], indicated Resident R20 was cognitively intact and had diagnoses of Parkinson's potential for actual harm disease, diabetes, and peripheral vascular disease.

Residents Affected - Many Resident R20's provider and nursing orders lacked indication Resident R20 required EBP.

Resident R20's care plan dated 1/26/24, lacked indication Resident R20 required EBP.

A facility document titled [NAME] NA Report Sheet no date, lacked indication Resident R20 required EBP.

An observation on 8/5/24 at 12:48 p.m., Resident R20 was sitting in their room in a wheelchair. Their door was open and on the outside of the door was a sign. The sign directed staff to gown and glove when providing close contact cares.

Upon Resident R20's door was also a hanging storage rack that had gowns and gloves.

An observation on 8/7/24 at 7:32 a.m., NA-F entered Resident R20's room to assist with morning cares. NA-F performed hand hygiene before entering Resident R20's room and then obtained gloves from the bathroom. NA-F did not place a gown on. NA-F took a urinal half filled with urine from Resident R20's table and went into the bathroom to empty. The urinal was brought back to the beside and placed on the floor near Resident R20's bed. Without removing gloves or performing hand hygiene, NA-F went over to Resident R20's door and obtained a transfer belt. NA-F returned to Resident R20's bed and grabbed the bed control to lift the bed up. Resident R20's blue boots were removed, and compression socks placed. Resident R20's bed was lowered and NA-F assisted Resident R20 to sit up. Once at the end of the bed, Resident R20 was assisted to put on their slippers and NA-F placed the transfer belt around Resident R20. With assistance, Resident R20 was walked into the bathroom and to stand in front of the toilet. NA-F assisted with Resident R20's pants and removed Resident R20's brief soiled with urine and placed in the garbage. Resident R20 then sat on the toilet. NA-F removed gloves and without hand hygiene donned new gloves and shut the door slightly and straightened Resident R20's bed. Resident R20 was done and NA-F went in to assist Resident R20 to stand and provided personal cleaning for Resident R20. Without removing gloves or performing hand hygiene, NA-F assisted with placing a clean brief and pulled up Resident R20's pants. Resident R20 was assisted out of the bathroom to sit in their recliner. NA-F then obtained a washcloth and wet down with warm water. The washcloth was given to Resident R20 to wash his face. NA-F then removed gloves and without performing hand hygiene NA-F donned new gloves and assisted Resident R20 with a clean shirt. Resident R20 asked for dentures and NA-F took the white denture container, brought them to the sink and took the dentures out of the case to rinse before handing to Resident R20 to place in mouth. After Resident R20 was done, NA-F removed gloves and tied up Resident R20;s soiled garbage. NA-F left room and brought soiled bag to soiled utility room garbage. NA-F then washed hands.

When interviewed on 8/7/24 at 7:53 a.m., NA-F verified they did not change gloves after emptying the urinal and assisting with personal cares for Resident R20. NA-F further verified hand hygiene was not completed after glove removal. NA-F further stated they usually keep hand sanitizer in their pockets however the shirt they were wearing did not have pockets to keep sanitizer handy. NA-F verified Resident R20 had enhanced barrier sign or the hanging container of gowns and gloves. NA-F stated they should have been in a gown and gloves when providing cares.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 19 245342 Department of Health & Human Services Printed: 09/14/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 245342 B. Wing 08/07/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

The Estates at Greeley LLC 313 South Greeley Street Stillwater, MN 55082

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 When interviewed on 8/7/24 at 11:40 a.m., the Director of Nursing (DON) expected staff to remove gloves and perform hand hygiene when moving from unclean to clean areas. DON further stated staff were Level of Harm - Minimal harm or expected to wear gown and gloves when assisting with cares for residents on EBP. potential for actual harm When interviewed on 8/7/24 at 1:18 p.m., the infection preventionist (IP) expected staff to follow any Residents Affected - Many precautions that were posted outside of the rooms. IP stated Resident R98 had admitted with C. Diff and was going to remain on precautions until the antibiotic was completed. IP stated staff were instructed that if they are only dropping something off and not having hands on contact with the environment or resident, gowning and gloves was not needed. Any staff who had contact with the environment or hands on with the resident were expected to gown and glove. IP reviewed the contact isolation sign that was posted on Resident R98's door and verified it said all staff who enter were required to gown and glove. IP wasn't sure about why the contact isolation sign said only staff were required to gown and glove and did not instruct hand washing with soap and water. IP stated the facility had another sign for enteric precautions that instructed all who enter gown, gloves and wash hands with soap and water to due to how easily C. Diff was spread. IP further stated hand sanitizer was not enough. IP stated the enteric precautions sign should be in place for residents with C. Diff. Residents who require EBP are identified with signage on the doors. Staff were expected to wear gown and gloves with any hands-on resident cares such as toileting or transferring. Furthermore, IP expected staff to perform hand hygiene after any glove removal and when moving from dirty tasks to clean tasks. This was important to minimize risk of infections.

A facility policy titled Transmission-Based Precautions revised 7/2023, directed staff to use TBP for residents who are known to be infected with an infectious agent. Contact precautions was used when the infection was spread directly person to person or indirect contact with the resident or environment. Appropriate PPE included gown and gloving upon entering the room or making direct contact with the resident or environment. Upon exiting the room, hand hygiene was required. The facility policy lacked direction on enteric precautions or when hand washing with soap and water required.

A facility policy titled Handwashing Policy revised 2/2024, directed proper hand washing should be used to protect the spread of infection. Hand washing shall be completed after changing incontinent products. Furthermore, hand hygiene was required after glove removal and before glove donning.

A facility policy titled Enhanced Barrier Precautions dated directed staff to initiate EBP for residents with residents wth wounds and PPE should be worn during high contact resident care activities such as dressing, transferring and hygiene.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 19 245342