**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review and interviews, the facility failed to monitor the temperatures for 2 of 4 sampled residents, Resident #43 and Resident #98, who were being treated with an antibiotic for respiratory infection, as evidenced by no temperatures were documented.The findings included:Review of the facility policy titled Vital Signs revised on 04/28/24, documented in part: Vital signs are indicators of health status, including temperature, pulse, blood pressure, respiratory rate, oxygen saturation, and pain. Policy Explanation and Compliance Guidelines: 4. Vital signs should be obtained at least in the following circumstances: c. daily for a resident receiving skilled services per physician order. At least weekly for resident's receiving custodial care, or nonskilled services. When residents' general condition changes. Vital signs should be obtained by the nurse when administering certain medications or monitoring for effectiveness of medication or therapies. Record review revealed that Resident #43 was admitted to the facility on [DATE]. The quarterly comprehensive assessment dated [DATE] documented a Brief Interview Mental Status score of 14 on a 0-15 scale, indicating no cognitive impairment. 1. Record review revealed a progress note dated 06/24/25 written by the attending physician documented she saw Resident #43 and the resident had a persistent cough and shortness of breath. Photographic Evidence Obtained.Review of a physician order dated 06/24/25 for Resident #43 revealed an order instructing staff to administer Levaquin(antibiotic) 500mg daily for 7 days for cough. Record review of the vital signs for Resident #43, revealed that the last documented temperature was on 05/19/25 at 6:24 PM. During a brief conversation with Director of Nursing (DON) on 06/26/25 at 12:50 PM, The DON was asked to show where the staff are documenting temperatures for Resident #43. The DON looked in the resident's record. After looking in the record, the DON stated I don't see any temperatures documented prior to 05/19/25.During an interview on 06/26/25 at 12:53PM, Staff J, Registered Nurse (RN), when asked where they document the vital signs for a resident, Staff J went to the computer and as viewing a resident's record she stated, Some residents have an order on the Medication Administration Record (MAR) to document vital signs every shift, otherwise it's documented in the vitals tab in the resident's record. When asked where they documented the vital signs for Resident #43, Staff J stated, under the vital signs tab. When asked where the vital signs obtained today for Resident #43 were documented, Staff J, while looking at the resident's record, stated right here. When asked, according to what was documented, when was the last time Resident #43's temperature last taken, Staff J stated, on 05/19/25. She was asked if the resident is currently being treated for a respiratory infection and she said yes. When asked what vital sign is important to check when a resident is on an antibiotic, Staff J stated, The temperature. When asked what Resident #43's temperature was today, she stated I didn't check it. Review of a progress note dated 06/25/25 at 12:37 PM, written by Staff J, documented that Resident #43 was on Levaquin [antibiotic] for Pneumonia with no fever. Further review of the resident's record did not reveal a documented temperature taken on the Resident #43 on 06/25/25. 2. Record review revealed that Resident #98 was admitted to the facility on [DATE]. Review of the quarterly comprehensive assessment dated [DATE] documented a Brief Mental Status Interview (BIMS) score of 09 on a 0-15 scale, indicating severe cognitive impairment. There were documented medical diagnoses of history of Pleural Effusion (fluid in the lungs and chest) and Acute Asthma (airway become inflamed). Review of a progress note dated 06/20/25 written by the attending physician revealed that she saw and examined Resident #98 and the resident continues to have coughing and wheezing. The physician's plan was for the resident to see a pulmonologist and for staff to continue administering breathing treatments as needed to the resident. A second progress note written by staff, dated 06/21/25 at 6:30 PM, revealed that Resident #98 had a productive cough and complained of a sore throat. Review of a progress note dated 06/22/25, indicated that the attending physician gave an order instructing staff to administer Levaquin (antibiotic) 750mg daily for 7 days to treat pneumonia. Review of a progress note dated 06/25/25 at 1:02 PM, Staff J, RN, documented Resident #98 was taking Levaquin 750 mg for Pneumonia with no fever or allergic reaction. There was no documentation by Staff J of her checking the resident's temperature on 06/25/25. Review of the vital signs documented for Resident #98 indicated that the last temperature checked on this resident was on 06/17/25. Photographic Evidence Obtained. 3. Record review revealed Resident # 66 was admitted on [DATE] with diagnoses that included Cardiac Arrest, Respiratory Failure with unspecified Hypoxia, Tracheostomy status, Anoxic Brain Damage, and Persistent Vegetative state. Review of the annual Minimum Data Set (MDS) assessment, dated 06/02/25, for Resident #66, under Section C of the Brief Interview of Mental Status (BIMS) score was disabled by questions B0100 and C0100, revealing a zero (0), indicating severe cognitive impairment and the resident is rarely/never understood. Review of the physician orders for Resident #66, dated 05/08/25, revealed an order for: Enalapril Maleate oral tablet, 2.5 milligram (mg), give 2.5 mg via g-tube two times a day for hypertension, hold for systolic blood pressure (BP) less than 90. Review of a nursing care plan goal dated 10/24/24 revealed Resident #66 is ventilator dependent related to perfusion deficit. The interventions for Resident #66 included the following: remain hemodynamically stable through the review date, remain free of complications related to decreased cardiac output, pneumothorax, subcutaneous emphysema, decreased renal perfusion, increased ICP, and hepatic congestion through the review date. Review of the June 2025 Medication Administration Record (MAR) revealed no documented BP during the 8:00 AM and 4:00 PM for the Enalapril administrations on 06/08/25, 06/09/25, 06/10/25 and 06/11/25. There were check marks and nurses' initials indicating Enalapril was administered at those dates and times by staff Nurses. In an interview with the Assistant Director of Nursing (ADON) on 06/24/25 at 9:47 AM, who when asked if BP parameters are documented in resident's MAR, responded, BP including other vital signs are documented in the provided spaces in MAR. He stated that staff Nurses document the vital signs, and bp parameters in MAR for antihypertensive medications. An interview was conducted with Staff Y, Registered Nurse (RN), on 06/25/25 at 04:00 PM, who has been working in the facility for a year, and who when asked what check marks on the top of nurse's initials mean parallel to the medication on MAR, responded, The medication was administered by the nurse with the initials present on MAR. The check mark indicated the medication was administered. An interview was conducted with Staff J, RN, on 06/25/25 at 4:10 PM, who when asked if the medications were administered to Resident #66 on the above dates, responded, Upon checking the e-MAR, it revealed an 0 indicating the medications were administered on the above dates. She added that when a medication was not administered, nurses write the reason on the progress notes. Staff J checked Resident #66's progress notes and stated there were no written notes indicating the medication was not administered on the dates mentioned. She also checked Resident 66's admission date which she stated was in 2023. Saff J stated Resident #66 was readmitted on [DATE], indicating the resident has not left the facility since then, so there was no reason why the Enalapril medication was not administered. She verified that the nurses did not document the vital signs and BP in the MAR, when the medication was administered on the above dates.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it followed the physician's order for splints in order to prevent further decline in range of motion (ROM) for 2 of 2 sampled residents observed, Resident #53 and Resident #44.The findings included:Review of the facility policy, titled, Policy and Procedure - Range of Motion (ROM) Splints, Braces, Orthotics, provided by the Director of Nursing (DON), revised 10/26/23, documented in the Policy Statement: Residents identified as a risk for contractures will have ROM program .which includes the programs provided to prevent contractures and keep joints as limber as possible . Splints, braces and orthotics will be applied according to manufacturer's instructions and/or instructions from physical and occupational therapy .Purpose: To maintain a resident's ability to move a joint through its normal range of movement and perform activities of daily (ADL). To prevent pain, discomfort, swelling and stiffness when joint movement is limited or contracted. To prevent contractures and to provide comfort and support for a joint and prevent pain in an already deformed/contracted, weak joint Splints/Braces Orthotics .Nursing staff will: Prepare joint for splint - proper alignment, ROM, warm water soak when indicated. Always inspect skin carefully before application and after removal. Be gentle and move slowly when applying devices .Caution to not pull strap too tight. Allow your fingers to comfortably fit in between device and skin. Report all skin problems, redness, swelling, pain or changes in fit to nurse and therapy immediately. Follow the device schedule according to therapy instructions. Store splints in a consistent place away from heat sources. Follow manufacturer's instructions for cleaning. Document according to facility protocol. Follow applications of splints, braces and orthotics according to a manufacturer's Physical and Occupational Therapy instructions .Record review revealed Resident #53 was originally admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Traumatic Brain Injury and Orthostatic Hypotension. She had a Brief Interview Mental Status (BIMs) score of 00, indicative of severe impairment. On 02/01/25 the physician's order documented for Adaptive Equipment: Right Blue comfy elbow and Bilateral (Right and Left) Pink [NAME] hand splints to be worn from AM care to hours of sleep as tolerated. Review of Resident #53's care plan initiated 06/12/22 indicated Focus: Child has self-care deficit/inability to use call bell. She requires total assistance with bathing, hygiene, dressing, feeding, toileting, positioning and transfer related to Subdural Hematoma, Traumatic Cerebral Edema, Brain Herniation status post motor vehicle accident. She was admitted with multiple fractures including left clavicle, thoracic spice, Pubis Sacrum, status post bilateral Strokes, (Craniotomy 06/12/22, impaired functional range of motion to all extremities (Hypotonia). Interventions: Apply right comfy hand splint, left [NAME] splint and right elbow comfy to be worn after AM care until hours of sleep and with therapy Goal: Child's needs will be anticipated, and will be kept clean, dry, and comfortable on a daily basis thru next review date.On 06/23/25 at 10:10 AM during an observation conducted of Resident #53, it was observed the resident had bilateral hand contractures. Resident #53 was observed as not having her ordered elbow splints on and in place, nor her bilateral hand splints on and in place. There were no splints or braces noted at the bedside. Photographic Evidence Obtained. On 06/23/25 at 3:16 PM, during a second observation conducted of Resident #53, the resident was observed again with no ordered elbow splints in place and no bilateral hand splints in place. There were none noted at the bedside.On 06/24/25 at 10:12 AM during a third observation conducted of Resident #53, the resident was again observed with no ordered elbow splints on and no bilateral hand splints on and none noted at the bedside.On 06/24/25 at 1:39 PM during a fourth observation conducted of Resident #53, she was now observed sitting up in her wheelchair in her room and she did not have her ordered elbow splints on, no bilateral hand splints on, and still none noted at the bedside.On 06/25/25 at 11:18 AM during a fifth observation conducted of Resident #53, she was observed resting in bed in her room. The observation revealed no ordered right elbow splint on, no bilateral hand splints on, and still none noted at the bedside.On 06/25/25 at 11:15 AM during an interview conducted with Staff Q, Physical Therapist (PT), who was Certified in Neurodevelopmental treatment (C/NDT), and who had previously worked with this resident in the past, she stated that Resident #53 had not displayed any behaviors that would prevent her from providing care to the resident.On 06/25/25 at 11:45 AM during an interview conducted with Staff O, Certified Nursing Assistant (CNA), she also indicated that Resident #53 had not exhibited any behaviors, to her knowledge, that would prevent her from providing care to the resident. Staff O also stated that the resident's two (2) hand splints and a right elbow splint, were kept in her closet, across from her bed, down inside of a bin. Staff O acknowledged that Resident #53 was not currently wearing any splints to her hands or right elbow at the time. Staff O stated the last time she recalled seeing Resident #53 wearing her splints was during the last week, Friday, June 06/20/25. Computerized record review of the Treatment Administration Record (TAR) for Monday 06/23/25 and for Tuesday 06/24/25, indicated that Resident #53's bilateral hand splints and her right elbow splint, had been checked and initialed as if they had been put on and in place, for both days. Observation revealed they had not been placed on the resident.During an interview conducted on 06/25/25 at 12:37 PM with Staff P, Registered Nurse (RN), she indicated Resident #53 had not exhibited any behaviors, that would prevent her from providing care to the resident. Staff P also acknowledged that Resident #53 had not currently been wearing any splints to her hands or right elbow. She added that the last time she saw the resident wearing her hand splints and right elbow splint was last week. On neither of the above two (2) days during this survey, had nursing or therapy staff been observed as having placed Resident #53's bilateral hand splints, or her right elbow splint on. On 06/25/25 at 11:25 AM, an interview was conducted with Staff R, Occupational Therapist (MOTR/L), who indicated Resident #53 had not exhibited any behaviors, while she was providing care to her on Wednesday 06/18/25 last week. She stated the resident was agreeable to treatment with no issues. Staff R stated the resident was not currently wearing any splints to her hands or right elbow. She stated she had not worked with Resident #53 for the past two (2) days. Staff R acknowledged there were no entry notations to document that Resident #53 had been seen by OT on Monday 06/23/25 or on Tuesday 06/24/25. Staff R stated the last time Resident #53 was documented as having had her hand splints and right elbow splint on was on Thursday 06/19/25, one (1) week ago. On 06/25/25 at 11:49 AM, an interview was conducted with the Director of Therapy, who stated Resident #53 has not exhibited any behaviors that would interfere with her providing care to her. The Director stated the resident was not currently wearing any splints to her hands or right elbow now, but she did not know why she was not wearing them. She stated the last time she recalled Resident #53 wearing them was last week. There was no documentation reviewed in the past week or longer to indicate that there were any behaviors, issues or concerns, relating to this resident and the application of her bilateral hand splints or right elbow splint. There was no documentation noted to indicate that the application of Resident #53's splints had ever been poorly tolerated by the resident.The DON acknowledged on 06/25/25 at 1:25 PM that the resident's hand and elbow splints should have been applied to the resident, as ordered by the physician. 2. Record review revealed Resident #44 was readmitted to the facility on [DATE] with diagnoses of Hemiplegia, Adult Failure to Thrive, and Parkinson's Disease. Review of the Significant Change Minimum Data Set (MDS) assessment showed Resident #44 has a Brief Interview of Mental Status (BIMS) score of 06, indicating severe cognitive impairment. In an observation conducted on 06/24/25 at 9:00 AM, Resident #44 was observed in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splint in place. In an observation conducted on 06/24/25 at 10:40 AM, Resident #44 was observed in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splints in place.In an observation conducted on 06/24/225 at 12:35 PM, Resident #44 was noted in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splint in place. In an observation conducted on 06/24/25 at 2:30 PM, Resident #44 was noted in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splint in place. In an observation conducted on 6/24/2025 at 3:00 PM Resident #44 was noted in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splint in place. In an observation conducted on 06/25/25 at 9:00 AM, Resident #44 was noted in the room sitting on a chair. Closer observation showed that his left hand was very contracted with no splint in place. Review of the care plan dated 06/12/25 showed Resident #44 is risk for skin breakdowns related to impaired mobility. Resident #44 wears a left-resting hand splint. In an interview conducted on 06/24/25 at 4:20 PM with the Rehab Director, she stated that Resident #44 has a left-hand splint, which is placed on during the day and tolerated. It is usually during the day hours when the morning shift starts until before the morning shift is over. Nursing usually documents if the splint is provided in the Point Click Care (PCP) Electronic System. Resident #44 experiences contractions in his fingers, and the splint helps maintain skin integrity, ensuring that his fingers do not dig into the palms. According to the Rehab Director, it is usually the Certified Nursing Assistants who oversee the splint orders. In an interview conducted on 06/24/25 at 4:29 PM with Staff A, Licensed Practical Nurse (LPN), stated the splint is placed on Resident [#44] by the nurse or the Certified Nursing Assistant that is assigned to the resident. It is usually placed daily, right after morning care. When asked if it is documented anywhere in the Electronic Record, she said 'no'. She stated that she worked the morning shift today, and when asked if she had placed the splint on Resident #44 that morning, she replied, 'no'.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations interviews and record reviews, the facility failed to follow the professional standards of care, as evidenced by failure to verify gastrostomy placement, for 1 of 5 sampled residents on tube feedings, Resident #25. The findings included: Review of the American Society for Parenteral and Enteral Nutrition (ASPEN), Safe Practices for Enteral Nutrition Therapy revealed one of the recommendations to prevent aspiration related to enteral nutrition, is to verify that feeding tube is in proper position before initiating feedings. https://aspenjournals.onlinelibrary.[NAME].com/doi/full/10.1177/0148607116673053.Review of the facility's policy titled, Care and Treatment of Feeding Tubes, with a revision date of 04/01/24, revealed the facility is to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Additionally, license nurses will monitor and check that the feeding is in the right location, and that tube placement will be verified before beginning a feeding and before administering medications (6). Record review revealed Resident # 25 was admitted on [DATE] with diagnoses that included Tracheostomy Status, Unspecified effects of Drowning and non-fatal submersion, Dysphagia, Gastrostomy Status, Gastroesophageal Reflux Disease (GERD), Respiratory Disorders, and Anoxic Brain Damage.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] under Section C revealed the Brief Interview of Mental Status (BIMS) score for Resident #25 was disabled by questions C0100, indicating an attempt to conduct interview with the resident resulted to code 0 (zero), or a no, which indicated the resident is rarely/never understood. Review of the physician orders revealed the following: on 05/21/25, Enhanced Barrier Precautions (EBP) as indicated for percutaneous endoscopic gastrostomy (PEG)and tracheostomy tubes, every shift; on 04/29/25, enteral feed four times a day, to give 195 milliliters (mL) of Peptamen [NAME] 1.5, run over one hour per pump via gastrostomy (g) tube, and from 8:00 PM to 6:00 AM, give 105 ml/ hour for 10 hours of Peptamen [NAME], 1.5 overnight, to be infused via g tube by pump. Additional physician order revealed feeding pump may be turned off for care and treatment every shift. Review of the nursing care plan revealed Resident #25 is at risk for aspiration secondary to gastrostomy (g) tube dependency, tracheostomy placement, and diagnosis of Gastroesophageal Reflux Disease (GERD). Review of the nursing care plan interventions included the following: assess bowel sounds every shift; check gastrostomy (g) tube for patency and placement before administration of medication and flushes; and check g tube for patency before administration of feeding and flushes. An observation was conducted on 06/24/25 at 10:44 AM with Staff H, Licensed Practical Nurse, LPN, who stated she would give the feeding to the resident. Staff H put on yellow gown after performing hand hygiene, went straight to the resident who was sitting on a wheelchair, exposed the resident's G-tube and connected the ends of resident's G-tube to the end of tube feeding connector. Staff H did not disinfect the ends of both G-tube ports and the tip of the tube feeding. Staff H did not check for G-tube placement or assess Resident #25's bowel sounds.An interview was conducted with Staff H on 06/24/25 at 4:53 PM, who when asked what nurses do before administering feeding in a G-tube, replied, I should check the placement. She added that she only checks the G-tube placement in the morning and not during the next tube feedings. When asked if that was the facility's policy, she responded, I always check it only in the morning.An interview was conducted with Staff H on 06/26/25 at 3:04 PM, who when asked why she did not check the G-tube placement before administering the feeding to this resident, responded, I did not check the G-tube placement before administering the feeding, because when I do it in the morning, I do not need to check it again it during the next feedings. When she was asked how often she gets in-service training for G-tube care, she responded, I do not remember the dates. When asked if she documented any G-tube feedings in the progress notes, she responded, No, I do not write when I check for G-tube placement and residual in the progress notes. She added that there is no section in the Medication Administration Record (MAR) for her to write for any G-tube placement checks for residual and placement before medication and feeding administration.An interview was conducted with the Assistant Director of Nursing (ADON) on 06/26/25 at 03:13 PM regarding the care of a resident with a G-tube, who responded, I check for residual volume, and G-tube placement before feedings and medication administration. He added that it is standard practice. and he does not know if nurses in the facility are doing them. When the ADON was asked if the standards of practice for checking G-tube placement and residual volume before administering medications are included in the physician orders, he responded, I have not seen those orders for residents with G-tube feedings. He added that he writes events that happened to residents during tube feedings in the progress notes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to follow their policy for proper tracheostomy care for 1 of 3 resident (Resident #23), and failed to perform pre and post respiratory assessment for 1 of 3 sampled residents reviewed for tracheostomy care (Resident #695); failed to obtain written and care treatment orders for 1 of 5 sampled residents, Resident #53; failed to obtain oxygen therapy orders for 1 of 5 sampled residents, Resident #84; failed to perform pre and post assessments including vital signs for 1 of 5 sampled residents, Resident#695; and failed to properly store and maintain respiratory equipment and supplies for 3 of 5 sampled residents reviewed for oxygen therapy, Resident #31, Resident #6, and Resident #25.The findings included:Review of the policy titled, Tracheostomy Care-Suctioning with a revision date of 03/27/24, revealed the facility will ensure that residents who need respiratory care, including tracheal suctioning are provided such care consistent with professional standards of practice. The procedures included the following: raise the head of bed to 30-45 degree angle, using sterile technique, open the suction catheter kit and put on sterile gloves; consider the glove on your dominant hand sterile, and the non-dominant hand clean; using the non-dominant (clean) hand, pour the normal saline solution into the disposable sterile solution container; remove the suction catheter from it's wrapper with dominant (sterile) hand, coiling it to keep it from touching a non-sterile object; and document procedure and any significant findings. Review of policy titled, Respiratory Care Manual with an effective date of 07/18, revealed the following: respiratory equipment shall be changed as scheduled to control bacterial inoculation of respiratory therapy equipment; oxygen tubing is to be changed every Monday and as needed if grossly soiled (8); all equipment shall be labelled with name, date and therapist's initials (11). Review of policy titled, Purpose: Medical Equipment Cleaning, Storage, Distribution and Repair, revealed the Respiratory Department (if appropriate) will be responsible for all respiratory equipment distribution.1. Record review revealed Resident #23 was admitted on [DATE] with diagnoses that included Arnold Chiari Syndrome with Spina Bifida and Hydrocephalus, Severe Intellectual Disabilities, Respiratory Failure and Anoxic Brain Damage. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], under Section C of the Brief Interview of Mental Status (BIMS) score for Resident #23 revealed an attempt to conduct an interview resulted to a code 0 (zero), indicating no, and the resident is rarely/never understood.Section GG revealed Resident #23 was dependent on chair-to-bed-to-chair (wheelchair) transfer. Section O revealed yes responses to both suctioning and tracheostomy care. Review of the physician orders dated 05/21/25 revealed Enhanced Barrier Precautions (EBP) as indicated for Percutaneous Endoscopic Gastrostomy (PEG) tube and tracheostomy, every shift. During an observation on 06/23/25 at 10:00 AM, Resident #23 was awake and sitting in wheelchair. A tracheostomy was observed in front of the neck which was open to air and not attached to an oxygen supply. During a tracheostomy care on 06/24/25 at 4:41 PM, the following were observed:Staff F, Respiratory Therapist, (RT), prepared the supplies on top of resident's meal table without first disinfecting the area. Staff E, RT stated she would help Staff F. Both Staff performed handwashing and donned Personal Protective Equipment (PPE) gown and clean gloves. Resident #23 was inside the crib and lying flat with rails of crib up on both sides.Staff F opened the tracheostomy kit, put a wrapped, unopened sponge dressing over the newly opened sterile tracheostomy kit. When asked why he did that, he stated that is how he always does it. He removed the still wrapped sponge gauze dressing from the top of the tracheostomy kit and put it to the side. Staff F, with clean gloves, approached the resident's bed and started manipulating the neck collar without informing the resident what he was planning to do. The resident remained flat in bed and the crib side rails were up. Staff E, RT stated she would try to hold the tracheostomy tube while Staff F, RT was cleaning and changing the tracheostomy collar and dressing around the resident's neck. Staff E put on sterile gloves but did not maintain sterility. She was touching parts of her wrist with the sterile right-gloved hand, during the donning of the left-hand glove. When Staff E was asked if she maintained one dominant hand sterile, she replied, yes. When asked why she touched the wrist of her left hand with the supposedly sterile right-gloved hand, she went and removed both gloves but did not maintain sterility as well after putting on a new set. When the gloves were both on, she picked up the glove's wrapper using the right hand and touched the crib with her left hand. Staff E went and stayed next to Resident #23's left side and held the tracheostomy tube (crib rails were up, and the resident still lying flat), while Staff F was changing and cleaning the neck collar using dressing wet with saline, dry dressing and a new neck collar found inside the opened tracheostomy kit. Staff F placed a split dressing under the tracheostomy opening.After changing the neck collar and the dressing, Staff F removed his gloves, performed hand hygiene, and opened a tracheostomy suction catheter / cannula kit on the left side of Resident #23's bed. He picked up the right sterile glove from the kit and put it on his right hand, then with the supposedly sterile right gloved hand, he touched his bare left hand with the right gloved hand, while donning the left glove. He did not change his gloves and proceeded. When both gloves were on, the opening flap of the suction cannula kit went back to its original position, so Staff F, using his left hand, opened the flap and grabbed the suction cannula inside using his right hand. When asked if he would change his gloves, he replied, no. He inserted the end tip of the catheter / cannula from the kit into the suction tubing. Staff E turned on the suction switch, then Staff F started to put in the end tip of catheter / cannula inside Resident #23's tracheostomy. Staff F stated, he needed saline. Staff E gave him an unopened saline container. Staff F opened the saline using his right hand while his left hand was holding the suction tubing and the saline container. He placed a drop of saline directly on the tracheostomy opening with the resident lying flat and inserted the cannula to suction one more time using his left hand. When done, both staff were asked if they followed the tracheostomy policy, and they both responded, yes. When Staff F was asked if tracheostomy suctioning is done after changing the neck collar and neck dressing, both did not reply. Record review of respiratory progress notes did not indicate the resident's position during the procedure, and the practice of sterility during suctioning of the tracheostomy tube.In an interview conducted with Staff M, Registered Respiratory Therapist (RRT) and Staff N, Certified Respiratory Therapist (CRT), when asked if they must use sterile technique when performing tracheostomy tube suctioning, replied, We use sterile gloves on our dominant hands when suctioning, and our non-dominant hands are used for other things like pouring solution and connecting the ends of tubing. When asked regarding tracheostomy care, which one is done first, the changing of neck collar and dressing or the suctioning, both replied, Suctioning is done first, second is giving treatments, and lastly the changing of collar and dressing around the collar.When they were asked about the maintenance of oxygen concentrators, Staff M, RRT, stated that the concentrator is checked by the facility's maintenance and when it is not working, the Staff RT will put a sticker into it indicating it is defective. Staff M, RRT added, Everything and all concentrators are working here. If something goes wrong with the concentrator, the RT calls the maintenance.2. Record review revealed Resident #31 was admitted on [DATE] with diagnoses that included Cerebral Palsy (an abnormal development or damage to parts of the brain), Gastro Esophageal Reflux Disease without Esophagitis, Persistent Vegetative State, Hypoxic Ischemic Encephalopathy (a brain injury caused by oxygen and blood flow deprivation), and Tracheostomy Status. Review of the MDS assessment dated [DATE] revealed Section C for the BIMS score for Resident #31 was not attempted. Section O revealed yes responses to both suctioning and tracheostomy care. Review of the physician's orders dated 05/24/25 included oxygen as needed up to 6 liters per minute (LPM) via cool aerosol to maintain saturation of greater that 90%; notify the nurse and the physician if the resident needs 6 LPM for more than 1 hour. Review of the care plan dated 05/29/25 revealed Resident 31 was at risk to develop pneumonia, acute respiratory infections, aspiration, tracheitis and atelectasis secondary to tracheostomy tube and gastrostomy tube placement. During an observation on 06/23/25 at 12:10 PM, there was an Ambu bag (a handheld bag valve mask {BVM} use to provide positive ventilation) on the foot part of Resident #31's bed. The Ambu bag was not contained, was directly on top of resident's bed linen, was not labelled nor dated. During another observation on 06/25/25 at 11:39 AM, Resident #31's oxygen tubing was dated 06/12/25 (11 days old). The tubing was connected to the tracheostomy system. In an interview conducted with Staff F, RT, on 06/24/25 at 5:15 PM, when asked how often the suction tubing and the suction canister are changed, responded, Weekly and when necessary, like when they smell bad. He added that oxygen tubing is changed every Sunday night. When asked how the Ambu bags should be contained and stored next to resident's area, he added It should be contained in a plastic bag. When asked if the Ambu bag should be left on resident's bed, he responded, No, Ambu bags are always contained and stored in bags when not in use, on the back of resident's wheelchair, or at bedside for easy access during emergency. In an interview with Staff M, RRT, on 06/25/25 11:47 AM, he stated the oxygen tubing is changed every Sunday. He added that respiratory staff put a sticker label on respiratory system tubing and supplies with typewritten staff initials and date. 3. Record review revealed Resident #6 was admitted on [DATE] with diagnoses that included Spastic Quadriplegic Cerebral Palsy, Severe Hypoxic Ischemic Encephalopathy, Dysphagia, and Tracheostomy Status. Review of the quarterly MDS assessment dated [DATE], under Section C for BIMS, revealed it was disabled by questions B0100 and C0100 indicating it was attempted, and resident was able to do the following: able to report correct year, able to report correct month, but did not generate a BIMS score. Section O revealed yes responses to oxygen therapy, suctioning and tracheostomy care.Review of the physician orders revealed the following: on 06/08/25, oxygen as needed, up to 6 LPM via tracheostomy to maintain oxygen saturation of greater than 90%, if oxygen needs exceeded 5 LPM, notify physician; Enhanced Barrier Precautions (EBP) as indicated for percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy tube every shift; and on 01/13/22, tracheostomy care twice daily and as needed every shift.Review of the care plan revealed Resident #6 has an artificial airway, and he is at risk for decannulation, pneumonia, acute respiratory infections, aspiration, further tracheitis and atelectasis. Some interventions included: administer respiratory treatments and chest physiotherapy (CPT) as ordered, provide oxygen as ordered, assess lung sounds every shift, monitor oxygen saturation as ordered, and suction as needed. During an observation conducted on 06/23/25 at 9:23 AM, an Ambu bag and emergency respiratory system were noted on the foot part of the resident's bed. The system was not labelled, dated and not contained in a bag. They were directly touching the bed linen. Further observation revealed an oxygen tubing connected to the resident's tracheostomy system had a date of 06/15 (8 days old). During an observation conducted on 06/25/25 at 11:42 AM, the oxygen tubing remained with a date of 06/15 (10 days old). 4. Record review revealed Resident # 25 was admitted on [DATE] with diagnoses that included Tracheostomy Status, Unspecified effects of Drowning and non-fatal submersion, Dysphagia, Gastrostomy Status, Respiratory Disorders in Diseases classified elsewhere, and Anoxic Brain Damage. Review of the quarterly MDS assessment dated [DATE] under Section C revealed the BIMS score for Resident #25 was disabled by questions C0100, indicating an attempt to conduct interview with the resident resulted to a code 0 or a no, indicating resident is rarely/never understood. Review of the physician orders revealed the following: oxygen up to 6 liters as needed via tracheostomy, to maintain oxygen saturation greater than 90%; tracheostomy care twice daily and as needed; and Albuterol Sulfate nebulization solution (2.5 milligram {MG/3 milliliters (ML}) 0.083% 3 ml via tracheostomy every 4 hours as needed for shortness of breath and wheezing.Review of the respiratory progress notes dated 06/23/25 revealed the resident remained in good condition without respiratory distress; all vital signs are within normal range; all medications and treatments given as ordered without side effects. Review of the respiratory progress notes dated 06/18/25 revealed the resident was saturating at 100%, tracheostomy collar in place, tracheostomy care was done; secured and intact; all treatment was given and emergency equipment at bedside.During an observation conducted on 06/23/25 10:14 AM, Resident #25 was sitting in a wheelchair next to an oxygen concentrator which had an electrical safety inspection date of 05/2024, due on 05/2025, with serial number 873330. The oxygen tube was coiled sitting on top of the concentrator. It was unlabeled, undated, and not contained in a bag. During an observation conducted on 06/24/25 at 11:56 AM, the concentrator had the same electrical safety inspection due date with serial number 873330. There was no oxygen tubing on top of the concentrator.In an interview conducted with the Maintenance Director on 06/24/25 at 2:30 PM, he stated that Cypress Medical LLC performs the checking of all oxygen concentrators every 6 months. He added that it is not part of his job to check the oxygen concentrators, but part of the Biomedical Engineer staff's job. In an interview with the Administrator on 06/24/25 at 3:00 PM, he stated the list of all oxygen concentrators used in the facility would be provided. A provided 3-page report titled, Annual Concentrator PM Inspection dated 05/29/25, stated that these tests maintain compliance for a period of one year from testing date. All 3 pages contained concentrator that passed the testing inspection performed by [NAME] of Cypress Medical. The list did not include the oxygen concentrator next to Resident #25's crib.An interview was conducted with the Respiratory Director on 06/25/25 at 12:15 PM, who when asked about undated and unlabeled respiratory supplies, responded, All must have stickers, with date and RT staff initials, indicating RT staff checked and changed them. When she was asked how often respiratory oxygen tubing and system are changed, she responded, Weekly and as needed. When she was asked if RT staff make sure all respiratory systems are monitored and checked every shift, she responded. Staff monitor all respiratory system, and equipment as often as possible. When she was asked about oxygen concentrators, she responded, The Maintenance staff check and maintain them. When she was asked about emergency respiratory supplies storage and maintenance, she responded, All are stored in the bag when not in use. 5. Review of the facility policy titled, Policy and Procedure Braces , provided by the Director of Nursing (DON) revised 10/26/23, documented in the Policy Statement: .braces will be applied according to manufacturer's instructions .Purpose: To prevent pain, discomfort, swelling and stiffness .Braces .Nursing staff will: Always inspect skin carefully before application and after removal. Be gentle and move slowly when applying devices .Caution to not pull strap too tight. Allow your fingers to comfortably fit in between device and skin. Report all skin problems, redness, swelling, pain or changes in fit Document according to facility protocol. Follow applications of braces according to a manufacturer's instructions .Record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses which included Cerebral Palsy, Traumatic Brain Injury and Orthostatic Hypotension. She had a Brief Interview Mental Status (BIMS) score of 00, indicative of severe impairment; the child is non-verbal and unable to verbalize her needs or distresses.On 01/30/25, the Physician's Order documented for Tracheostomy (Trach) Stoma Care: Clean with normal saline, pat dry and cover with dry dressing every shift.During an observation conducted on 06/23/25 at 10:07 AM, it was observed that Resident # 53 was wearing a Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck, with no dressing observed at this site; potential choking hazard. Photographic Evidence Obtained. There were no new current specific written physician's orders noted in the record, pertaining to the Velcro Trach collar/strap brace, to indicate that it needed to be checked and that the resident's skin needed to be assessed, nor were there any directives for care and treatment of such. On 06/23/25 at 3:16 PM during a second observation of Resident #53, she was still observed wearing the Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck, with still no dressing observed at this site. There were no new current written specific physician's orders noted in the record, pertaining to the care and treatment of the Velcro Trach collar/strap brace. On 06/24/25 at 10:21 AM during a third observation of Resident #53, she was observed to have a new/different undated Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck, with still no dressing observed at this site. There were no new current specific written physician's orders noted in the record, pertaining to the care and treatment of the Velcro Trach collar/strap brace. An interview was conducted on 06/24/25 at 1:22 PM with Staff S, Registered Respiratory Therapist (RRT), in which he checked the record and stated that RRTs do not do any daily routine treatments for Resident #53. He indicated that all tracheostomy care is performed by the nurses. Staff S added that the Tracheostomy care change is done twice per month by the RRTs on every 15th and 27th of the month. On 06/24/25 at 1:39 PM during a fourth observation of Resident #53, she was observed sitting up in her wheelchair in her room and noted as wearing a new/different undated Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck. There were no new current specific written physician's orders noted in the record, pertaining to the care and treatment of the Velcro Trach collar/strap brace. An interview was conducted on 06/25/25 at 12:50 PM with Staff P, Registered Nurse (RN), who indicated Resident #53 had not exhibited any behaviors while she was providing care to her. Staff P acknowledged there was no current order in Point-Click-Care (PCC) for nursing to provide care and treatment for Resident #53's Velcro Trach collar/strap brace which was located just above the child's open Trach stoma site and wrapped around her neck. Staff P stated she had not changed or provided care to this child's Velcro Trach collar/strap brace. She stated the Respiratory department was primarily responsible for doing this. Staff P stated if nursing were to see something that was an issue or concern, that they would address it as well.On 06/25/25 at 12:59 PM, an interview was conducted with Staff T, Certified Respiratory Therapist (CRT), who indicated Resident #53 had not exhibited any behaviors, while he was providing care to her. Staff T stated that the following physician's order was written for Stoma Care: Clean with normal saline, pat dry and cover with dry dressing every shift and as needed. He acknowledged that currently there was no order in Point-Click-Care (PCC) for RT to provide care and treatment for the child's Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck. Staff T went on to say that he had not changed nor provided care to this child's Velcro Trach collar strap/brace, because he responded, he was not in the facility, and that sometimes, depending on how the child feels, she may take off the gauze, that would be put in place underneath this Velcro Trach collar/strap brace. Staff T was unable to show written documentation of the child having taken off the gauze, nor was he able to show any documentation of whether or not this child's skin underneath was being checked and assessed. There was no evidence to indicate that the Velcro neck collar/strap brace was being checked for proper fit and tightness. Staff T stated that it was the RT department's responsibility to change this.An interview was conducted with the Director of Respiratory Therapy, on 06/25/25 at 1:21 PM, who stated Resident #53 had not exhibited any behaviors, to indicate that she nor her staff were unable to provide care to this child. The Director indicated that she did not know if there currently was an order to provide care and treatment for the child's Velcro Trach collar/strap brace located just above the child's open Trach stoma site and wrapped around her neck. She stated it was her understanding that the nurses watch for any type of wound care and then their department would take over the care. The Director acknowledged that her staff have changed or provided care to this child's Velcro Trach collar/strap brace She stated on the Respiratory Administration Record (RAR), the RTs (who were responsible for the respiratory care) had been initialing that the stoma care was being provided on a daily basis to this child. The Respiratory Director was unable to show or provide any written documentation of the child having taken off the gauze, nor was she able to show any documentation of whether or not this child's skin underneath was being checked and assessed. There was no evidence to indicate that the child's Velcro Trach collar/strap brace was being checked for proper fit and tightness.Record review of Resident # 53's care plan initiated 01/29/25 indicated Focus: Child was decannulated at the Hospital Interventions: Clean trach stoma with normal saline, dry and cover with dry dressing, every shift for Trach stoma removal Universal Precautions as appropriate. Goal: Child will have no abnormal drainage around trach site through the review date.Record review of Resident #53's care plan initiated 06/12/22 indicated Focus: Child has self-care deficit/inability to use call bell. She requires total assistance with bathing, hygiene, dressing, feeding, toileting, positioning and transfer related to Subdural Hematoma, Traumatic Cerebral Edema, Brain Herniation status post motor vehicle accident. She was admitted with multiple fractures including left clavicle, thoracic spice, Pubis Sacrum, status post bilateral Strokes, (Craniotomy 06/12/22, impaired functional range of motion to all extremities (Hypotonia). Interventions: Preventative and protective skin care as ordered/indicated .Goal: Child's needs will be anticipated, and will be kept clean, dry, and comfortable on a daily basis thru next review date.There was no documentation reviewed within the past week or more, to indicate that there were any behaviors, issues or concerns, relating to this child and her stoma site. There was no written documentation provided to show that Resident #53 had ever taken off the gauze, or any documentation indicating what the condition of the child's skin underneath, nor whether or not it is being checked and assessed and neither to show that the Velcro Trach collar/strap brace was being checked for proper fit and tightness.The Director Of Nursing (DON) further recognized and acknowledged on 06/26/25 at 1:35 PM that the resident's skin on her neck underneath the Velcro Trach collar/strap brace should have been checked and assessed and the resident's condition or status needed to be documented.6. Review of the facility policy titled, Oxygen Administration, provided by the DON reviewed/revised documented in the Policy Statement documented: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences .Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician Record review revealed Resident #84 was admitted to the facility on [DATE] with diagnoses which included Hypertension, Seizure Disorder and Respiratory Failure. She had a Brief Interview Mental Status (BIM) score of 00, indicative of severe cognitive impairment.Review of the physician orders dated 04/25/25 indicated: Bivona 4.0 L= 49 Tracheostomy change monthly & as needed (PRN) and Tracheostomy care twice daily & as needed. Medical Doctor Ventilator orders: Synchronized Intermittent Mandatory Ventilation/Pressure Controlled (SIMV/PC): Rate 28, PC 22, Pressure Support Ventilator (PSV) 11, Positive end-expiratory pressure (PEEP) + 8, Inspiratory Time (TI) 0.8, Peak Inspiratory Pressure (PIP) 30; Titrate oxygen to maintain Oxygen Saturation (SpO2) 90% or >.On 06/24/25 at 9:43 AM, during an observation, Resident #84, was observed with a Tracheostomy and on a Ventilator, had liquid Oxygen infusing at six (6) liters, as verified by Staff D, Registered Respiratory Therapist, who had currently been in the resident's room, providing respiratory care, to her. Computerized record review revealed there was no actual specific previous or current physician's order on file for Resident #84's liquid oxygen therapy, in order to specify the maximum/up to number of liters to provide. There was no documentation noted in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) of this. On 06/24/25 at 2:52 PM, during an observation, Resident #84 was observed with a Tracheostomy and on a Ventilator still had liquid Oxygen infusing at six (6) liters.There was still no actual specific previous or current physician's order on file for Resident #84's liquid oxygen therapy, in order to specify the number of liters to provide. There was no documentation noted in the MAR or in the TAR, of this.On 06/25/25 at 11 AM, during an observation, it was noted that Resident #84, was with a Tracheostomy and on a Ventilator now had liquid Oxygen infusing at five (5) liters.There was still no actual specific previous or current physician's order in the record for Resident #84's liquid oxygen therapy, to specify the maximum/up to number of liters to provide. There was no documentation noted of this in the MAR or in the TAR.An interview was conducted on 06/25/25 at 12: 15 PM with Staff U, Registered Nurse (RN), who stated Resident #84 was currently receiving five (5) liters of liquid Oxygen; with an Oxygen saturation currently at 97%. Staff U acknowledged there was no actual specific physician's order for Resident #84's liquid Oxygen Therapy, to be in place. Staff U stated there should have been a physician's order in place with exactly what the parameters should be there, but she did not know why it was not there.During an interview on 06/25/25 at 12:25 PM with Staff D, she stated Resident #84 was currently receiving five (5) liters of liquid Oxygen; with an Oxygen saturation currently at 96%, heart rate was 133 and respiratory rate was 28. Staff D acknowledged there was no actual specific physician's order for liquid Oxygen Therapy, in place, that specified the maximum/up to number of liters and outlining the exact parameters to provide, for the resident. She stated she did not know why the order was not there, but she would enter it now. During an interview conducted with the Director of Respiratory on 06/25/25 at 12:40 PM, she stated Resident #84 was now currently receiving four (4) liters of liquid Oxygen; with an Oxygen saturation currently at 96%. She acknowledged there was no actual specific physician order for Resident #84's liquid Oxygen Therapy, to specifying the maximum/up to number of liters and to outline the exact parameters to provide. She stated a new order had been entered for clarification. The Director stated this was an over-sight, and that she had just missed it.Record review of the Resident #84's care plan initiated 08/12/24 indicated Focus: Baby has Oxygen therapy related to ineffective gas exchange, Respiratory illness Interventions: Oxygen settings: Oxygen as needed Goal: The Baby will have no signs and symptoms of poor oxygen absorption through the review date.The DON further recognized and acknowledged on 06/25/25 at 12:52 PM that a physician's order must be obtained for Oxygen therapy administration. 7. Review of a policy titled Oral Inhalation Administration revised 2024, documented in part .Nebulizer-Administering Medications through a small volume handheld nebulizer. D. Obtain baseline pulse, respiratory rate and lung sounds. T. Obtain post-treatment pulse, respiratory rate and lung sounds and document findings [on the MAR or in the resident's medical record] Photographic Evidence Obtained. Record review revealed Resident #43 was admitted to the facility on [DATE]. Review of the quarterly comprehensive assessment dated [DATE] documented a Brief Interview Mental Status score of 14 on a 0-15 scale, indicating no cognitive impairment. Record review revealed a physician order for Resident #43 dated 06/24/25 that instructed the staff to administer ipratropium-albuterol [medication to treat breathing difficulty] 3 milliliters by nebulizer three times a day for shortness of breath and wheezing. Review of the MAR for the month of June 2025 indicated that the scheduled times to administer the medication to Resident #43 were 9:00 AM, 2:00 PM, and 9:00 PM. According to the documentation on the MAR, staff were administering the medication. Further review of the MAR did not instruct the staff to document pre or post vital signs and lung sounds when administering the breathing treatment as indicated in the facility's policy. Review of Resident #43 vital sign record or progress notes did not indicate that staff were checking her vital signs or lungs sounds pre or post administration of the nebulizer treatment. 8. Record review revealed Resident #57 was admitted to the facility on [DATE]. Review of the quarterly comprehensive assessment dated [DATE] documented a BIMS score of 15 on a 0-15 scale indicating no cognitive impairment. Review of the physician orders revealed an order dated 01/20/25 that instructed the staff to administer ipratropium-albuterol 3 milliliters by nebulizer every 6 hours as needed for shortness of breath and wheezing.During an interview on 06/25/25 at 1:30 PM, when asked 'how are you doing', Resident #57 stated I'm doing ok. I still have a lot of congestion, as she points to her chest. When asked 'have you been offered a breathing treatment', the resident stated, No, I haven't had one since yesterday. I guess I have to ask for it. Review of the MAR for the month of June 2025 indicated Resident #57 was administered a nebulizer treatment by staff on 06/24/25, 06/25/25, and 06/26/25. According to the documentation on the MAR, staff were administering the medication. Further r[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to provide accurate fluid consistency per the physician orders for thickened liquids for 1 of 3 sampled residents, Resident #408, as evidenced by the resident was provided liquids in the consistency that was not ordered for her. The findings included:1 Record review revealed Resident #408 was admitted to the facility on [DATE]. Review of the initial comprehensive assessment was still in progress and a Brief Interview Mental Status score was not yet documented. There was documented medical diagnoses history of Parkinson's disease (disorder affecting central nervous system) and dementia (memory loss) for Resident #408. Review of the physician orders revealed Resident #408, was on a regular diet that is to be mechanically soft, and the liquids should be of nectar (mildly thick, not thin) thickened consistency. During an observation on 06/23/25 at 12:27 PM, in the resident's room, Resident #408 was sitting up in bed, while being fed by Staff X, Certified Nursing Assistant (CNA). The resident had eaten 80% of her meal. Resident #408 was coughing a lot. When asked how the lunch was, she stated, I'm full. I can't eat anymore. Staff X had a cup of thickened water in her hand that she was attempting to assist the resident with drinking. There was an almost full cup of juice with ice cubes floating on top sitting on the tray, The ice cubes had changed the consistency of the nectar thickened juice. When Staff X was made aware of the ice cubes in the juice, she stated, I didn't give it to her. When asked where the juice came from, she stated, It was on the tray. The Dietician walked into the resident's room and stated she was checking to see how the resident did with eating lunch. At this time, the Dietician was made aware of the ice cubes in the cup of thickened juice. When asked whether Resident #408's juice should have ice cubes in it, the Dietician stated, No, I don't know what happened in the kitchen. Photographic Evidence Obtained.During an interview with the Dietitian, on 06/23/25 at 12:54 PM, she said the kitchen staff was educated on the ice being in Resident #408's thickened juice and the staff said it must have happened by an accident. The Dietitian was made aware of the risk of Resident #408 choking and that she was observed coughing a lot. She stated, I know, it's not an excuse, because it was unsafe for the resident. During an observation on 06/25/25 at 2:08 PM, Resident #408 was noted to have a sippy cup of thickened water with a straw sticking out of it, sitting on the bedside table next to her bed. Photographic Evidence Obtained. 2. Record review revealed Resident # 408 was admitted on [DATE] with diagnoses that included Parkinson's Disease without Dyskinesia (involuntary erratic, writhing movements of face, arms, legs or trunk), Recent Thoracentesis (a surgical procedure of removing excess fluids between the lungs and chest wall) related to Pleural Effusion, Acute Respiratory Failure with Hypoxia, and Atrial Fibrillation. Review of admission Minimum Data Set (MDS) assessment under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 13 indicating Resident #408 had intact cognition. Review of the physician orders dated 06/17/25 revealed a regular diet, minced, moist with mildly thick liquids. A nursing care plan review revealed Resident #408 has potential for weight loss and altered nutrition/hydration status. The interventions included providing a regular diet consisting of minced, moist with mildly thick liquids. A review of June 2025 MAR revealed a space for diet was filed with the following information: regular diet 5-minced and moist (mechanical soft ground) texture, 2-mildly thick (nectar thick) consistency. During a medication pass observation on 06/24/25 at 9:33 AM, with Staff L, Licensed Practical Nurse (LPN), who was observed to pour water into a plastic cup. The water was from a pitcher on medication cart 2. She brought this water inside Resident #408's room and provided it to the resident when oral medications were inside the resident's mouth. Resident #408 coughed as soon as she swallowed the water provided by Staff L, LPN. When Staff L, LPN, was asked why she gave the water from the medication cart, and not the thickened fluid which was on top of Resident #408's table and directly in front of the resident, she did not respond. When asked if she read the MAR before providing liquids to this resident, she did not respond. In an interview with the Assistant Director of Nursing on 06/24/25 at 9:47 AM, who when asked how Nurses would know that a resident needed thickened liquids during medication administration, responded, Thickened liquids orders should be written in Medication Administration Record (MAR). He added that every medication cart, must have a thickened liquid container for Staff to provide for residents with thickened liquid orders. When he was asked if he observed any thickened liquid container on Medication Cart 2, which was used by Staff L , LPN, he responded, This cart does not have any thickened liquids. He added that staff must have thickened liquids before starting medication administration to residents.

Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and sanitary conditions, and to prevent foodborne illnesses during two of the two visits to the main kitchen.The findings included:In a tour of the main kitchen on 06/23/25 at 7:58 AM with the Food Service Director, the following issues were noted:a. A round garbage bin was partially covered in the food production area.b. The reach-in freezer contained a yellow-colored frozen food item that was not labeled or dated. c. The reach-in freezer was noted with a box of frozen egg patties that was partially opened to the air and not sealed. d. The reach-in freezer noted five frozen meals of Pot Roast of Beef that did not have an expiration date or the date that they were placed in the reach-in freezer. e. The reach-in Traulsen refrigerator noted 46 fluid ounces of thickened cranberry cocktail, which expired on 06/05/25.f. The walk-in refrigerator was noted with a box of chicken thighs with the bag opened and exposed to the air, not sealed. g. The reach-in Frigidaire was stocked with two personal bottles of water, each 24 ounces. h. The dry storage room noted 46 fluid ounces of thickened cranberry cocktail, which expired on 06/05/25.In an observation conducted on 06/24/25 at 12:40 PM, in the second-floor pantry unit, two packs of vanilla pudding, 4 ounces each, were with an expiration date of 06/12/25. In a second tour of the main kitchen during the lunch tray line on 06/25/25 at 11:15 AM, the following was noted: The Food Service Director was taking the temperature of foods on the tray line using a facility-calibrated thermometer. He was observed putting his bare hands halfway into the food containers to take the temperature of the different foods. In an interview conducted on 06/26/25 at 3:00 PM with the facility's Administrator, he was told of the findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to maintain the infection control standards in the laundry room; failed to maintain a sanitary environment during tube feeding for 1 of one sampled resident, Resident #95; failed to maintain the infection control standards for Enhanced Barrier Precautions (EBP), for 2 of 64 sampled residents, Resident #19 and Resident #88; and failed to follow the Center for Disease Control and Prevention (CDC), EBP guidelines for 4 of 64 sampled residents, that included 56 adults and 8 pediatrics, Resident #31, Resident #6, Resident #23, and Resident #25. The findings included:Review of the Center for Disease Control and Prevention (CDC), Enhanced Barrier Precautions guidelines, revealed the following: Everyone must clean their hands, including when both entering and leaving the room: Providers and Staff must also wear gloves and a gown for the following; high-contact care resident care activities, dressing, bathing-showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting: Device care or use; central line, urinary catheter, feeding tube, tracheostomy: Wound care with any skin opening requiring a dressing. Website: https://www.cdc.gov/long-term-care facilities/media/pdfs/Review of the facility's Enhanced Barrier Precautions (EBP) policy with an implementation date of 04/01/24, revealed the following: EBP is an infection control intervention designed to reduce transmission of multi-drug-resistant organism; All staff receive training on EBP upon hire and at least annually and are expected to comply with all designated precautions.Review of the facility's policy titled, Care and Treatment of Feeding Tubes, with a revision date of 04/01/24 revealed the following: to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible; to use infection control practices and related techniques to minimize the risk of contamination (7.e).1. Record review revealed Resident #31 was admitted on [DATE] with diagnoses that included Cerebral Palsy, Gastro-Esophageal reflux Disease without Esophagitis, Hypoxic Ischemic Encephalopathy, Tracheostomy status, and Persistent Vegetative State. Review of the most recent Minimum Data Set (MDS) assessment, dated 06/02/25, under Section C of the Brief Interview of Mental Status (BIMS) revealed a score of 0, or a no, indicating Resident #31 is rarely/never understood indicating severe cognitive impairment. Review of the physician orders dated 05/25/25 revealed EBP is indicated for percutaneous endoscopic gastrostomy (PEG) tube and tracheostomy every shift; wound consult for the left knee; apply [NAME] bag (a closed enteral decompression system to allow evacuation of excess gas and drainage collection of enteral feeding formula) to g tube continuously, okay to clamp for 1 hour after medications were given. Review of the nursing care plan dated 02/13/25 revealed Resident #31 requires EBP related to tube feeding, tracheostomy and ventilator dependency. The nursing care plan goal was for this resident to be free from multi-drug-resistant organism (MDRO) through review date by the following interventions: ensure access to alcohol-based hand rub; perform hand hygiene before and after caring for this resident, provide education to the resident/ family, responsible party and visitors.During an observation on 06/23/25 at 9:13 AM, Resident #31's Ambu bag and emergency respiratory tube and supplies were on the bottom part of his bed. The system was not contained in the bag and was not dated.During the continuing observation conducted on 06/23/25 9:15 AM, Staff F, Respiratory Therapist (RT), who has been working in the facility for 5 years, did not perform hand hygiene when he entered the residents' room. The room had an EBP sign on the door. He touched the resident's Ambu bag and respiratory supplies on the foot part of the bed and dug inside a black bag, showing the surveyor of another Ambu bag was inside a plastic bag on 06/23/25 09:16 AM. Staff F left the room without performing hand hygiene and went into the next room. He did not perform hand hygiene before entering another resident's room and after leaving another resident's room. 2. Record review revealed Resident #6 was admitted on [DATE] with diagnoses that included Spastic Quadriplegic Cerebral Palsy, Vegetative State, Anoxic Brain Damage, Tracheostomy and Gastrostomy status.Review of the most recent MDS dated [DATE] revealed the BIMS score was disabled by questions C100, indicating resident is never/rarely understood, indicating severe cognitive impairment. Review of physician orders revealed the following: on 01/13/22, tracheostomy care twice daily & as needed; on 04/28/25, enteral feed; and on 05/21/25, EBP for PEG tube and tracheostomy every shift. Review of the nursing care plan dated 02/13/25 revealed a goal for Resident #6 to be EBP related to tube feeding, tracheostomy and ventilator dependency. The interventions included make gown, gloves and face protection available and use for high contact activities; ensure access to alcohol-based hand rub; and perform hand hygiene before and after caring for the resident. During observation on 06/23/25 09:23 AM, Resident #6's Ambu bag and emergency respiratory tube were on the on the foot part of his bed. The respiratory tubing and system were undated and not contained in a bag. The observation revealed the oxygen tubing had a date of 06/15 (8 days old).Staff F, RT, when he saw the Ambu bag and respiratory supplies on the foot part of the bed, gathered and put them in a bag. He did not perform hand hygiene before touching the respiratory supplies and after putting them in the bag. He did not perform hand hygiene before leaving the resident's room. 3. A record review revealed Resident #23 was admitted on [DATE] with diagnoses that included Arnold Chiari Syndrome (a structural defect in the brain where brain tissue extends into the spinal column) with Spina Bifida (a birth defect characterized by failure of the spinal cord to develop properly), and Hydrocephalus ( an abnormal buildup of cerebrospinal fluid within the brain's ventricles), respiratory Failure with Hypoxia, Anoxic Brain Damage, and Gastrostomy status. A review of recent MDS dated [DATE] revealed BIMS was disabled by C0100 indicating a score of 0 or no, resident is rarely/never understood. Section O revealed yes responses to suctioning and tracheotomy care. An additional review of physician orders revealed the following: suction oropharyngeal and nasopharyngeal airway as needed, every 4 hours; EBP as indicated for PEG tube and tracheostomy, every shift; tracheostomy care twice daily and as needed, and every shift; document tolerance of procedure in progress notes. A further review of Resident #23's nursing care plan dated 01/17/25 revealed goals to prevent the risk of decannulation, pneumonia, acute respiratory infections, aspiration, tracheitis, atelectasis and respiratory distress. The interventions were the following: assure tracheostomy collar is secured and maintain an open airway. During an observation conducted on 06/24/25 at 4:37 PM, Staff E, RT entered the resident's room without performing hand hygiene. She immediately put on a yellow PPE (personal protective equipment) gown.Staff F, RT , did not perform hand hygiene before entering the residents' room and did not disinfect the area where respiratory supplies were opened before tracheostomy care. During a tracheostomy care on 06/24/25 at 4:41 PM, the following were observed:Staff F, Respiratory Therapist, (RT) prepared the supplies on top of resident's meal table without first disinfecting the area. Staff E, RT stated she would help Staff F. Both staff performed handwashing and donned Personal Protective Equipment (PPE) gown and clean gloves. Resident #23 was observed inside the crib and lying flat with rails of crib up on both sides.Staff F, RT opened the tracheostomy kit, but put a wrapped, unopened sponge dressing over the newly opened sterile tracheostomy kit. Staff F contaminated the sterile supplies inside the kit by placing an unopened sponge dressing on top of it. When asked why he did that, he stated that is how he always does it. He removed the still wrapped sponge gauze dressing over the top of the tracheostomy kit and put it to the side. Staff F, while with clean gloves on, approached the resident's bed and started manipulating the neck collar of the trach without informing the resident what he was planning to do. The resident remained flat in bed and the crib side rails were up. Staff E stated she would try to hold the tracheostomy tube while Staff F was cleaning and changing the tracheostomy collar and dressing around the resident's neck. Staff E put on sterile gloves but did not maintain sterility, as evidenced by touching parts of her wrist with the sterile right-gloved hand, during the donning of the left-hand glove. When she was asked if she maintained one dominant hand sterile, she replied, yes. When asked why she touched the wrist of her left hand with the supposedly sterile right-gloved hand, she removed both gloves but did not maintain sterility as well after putting on a new set, as she picked up the gloves' wrapper using the right hand and touched the crib with her left hand. Staff E stayed next to Resident #23's left side and held the tracheostomy tube, while Staff F was changing and cleaning the neck collar using dressing wet with saline, dry dressing and a new neck collar found inside the opened tracheostomy kit. Staff F placed a split dressing under the tracheostomy opening.After changing the neck collar and the dressing, Staff F removed the gloves, performed hand hygiene, and opened a tracheostomy suction catheter/cannula kit on the left side of Resident #23's bed. He picked up the right sterile glove from the kit and put it on his right hand, then touched his bare left hand with the right gloved hand, while donning the left glove. He did not change his gloves and proceeded. When both gloves were on, the opening flap of the suction cannula kit went back to its original position, so Staff F using his left hand, opened the flap and grabbed the suction cannula inside using his right hand. When asked if he would be changing his gloves, he replied, no. He inserted the end tip of the catheter/cannula from the kit into the suction tubing. Staff E turned on the suction switch, then Staff F, RT started to put in the end tip of catheter/cannula inside Resident #23's tracheostomy. Staff F stated he needed saline. Staff E gave him an unopened saline container. Staff F opened the saline using his right hand while his left hand was holding the suction tubing and the saline container. He placed a drop directly on the tracheostomy opening (the resident remained lying flat), then inserted the cannula to suction one more time using his left hand. Both staff were asked if they followed the tracheostomy policy, and they both responded, yes. When Staff F was asked about his dominant hand, he stated, 'right'. When asked if tracheostomy suctioning is done after changing the neck collar and neck dressing, both did not reply. Review of respiratory progress notes did not indicate resident's position during the procedure, and the practice of sterility during suctioning of the tracheostomy tube.In an interview conducted with Staff M, Registered Respiratory Therapist (RRT) and Staff N, Certified Respiratory Therapist (CRT), when asked if they must use sterile technique when performing tracheostomy tube suctioning, replied, We use sterile gloves on our dominant hands when suctioning, and our non-dominant hands are used for other things like pouring solution and connecting the ends of tubing's. In an interview conducted with Staff D, RRT, on 06/26/25 at 10:43 AM, when she was asked how often respiratory and oxygen tubing connected to tracheostomy system are changed, responded, Oxygen solution and tubing systems are changed when it is empty and not based on specific time, and all oxygen tubings are changed every Sundays. She stated she lets her other co-workers know that tubings were changed because she put a yellow or a white sticker label with the date and her initials. She stated she also put a date on a tracheostomy collar.When she was asked how she performs tracheostomy collar care, she responded, I make sure the resident is sitting upright as tolerated.When she was asked regarding nebulizing treatment and supplies, she responded, I make sure I change the supplies every week. On Saturdays, I label it with a sticker so another Therapist will know it has been changed. She added that emergency respiratory supplies, like Ambu bags, are never placed on the resident's bed, but near the resident's bed with label. When she was asked to explain tracheostomy care, she responded, I wash my hands, put on clean gloves, assess resident's breathing, open the suction and the kit, practice sterile technique when opening suction catheter and tracheostomy kit, by assigning the dominant hand as sterile and non-dominant hand as clean. 4. Record review revealed Resident # 25 was admitted on [DATE] with diagnoses that included Tracheostomy Status, Unspecified effects of Drowning and non-fatal submersion, Dysphagia, Gastrostomy Status, Gastroesophageal Reflux Disease (GERD). Respiratory Disorders in Diseases classified elsewhere, and Anoxic Brain Damage.Review of the quarterly MDS assessment dated [DATE] under Section C revealed the Brief Interview of Mental Status (BIMS) score was disabled by questions C0100, indicating an attempt to conduct interview with the resident resulted to code 0 (zero), or a no, indicating the resident is rarely/never understood. Review of the physician orders revealed the following: on 05/21/25, Enhanced Barrier Precautions (EBP) as indicated for percutaneous endoscopic gastrostomy (PEG)and tracheostomy tubes, every shift; on 04/29/25, enteral feed four times a day, to give 195 milliliters (mL) of Peptamen [NAME] 1.5, run over one hour per pump via gastrostomy (g) tube, and from 8:00 PM to 6:00 AM, give 105 ml/ hour for 10 hours of Peptamen [NAME], 1.5 overnight, to be infused via g tube by pump. Additional physician order revealed the feeding pump may be turned off for care and treatment every shift. An observation was conducted on 06/24/25 at 10:44 AM with Staff H, Licensed Practical Nurse, LPN, who stated she would give a feeding to the resident. Staff H put on yellow gown after performing hand hygiene, went straight to the resident who was sitting on a wheelchair, exposed the resident's g tube and connected the ends of resident's G-tube to the end of tube feeding connector. Staff H, LPN did not disinfect the ends of both g tube port and the tip of the tube feeding. When Staff H, LPN was asked if she performs any disinfection of the PEG tube connections, she responded, No, I did not. When asked if she should perform disinfection of the two ends, she responded, I should do it. This surveyor waited but Staff H did not perform any disinfection after stating, she should do it. 5. Review of the facility policy titled, Laundry, provided by the Director of Nursing (DON), implemented 01/07/25, documented in the Policy Statement: The facility launders linens and clothing in accordance with current CDC guidelines to prevent transmission of pathogens Policy Explanation and Compliance Guidelines: 12. Laundry staff will in serviced on handling linens and laundry on a regular basis.During the Laundry room observation conducted on 06/24/25 at 11:45 AM, it was observed that one (1) of the laundry aides had a pair of her personal prescription glasses sitting atop the table, which is used for placing clean laundered gowns for resident use. Photographic Evidence Obtained.An interview was conducted on 06/24/25 at 11:52 AM with Staff V, laundry aide, who acknowledged that neither the glasses, nor any other personal items and objects, should be placed on top of the table, which is utilized for placing clean resident gowns, and are worn when providing care to the residents.On 06/24/25 at 11:56 AM, an interview was conducted with both the Director of Housekeeping, and the Housekeeping District Manager, who both acknowledged that Staff V's personal prescription glasses sitting atop the table, which is used for placing clean laundered gowns for the residents, should not have been placed there. The Housekeeping District Manager actually suggested that Staff V should have had the glasses hanging on a neck string, for safe keeping.On 06/24/25 at 1 PM, an interview conducted with the Administrator and with the Director of Nursing (DON) who both acknowledged that Staff V's personal prescription glasses should not have been placed atop the table, which is used for placing clean laundered gowns for the residents.6. Review of the facility policy titled, Care and Treatment of Feeding Tubes, provided by the (Director of Nursing) DON, revised 04/01/24, documented in the Policy Statement: It is the policy of this facility to utilize feeding tubes in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible. Policy Explanation and Compliance Guidelines: 1. Feeding tubes will be utilized according to physician orders 7. Direction for staff on how to provide the following care will be provided: .d. Use of infection control precautions and related techniques to minimize the risk of contamination On 06/23/25 at 12:57 PM, during an observation, it was revealed that Resident #95's Tube Feeding (TF) of Peptamen Jr. with 300 ml remaining in the bag, was hung on 06/23/25 at 4 AM; with a total volume of 500 ml in the bag. It was observed uncapped on the Intravenous (IV) pole with the end tip of the feeding tube uncovered and exposed for over one (1) hour, prior to being re-attached to Resident #95, Jejunostomy (J-tube). Photographic Evidence Obtained. On 05/14/25, the physician's order documented for, every day and night shift run Peptamen Jr 1.0 at 65 ml/hour x 20 hours via J-tube per pump [break from 10 AM-2 PM].On 06/24/25 at 10:54 AM, during a second observation, it was revealed that Resident #95's TF of Peptamen Jr. with 400 ml remaining in the bag, which was hung on 06/24/25 at 5 AM; and was with a total volume of 500 ml bag, it was observed as being uncapped on the IV pole with the tip end of the tubing; uncovered and exposed.On 06/24/25 at 1:18 PM, during subsequent rounds, Resident #95's TF of Peptamen Jr. with 400 ml remaining in the bag and which was hung up on 06/24/25 at 5 AM TF; with a total volume of a 500 ml bag, was still observed as being uncapped on the IV pole with the tip end of the tubing; uncovered and exposed. On 06/24/25 at 2:06 PM an observation was conducted of the nurse who was resuming administration of the Resident #95's TF, at that time, it was noted that the nurse used the exact same Peptamen Jr. TF bag and tubing that had been previously hanging up on the IV pole since 10:54 AM earlier that morning, with the same exposed and uncapped tip (for a time frame of over four (4) hours), and attached it directly for infusion via pump, into the child's abdominal J-tube site, without even first wiping the uncovered tip end with an alcohol swipe. During an interview conducted on 06/24/25 at 4:11 PM with Staff W, Registered Nurse (RN) she stated that in between feedings, when the TF is not in use, that she will either use the original clear plastic cover that is packaged with the TF tubing kit, or she will use a replacement white top cover called the Enteral Distal End Enfit Transition Connector with cap to cover the TF tip. Staff W went on to say that these caps are supposed to be kept on top of the IV pole, next to the child's TF bag and then put in place in order to prevent infection. Staff W ended by acknowledging that she had not covered the TF tip end, which had been uncovered and exposed, prior to insertion into the child's abdominal J-tube site. Record review of the Resident # 53's Care plan initiated 02/19/25 indicated Focus: Child is at risk for alteration in nutritional status and aspiration. Related to neurological impairments. Total nutritional/hydration support via tube feeding. Interventions: Provide enteral nutrition support as ordered and readjust as needed .Goal: Provide adequate nutritional/hydration support appropriate for weight/growth without signs and symptoms of aspiration on daily on-going basis. Maintain Body Mass Index (BMI) for age =/> 5th% tile with no signs or symptoms of dehydration and intact skin .The Administrator and the DON both further recognized and acknowledged on 06/24/25 at 4:20 PM and on 06/25/25 at 2:40 PM that (J-tube) tip tubing should remain covered and capped, when not actively in use and infusing. And, proper infection control techniques should always be practiced during a resident's tube feeding (TF).7. Review of the facility policy titled, Suprapubic Catheter Care, provided by the DON, reviewed 01/2025, documented in the Policy Statement: Purpose: The purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Preparation: Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed .Equipment and Supplies: .Personal protective equipment (e.g. gowns, gloves, mask, etc. as needed) Review of the facility policy for EHB, provided by (Director of Nursing) DON implemented 04/01/24, documented in the Policy Statement: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Definitions: Enhanced barrier precautions EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Policy Explanation and Compliance Guidelines: .2. Initiation of Enhanced Barrier Precautions: .b. An order for enhanced barrier precautions will be obtained for residents with any of the following: .indwelling medical devices (e.g Urinary Catheters even if a resident is not known to be infected or colonized with an Multi-Resistant Drug Organism (MDRO) 3. Implementation of Enhanced Barrier Precautions: a. Make gowns (may use reusable gowns) and gloves available immediately near or outside of the resident's room .b. Personal Protective Equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not be donned prior to entering the resident's room .4. High-contact resident care activities include: .g. Device care or use: .Urinary Catheters/Supra-pubic) .10. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until discontinuation of the indwelling medical device that placed them at higher risk. On 06/24/25 at 2:43 PM, a Suprapubic Catheter Care observation was conducted of Resident #19, who was resting in bed with the television on. The physician order dated 06/24/25 was for Indwelling Suprapubic Catheter Size: 18 Fr 20 CC: Obstructive UROPATHY. Staff X, Certified Nursing Assistant (CNA), was present and was assisted by Staff Y, Registered Nurse (RN)/Unit Manager (UM) of the 2nd floor Geriatric Unit, in removing Resident #19's Suprapubic dressing and providing catheter care to the resident. On 06/24/25 at 3:10 PM Staff Y, gathered some supplies, washed her hands before and after 35-40 seconds, she only donned a clean pair of gloves. Staff Y then proceeded to clean the surrounding skin area with normal saline and then she applied a border dressing. Lastly, Staff Y dated and applied the split border dressing to Resident #19's Suprapubic catheter site. Staff Y was not observed to first don a clean yellow gown, prior to, or at any time during the Suprapubic catheter dressing procedure for Resident #19, who was on Enhanced Barrier Precautions (EBP), as per initial order date of 11/11/24.Record review of the Resident #19's care plan initiated 03/04/20 indicated Focus: Resident has Suprapubic catheter related to Benign Prostatic Hypertension (BPH), Obstructive Uropathy Interventions: Enhanced Barrier Precautions as indicated. Indwelling Suprapubic Urinary Catheter care every shift Goal: Resident will show no signs/symptoms of Urinary infection through review date.Staff Y, RN / Unit Nurse / Unit Manager, on 06/24/25 at 3:43 PM acknowledged that she should have donned a clean yellow gown prior to the start of the application of Resident #19's Suprapubic dressing and she should have continued to wear one, throughout the care procedure.The DON and the Administrator further recognized and acknowledged on 06/24/25 at 3:51 PM and on 06/25/25 at 3:48 PM, that the nurse should have donned a clean yellow protective gown prior to the start of the application of the resident's Suprapubic dressing, and throughout the procedure. 8. In an observation conducted on 06/23/25 at 7:30 AM, Staff C, Certified Nursing Assistant (CNA), was noted in the hallway wearing a gown. She walked into an Enhanced Barrier Precaution (EBP) room and removed her gown into a garbage bin, which was located in the middle of the room. 9. In an observation conducted on 06/23/25 at 10:17 AM, Staff B, CNA, was noted going into Resident #88's room who was on EBP. She was noted pushing a Hoyer lift into the room without cleaning the equipment first. Staff B washed her hands, wore gloves and a gown, and proceeded to use the Hoyer lift to get Resident #88 from her bed to the chair. Staff Z, CNA, was also in the room assisting her in moving Resident #88 from the bed to the chair. Further observation showed Staff B taking the Hoyer lift out of the room without cleaning the equipment after use and placing it in the hallway. In an interview conducted on 06/26/25 at 1:26 PM, Staff B stated that she washes her hands before and after entering a room when providing direct care to a resident on EBP. According to Staff B, the Hoyer lift is cleaned with wipes after each use and is used by all staff members on the floor when needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 12 of 30 resident rooms, 1 of 1 clean linen storage rooms, and 1 of 1 clean nursing wound storage supply room located on the Second Floor Geriatric Unit. The findings included: During the initial observational tour conducted on 03/25/24 and the Environment Tour conducted on 03/28/24 at 10:30 AM accompanied with the Administrator, Director of Nursing, and Director of Housekeeping, and on the Geriatric Unit located on the second floor of the facility, the following was noted: a. room [ROOM NUMBER]: The exteriors of the room chairs (2) were noted to be heavily worn, in disrepair, and areas of paint stains, bathroom call bell cord was wrapped around the bathroom handrail (the resident stated she utilizes the bathroom independently), and one of 2 bathroom lights was not working. b. room [ROOM NUMBER]: The exteriors of the room chairs (2) were noted to be heavily worn, in disrepair, the exteriors bathroom wall handrails (2) were noted to be rust laden, the shower room floor was noted to have large areas of peelings paint, and the bathroom floor was noted to be soiled and heavily stained. c. room [ROOM NUMBER]: The bathroom toilet required re-caulking to the floor, the bathroom wall was noted to have areas of dried brown matter, the exterior of room chairs (2) heavily worn and stained, the room electric wall cover was broken, and the bathroom emergency call cord was wrapped around the wall handrail. d. room [ROOM NUMBER]: Large areas of the bathroom floor were heavily black stains, the bathroom portable over-commode chair was rust laden, the bathroom wall was damaged and in disrepair, and the exteriors of room chairs (2) were heavily worn and stained. e. room [ROOM NUMBER]: the exterior of the room chair was heavily worn and stained, large areas of the shower room floor were noted to have peeling paint, the bathroom floor soiled and stained, live roach were noted on bathroom floor, the bathroom toilet had noted areas of dried brown matter, the bathroom and room baseboards were in disrepair. f. room [ROOM NUMBER]: The exterior of room chairs were noted to be heavily worn and stained with a white paint-like substance. g. room [ROOM NUMBER]: The exterior of the room chairs was noted to be heavily worn and stained with a white paint-like substance, and the room wall corners were damaged and in disrepair. h. room [ROOM NUMBER]: The bathroom emergency call pull cord was wrapped numerous times around the wall handrails (the resident stated she utilizes the bathroom), one of two bathroom light bulbs were not working, and the exterior of room chair was heavily worn and stained with a white paint-like substance. i. room [ROOM NUMBER]: The exterior of the room chair was heavily worn and stained with a white paint-like substance, and the room dresser was noted to have broken drawers (2). j. room [ROOM NUMBER]: The exterior of the room dresser was noted to be heavily worn and stained and would not close properly. k. room [ROOM NUMBER]: The room dresser drawers (2) were noted to be in disrepair and would not close properly. l. room [ROOM NUMBER]: The bathroom toilet required re-caulking to the floor, the bathroom ceiling tiles (5) were stained brown in color, the shower room floor was noted to have large areas of peeling paint, the bathroom emergency pull cord was wrapped numerous times around the wall hand rails, and the exterior of the room chair was noted to be heavily worn and stained with a white paint-like substance. m. Clean Linen Storage Room: Approximately 5 of the room ceiling tiles were noted to be stained brown in color. n. Clean Nursing Wound Storage Supply Room: The entrance area to room had a heavy build-up of a unidentified black substance, the room walls were soiled and dust laden, the room floor was heavily soiled and had a build-up of supply trash. Following the 03/28/24 tour, the findings were again discussed and confirmed with the Administrator.

Based on observation, interview, and record review, the approved facility menu was not being followed for physician ordered diets that included: Regular Diet (total 7 residents - included sampled Residents #9 and #85), Soft & Bite Sized Level 6 (total 7 residents - included sampled Resident #2), and Moist & Minced Level 5 (included Resident #3). The findings included: Review of the approved menu for the Lunch meal of 03/27/24 noted the following to be served: - Regular Chicken Stew - 12-ounce portion to be served - Soft Bite Sized Level 6 (SB6) - 4-ounces [NAME] with Thickened Sauce - Moist & Minced Level 5 (MM5) - 4-ounces [NAME] with Thickened Sauce Observation of the tray line assembly in the Main Kitchen on 03/27/24 at 11:30 AM, accompanied with the Corporate Food Service Director (CFSD) noted the following: a. Staff B, the PM cook, was noted to be utilizing a #12 scoop (2-3 ounces) as a standard serving of the Regular Chicken Stew. The surveyor reviewed the approved lunch menu which documented a 12-ounce portion. Interview with Staff B, at the time of the observation, stated he thought a #12 scoop provided a 12-ounce portion. The CFSD informed Staff B that a #6 scoop X 2 should have been utilized as a standard portion. b. Observation of the lunch meal tray line noted that the Steamed [NAME] with Thickened Sauce was not prepared for SB6 diet, and the MM5 diet. Interview with Staff A, the AM cook, at the time of the observation noted that she was unaware the approved menu included Steamed [NAME] with Thickened Sauce was included on the menu for SB6 and MM 5 Diets. Review of the facility Diet Census for 03/27/24 noted the following physician ordered diets: - Moist & Minced Level 5 - 1 resident (included sampled Resident #3). - Soft & Bite Sized Level 6 - 7 residents (included sampled Resident #2). - Regular Diet = 2 residents (included sampled Resident's # 9, and #85). Review of the facility's Mechanically Altered Diets (SB5 & MM5) submitted by the Corporate Dietitian on 03/27/23 noted the following: Review of Soft & Bite Sized Level 6 (SB6) included: Level 6 used if not able to bite off pieces of food safely but are able to chew bite sized pieces down into little pieces that are safe to swallow. S&B foods need a moderate amount of chewing for the tongue to collect the food in a ball and bring it to the back of the mouth for swallowing. The pieces are bite sized to reduce choking risk. S&B foods are eaten using a fork, spoon, or chopsticks. No bigger than 1.5 cm X 1.5 cm for adults. Rice requires a sauce to moisten it and hold it together. [NAME] should not be sticky or gluey, and should not separate into individual grains when cooked and served. May require a thick, smooth, non-pouring sauce to moisten and hold together. Review of Minced & Moist #5 (MM5) included: Level 5 used if you're not able to bite off pieces of food safely but have some chewing ability. People are unable to chew down into little pieces that are safe to swallow . MM foods only need a small amount of chewing for the tongue to collect the food into a ball and bring to the back of the mouth for swallowing. It is important that MM foods are not sticky because this can cause foods to stick to the cheeks, teeth, and roof of mouth. These foods are for eating using a spoon and fork. Rice requires a sauce to moisten and hold it together . [NAME] should not be sticky or gluey and should not separate when cooked and served. May require a thick, smooth, non-pouring sauce to moisten and hold the rice together.

Based on observation, record review, and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety that included failure to hold hot and cold foods at the regulatory temperature of 41 degrees Fahrenheit (F) or below, or 135 degrees F or higher. The findings included: Review of the facility's Policy and Procedures for Food Temperatures (Manual 3-24 - 2015) documented, in part, the following: 1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees Fahrenheit (F). 2. All cold food items must be maintained and served at a temperature of 41 degrees F or below. 3. Tray line and alternative meal preparations an service areas will avoid the following methods: Holding foods in the temperature danger zone (41 degrees F to 135 degrees F). Holding foods on a steam table for more than 4 hours. During the observation of the lunch tray line assembly in the main kitchen on 03/27/24, at 11:45 AM and accompanied with the facility's Corporate Food Service Director (CFSD), revealed the temperatures of tray line foods were taken with the facility's calibrated digital food thermometer. The findings noted that foods were not being held at the regulatory temperatures of 41 degrees F or less for cold foods and 135 degrees or higher for hot foods. The temperatures were recorded as follows: a. Pureed Seasoned Cabbage & Carrots (25 portions) = 106 degrees F. b. Individual Low fat Yogurt (3 portions) = 46 degrees F. c. Individual Health Shakes (6 portions) = 46 degrees F. d. Thickened Apple Juice (2 portions) = 45 degrees F e. Individual Regular Milk Cartons (3 portions) = 48 degrees F. f. Thickened Cranberry Juice (3 portions) = 46 degrees F. g. Individual Tossed Salads (7 portions) = 64 degrees F. Following the temperature testing of 03/27/24, the hot and cold recorded temperatures were again confirmed with the Corporate Food Service Director (CFSD). The CFSD stated that the hot food failed to be within regulatory temperature prior to being transferred to the steam table and the cold foods failed to be refrigerated properly prior to the start of the tray line.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #17 was admitted to the facility on [DATE]. Resident #17 had a medical history significant for Cerebral Palsy, Quadriplegia, Seizures, and was dependent on a gastrostomy tube for nutrition intake. An Annual Minimum Data Set (MDS) was done on 11/12/22. This MDS showed Resident #17 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated he was severely cognitively impaired. This MDS showed Resident #17 was receiving tube feeding for all meals. This MDS documented Resident #17 had known weight loss but that he was not on a prescribed weight loss regimen. Review of Resident #17's Care Plans revealed a care plan was written on 08/06/18 regarding Resident #17 being at risk for altered nutrition. There was no care plan written regarding the noted weight loss. Review of Resident #17's physician orders revealed a previous order from 08/10/21 to 11/17/22 for Enteral Feed every 4 hours Nutren Jr Fiber 245 mL via G-Tube every 4 Hours run over 1 Hour per feeding tube. From 11/17/22 to 12/01/22, a new order was written for Enteral Feed every 4 hours Give 260 mL Nutren [NAME] w/ Fiber via g-tube every 4 hours run over 1 hour per feeding tube. On 12/01/22, a new and current order was written for Enteral Feed every 4 hours Run Nutren [NAME] w/ Fiber at 65 mL/hr x 24 hours continuously via g-tube per pump. During the initial tour of the facility conducted on 01/09/23 at 11:01 AM, it was noted that Resident #17 had a bag of Nutren [NAME] plus Fiber tube feeding infusing. During the initial review of Resident #17's record, it was noted that Resident #17 had suffered a significant weight loss. On 08/05/22, Resident #17 weighed 79.81 pounds; on 01/05/23, Resident #17 weighed 66.8 pounds, which indicated a 16.30% weight loss in 5 months. This is considered significant weight loss. Further review of Resident #17's weights revealed the following: on 07/05/22, Resident #17 weighed 75.62 pounds; on 08/05/22, Resident #17 weighed 79.81 pounds; on 09/05/22, Resident #17 weighed 75.4 pounds; on 10/05/22, Resident #17 weighed 71.65 pounds; on 11/15/22, Resident #17 weighed 67.68 pounds; on 12/01/22, Resident #17 weighed 66.81 pounds; and on 01/05/23, Resident #17 weighed 66.8 pounds. On 01/11/23, the surveyors asked to have Resident #17 weighed. Staff D, CNA, weighed Resident #17 using a Hoyer lift. Staff D ensured Resident #17 was wearing only a diaper for this weight. The Hoyer lift scale was zeroed prior to obtaining Resident #17's weight. The weight taken was 67.2 lbs. This represented a 0.4-pound weight gain since the weight recorded on 01/05/23. Review of the Dietary Notes revealed Staff A, Registered Dietitian (RD), was aware of the weight gain noted in August 2022. The note stated that Staff A notified the physician but planned to continue to monitor Resident #17's weights and make no changes at that time. Another Dietary Note, written on 09/06/22, indicated Staff A was aware of the weight loss, but she recommended no changes to the tube feeding at that time. On 10/07/22, Staff A documented a note indicating she was aware of Resident #17's continued weight loss but again offered no interventions. On 12/01/22, Staff A documented her next note indicating she was going to increase Resident #17's tube feeding to provide additional calories and maximize absorption to promote weight restoration. An interview was conducted with Staff A, RD, on 01/11/23 at 1:40 PM. When asked specifically about this resident, Staff A stated that the weight done in August [2022] was presumed to be incorrect, since it was above what Resident #17's usual weight fluctuations were. She clarified that she asked Staff D to re-weigh Resident #17 and the weight was still 79 pounds. Staff A said they assumed Resident #17 was constipated and that his would fluctuate back to his baseline, and this is why she offered no interventions at that time. Staff A stated Resident #17's weight did trend down to his baseline after August 2022 but that he continued to drop in weight in September and October 2022. Staff A said she spoke to the Nurse Practitioner (NP) in October but was told not to make any changes at that time. In December 2022, Staff A said she changed Resident #17 to continuous feedings to maximize absorption. Staff A stated she had plans to make additional adjustments this week and that she would possibly add a zinc supplement. She clarified that zinc increases metabolic efficacy. The facility staff did not act in a timely manner to intervene for Resident #17's significant weight loss over the course of the 5 months. Based on interviews, observations and record review, the facility failed to provide nutritional assessments and interventions promptly and follow up on monthly weights for 2 of 4 sampled residents reviewed for nutrition, Residents #17, and #7. The findings included: A review of the facility's policy, titled, Nutritional Assessment/Evaluation, revised on 9, 2017, showed the following: the Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional Assessment/Evaluation for each resident upon admission (within current initial Assessment / Evaluation timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition. 2. The nutritional Assessment / Evaluation will be a systematic, multidisciplinary process that includes gathering and interpreting data and using that data to help define meaningful interventions for the resident at risk for or with impaired nutrition. A review of the facility's policy, titled, Weight Assessment/Evaluation and intervention, revised on 11/2021, showed the following: Any weight change of 5% or more since the last available weight will be retaken for confirmation. If the weight is verified, nursing will notify the Dietitian. Monthly weights will be finalized by the 15th of each month, the Dietitian will review the Weight Record to follow individual weight trends over time, and trends will be evaluated by the Dietitian to determine whether the criteria for insignificant weight change has been met. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria: a. one month - 5% weight loss is significant; greater than 5% is severe. B. Three months -7.5% weight loss is significant; greater than 7.5% is severe. C. 6 months - 10% weight loss is significant; greater than 10% is severe. 1. Record review showed that Resident #7 was readmitted on [DATE] with diagnoses of Spinal Bifida and Respiratory Failure. There was a physician's order, dated 12/16/20, for small Portion diet, Pureed texture, thin liquid consistency, divided plate 3 x/day with thin liquids. An order dated 07/11/22 was documented for enteral feeding five times a day to give 250 milliliters of Peptamen [NAME] 1.5 (tube feeding formulary) 5 times a day. A continued review showed an order for weights twice a month, which was dated 12/15/22. An observation was conducted on 01/09/23 at 10:00 AM. Resident #7 was noted in the room with the breakfast tray on the bed. Closer observation showed a tray with a Puree diet and no adaptive devices for a divided plate. The resident ate about 50% of her breakfast. In another observation conducted on 01/09/23 at 12:30 PM in the main dining room, Resident #7 ate her lunch meal with a divided plate and puree consistency. She ate about 50% of her lunch meal. In an observation conducted on 01/11/23 at 8:00 AM, Resident #7 was noted in the room with the breakfast tray on the bed. She did not eat any of the items on the tray. In this observation, Resident #7 was asked if she wanted to lose weight, and she gave two thumbs up, and when asked if she wanted to gain weight, she gave two thumbs up as well. In an observation conducted on 01/12/23 at 8:45 PM, Resident #7 was not in the room, and her breakfast tray was left on the bed. Closer observation showed that she ate about 50% of her breakfast meal. A review of the weight log showed the following weights for Resident #7 with no further weight obtained after the 12/15/22 weight until surveyor intervention: These were the following weights: 01/11/23 59.6 Lbs. (pounds) 12/15/22 57.99 Lbs. Standing 12/01/22 58.87 Lbs. Standing 11/15/22 58.32 Lbs. Standing 11/02/22 56.22 Lbs. Standing 10/19/22 58.42 Lbs. Standing 10/05/22 61.2 Lbs. Standing 09/05/22 62.61 Lbs. Standing 08/05/22 65.04 Lbs. Standing The weight loss from 08/05/22 to 10/19/22 showed 10.18 percent (%) weight loss in two months. The last weight documented in the electronic system was on 12/15/22, and no other weight was documented as taken after 12/15/22. A progress note written on 08/25/22 showed Resident #7 was on a Puree diet and tube feeding with Peptamen [NAME] (formulary type) at 250 milliliters (ml) 5 times a day. Another progress note on 09/27/22 showed that Resident #7 had a 3.7 percent weight loss in 1 month. It further showed that a potential for weight loss is anticipated with the recent COVID-19 infection. In this note, Staff A, Clinical Dietitian, recommended monitoring weight trends more frequently. On 10/19/22, Resident #7's weight dropped to 58.42 pounds from 65.04 pounds, and no progress note was completed by Staff A, addressing the severe weight loss of 11%. The next progress note was on 11/26/22, which was two months later. This note showed that Resident #7 was placed on an appetite stimulant and staff noted that she lost 7.4% of her body weight in 3 months. No other recommendations were noted at this time. Staff reported that they would continue to monitor the intake of meals and the weight trends. A Nutritional assessment, dated 12/22/22, showed that Resident #7 had a 7.4% weight loss in 3 months, and Staff made no further recommendations. Further review of the weight log showed that no new weight was taken since 12/15/22, 27 days apart. The care plan, dated 12/22/22, showed to provide Resident #7 with adequate nutritional / hydration support appropriate for weight / growth on an ongoing daily basis. Maintain weight/height +/- 3# per quarter with no signs or symptoms of dehydration and intact skin. In an interview conducted on 01/10/23 at 3:30 PM, Staff C, Licensed Practical Nurse (LPN), stated that Resident #7 is not verbal. She further said that she could communicate with staff by using her thumbs up if she wants something. In an observation conducted on 01/11/23 at 10:23 AM, Staff D, Certified Nursing Assistant (CNA), was asked to take the weight of Resident #7. Resident #7 was able to walk herself onto the standing scale, and the recorded weight was noted at 59.6 pounds, which is a 1.61 pound weight increase since the weight of 12/15/22. In this observation, Staff D was asked if she was aware of any orders to take the weight on residents more than once a month, and she said no. She stated that she has no access to the orders in the electronic charting and any orders for weights are given to her from the Dietitian. She further said that all weights that are taken for the day are given back to the Dietitian to input into the electronic system. In an interview with Staff A, Registered Dietitian, on 01/11/23 at 1:26 PM, she said that when residents are first admitted , she has 72 hours to do the initial assessment but usually gets it done within the first few days. Every 60 days, she will make a follow-up note and the quarterly evaluation after that. For the most part, she feels that most of the kids in this facility are stable. When asked about the weight policy, she reviews the order listing report every morning for any changes or any new orders for weight changes. She then creates a list that is given to Staff D, Certified Nursing Assistant. The list is broken down to residents who need their weight taken once a month, twice a month, weekly or more often. When asked if she knew that Resident #7 had an order for weights twice a month, she said yes. When asked why it was not done, she said it was her fault as she did not move Resident #7 to the twice-a-month list she created. She further acknowledged that Resident #7 had a weight loss of 11% from 08/05/22 to 10/19/22, and no nutritional interventions were made to address the weight loss.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain aspiration precautions for a resident who was being fed by enteral means (tube feeding), as evidenced by staff not consistently keeping the head of the bed elevated while the tube feeding was running for Resident #77; and failed to follow Practitioner orders for tube feeding (Resident #98), for 2 of 6 sampled residents reviewed for tube feeding. The findings included: 1. Resident #77 is two years old and has a tracheostomy related to Impaired breathing mechanics, is on a ventilator and has a history of Chronic Respiratory Failure and Dysphagia. He was initially admitted on [DATE] and readmitted on [DATE]. In an observation conducted on 01/10/23 at 3:00 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen [NAME] (tube feeding formulary). Staff B, Licensed Practical Nurse (LPN), was noted outside the room on her computer. In an observation conducted on 01/10/23 at 3:30 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen [NAME] (tube feeding formulary). Staff B, LPN, was noted outside the room on her computer. In an observation conducted on 01/10/23 at 3:45 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters (ml) an hour with Peptamen [NAME] (tube feeding formulary). In this observation, Staff B was asked by the surveyor if it was okay that the tube feeding was still running while Resident #77 was flat across the bed. Staff B said that Resident #77 tends to move a lot and that she is not his nurse for the day. When asked how often the staff monitors the residents, she said there is no particular time frame, and they can check at any given time. When the surveyor expressed concerns regarding the tube feeding running while Resident #77's head was not elevated, Staff B turned Resident #77 sideway and elevated the mattress. In an observation conducted on 01/10/23 at 4:30 PM, Resident #77 was noted in his crib sleeping sideways across the mattress with his head flat down. Continued observation showed a tube feeding running at 40 milliliters an hour with Peptamen [NAME] (tube feeding formulary). Staff B, LPN, was noted outside the room on her computer. A review of the orders showed an order for Aspiration precautions to keep the head of the bed elevated during feedings as tolerated every shift dated 12/24/22 and another order for tube feeding Peptamen [NAME] (tube feeding formulary) continuously run over 40 ml for 24 hours via G-tube per pump dated 12/20/22. The care plan dated 11/23/22 showed that Resident #77 is at risk for aspiration related to Enteral Tube Dependency and Tracheostomy Status, with interventions to: Keep the head of the bed elevated during feeding as tolerated. It further showed that Resident #77 is at risk for nutritional status and aspiration alteration with : Total nutritional / hydration support via G-Tube and is vent-dependent and has a diagnosis of dysphagia. In an interview conducted on 01/12/23 at 10:00 AM with the facility's Administrator, he was told of the findings. 2. Resident #98 was admitted to the facility on [DATE]. Resident #98's diagnoses included: Cerebral Palsy, Seizure disorder, Chronic lung disease, Atrasia of Foramina, Epilepsy, Disturbances of Salivary secretion, Lack of expected normal physiological development n childhood, Diaphragmatic Hernia without obstruction or gangrene, Calculus of Kidney, and spastic quadriplegic. Resident #98's orders included: 09/22/22 - NPO [nothing by mouth] diet, NPO texture - feeds per g-tube only 12/19/22 - Enteral Feed - every shift Run Peptamen w/ Prebio at 50 mL/hr continuously via g-tube per pump. On 09/22/22, the resident weighed 75 lbs. On 12/05/22, the resident weighed 70 pounds which is a -6.67 % loss. On 01/09/23 at 10:17 AM, Resident #98 was observed in bed with enteral feeding pump display reading Flow error - clog in line downstream of pump. The date mark on the 1000 milliliter bag of supplement documented the supplement was initiated on 01/09/23 at 10:00 AM. On 01/10/23 at 7:54 AM, Resident #98 was observed in bed with tube feeding initiated at 50 milliliters per hour (ml/hr). The dated mark on the 1000 milliliter bag of the supplement documented the supplement was initiated on 01/09/23 at 10:00 AM. At the time of the observation, there was approximately 600 milliliters remaining in the 1000 milliliter bag of the supplement. At a rate of 50 ml/hr over 20 hours, the resident should have received the entire 1000 milliliters. 01/10/23 at 2:50 PM, Resident #98 was observed in bed with the same supplement that was initiated on 01/09/23 at 10:00 AM, according to the date mark on the bag of supplement. At the time of the observation, there was 200 milliliters remaining in the 1000 milliliter bag of the supplement. There was no documentation to justify why the order for enteral feeding was not met. During an interview, on 01/10/23 at 3:51 PM with Staff H, Registered Nurse (RN), confirmed that the bag of supplement was the bag from the observations for the entirety of the previous day and this day. Staff H stated, Maybe something happened on the night shift. If anything would have happened, they would have to document something in the MAR (Medication Administration Record) or in the progress notes. When I came this morning, the night nurse had put a new bag and had not connected it to the tube-feeding. The night nurse was the one that placed the new bag. She did not tell me if anything happened and did not report anything to me. During an interview, on 01/11/23 at 1:27 PM, with Staff A, Registered Dietician / Licensed Dietician (RD/LD), Staff A confirmed the order for the enteral feeding and acknowledged that the order had not been met, as well as the lack of documentation and communication as to why the feeding was not done as ordered.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #6 was initially admitted to the facility on [DATE] and was last readmitted on [DATE]. Resident #6 had a medical history significant for Cerebral Palsy, dependence of Tracheostomy and Gastrostomy tube, persistent vegetative state, Dysphagia, Epilepsy, and Hypoxic Ischemic Encephalopathy. A Quarterly Minimum Data Set (MDS), dated [DATE], showed Resident #6 had a Brief Interview of Mental Status (BIMS) score of 99, which indicated Resident #6 had severe mental impairment. This MDS documented Resident #6 had a tracheostomy and that she was receiving oxygen therapy. Review of Resident #6's care plans revealed there was a care plan in place regarding Resident #6 having an artificial airway in place and for the staff to monitor her oxygen saturation numbers and to provide oxygen as ordered. Initial review of Resident #6's physician orders conducted on 01/09/23 revealed there was no active order for oxygen present. During observation conducted on 01/09/23 at 10:53 AM, it was noted that Resident #6 was receiving oxygen via a tracheostomy mask at 3 liters per minute. The oxygen tubing was dated 01/07/23. During the initial review of Resident #6's record, it was noted that Resident #6 did not have an active physician order for oxygen. Additional observations made of Resident #6 on 01/10/23, 01/11/23, and 01/12/23 revealed Resident #6 was on oxygen continuously through a tracheostomy mask. An interview was conducted with Staff E, Respiratory Therapist, on 01/11/22 at 1:30 PM. The surveyor asked Staff E to find the order for the oxygen in Resident #6's chart. Staff E looked and said he could not find the active oxygen order. He told the surveyor he would talk to the doctor to make sure an order for oxygen was added to the chart. Based on review of policy and procedure, observation, record review and interview, the facility failed to ensure that it obtained a current, written physician's order for Oxygen therapy treatment for 2 of 2 sampled residents observed, Resident #358 and Resident #6. The findings included: Review of the facility policy and procedure on 01/11/23 at 1:55 PM, titled, Oxygen Administration, provided by the Director of Nursing (DON) revised 05/04/22, documented in the Policy Statement: Oxygen is administered to residents who need it, consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences Policy Explanation and Compliance Guidelines: 1. Oxygen is administered under orders of a physician 3. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy. 4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. They type of oxygen delivery system. b. When to administer, such as continuous or intermittent and/or when to discontinue. c. Equipment setting for the prescribed flow rates. d. Monitoring of SpO2 (oxygen saturation) levels and/or vital signs, as ordered. e. Monitoring for complications associated with the use of oxygen. Review of the facility policy and procedure on 01/11/23 at 2:05 PM, titled, Medication Administration, provided by the DON revised 05/04/22, documented in the Policy Statement: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review of facility's undated licensed Registered nurse job description on 01/11/23 at 2:11 PM provided by the DON documented, Purpose of Your Job Position: .provides direct care, administers treatments and medications, organizes and distributes daily assignments to direct care staff consistent with staff competency and each individual resident's comprehensive resident assessment and care plan .Performance Requirements: Knowledge of nursing principles and professional standard of nursing practice and ability to apply to resident specific circumstances. Able to identify, implement and evaluate appropriate objectives and interventions for residents. Review of facility's undated licensed Practical nurse job description on 01/11/23 at 2:22 PM provided by the DON documented Purpose of Your Job Position: .provides nursing care according to physician's instructions and in conformance with state approved Florida Board of Nursing Practice, established standards and administrative policies .Duties: 1. Check and administer medications and treatments per standards of Florida Nurse Practice Act and facility policy; order medications from pharmacy .5. Maintain accurate records of nursing and medical care received by the resident . 1. Resident #358 was admitted to the facility on [DATE] with diagnoses which included Embolism and Thrombosis of Unspecified Artery, Unspecified Fracture of Sacrum, Idiopathic Peripheral Autonomic Neuropathy, Post-Menopausal Bleeding and Obstructive and Reflux Uropathy. She had a Brief Interview Mental Status (BIMS) score of 14, indicating cognition was intact. During an observation conducted on 01/09/23 at 11:20 AM, Resident #358 was observed with Oxygen infusing in place at 2-3 liters/minute. Photographic Evidence Obtained. A brief interview with Resident #358 on 01/09/23 at 11:26 AM was conducted who stated she was not wearing any oxygen prior to admission to the facility, at home. The resident also stated that she has been wearing her oxygen here in the facility continuously. She also stated that she has not had any shortness of breath or difficulty breathing while residing in the facility. On 01/10/23, Resident #358's Oxygen Saturation Summary, dated 12/31/22 through 01/10/23, documented that the Resident #358's Oxygen Saturation Levels were in a range of: 97-98% were either on Room air or Oxygen via nasal cannula. Neither the Medication Administration Record (MAR), Treatment Administration Record (TAR), facility nursing progress notes, nor the resident's care plan reflected or made reference to any Oxygen orders / treatments for Resident #358, during her facility stay from 12/31/22 to current. 01/10/23 9:41 AM, the resident was observed with Oxygen infusing at 3 liters/minute. 01/10/23 01:55 PM, the resident was observed with Oxygen infusing at 3 liters/minute. 01/11/23 at 9:55 AM, the resident was observed with Oxygen infusing at 3 liters/minute. A side-by-side record review was conducted with the Assistant Director of Nursing (ADON) in which it was noted / indicated that there was no physician order for Oxygen Therapy to be administered to Resident #358, during her facility stay. An interview was conducted with Staff F, Licensed Practical Nurse (LPN), on 01/11/23 at 9:55 AM regarding Resident #358's Oxygen therapy infusion, who acknowledged the resident did have the Oxygen infusion and she should have had an order on file for it. An interview was conducted with the Assistant Director of Nursing (ADON), on 01/11/23 at 10:05 AM regarding Resident #358's Oxygen therapy infusion, who also acknowledged that there should have been an order on file for it. The Oxygen order was not obtained and recorded in the resident's medical file, until after surveyor inquisition / intervention. The DON further recognized and acknowledged on 01/11/23 at 12:10 PM that a physician's order should have been obtained and this was not done.