**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2), rights for a fair and proper discharge when the facility failed to do an accurate assessment of the resident's mental capacity to understand the meaning of leaving the facility against medical advice (AMA) and denied the resident an appropriate assessment to determine return to the facility after being cleared by the emergency department (ED) physician. This facility failure resulted in an extended hospital stay and transfer from the ED to a facility more than two hours away limiting the resident's only nearby advocate's ability to visit and provide support. Findings: During a review of the medical record (MR) for Resident 2, the Face Sheet (FS), indicated a [AGE] year-old female admitted to the facility on [DATE] and discharged on [DATE]. Resident 2 had multiple diagnoses including cerebral infarction ([stroke] decreased oxygen supply causing brain damage), encephalopathy (brain dysfunction that causes confusion, memory loss, and personality changes), cytotoxic cerebral edema (brain swelling that causes confusion), anxiety (emotion that causes restlessness and difficulty concentrating), history of traumatic brain injury (brain injury that can cause memory issues, mood swings, memory problems and personality changes). During a review of Resident 2's Comprehensive Nursing Observations Upon admission (CNOUA), dated [DATE] at 4 p.m., the CNOUA indicated, Elopement Risk Evaluation . The resident has attempted to leave a residence or other place unescorted that placed him/her in danger . Yes . The resident is cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disorganized all the time) and independently ambulatory . Yes . Interventions: Elopement Deterrent Device Implemented. During a review of Resident 2's Clinical Notes Report (CNR), dated [DATE] at 11:57 p.m., the CNR indicated, Resident needed constant supervision d/t [due to] poor safety awareness. The CNR dated [DATE] at 11:25 a.m., the CNR indicated, Resident noted with impulsiveness and impaired regard for safety upon admission. Resident attempted to walk up out of w/c [wheelchair] towards the exit. Wander guard [a wander management system designed to protect memory care residents] placed and working properly. Resident not easily redirected During a review of Resident 2's CNR, dated [DATE] at 1:51 a.m., the CNR indicated, Resident needed constant supervision d/t [due to] poor safety awareness. During a review of Resident 2's CNR, dated [DATE] at 11:14 p.m., the CNR indicated, Very confused . looking for the husband. She was always followed by one CNA [Certified Nursing Assistant]. During a review of Resident 2's CNR, dated [DATE] at 12:06 p.m., the CNR indicated, Not capable of making own decisions. During a review of Resident 2's CNR, dated [DATE] at 2:36 p.m., the CNR indicated, Exhibiting impulsive behavior AMB [as manifested by] walking around room/hallways looking for her husband. She was always followed by one CNA. During a review of Resident 2's Initial Discharge Plan & Assessment (IDPA), dated [DATE] at 9:13 a.m., the IDPA indicated, BARRIERS TO discharge: Not capable of making decisions. During a review of Resident 2's CNR, dated [DATE] at 6:19 p.m., the CNR indicated, Prefers to be out wandering in halls. CNA supervision always. During a review of Resident 2's Interdisciplinary Team Care Plan Review (ITCPR), dated [DATE] at 1:17 p.m., the ITCPR indicated, Summary of Care Plan Review . There are concerns over her safety r/t [related to] noted impulsivity . Per her friends . they express concern over her behaviors, poor decision making over the past few years . DC [discharge] plan discussed, her plan is unclear at this time . Residents cognition fluctuates at times. During a review of the police report titled, Incident Detail Report (IDR), dated [DATE], the IDR indicated, Priority: Law Code 2 [immediate risk of serious injury to a person] . Caller Name: [facility staff name] . 16:14:26 [4:14 p.m. and 26 seconds] . 16:14:49 . SUBJ [subject] ALREADY ON THE ON RAMP TO HWY 1 . STAFF MEMBER IS WITH SUBJ . 16:16:16 . SUBJ ON HWY 1 NB [northbound] . SUBJ ON FOOT . 16:17:43 . OFFICER REQ [requesting] AMBULANCE PRECAUT [as a precaution] . 16:19:05 . SUBJ WALKING ON HWY 1 . 16:19:33 . RP [reporting party] IS FOLLOWING THE RESD [resident] . 16:23:36 . MULT [multiple] VEHS [vehicles] PULLED OVER THAT ARE ALL ASSOCIATED W/ [facility name] . NOW BECOMING COMPLICATED, PT [patient] IS GETTING AGITATED . 16:25:01 . ANOTHER STAFF MEMBER SLOWING TRAFFIC ON SIDE OF PT BECAUSE PT WAS IN LANE . SILVER SUV GOING SLOWLY ALONG SIDE HER, SLOWING TRAFFIC DOWN . 16:25:15 . ALMOST TO MBB [[NAME] Bay Blvd] EXIT . 16:27:42 . PT NOW AT MBB EXIT SIGN NB 1 . 16:28:36 . PT IS NOW GETTING IN BLU TRK [truck] W/ 2 STAFF MEMBERS . 16:29:26 . ADVSING RP TO HAVE BLU TRK PULL OVER SAFELY OFF OF MBB EXIT SO DEPS [deputies] AND AMB [ambulance] CAN MEET HER . 16:29:59 . RP DOESNT BELIEVE THEY CAN GET MUCH FURTHER W/PT IN VEH . 16:30:54 . PT TRIES TO JUMP OUT OF VEH WHEN THEY MOVE . 16:32:49 . RP IS REQ [requesting] TO HAVE AMB RESPOND TO MBB BLVD EXIT SIGN / HWY 1 . 17:05:27 . TURNED OVER TO MEDICS FOR TRANSPORT TO [hospital name]. During a review of Resident 2's CNR, dated [DATE] at 5:01 p.m., the CNR indicated, Resident desired to leave the facility . Offered AMA resident refused to wait for paperwork. Resident left the facility with staff members accompanied. Staff called EMS and [police name] PD [police department]. Resident transported by ambulance to acute care center. Resident refusing to return to facility per PD. During a review of Resident 2's ED (Emergency Department) Note-Physician (EDNP), dated [DATE] at 7:45 p.m., the EDNP indicated, Patient states that she and her husband were in a cult type situation. This is why they left the facility . Delusional . I think she is experiencing intermittent delusions from her recent frontal lobe stroke. There is no medical reason to be found today for the symptoms . I was able to speak with the patient's friend [advocate's name] at the bedside . [advocate's name] has concerns about the patient being discharged back to her house where she lives alone. I do share these concerns as well. Therefore, I subsequently called [facility physician name] . She agrees that discharging from the ED tonight may not be in the patient's best interest and she recommends sending her back to [facility name] where they can work on the social issues for a better discharge plan. Patient and friend [advocate's name] are in agreement with this treatment plan . Disposition: Discharge back to [facility name]. Condition stable. During a review of Resident 2's Discharge Against Medical Advice (AMA), dated [DATE] at 8:46 p.m., the AMA indicated, discharged to Address . [Hospital name and address]. During a review of resident 2's CNR, dated [DATE] at 10:25 a.m., the CNR indicated, late entry for [DATE] approximately 1610 [4:10 p.m.]. Resident attempted to leave the facility. wander guard (wrist alarm) was activated. This writer attempted to redirect resident back to the station. Resident stated, Now you're trying to hold me prisoner, You can't hold me here against my will. I have the right to leave. Writer and Social Services attempted to explain discharge process and AMA. Resident verbalized understanding and pushed this writer aside several times. Resident accompanied by Social Services and this writer until PD [police department] and EMS [emergency medical services] arrived. During a review of Resident 2's EDNP, dated [DATE] at 11:13 p.m., the EDNP indicated, Nursing staff called [facility name] who informed us that she could not return because she had been discharged against medical advice. and no longer had a bed. I discussed with the patient who wishes to return to [facility name] and does not recall the events that led to her endorsing a desire to leave [facility name] . I called to discuss with [administrator name] . I was highly doubtful that this patient had capacity to make an AMA decision or understand the prerequisite informed consent [ensuring the patient comprehends the information provided and can make a rational choice] . I discussed with . physician on-call for [facility name] . [physician name] does not have the power to overrule the admin on this decision who are not allowing the patient to return because she had signed out AMA . I then discussed with . [Chief Operating Officer (COO) name]. She indicated to me the reason the patient cannot return to the facility is because she requires higher level of care . the patient is calm and cooperative and desires to return to [facility name] . and that it would be safe to do so . I explained my concerns that the patient was allowed to be discharged AMA when she does not likely have capacity to make that decision, and I am highly doubtful that she was adequately consented for that decision . admitted into observation today [DATE] 01:42:25 [1:42 a.m.] for continued monitoring of social situation and to ensure patient safety. During a review of Resident 2's CNR, dated [DATE] at 12:15 p.m., the CNR indicated, Writer [administrator] spoke to [hospital name] regarding resident returning to facility . Writer explained to [hospital name] that facility is no longer able to accept resident due to her erratic behavior and poor safety judgement/impulsivity. During a review of Resident 2's ED Supervision/Handoff (EDSH), dated [DATE] at 11:07 a.m., the EDSH indicated, The patient was stable for transfer . discharged from observation status. Review of the facility's Facility Assessment ([FA] an evaluation of the facilities resident population and the resources needed to provide the necessary care and services), dated 2025, the FA indicated, Mental Health and behavior/ Specific care and practices: Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior. Identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment . In-service training includes . Cognitive impairments and how to provide care/services. Behavioral Management and how to provide care / services . Facility has a holistic protocol and plan of care to meet the care requirements for residents needing attention pertaining to their mental, behavioral, psychosocial, and cognitive well-being. Staff is trained sufficiently in the provision of dementia and behavioral management. Facility utilizes an attending psychologist and external psychiatric services to help meet the needs of residents with mood, behavioral, and psychiatric challenges . The facility staffs according to resident needs and based on acuity and census. During an interview on [DATE] at 12 p.m. in the Administrator's office with the Chief Operating Officer (COO) and the Administrator (ADM), COO stated Resident 2's discharge was, technically an AMA. During an interview on [DATE] at 10:26 a.m. with the Nursing Supervisor (NS), NS stated she did not see any behaviors from Resident 2 since her admission on [DATE]. When asked what she remembers about Resident 2 NS stated, I can't remember. When asked again, NS stated Resident 2 was restless and had confusion. Resident 2 didn't remember where she was and thought her husband was still alive. During an interview on [DATE] at 10:39 a.m. with the Medical Records Supervisor (MRS), MRS stated when Resident 2 got into the ambulance she asked the medics if they could take her home. MRS also stated Resident 2 was confused and she wanted to go home to be with her husband. During an interview on [DATE] starting at 11:04 a.m. with a Licensed Vocational Nurse (LVN), LVN stated she went to the front of the facility and explained to Resident 2 that if she went out of the building, it's an AMA. LVN also stated that Resident 2 stated, No, I'm leaving. LVN next stated, No, she did not have the AMA form with her and did not sign it until the ED doctor asked for it. During an interview on [DATE] at 11:18 a.m. with ADM, ADM stated she instructed staff to send the face sheet, medication list, and allergies. ADM further stated the AMA form was sent because the doctor at the ED wanted a copy of it. ADM further stated, Yes, it was the AMA form printed earlier that Resident 2 refused to sign. ADM was asked why Resident 2 wasn't allowed to return after the ED visit. ADM stated they never said she wanted to come back. During an interview on [DATE] at 12:05 p.m. with Resident 2's friend (Advocate), Advocate stated on [DATE] before the incident with Resident 2 Advocate was contacted by SSD. Advocate next stated SSD said Resident 2 was running out of Medicare (insurance) and SSD asked Advocate to call around and find other placement for her. Advocate additionally stated, It seems like they wanted to wash their hands of her. Advocate further stated Resident 2 was very confused when she met her at the ED and believes Resident 2 was not able to make a decision to AMA in her state. Advocate stated since 2006 Resident has become more confused. It takes some time talking to her in order for her to come back to the current time and Resident 2 can reorient for only short periods. Advocate said Resident 2 wanted to return to the facility. During an interview on [DATE] at 5:09 p.m. with the facility physician (PHY), PHY stated Resident 2 was probable not capable of making the AMA decision at the time of the incident. PHY next stated she did not assess Resident 2 to determine if she could return to the facility. PHY stated she spoke with the ED physician twice. The ED physician evaluated Resident 2 and thought she was OK to return to the facility. The ED physician thought Resident 2's behavior was related to her stroke. PHY additionally stated she called the ADM who said Resident 2 was not able to return because she AMA'ed to the nurse and the police. PHY was asked if there is a service Resident 2 needed that the facility was not able to provide. PHY stated she does not know of one. During an interview on [DATE] starting at 1:48 p.m. with the Ombudsman (OMB), OMB stated they did receive a call from SSD on the morning of [DATE] letting them know that SSD thought Resident 2 was going to be a difficult discharge. OMB further stated OMB has heard other families say they got a call from the SSD around day 21 of their Medicare stay with SSD telling them the Medicare is about to end and they needed to find other placement. OMB additionally stated OMB has tried to educate the facility that they cannot tell families they need to find placement for the Residents. During an interview on [DATE] at 4:45 p.m. with ADM, ADM stated Resident 2 left AMA from the facility. ADM stated her staff called 911 and followed the Resident onto the highway because they have a heart and not because they were concerned about her safety. ADM stated they did not provide the hospital with the usual transfer documents because she wasn't transferred, she was an AMA. ADM stated nobody assessed Resident 2 after she was cleared by the ED physician because there wasn't a need to assess her because we weren't accepting her back. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge Requirements, undated, the P&P indicated, It is the policy of Compass Health facilities that residents will be allowed to remain in Compass Health facilities unless . The transfer or discharge is necessary for the welfare of the individual resident . the resident's needs cannot be met .The decision for admission is based on the availability of the facility to meet the expressed needs and expectations of the residents to the extent possible . When Compass Health facilities transfers or discharges a resident under any of the above circumstances, appropriate documentation shall be made in the resident's clinical record. All appropriate information will be communicated to the receiving health care institution or provider. During a review of the facility's P&P titled, Against Medical Advice (AMA) Procedure, undated, the P&P indicated, The purpose of this procedure is to ensure that resident is aware of their rights regarding leaving against medical advice. Review of the National Library of Medicine website, https://www.ncbi.nlm.nih.gov/books/NBK430827/, accessed on [DATE], indicated, Informed consent is a cornerstone of medicine, ensuring ethical treatment decisions and patient-centered care . screen patients for factors that may affect their ability to understand and provide informed consent, such as . cognitive impairments, or emotional distress . Informed consent can be challenging in specific situations, such as with patients who have impaired decision-making capacity due to cognitive impairments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) had Ativan (lorazepam -antianxiety medication): 1) administered as ordered by the physician and 2) reported to the physician when the Ativan was not effective. These failures resulted in Resident 2 receiving more Ativan than prescribed, and to a delay in notifying the physician when medication did not appear effective. Findings: Review of [NAME] and [NAME], Tenth Edition, Fundamentals of Nursing, page 607-608 in the section titled, Medication Administration, indicated, To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some ways to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation 7. The right indication. During a review of Resident 2's Physician Order Sheet (Order), dated 4/2025, the Order indicated: - Ordered 4/4/25, Ativan 0.5 milligrams (mg) tablet oral (po, by mouth) as needed every six hours for anxiety manifested by frequent physical restlessness with impaired regard for safety, such as frequently attempting to stand up impulsively. - Ordered 4/5/25, Ativan 2 mg/ml (milliliter) injection solution. Give 0.5 ml (1 mg) intramuscular (IM) as needed every six hours when the resident is unable to receive po dose. For anxiety manifested by frequent physical restlessness with impaired regard for safety, such as frequently attempting to stand up impulsively. 1) During a concurrent interview and record review on 5/2/25 at 3:45 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR), dated 4/2025 was reviewed. The MAR indicated: - Ativan 0.5 mg tablet by mouth as needed every six hours starting 4/4/25 was administered on 4/11/25 at 4:21 a.m. and 6:30 a.m., two hours and eight minutes apart. DON stated, I could not find a note, indicating the physician was notified of the error. DON further stated, Of course, the nurses should be following the physician's order. -Ativan 2 mg/ml injection solution as needed every six hours, to administer when the resident is unable to receive po dose, was administered 4/7/25 at 3:10 p.m. without the po dose being tried first. DON reviewed Resident 2's medical record for a note indicating the physician was notified of the error and stated she did not see one. DON further stated the nurse should have tried to give it po before IM. 2) During a concurrent interview and record review on 5/2/25 at 3:45 p.m. with the Director of Nursing (DON), Resident 2's Medication Administration Record (MAR), dated 4/2025 was reviewed. The MAR indicated: -Ativan 0.5 mg tablet by mouth as needed every six hours starting 4/4/25 was administered on 4/6/25 at 12 p.m. At 1 p.m. the result was, No Effect. DON reviewed the medical record and did not find any note indicating the physician was notified. DON stated she would expect the nurse to notify the physician.

Based on interview and record review, the facility failed to ensure language assistance services were provided for one of 18 sampled residents (Resident 36), whose primary language is Farsi. This failure had the potential to violate Resident 36's right to be fully informed, in a language he could understand, and make decisions about his medical condition. Findings: During a review of Resident 36's admission Minimum Data Set (MDS - a standardized assessment tool that measures health status in nursing home residents) the MDS Section A dated 8/20/24 indicated Language, Farsi. During an interview on 11/13/24 at 10:33 a.m. with Licensed Nurse (LN) 2, LN 2 acknowledged Resident 36's primary language is Farsi. LN 2 indicated the facility does not have language assistance services for staff to use to communicate with Resident 36. During a review of Resident 36's care plan (CP- a document that summarizes how a patient's needs will be met, and their care will be managed)) titled Communication dated 8/13/24, the CP indicated Sometimes understood in ability to express ideas and wants. Farsi is his primary language. During an interview on 11/13/24 at 10:35 a.m. with the facility's Director of Nursing (DON), the DON acknowledged Resident 36's primary language is Farsi. DON confirmed the facility does not have language interpretation or translation services for nursing staff to use to communicate with Resident 36 in Farsi. DON stated, We don't have a translation service. The facility was not able to provide a policy & procedure (P&P) to indicate a process was in place for staff to communicate with residents who have limited English proficiency.

Based on observation, interview, and record review the facility failed to ensure two of 18 sampled residents (Resident 39 and Resident 40) had their call light within reach. These failures had the potential to result in residents not being assisted timely and had the potential to affect their psychosocial and personal hygiene needs. Findings: During an observation on 11/12/24 at 11:19 a.m. in Resident 39's room, Resident 39's call light was found on the floor. Resident 39 was not able to reach or see the call light. During an observation on 11/12/24 at 2:10 p.m. in Resident 40's room, Resident 40's call light was not placed within reach and was observed over the nightstand. During an observation on 11/12/24 at 3:30 p.m. Resident 40's call light was still over the nightstand and not placed within Resident 40's reach. During an observation on 11/13/24 at 10:04 a.m. in Resident 39's room, Resident 39's call light was found dangling from Residents 39's bed and was not within reach. During a concurrent observation and interview on 11/13/24 at 10:10 a.m. with a Certified Nursing Assistant (CNA 2), at Resident 39's bedside, CNA 2 stated, the call light should be within resident's reach, not on the floor and not dangling from the bed. During a concurrent interview and record review on 11/14/24 at 11:00 a.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Emergency Electrical Power System undated, was reviewed. The P&P indicated in part .The nurse's station is equipped to receive resident calls through a communication system from resident rooms .The system is in operating order . shall be readily accessible to residents at all times. The system is accessible to residents while in their bed. The DON agreed call lights should not be on the floor, dangling from the bed or out of resident's reach.

Based on observation and interview the facility failed to ensure expired medications were not stored and available for use. This failure had the potential for unsafe and ineffective medication administration to residents. Findings: During a concurrent observation and interview with Licensed Nurse (LN1) on 11/12/24 at 11:15 a.m., in the B-Hall Nurse Station 1 there was a meedication storage room refrigerator. A box containing five vials of Engerix-B® Hepatitis B (a liver infection) Vaccine (safe and effective way to protecting people from harmful diseases) (protects against hepatitis B, a liver infection caused by the hepatitis B virus), 20 mcg/mL (microgram/milliliter - unit of measure) with was observed with an expiration date of 8/24/24. LN 1 acknowledged the expiration date and stated, It should be discarded. During an interview on 11/12/24 at 12:15 p.m. with Director of Nursing (DON), the DON confirmed the five vials of Engerix-B® Hepatitis B Vaccine were expired and should be discarded. During a review of the facility's policy and procedure (P&P) titled, Disposal of Medications, undated, the P&P indicated, Outdated medications, contaminated or deteriorated medications, and the contents of containers with no label shall be destroyed.

Based on observation, interview, and record review the facility failed to ensure pureed food was prepared by methods that conserved nutritive value, flavor, and was palatable. This failure resulted in lack of flavor and palatability in pureed foods and has the potential for the eight residents on a pureed diet to have a decreased food intake which can further compromise the nutrition and medical status. Findings: During a concurrent observation and interview on 11/13/2024 at 10:13 a.m. in the kitchen, [NAME] (CK) 1 was observed making pureed chicken for eight residents. CK 1 stated that chicken had been cooked with tarragon and paprika. CK1 was observed placing approximately 5 cups of cooked chicken into a blender then added hot water to the fill the contents to the top of the blender to total 8 cups. CK1 then blended the chicken and poured contents into a large bowl. CK1 added an unmeasured amount of thickener three times to reach a mashed potato like consistency. CK1 then placed pureed food into oven to keep warm until tray line. During an observation on 11/13/2024 at 10:31 a.m. in the kitchen, CK1 was observed making pureed orzo by adding 4.5 cups of orzo to blender then adding 8 cups of water. CK1 then blended the mixture, poured mixture into a large bowl and added an unmeasured amount of thickener three times to reach a mashed potato like consistency. During an interview on 11/13/2024 at 12:26 p.m. in Hall D/C a regular diet and pureed diet test tray was tasted with Dietary Manager (DM). Food temperature was adequate. DM acknowledged that the pureed diet was not as flavorful as the regular foods. DM stated that orzo in the pureed diet did not have the green herbs that the regular food tray did. DM stated that maybe the seasoning was added later to the regular food that were not added to the pureed food. The pureed spinach was more gelatin like. DM acknowledged and confirmed the pureed spinach was more gelatin-like, pasty, and very thick. During a review of the recipes titled Spinach Sauteed with Garlic (fresh), Orzo Lemon Herb, and Chicken Greek [3] (thigh), dated 11/13/2024, the menu indicated in part, IDDSI Level 4 -Pureed: Measure desired # of servings into a food processor. Blend until smooth. Use the Fork Drip Test and the Spoon Tilt Test to confirm texture is within IDDSI Level 4 specifications. It also showed for any of the modified texture diets to, Add small amounts of gravy, sauce, vegetable juice, cooking water, fruit juice, milk or half and half to meet desired consistency and to add commercial thickener if product needs thickening. During an interview with the Dietary Manager (DM) on 11/13/2024 at 4:24 p.m., in the kitchen, the DM stated that the cooks do not usually do the fork drip or spoon tilt test to check or determine if the recipe consistency was prepared properly. DM stated that they usually do visual observation because they have been doing it for so long. During an interview with the Registered Dietitian (RD) on 11/14/24 at 9:24 a.m., RD stated when foods are pureed, and the cook uses that much water then can dilute food and that would change flavor with so much water and food thickener. RD stated food for puree menu items should be prepared and seasoned like the regular food items. RD acknowledged that less water and thickener is better and would taste better. RD stated expect staff to follow recipes and recipes for puree. RD stated residents on puree already can have more concerns or not able to speak for themselves. RD stated she does not do any of the fork or spoon tests for puree foods on any of the audits that she does. RD stated puree foods can be looked more closely on how they are preparing the puree foods.

Based on observation, interview, and record review the facility failed to ensure resident preferences were accommodated on meal trays for three of 18 sampled residents (Resident 18, 27, and 63). This failure has the potential to result in residents not having their food preferences met. Findings: During a lunch meal observation and a concurrent review of Resident 18's lunch meal tray ticket, and concurrent interview with a Dietary Aide (DA3) on 11/12/24 at 12:21 p.m. in the kitchen, the try ticket showed, **NO SOUP SPOONS ON TRAY***. Upon observation one soup spoon and one regular tablespoon were located on Resident 18's meal tray. When the cart was ready to leave the kitchen, DA3 was asked about the spoon and stated, Oh no and took it off the tray. During a lunch meal observation on 11/12/24 at 12:35 p.m. in the kitchen, the lunch tray ticket showed Resident 63 had requeseted a Peanut Butter (Packet)*. There was no peanut butter packet on the lunch tray. During a lunch meal observation on 11/12/24 at 12:37 p.m. in the kitchen, Resident 27's lunch meal tray ticket showed a request for three packets of salt. An observation of the lunch tray showed only one packet of salt was located on the lunch tray. During an interview on 11/12/24 at 12:39 p.m. in the kitchen with DA3, DA3 reviewed the lunch tray cart and the meal tickets and confirmed the peanut butter was missing on Resident 63's meal tray that should be there and there needed to be two more salt packets added to Resident 27's meal tray. During an interview on 11/14/24 at 9:23 a.m. with the Registered Dietitian (RD), RD stated that she would expect kitchen staff to read the meal tickets and if preferences listed on the meal ticket, then it is important to have it done correctly. RD stated she expects kitchen staff to follow what is written on the meal tickets.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to implement transmission-based precautions (actions to control how infection is spread) for one of 18 sampled residents (Resident 446) when the facility staff did not implement their Policy and Procedure (P&P) titled, Enhanced Barrier Precautions. This failure placed Resident 18 at an increased risk of acquiring an infection due to their medical condition. Findings: During a tour of facility on 11/13/24 at 10:30 a.m. it was observed that there was no Personal Protective Equipment outside of room [ROOM NUMBER] and there was no sign stating Enhanced Barrier Precautions (EBP) on the wall or door to Patient 446's room. During a concurrent interview and record review on 11/13/24 at 10:42 a.m., with Licensed Nurse (LN4), Patient 446's medical record was reviewed. The medical record indicated Resident 446 was ordered for EBP. LN4 confirmed that Resident 446 had an order for EBP due to an indwelling medical device and acknowledged that Resident 446 should be on EBP precautions. LN4 confirmed that there was not an EBP sign on the wall or door of Resident 466's room. LN4 stated there should be a sign alerting staff to EBP per facility policy. During a review of the facility policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 08/2022, the P&P indicated, 5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization . 10. Signs are posted on the door or wall outside the resident room indicating the type of precautions and PPE required. 11. PPE is available outside of the resident rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and review of facility documents, the facility failed to ensure food and ice were stored, prepared, and served in accordance with professional standards for food service safety when: 1. Facial hair coverings were not worn during food preparation; 2. One ice machine contained a brownish pink substance on the censor on the metal grate where ice is formed; and 3. There was lack of an air gap for one of the ice machines located in central supply room. This failure has the potential to result in the growth of microorganisms that can cause foodborne illness to residents. Findings: 1. During an observation on 11/12/2024 at 12:28 p.m. in the kitchen, Diet Aid (DA) 2 was seen putting cold items from the reach in refrigerator onto lunch trays. DA2 was wearing a blue surgical mask. Facial hair was seen outside of the surgical mask on both sides of the face that was uncovered. During an observation on 11/12/2024 at 3:54 p.m. in the kitchen, DA2 was preparing dinner trays. DA2 was placing silverware, condiments, and desserts on meal trays. DA2 had facial hair uncovered. During a concurrent observation and interview on 11/13/2024 at 2:55 p.m. in the kitchen, DA 1 was making salad. DA1 had facial hair uncovered. During an observation on 11/14/2024 at 9:22 a.m. in the kitchen, [NAME] (CK) 1 was at stove cooking food with no facial hair covering. During an observation on 11/14/2024 at 10:44 a.m. in the kitchen, CK1 was preparing food. [NAME] restraint was noted around chin. Hair above upper lip was exposed and not covered. During an observation on 11/14/2024 at 10:58 a.m. in the kitchen, DA1 was pouring tomato juice into cups and facial hair was uncovered. During an interview on 11/14/2024 at 11:49 a.m. with RD, RD stated her expectation is that any and all facial hair should be covered while in the kitchen. During a review of the facilities policy and procedure (P&P) titled, Employee Sanitary Practices, dated 2022, the P&P indicated in part, All food and nutrition services employees will practice good personal hygiene and safe food handling procedures. All employees will: Wear hair restraints (hairnet, hat, and/or beard restraints) to prevent hair from contacting exposed food. This does not apply to employees who have a totally shaved or bald head. If face coverings or mask are required to be worn during work hours, nose and mouth must be securely covered. Hands are to be washed before putting on a mask and after disposing of it. If masks are touched or adjusted during the shift, hands must be washed immediately after. 2. During a concurrent observation and interview on 11/13/2024 at 2:37 p.m., Certified Nurse Assistant (CNA) 4 was filling a water pitcher with ice from the ice machine in the central supply room for two resident's. CNA4 confirmed she was using the ice for the residents. During a concurrent observation and interview on 11/13/2024 at 2:46 p.m. in the central supply room with the Maintenance Supervisor (MS) and Maintenance Worker (MW) the ice machine cleaning process was reviewed. MW stated that the ice machine was cleaned three weeks prior. MW removed the upper cover. On the metal grate was a censor that had brownish pink substance around sides. When wiped with a white paper towel the substance came off. MS acknowledged that there was substance located on the censor. 3. During a concurrent observation and interview starting at 11/13/2024 at 2:46 p.m. with MS, the floor sink/drain next to the ice machine where there were pipes going into it and there was no air gap present. MS acknowledged the pipes were down in the floor drain/sink and no air gap was present. During a review of FDA's (Food and Drug Administration), Food Code 2022, Section 5-202.13 Backflow Prevention, Air Gap, The FDA Food Code indicated, An air gap between the water supply inlet and the flood level rim of the plumbing, fixture, equipment or nonfood equipment shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). In, Section 5-203.14 Backflow Prevention Device, the FDA Food Code indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, including on a hose [NAME] if a hose is attached or on a hose [NAME] if a hose is not attached and backflow prevention is required by LAW, by: (A) Providing an air gap .; or (B) Installing an APPROVED backflow prevention device. (Air gap: An air gap refers to a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the equipment and possibly contaminating the area used. An air gap is a way to make certain wastewater and contaminants never re-enter the clean water supply.)

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 1 and 3), had their preference for bedtime honored. This facility failure resulted in Residents 1 and 3 not having their rights supported when making their choice of when to go to bed for the evening. Findings: During a review of the facility's policy and procedure (P&P) titled, Self Determination, undated, the P&P indicated, Residents shall have the right to choose and participate in activities, schedules, and health care consistent with his/her interests, assessments, and plan(s) of care . Residents are encouraged to make choices about aspects of their life in Compass Health facilities that are significant to them. During an interview on 9/29/2023, at 4:20 p.m., with Resident 1, Resident 1 stated certified nursing assistant (CNA) [CNA1 name] and [CNA2 name] puts Resident 1 to bed too early at about 5:30 p.m., even after Resident 1 lets them know he would like to go to bed later. During a review of Resident 1's Minimum Data Set ((MDS) standardized tool used to communicate resident problems and strengths), dated 8/9/2023, the MDS indicated Resident 1's Brief Interview for Mental Status ((BIMS) screener that aids in detecting impaired thinking) score was 14 (cognitively intact). During a review of Resident 1's Care Plan ((CP) a plan for the action the staff should take to help a resident meet their goals), titled, Risk for Skin Breakdown, dated 11/19/2013, the CP indicated, Encourage OOB [out of bed] activity as appropriate. During a concurrent interview and observation on 9/29/2023, at 4:40 p.m., with CNA1 at a hallway kiosk (computer attached to the wall for the CNA to view and record resident information), CNA1 stated the opening page will show the needs of the resident. CNA1 pointed out where it indicates if assistance is needed to transfer (move from wheelchair to bed) and stated it does not indicate preferences for bedtime. During a concurrent interview and observation on 9/29/2023, at 5:20 p.m., with Resident 3 in their room, Resident 3 demonstrated with a hand brushing motion and stated [CNA1 name] brushes Resident 3 off or says, Go to bed [Resident 3 name]. During a review of Resident 3's MDS, dated 8/30/2023, the MDS indicated Resident 3's BIMS score was 15 (cognitively intact). During a review of Resident 3's CP, titled, [Resident 3 name] and his family members have many specific requests ., dated 2/19/2020, the CP indicated, Support resident in making choices concerning environment, leisure, and care . Staff will explore reasonable accommodations and solutions with [Resident 3 name] to meet their specific requests or needs.

Based on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 11), personal information was protected. For Resident 11, this facility failure had the potential to result in a loss of dignity. Findings: During a review of the facility's policy and procedure (P&P) titled, Dignity Procedure dated 3/1/2018, the P&P indicated, The purpose of this procedure is to ensure that residents are cared for in a manner and in an environment that maintains or enhances each resident's dignity and respect . During an observation on 3/1/22, at 9:55 a.m., in the hallway outside of Resident 11's room, a pink sign labeled, [Resident 11] This resident has a visit on DATE: Every Saturday TIME: 4:15 pm LOCATION: ZOOM MEETING PLEASE HAVE RESIDENT READY 15 MIN BEFORE APPOINTMENT THANK YOU ACTIVITY DEPARTMENT please have up in chair/bed. THX! During an interview on 3/2/22, at 2:25 p.m., with a licensed nurse (LN2), LN2 stated, Ya, I can see where it would be a dignity issue.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop a person-centered, comprehensive care plan (describes the care and support provided to meet health needs), to two of 18 sampled residents, to address respiratory care needs (Resident 76) and dementia care needs (Resident 45). These facility failures had the potential for care and services not to be provided to residents to attain or maintain quality of life. Findings: 1. During a review of Resident 76's, Face Sheet (FS), dated 8/28/19, the FS indicated in part, Resident 76 is a [AGE] year-old male, who was admitted in the facility on 8/28/19. Resident 76's admitting diagnoses included, Hemiplegia (paralysis of one side of the body following injury to the brain) following Cerebral Infarction (Stroke) affecting left non-dominant side, Oropharyngeal Dysphagia (a disorder to which you can not properly swallow food, liquid or saliva), Muscle Weakness, and Gastrostomy Status (a tube placed into the stomach for nutritional support). During a concurrent observation and interview with Resident 76, on 2/28/22 at 3:40 p.m., Resident 76 was observed inside his room, lying in bed, awake and alert. Resident 76 had a left arm contracture (permanent shortening of a muscle or joint), a slightly mumbled speech, and occasionally struggled to cough and clear his throat effectively. On further observation, there was a suction machine on top of Resident 76's bedside table. When asked if the suction machine was used on him, Resident 76 stated, They're (referring to staff) supposed to suction me (pointing at his mouth, indicating increased oral secretions) but the nurses rarely use it because they're too afraid. After clarifying his statement, Resident 76 acknowledged that staff was supposed to suction his excessive oral secretions. During a concurrent interview and record review, on 3/2/22 at 10 a.m., with the Assistant Director of Nursing (ADON), Resident 76's, Treatment Orders (TO) and Care Plan (CP) Report, dated 8/28/19 - present, were reviewed. Resident 76's, TO, indicated in part, Suction as needed (PRN for increased oral secretions), with an order date of 2/17/21. A review of Resident 76's, CP report, did not indicate, a care plan was initiated to manage the resident's ineffective cough, which could have included other appropriate goals and other care interventions aside from suctioning. The ADON verified the finding and acknowledged that a comprehensive care plan should have been initiated specific to Resident 76's respiratory care needs. 2. During a review of Resident 45's, Face Sheet (FS), dated 4/6/18, the FS indicated in part, Resident 45 is a [AGE] year-old male, who was admitted in the facility on 4/6/18. Resident 45's admitting diagnoses included, Dementia, Unspecified (loss of thinking, remembering, and reasoning due to advanced age), Unspecified Psychosis (a condition that affects the way your brain processes information), Oral Dysphagia (difficulty of swallowing), and Difficulty of Walking. During a concurrent observation and interview on 3/1/22 at 10:10 a.m., with a licensed nurse (LN1), Resident 45 was observed inside his room, lying in bed sleeping, with the height of the bed at its lowest position and on oxygen therapy via a nasal cannula (a flexible tube that has two open prongs intended to sit just inside your nostrils) running at 2 LPM (liter/s per minute). According to LN1, Resident 45 had a rough night and did not get too much sleep. LN1 described Resident 45 as confused, incoherent and anxious at times. During a concurrent interview and record review on 3/2/22 at 10:30 a.m., with the Assistant Director of Nursing (ADON), Resident 45's, Care Plan (CP) Report, dated 4/6/18 - present, was reviewed. Resident 45's, CP report, indicated, goals and interventions to manage his current acute medical conditions (such as moderate hearing loss, nausea, vomiting, and weight loss) and psychosocial issues (such as anxiety and depression), without mentioning specific goals and interventions to address his dementia care needs. After further review of the report, the ADON verified and acknowledged that a comprehensive care plan should have been initiated to specifically address Resident 45's dementia care needs. During a review of the facility's, policy and procedure (P&P), titled, Care Plans Procedure, revised 3/1/18, the P&P indicated in part, Purpose: The purpose of this procedure is to ensure that staff initiates care plans for identified problems of the resident. The P&P indicated further, Procedure: a) Complete Resident Comprehensive Assessment . b) Identify resident's needs and/or problems, c) Initiate care plans, and d) Care plans are developed and reviewed by the interdisciplinary team. During a review of the facility's, policy and procedure (P&P), titled, Develop/Implement Comprehensive Care Plan, revised 3/1/18, the P&P indicated in part, Each resident care plan shall include measurable objectives, the professional discipline responsible for each element of care and timeframes to meet the resident's needs identified in the comprehensive assessment. The P&P indicated further, The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure timeliness in the development and revision/update of the person-centered, comprehensive care plans (describe the care and support provided to meet health needs), to two of 18 sampled residents (Residents 76 and 45), when: 1. Care plan was not developed and initiated timely to address Resident 76's respiratory care needs, 2. Care plan to address Resident 76's care needs related to difficulty in swallowing was not updated to reflect current speech-language therapy recommendations, 3. Care plan was not developed and initiated timely to address Resident 45's dementia care needs. These failures had the potential for the provision of care and services to these residents not being provided timely which could affect residents quality of life. Findings: 1. During a review of Resident 76's, Face Sheet (FS), dated 8/28/19, the FS indicated in part, Resident 76 is a [AGE] year-old male, who was admitted in the facility on 8/28/19. Resident 76's admitting diagnoses included, Hemiplegia (paralysis of one side of the body following injury to the brain) following Cerebral Infarction (Stroke) affecting left non-dominant side, Oropharyngeal Dysphagia (a disorder to which you can not properly swallow food, liquid, or saliva), Muscle Weakness, and Gastrostomy Status (a tube placed into the stomach for nutritional support). During a concurrent observation and interview with Resident 76, on 2/28/22 at 3:40 p.m., Resident 76 was observed in his room, lying in bed, awake and alert. Resident 76 had a left arm contracture (permanent shortening of a muscle or joint), a slightly mumbled speech, and occasionally struggled to cough and clear his throat effectively. On further observation, there was a suction machine on top of Resident 76's bedside table. When asked if the suction machine was used on him, Resident 76 stated, They're (referring to staff) supposed to suction me (pointing at his mouth, indicating increased oral secretions) but the nurses rarely use it because they're too afraid. After clarifying his statement, Resident 76 acknowledged that staff was supposed to suction his excessive oral secretions. During a concurrent interview and record review, on 3/2/22 at 10 a.m., with the Assistant Director of Nursing (ADON), Resident 76's, Treatment Orders (TO) and Care Plan (CP) Report, dated 8/28/19 - present, were reviewed. Resident 76's, TO, indicated in part, Suction as needed (PRN for increased oral secretions), with an order date of 2/17/21. A review of Resident 76's, CP report, did not indicate, a care plan was initiated to manage the resident's ineffective cough, which could have included other appropriate goals and care interventions aside from suctioning. The ADON verified the finding and acknowledged that a comprehensive care plan should have been initiated specific to Resident 76's respiratory care needs. 2. During a review of Resident 76's, SLP (Speech-Language Pathologist [assesses, diagnoses, treats, and helps to prevent communication and swallowing disorders]) Evaluation and Plan of Treatment (SLPPT), dated 9/10/21, the SLPPT indicated in part, Objective Progress/Short-term Goals .Patient will increase oral phase swallow skills to Mild as evidenced by increased ability to safely swallow ice chips to promote swallow function and build swallow endurance The SLPPT also indicated, Recommendations . Additional Intake Recommendations = Ice Chips only. During a concurrent interview and record review on 3/2/22 at 10:15 a.m., with the ADON, Resident 76's, SLPPT dated 9/10/21, and CP report dated 8/29/19 - present, were reviewed. The ADON verified the SLPPT additional intake recommendations for Resident 76. On review of Resident 76's CP report, specific to tube feedings, the interventions section of the CP, indicated in part, past SLP evaluation/s. Interventions were not updated to reflect Resident 76's most recent SLPPT recommendations. The ADON verified the finding and acknowledged that the tube feeding CP should have been updated. 3. During a review of Resident 45's, Face Sheet (FS), dated 4/6/18, the FS indicated in part, Resident 45 is a [AGE] year-old male, who was admitted in the facility on 4/6/18. Resident 45's admitting diagnoses included, Dementia, Unspecified (loss of thinking, remembering, and reasoning due to advanced age), Unspecified Psychosis (a condition that affects the way your brain processes information), Oral Dysphagia (difficulty of swallowing), and Difficulty of Walking. During a concurrent observation and interview on 3/1/22 at 10:10 a.m., with a licensed nurse (LN1), Resident 45 was observed in his room, lying in bed sleeping, with the height of the bed at its lowest position and on oxygen therapy via a nasal cannula (a flexible tube that has two open prongs intended to sit just inside your nostrils) running at 2 LPM (liter/s per minute). According to LN1, Resident 45 had a rough night and did not get too much sleep. LN1 described Resident 45 as confused, incoherent and anxious at times. During a concurrent interview and record review on 3/2/22 at 10:30 a.m., with the Assistant Director of Nursing (ADON), Resident 45's, Care Plan (CP) Report, dated 4/6/18 - present, was reviewed. Resident 45's, CP report, indicated, goals and interventions to manage his current acute medical conditions (such as moderate hearing loss, nausea, vomiting, and weight loss) and psychosocial issues (such as anxiety and depression), without mentioning specific goals and interventions to address his dementia care needs. After further review of the report, the ADON verified and acknowledged that a comprehensive care plan should have been initiated to specifically address Resident 45's dementia care needs. During a review of the facility's, policy and procedure (P&P), titled, Care Plans Procedure, revised 3/1/18, the P&P indicated in part, Purpose: The purpose of this procedure is to ensure that staff initiates care plans for identified problems of the resident. The P&P indicated further, Procedure: a) Complete Resident Comprehensive Assessment . b) Identify resident's needs and/or problems, c) Initiate care plans, and d) Care plans are developed and reviewed by the interdisciplinary team. During a review of the facility's, policy and procedure (P&P), titled, Develop/Implement Comprehensive Care Plan, revised 3/1/18, the P&P indicated in part, Each resident care plan shall include measurable objectives, the professional discipline responsible for each element of care and timeframes to meet the resident's needs identified in the comprehensive assessment. The P&P indicated further, The comprehensive care plan will describe services furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being During a review of the facility's, policy and procedure (P&P), titled, Care Plan Timing and Revision, revised 3/1/18, the P&P indicated in part, (name of organization) facilities will ensure the timeliness of each resident's person-centered comprehensive care plan .The comprehensive care plan will be reviewed, evaluated, and updated by the interdisciplinary team and appropriately revised after each comprehensive and quarterly assessment, and more often if there is a change in the resident's condition.

Based on observation, interview, and record review, the facility failed to ensure one of 9 sampled residents (Resident 14), had an accurate Face Sheet ((FS) a document used by physicians and care givers to have quick access to essential facts about a resident). For Resident 14, this facility failure had the potential to result in life saving procedures being performed against their wishes. Findings: During a review of the facility's policy and procedure (P&P) titled, Resident Records - Identifiable Information, dated 3/1/2018, the P&P indicated, Clinical records are maintained on each resident in accordance with accepted professional standards and practices. Clinical records are complete, accurately documented, readily accessible and systematically organized. During a review of Resident 14's Physician Orders for Life-Sustaining Treatment ((POLST) a medical order indicating end of life treatment wishes), the POLST indicated, if Resident 14 has no pulse and is not breathing, Do Not Attempt Resuscitation. During a review of Resident 14's FS, dated 3/1/22, at 7 a.m., the FS indicated, Resident 14's end of life wish was, Full Code [wishes all resuscitation procedures]; Do Not Resuscitate. During an interview on 3/1/22, at 11:42 a.m., with a licensed nurse (LN1), LN1 reviewed Resident 14's FS and stated the FS was not right because the end of life wishes listed, Are complete opposites. During an interview on 3/1/22, at 12:53 p.m., with the Director of Nursing (DON), DON reviewed Resident 14's FS and POLST and stated, They don't match, and they should.

Based on observation, interview, and record review, the facility failed to store and label opened containers of food in the refrigerator and freezer as indicated in the facility policy and procedure. This failure had the potential for food items to be stored for a duration that could cause the growth of microorganisms, which could lead to food borne illnesses in the facility's vulnerable population. Findings: During an observation on 02/28/22, at 9:30 a.m., in the facility kitchen, several opened containers of food were noted to be unlabeled: 1. Pineapple juice in the Walk in Refrigerator 2. Heavy Whipping Cream in the Walk in Refrigerator 3. Two containers of Ham base in the Refrigerator 4. Burger patties in the Walk in Freezer 5. Cheese Omelets in the Walk in Freezer During a concurrent observation and interview on 02/28/22, at 9:40 a.m., with the Director of Dietary Services (DDS), in the facility kitchen, the DDS confirmed the opened food stored in the refrigerator and freezer were not labeled. The DDS further stated this practice does not meet food safety practices. The DDS acknowledged the facility policy and procedure was not followed, but should have been. During a review of the facility policy and procedure titled, Food Storage, dated 2022, the policy indicated in section 13, Refrigerated Foods under f and g of Refrigerated foods, All foods should be covered, labeled, and dated and routinely monitored to assure that food will be consumed by their use by dates .All food in bulk containers that have been opened for partial use need to be labeled with an open date. Under section 14 Frozen foods, c and d, the policy and procedure indicated, All foods should be covered, labeled, and dated. All foods will be checked to assure that food will be consumed by their safe use by dates or discarded .All foods in bulk that have been opened for partial use needs to be put into a food safe container for storage. It needs to be labeled and dated with a Use By' date.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the, Dialysis/Nursing Facility Communication Report (Dialysis is a procedure used to remove waste products and excess fluid from the body), was completely filled out for one of one sampled residents (Resident 90). This facility failure had the potential to put Resident 90 at risk for unmet care needs. Findings: During a review of Resident 90's clinical record, on 11/7/19, at 1:55 PM, the admission record indicated Resident 90 was admitted to the facility on [DATE], with diagnoses including End Stage Renal Disease (last stage of chronic kidney disease), Diabetes mellitus (abnormal blood sugar levels), and muscle weakness. The following were noted on the, Dialysis/Nursing Facility Communication Log Report: 1. The, Intra-Dialysis Assessments, were not completed on 9/23/19, 10/4/19, 10/7/19, 10/11/19, 10/14/19, 10/18/19, 10/21/19, 10/23/19, 10/28/19, 10/30/19, and 11/4/19. 2. The, Post-Dialysis Assessments were not completed on 9/18/19, 9/20/19, 9/23/19, 9/25/19, 9/30/19, 10/2/19, 10/4/19, 10/7/19, 10/11/19, 10/14/19, 10/18/19, 10/21/19, 10/23/19, 10/25/19, 10/28/19, 10/30/19, 11/1/19, 11/4/19, and 11/6/19. During an interview and a concurrent record review with the Assistant Director of Nursing (ADON), on 11/7/19, at 2 PM, the ADON verified there were missing entries in the Dialysis Log, and stated the facility needs to complete the forms. When asked what was expected of the nurses, the ADON stated, They need to look at the site to make sure there's no redness, warmth, and swelling, assess the site and make sure it is patent, and of course write down the information on the log, sign, date, and time it. The ADON further stated, We need to make sure that when [Resident 90] comes back nothing is wrong. The nurse needs to check what happened in the dialysis, if there are any diet changes, and monitor the weight. A review of the facility's policy and procedure titled, Dialysis, dated 3/1/18, indicated in part, .Assess and document the resident's condition prior to departure for dialysis. Communicate pertinent information from assessment to dialysis center. Send necessary safety/comfort devices or equipment with resident to dialysis. Assess and document the resident's condition on return from dialysis.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 19's clinical record the admission record indicated Resident 19 had a diagnoses of Alzheimer's Dementia with Behavior. The MDS, dated [DATE], indicated Resident 19 had a diagnosis of Non-Alzheimer's Dementia. There was no comprehensive care plan for dementia in Resident 19's clinical record. During an interview and concurrent record review with the DON, on 11/6/19, at 4:46 PM, the DON confirmed that there was no care plan for Resident 19 regarding the diagnosis of Dementia. The DON stated We missed developing a Dementia care plan for the resident. I cannot find any care plans related to Dementia care. A review of the facility's policy and procedure titled, Develop/Implement Comprehensive Care Plan, dated 3/1/18, indicated, in part, Will develop and implement a comprehensive person-centered care plan for each resident using the results of the comprehensive assessment. Each resident's care plan shall include measurable objectives, the professional discipline responsible for each element of care, and time frames to meet the resident needs identified in the comprehensive assessment. Based on interview and record review, the facility failed to develop a dementia (chronic illness marked by memory disorders, impaired reasoning, and personality changes) care plan for two of four sampled residents (Residents 19 and 53). This facility failure had the potential to place Residents 19 and 53 at risk for not receiving effective care for residents with dementia. Findings: 1. During a review of Resident 53's clinical record, the admission record indicated Resident 53 had a diagnoses of Dementia. The Minimum Data Sheet (MDS - an assessment tool that measure health status in a nursing facility) dated 10/21/19 indicated Resident 53 has a diagnosis of Non-Alzheimer's Dementia. There was no comprehensive care plan for dementia in Resident 53's clinical record. During an interview and a concurrent record review with the Director of Nursing (DON), on 11/6/19, at 2:34 PM, the DON stated, I think we may have missed that, I need to add a dementia one [care plan]. During an interview with the DON, on 11/6/19, at 5:02 PM, the DON stated, It is important to have a Dementia care plan because it helps us focus on interventions pertaining to Dementia.

Based on observation, interview, and record review the facility failed to store waste for garbage collection in a sealed container on the facility property. This facility failure had the potential to attract vermin and expose residents, visitors, and staff to sources of infection. Findings: During an observation of the trash collection area at the back of the property, and concurrent interview with the dietary services director (DSS), on 11/4/19, at 9:12 AM, the large metal trash collection bin was full, and multiple white trash bags were observed preventing the lid from closing. The DSS indicated the excess bags should have been deposited in the large metal trash bin located behind that bin, because there was plenty of room in it, and the lid should not be open. A review of the facility's policy and procedure titled, Waste Disposal, dated 2014, indicated in part, Trash will be deposited into a sealed container outside the premises.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to: 1. Ensure oxygen tubing was dated for one of 24 sampled residents (Resident 391), 2. Ensure oxygen tubing were stored in the plastic bag when not in used for three of 24 sampled residents (Resident's 81, 393 and 395). These facility failures had the potential to result in spread of infection. Findings: 1. During an initial tour of the facility, on 11/4/19, at 8:35 AM, the oxygen tubing for Resident 391 was observed undated. A review of Resident 391's clinical record indicated Resident 391 was admitted on [DATE], with diagnoses that included acute respiratory failure (a disease that cause difficulty of breathing). During an interview with the Director of Nursing (DON), on 11/4/19, at 12:05 PM, the DON stated, The facility practice is that all oxygen tubing should be dated. 2. During an observation and concurrent interview with a licensed nurse (LN 3), on 11/5/19, at 12:30 PM, Resident 81's oxygen tubing was observed on the floor. LN 3 confirmed the finding and stated, Oxygen tubing should not be on the floor. It should be placed in the bag when not in use. During an observation and concurrent interview with a licensed nurse (LN 4), on 11/7/19, at 9:11 AM, Resident 395's oxygen tubing was on top of the disposable pad on the bed. LN 4 confirmed the finding and stated, It belongs to [Resident 395], and it should be in the bag. During an observation and concurrent interview with the DON, on 11/7/19, at 9:25 AM, Resident 393's oxygen tubing was on the floor. The DON confirmed the finding and stated, It is the facility practice that all oxygen tubing not in use should be placed in the designated bag.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation and concurrent interview with a licensed nurse (LN 2), on [DATE], at 11:30 AM, Resident 81 was observed receiving oxygen via a nasal cannula, and the oxygen machine was set between 2.5 and 3 liters per minute. LN 2 confirmed the finding. During a review of Resident 81's clinical record, Resident 81 was admitted on [DATE] to the facility with of chronic obstructive pulmonary disease (long term respiratory disease that often causes breathing problems). The physician's order, dated [DATE], indicated, Oxygen (O2) at 2 l/m [liters per minute] via nasal cannula at hour of sleep. During an interview and concurrent record review with LN 2, on [DATE], at 11:35 AM, LN 2 acknowledged Resident 81's physician orders included oxygen at 2 liters per minute via nasal cannula. LN 2 stated, It should be 2 liters per minute only. Based on observation, interview, and record review the facility failed to: 1. Discard outdated quality control solution (a liquid used to routinely test the accuracy of measurements) for the Glucometer machine (a device used to measure blood sugar levels) for 10 unsampled residents receiving blood sugar checks. 2. Ensure the physician's order for oxygen was followed for one of 24 sampled residents (Resident 81). These facility failures had the potential to result in inaccurate blood sugar results, for residents to have untreated low blood sugar or high blood sugar, and to result in insufficient oxygenation, increased carbon dioxide levels, and increased nasal dryness. Findings: 1. During an observation and concurrent interview with a licensed nurse (LN 5), on [DATE], at 6:07 AM, two expired bottles of quality control solution were found on the medication cart. The bottle for level 1 solution (lot# 1681711 3102) had a printed expiration date of [DATE]. LN 5 indicated it should have been discarded. The bottle for the level 3 solution (lot# 1681711 3202) had a handwritten opened date of [DATE]. The bottle label indicated Use within 3 months of opening. LN 5 indicated it should have been discarded in [DATE]. During a review of the Quality Control logs, on [DATE], at 6:44 AM, the logs for September, October, and November of 2019 indicated the expired level 3 solution had been used to perform quality testing on the Glucometer machines located on Medication Carts A and B. During an interview with the Director of Nursing (DON), on [DATE], at 2:40 PM, the DON indicated the control solution should have been discarded when it expired, per the manufacturer's recommendations. A review of, The Healthcare Professional Operations Manual, for the blood glucose monitor, indicated in part, Do not use expired control solution, and Discard any unused control solution three months after the opening date.

Based on observation, interview, and record review the facility failed to maintain the kitchen in a safe and sanitary condition when: 1. The ice machine was dirty. 2. Two Dietary Aides were not able to properly test the level of sanitizer in the dishwashing stations. These facility failures had the potential to expose residents and visitors to foodborne illness and to have items and surfaces improperly sanitized. Findings: 1. During an observation and concurrent interview with the facility director of maintenance (DOM), on 11/5/19, at 8:03 AM, the ice machine was wiped on the back of the inside of the machine twice with a paper towel. There was a goopy tan substance with black specks on the paper towel. The DOM acknowledged the finding, indicated the ice machine was cleaned once a month, and was due for cleaning, Next Friday. During an interview with the facility administrator (ADM), on 11/5/19, at 12:47 PM, the ADM indicated this was not acceptable. A review of the Policy and Procedure titled, Ice, dated 2014, indicated in part, Ice machines will be maintained in a clean and sanitary condition to prevent ice contamination. 2. During an observation of a dietary aide (DA 1), at the manual dishwashing station, on 11/4/19, at 9:34 AM, the DA 1 demonstrated how to test the sanitizing solution. The DA 1 took a piece of testing strip and submerged the entire strip in the sanitizer. DA 1 swirled the strip around for a couple of seconds, and pulled it out quickly. During an observation of a dietary aide (DA 2), at the dish machine station, on 11/4/19, at 9:40 AM, the DA 2 demonstrated how to test the sanitizing solution. The DA 2 pulled off a piece of the strip, quickly dipped it into the solution, shook off the excess solution, and compared the result with the guide on the strip package. During a review of the directions on the test strips package, on 11/4/19, at 9:51 AM, the instructions indicated in part, Dip paper into quat solution, not foam surface, for 10 sec. Don't shake. Compare colors at once. During an interview with the assistant dietary services director (ADSS), on 11/6/19, at 10:57 AM, the ADSS indicated staff who used sanitizer for dishwashing should have tested the sanitizer per the instructions on the package of the test strips to determine appropriate level of disinfection. A review of the Policy and Procedure titled, Cleaning Dishes- Manual Dishwashing, dated 2014, indicated in part, Check sanitation sink often using a test strip to assure the level of sanitizing solution is appropriate. Test the sanitizing solution in the sink using the manufacturer's suggested test strips to assure appropriate level.