**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure a portable oxygen tank was secured in the room of one sampled resident (Resident 22). The deficient practice had the potential to cause injury to residents and staff. Findings include: Resident 22 (R22) R22 was admitted on [DATE] with diagnoses including severe hypoxic ischemic encephalopathy (not enough oxygen or blood being supplied to the brain), and chronic respiratory failure. On 04/16/2025 at 10:29 AM, there was a portable oxygen tank standing upright in the corner of room for R22. The tank was free-standing and not attached to the wall or secured to any type of portable carrying device or cart. There was no regulator to determine amount of oxygen still left in bottle. On 04/16/2025 at 10:35 AM, a Licensed Practical Nurse (LPN) confirmed the tank was in the room and not secured. The LPN indicated all portable oxygen tanks should be secured whether empty or full. The LPN explained empty tanks would be taken to storage and kept separated from tanks which were full. On 04/17/2025 at 3:00 PM, a Respiratory Therapist (RT) indicated portable oxygen tanks should not be left attended without being secured in stand with buckle. Oxygen tanks were always kept in cart or [NAME] and then taken to storage area and kept separate from full tanks in a secured container rack. The RT verbalized it did not matter if tank was full, half full or empty all oxygen tanks should be secure at the tanks could cause injury to residents or staff if knocked over. On 04/17/2025 at 3:16 PM, the Director of Nursing (DON) explained checking room for potential hazards was shared task among leadership and staff. Respiratory equipment such as portable oxygen tanks would be in carrier bags, or a metal oxygen holder. The DON indicated the portable oxygen tank found in room for R22 should have been in an oxygen holder. The nursing staff and respiratory staff were primarily responsible for ensuring rooms were safe from hazards while making the normal rounds throughout the day. The DON verbalized there would be an increased risk of injury for kids roaming around who may inadvertently knock over a tank if not secured. The facility policy titled Administration of Oxygen Therapy (revised 06/2015) documented safety measures to include making sure the oxygen was in an approved stand to prevent rolling or accidental fall. Empty oxygen tanks were stored in a separate location or storage cart, oxygen storage areas were identified as oxygen storage full and oxygen storage empty.

Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed from the active supply and discarded. The deficient practice had the potential to compromise the effectiveness of the medication treatment. Findings include: On 05/24/2024 at 12:44 PM, an inspection of the facility's medication room with the Assistant Director of Nursing (ADON)(E2). The Narcotic (Narc) Box in the medication refrigerator stored expired Lorazepam 2mg/1ml oral, with an expiration date of 03/2024. On 05/24/2024 at 1:05 PM, the ADON confirmed the Lorazepam 2mg/1ml oral was expired and should have been removed from the active supply to prevent administration. The ADON indicated the expired medication should have been taken out of the refrigerator and placed in the designated area for disposal. On 05/24/2024 at 2:11 PM, the Director of Nursing (DON)(E1) explained the Pod 3 nurse holds the Refrigerator Narc Box key and therefore was responsible for checking the expiration dates daily upon shift change and discarding the expired medication appropriately. On 05/24/2024 at 2:36 PM, the Pod 3 Nurse (E3) explained the Pod 3 Nurse was responsible for checking the expiration dates and discarding expired medications appropriately at shift change. However, E3 was confused about what was the expiration date and what was the delivery date based on E3's understanding of the medication sheet. A facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, with the revision date of 01/01/22, revealed the facility should ensure medications and biologicals which had an expiration date on the label and had been retained longer than recommended by the manufacturer or supplier's guidelines were to be stored separate from other medications until destroyed or returned to the pharmacy or supplier.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review the facility failed to keep an accurate account of a resident's personal belongings for 1 of 12 sampled residents (Resident #5). The failed practice had the potential to lead to the loss of personal property for the resident. Findings include: Resident #5 (R5) R5 was admitted to the facility on [DATE] with medical diagnoses including seizures. On 03/07/2023 at 1:35 PM, the family member of R5 indicated R5 had missing clothes on a monthly base. A review of medical records for R5 lacked documented evidence an inventory sheet was completed. On 03/08/2023 at 4:46 PM, the Assistant Director of Nursing (ADON) indicated R5 had been in the facility since 2017 and some of their physical charts had been moved to an offsite location. The ADON explained they were unable to obtain the inventory sheets for R5 and there were no new inventory sheets created. On 03/07/2023 at 11:04 AM, Certified Nursing Assistant #1 (CNA1) indicated residents' personal items went missing a lot in the facility. CNA1 explained residents' personal items were documented on the inventory sheet upon admission and the inventory sheet was updated as new items were brought into the facility. On 03/09/2023 at 11:06 AM, the Director of Nursing (DON) explained inventory sheets for the residents were placed in their charts. The DON indicated a copy of the inventory sheet for R5 should have been available in their chart and on site. A review of the facility's policy titled Personal Effects policy revised 01/01/2011 revealed there needed to be a complete and accurate list of all residents' personal belongings and explained all items subsequently brought into the facility were added to the inventory list.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff followed the facility's policy and protocol related to emergency care for a resident with a potential emergent situation for 1 of 12 sampled residents (Resident #2). The failed practice had the potential to delay securing the safety of the resident. Findings include: Resident #2 (R2) R2 was admitted on [DATE] with medical diagnoses including seizures and cerebral palsy. The facility's policy titled Emergency Care last revised 02/10/2015 revealed the first staff member to discover a resident requiring emergency care was to shout for help and not leave the resident. On 03/09/2023 at 1:45 PM, R2 was observed lying in bed, eyes locked upward, increased reddish coloration of the face, and intermittent groaning sounds. Oxygen levels for R2 were being monitored through a small vitals machine which revealed oxygen levels between 75 to 84 percent. On 03/09/2023 at 1:45 PM, Certified Nursing Assistant #1 (CNA1) entered the room of R2 and indicated R2 was having a seizure. CNA1 left the room and verbalized they were going to go grab a nurse. Approximately thirty seconds later, three staff members entered the room of R2, including CNA1 and Registered Nurse #1 (RN1). On 03/09/2023 in the afternoon, RN1 indicated the resident had history of seizures. RN1 explained R2 had a seizure approximately every three months. RN1 explained a staff member should have stayed in the room with R2 when they were having the seizure. On 03/09/2023 in the afternoon, Certified Nursing Assistant #2 (CNA2) indicated in an Emergency, staff was to stay in the room with the resident and yell out for help. On 03/10/2023 at 12:01 PM, the Director of Nursing (DON) indicated a seizure was considered an emergency. The DON explained during emergency situations staff was instructed to yell out for help. The DON indicated staff was to remain in the room and not leave the resident unattended.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the [NAME] bag (continuous gastric pressure relief infusion set) for gastrostomy tube (GT) feeding was changed for 1 of 12 sampled residents (Resident 24), 2) the GT site and surrounding skin were assessed, cleansed and dressed as ordered for 1 of 12 sampled residents (Resident 24), and 3) a physician order was obtained timely for 1 of 12 sampled residents (Resident 8). Failure to follow proper GT feeding protocols could potentially result in complications such as infection or other medical issues related to improper management of the GT site and gastric pressure relief infusion set. Findings include: 1) A facility policy titled [NAME] Bags for Gastrostomy Tube Feedings revised on 01/13/2022, documented to change the [NAME] bag every seven days. Resident 24 (R24) R24 was admitted on [DATE], with diagnoses including gastrostomy status and obstructive hydrocephalus. On 03/08/2023 at 11:45 AM, R24 was sitting in the chair and tube feeding (TF) was infusing at 45 milliliters (ml) per hour. The TF bag was connected to another bag labeled [NAME] valve system continuous gastric pressure relief, which was soiled and dated 01/31/2023. On 03/08/2023 at 11:58 AM, a Registered Nurse 2 (RN2) confirmed the [NAME] bag was dated 01/31/2023. RN2 indicated the [NAME] valve system was utilized to relieve the gastric pressure in the resident's stomach. The RN explained the [NAME] set would serve as the main line and be connected to the resident's GT. RN2 indicated the use of the [NAME] set was required by order and should have been changed weekly but was not done for more than a month. R24's medical records lacked documented evidence a physician order was obtained for the use of the [NAME] valve system. On 03/08/2023 at 12:15 PM, a Charge Registered Nurse (CRN) explained the [NAME] valve system infusion set should have been changed every week and should have an order in place. The RN indicated the [NAME] valve infusion set was the main line in which the TF and the Mic-key button (a feeding tube button that sits at the level of the skin) were connected to the GT. The RN indicated the risk if the [NAME] valve set was not changed timely, it could lead to an increased risk of infection. On 03/08/2023 at 12:50 PM, the Assistant Director of Nursing (ADON) indicated the [NAME] valve set should have been changed weekly and required an order for continuous monitoring. The ADON indicated a physician order should have been obtained and the valve set should have been changed weekly to prevent complications. 2) A facility policy titled Gastrostomy Tube Feeding Site Care and Replacement (undated), documented to provide care for the Mic-Key Button insertion site. Inspect the skin around the stoma after feedings and medication passes to ensure there is no gastric leakage. Clean the skin around the stoma with warm water and soap using a cotton-tipped applicator or soft cloth. A physician order in R24's medical record dated 03/07/2023, documented to cleanse the enteral insertion site with normal saline. Assess the enteral site for redness and irritation. Apply split gauze on site every shift. On 03/07/2023 at 10:56 AM, R24 was in bed with eyes closed. TF was running at 45 milliliters (ml) per hour via kangaroo pump. The GT or Mic-Key Button insertion site was soiled with dried brownish residue around the site and had no dressing. On 03/08/2023 at 11:58 AM, a Certified Nursing Assistant confirmed R24's GT site had dried brownish residue. The CNA indicated the nursing staff were responsible for cleaning the site. The CNA called the assigned Registered Nurse 2 (RN2). RN2 confirmed R2's GT insertion site and the surrounding skin was soiled with dried brownish residues. The RN indicated the surrounding skin should be assessed, cleansed promptly, and dressed as ordered to prevent skin irritation, but this was not done. On 03/08/2023 at 12:15 PM, a Charge Registered Nurse (CRN) explained the GT site should have been assessed and cleansed each shift and depending on the order if a dressing was needed. The RN indicated if there was no order in place, the physician would be contacted to obtain orders for GT site care and the order should have been followed. 3) Resident 8 (R8) R8 was admitted on [DATE], with diagnoses including gastrostomy status and hypoxic-ischemic encephalopathy. On 03/07/2023 in the morning, R8 was in bed with eyes closed. The GT insertion site had no dressing. R24's medical records lacked documented evidence GT site care orders were obtained timely. On 03/08/23 at 3:27 PM, a Registered Nurse indicated a resident's GT site should have been assessed and cleansed each shift, depending upon the order. The RN indicated if there was no order, the physician would be notified to obtain one because everything should be covered by the physician's instructions. The RN confirmed the order was just placed dated 03/07/2023. On 03/08/23 at 3:29 PM, the Director of Nursing (DON) confirmed R8 had no GT care site orders in place until 03/07/2022. The DON indicated the residents on GT or Mic-Key Button were required to have an order to assess and cleanse the GT insertion site. The DON explained the admission staff was responsible for obtaining and transcribing the order set for GT site care but had missed it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure: 1) the availability of Tizanidine (a medication used as a muscle relaxant) and 2) the order was communicated and clarified for 1 of 12 sampled residents (Resident 26). Failure to administer the Tizanidine medication for muscle spasms on time could lead to ineffective management of muscle spasticity, which may result in increased risk of pain, discomfort, reduced mobility, withdrawal symptoms and adverse consequences. Findings include: Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including gastrostomy status, generalized idiopathic epilepsy and epileptic syndrome. The Brief Interview of Mental Status dated 01/23/2023, documented a score of 99, which means the interview was not completed due to cognitive impairment. A physician order dated 10/21/2022, documented to give a 0.5 milligram (mg) Tizanidine Hydrochloride tablet via gastrostomy tube (GT) three times a day for spasms. On 03/09/2023 at 8:35 AM, a Registered Nurse 2 (RN2) in POD 2 prepared all of R26's medications except the Tizanidine Hydrochloride (HCL). On 03/09/2023 at 11:30 AM, RN2 confirmed Tizanidine HCL had not been administered because it had not been available since the previous day. The RN indicated the Tizanidine was already requested from the pharmacy, but there was no delivery. The pharmacy request record dated 03/08/2023, documented Tizanidine HCL was requested due to non-availability. The Prescriptions Delivery Receipt dated 02/27/2023, documented Tizanidine 1 mg/1 ml oral solution was previously delivered. On 03/09/2023 in the afternoon, the Assistant Director of Nursing (ADON) indicated the physician order was in tablet form and converted by the pharmacy into a solution, but it was not communicated to the facility to clarify the order. The ADON conveyed it was important to clarify the order because if the order was in tablet form and the medication delivered was in solution, it may cause confusion with the staff during administration. The ADON indicated per verification from the pharmacy, Tizanidine was not delivered due to the pre-authorization issue. The pharmacy was compounding the medication into a solution, and it had an expiration date of 14 days. The ADON confirmed the facility was not aware of the information until during the survey. On 03/10/2023 at 2:29 PM, the pharmacist confirmed Tizanidine HCL was not delivered due to a pre-authorization issue and the medication was converted into a solution form. The pharmacist confirmed the order was in tablet form and was delivered in solution form because the order was for 0.5 mg. The solution form had an expiration date of 14 days. The pharmacist referred to the pharmacy general manager (GM) when asked if the information was communicated to the facility. On 03/10/23 at 2:51 PM, the pharmacy GM indicated the order was converted to a solution for the resident's safety. The pharmacy GM indicated the minimum dosage of the Tizanidine was 2 mg and could not be cut into quarters and the score of the pill could only be equally split into a half dosage (1 mg) and had to be compounded as a liquid formula. The viscosity of the medication could account for not having enough for a 14-day supply of the medication. The GM assumed the information was communicated to the facility. R26 ' s medical records lacked documented evidence the clarification or conversion of the Tizanidine medication was communicated. A Quality Improvement: Consultant Pharmacist Summary for the month of October 2022, documented isolated issues with new orders were inaccurately transcribed. On 03/10/2023 at 3:30 AM, the Director of Nursing (DON) confirmed there was no communication by the pharmacy regarding the conversion and the pre-authorization issue until 03/09/2023. The DON indicated the expectation was the medication would be available for timely administration. A facility policy titled Physician/Prescriber Authorization and Communication Orders to Pharmacy revised 01/01/2022, documented the facility staff should monitor pharmacy communications to address or correct all orders requiring clarification before the next scheduled medication delivery. Orders as entered by the nursing staff into an electronic record may require alterations or changes prior to pharmacy dispensing. The pharmacy will notify the facility when alterations require a physician's or prescriber's order. A facility policy titled Delivery and Receipt of Routine Deliveries revised 01/01/2022, documented if any item ordered by the facility was not received in the delivery, facility staff should check a pharmacy communication slip indicating the reason and should contact the pharmacy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure a resident who was receiving an anticoagulant medication was monitored for bleeding or an adverse reaction and the injection site was documented per policy for 1 of 12 sampled residents (Resident 34). Failure to adequately monitor the resident on anticoagulant (blood thinner) medication could increase the risk of bleeding and potentially lead to serious harm or death. Findings include: A facility policy titled Medication Administered through Certain Routes of Administration - Subcutaneous Injections, dated 01/01/2022, indicated to document the site of injection. Resident 34 (R34) R34 was admitted on [DATE], with diagnoses including long-term use of anticoagulants, left mastoiditis (bacterial infection of the mastoid bone located behind the ears), and mastoidectomy (a surgical removal of diseased mastoid air cells). The Brief Interview of Mental Status dated 02/17/2023, documented a score of 99, which means the interview was not completed due to impairment. The History and Physical dated 02/16/2023, documented had some communication with hematology as there was a concern of cerebral clot previously and recommended started on Lovenox which was initiated on 02/11/2023. On 03/07/2023 at 1:04 PM, R34 was verbally responsive and ambulatory. R34 had injection marks noted on the lateral arms and thighs. A Physician order dated 02/14/2023, documented Lovenox injections of 19 milligrams (mg) to inject subcutaneously every twelve hours for sinus venous thrombosis for five weeks. A Care Plan dated 02/15/2023, documented R34 was on anticoagulant therapy with Lovenox injections related to post-surgical. The interventions included monitoring for side effects and effectiveness every shift. R34's medical records lacked documented evidence the injection site was documented, and the adverse side effects of anticoagulant use were monitored. On 03/09/2023 at 4:00 PM, a Registered Nurse 2 (RN2) indicated R34 was on Lovenox anticoagulant therapy and should have been monitored for bruising, bleeding, and any possible side effects. RN2 explained there should have been an order to monitor, but one was not obtained. RN2 indicated a physician order should have been obtained because it would serve as a reminder R34 was at risk for bleeding. On 03/09/2023 at 4:10 PM, the Assistant Director of Nursing (ADON) explained the monitoring for bleeding and side effects was vital for anticoagulant use and a physician's order should have been obtained. On 03/09/2023 in the afternoon, the Director of Nursing (DON) confirmed R34 was on anticoagulant therapy and had been administered for three weeks since admission, but there was no monitoring in place for adverse reactions. The DON indicated there should have been a monitoring order in the Medication Administration Record, but one was not obtained. The DON indicated the Licensed Nurse was responsible for ensuring the appropriate orders were obtained and transcribed upon R34's admission. A facility policy titled Anticoagulation Management Guidelines dated 06/14/2011, documented the use of validated instruments to assess effectiveness, adherence, and outcomes. Resident and family education included the importance of follow-up monitoring, compliance issues, and the potential for adverse drug reactions and interactions. The facility evaluated anticoagulation safety practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure their medication error rate was not five percent or greater when two errors were identified with 25 opportunities observed, resulting in an error rate of 8%. Failure to reduce the medication error rate to less than 5% could lead to an adverse drug reaction from overdose or underdose, which can cause harm or injury to the resident. Findings include: A facility policy titled Medication-Related Errors revised 05/01/2010 documented: Delivery error: drug product not received by the facility at the required or expected time. Omission error: The facility failed to administer an ordered dose to the resident unless it was refused by the resident or not administered because of a recognized contraindication. Resident 26 (R26) R26 was admitted on [DATE], with diagnoses including gastrostomy status, generalized idiopathic epilepsy and epileptic syndrome. The Brief Interview of Mental Status dated 01/23/2023, documented a score of 99, which means the interview was not completed due to cognitive impairment. A physician order dated 10/21/2022, documented to give a 0.5 milligram (mg) Tizanidine Hydrochloride (Muscle relaxant) tablet via gastrostomy tube (GT) three times a day for spasms. On 03/09/2023 at 8:35 AM, during medication pass observation, Registered Nurse 2 (RN2) in POD 2 prepared all of R26's medications except the Tizanidine Hydrochloride (HCL). On 03/09/2023 at 11:30 AM, RN2 confirmed Tizanidine HCL had not been administered because it had not been available since the previous day. The RN indicated the Tizanidine was already requested from the pharmacy, but there was no delivery. The Prescriptions Delivery Receipt dated 02/27/2023, documented Tizanidine 1 mg/1 ml oral solution had previously been delivered. On 03/09/2023 in the afternoon, the Assistant Director of Nursing (ADON) confirmed Tizanidine HCL was not administered due to unavailability. The ADON explained Tizanidine HCL was requested on 03/08/2023 but was not delivered. The ADON indicated per verification from the pharmacy, Tizanidine was not delivered due to a pre-authorization, but the facility was unaware until a follow-up was done. The ADON indicated if an ordered dose was not administered, it was considered a medication error. On 03/10/2023 at 2:29 PM, the pharmacist confirmed the Tizanidine HCL was not delivered on time due to a pre-authorization issue and the medication was in need of conversion into a solution form. Resident 2 (R2) R2 was admitted on [DATE] with diagnoses including seizures, gastrostomy status and tracheostomy status. A Physician order dated 03/09/2023, documented Vitamin D3 tablet 1000 unit to give 1 tablet via Gastrostomy Tube (GT) daily for supplement. On 03/09/2023 at 9:15 AM, Registered Nurse 4 (RN4) prepared nine medications for R2, except a Vitamin D3 tablet. RN4 indicated Vitamin D3 tablets were not available in the medication cart but the liquid was. RN4 almost gave the VIT D3 liquid but was hesitant to convert the dosage from tablet form to liquid. On 03/09/2023 at 11:30 AM, during observation in the medication room, the charge Registered Nurse indicated the Vitamin D3 tablet was available. The CRN explained the Vitamin D3 tablet was difficult to administer via GT. The CRN indicated the order should have been clarified to change it to a liquid form. On 03/10/2023 at 3:30 AM, the Director of Nursing (DON) indicated the expectation was the medication would be available for timely administration.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to ensure formula cans, electrolyte solution bottles, and creams were dated when they were opened. Failure to date the items upon opening could lead to decreased potency, effectiveness, or even toxicity, putting the patient at risk of harm. Findings include: On 03/09/2023 at 9:52 AM, the medication cart in POD 2 contained unlabeled formula can, electrolyte solution bottle and creams as follows: -Pedialyte 1L electrolyte solution: 160 ml left in the bottle -Alfamino pediatric formula, [NAME] 400 g; approximately 8 scoops left. -Desitin daily defense cream 4 oz, opened and unlabeled -Zinc oxide ointment skin protectant -Thera Calazinc body shield -Eucerin cream 4 0z. On 03/09/2023 at 10:14 AM, a Registered Nurse (RN) confirmed the 400-gram formula can with approximately 8-10 scoops left in the can. The Pedialyte 1 liter electrolyte solution with 160 milliliters left in the bottle was opened but undated. The RN was unsure how long the formula can, and the electrolyte solution had been opened since it was not dated. The RN indicated each resident had a dedicated cream. The RN indicated the medication and supply should be labeled to monitor when it was opened and discarded to preserve its potency. THE RN confirmed the creams were actively used but not labeled with dates when it was opened. On 03/09/2023 at 12:18 PM, a charge RN indicated all the formula cans, Pedialyte water, and creams should have been dated per facility protocol. On 03/10/2023 at 11:14 AM, the Director of Nursing (DON) indicated the medications, formula, creams, and supplies should have been dated or labeled upon opening. The DON indicated when the container was opened, it was important to determine the expiration date. Pedialyte should be discarded within certain hours, the canned formula within 30 days, and treatment creams within six months. The Manufacturer's Instructions dated 2023, revealed after opening the Pedialyte oral rehydration solution, indicated after opening the bottle, replace the cap, refrigerate, and use within 96 hours or discard. The Manufacturer's Instructions dated 2015, revealed to tightly cover an open can and use within one month. A facility policy titled General Dose Preparation and Medication Administration revised 01/01/2022, documented to follow manufacturer medication administration guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to measure the accurate portion size when preparing a resident's lunch meal for one unsampled resident (Resident #27). The failed practice had the potential to not meet the resident's nutritional needs. Findings include: Resident #27 (R27) R27 was admitted on [DATE] with medical diagnoses including respiratory failure and gastrostomy. A Physician order dated 02/27/2023 revealed R27 was on a puree diet. On 03/09/2023 at 11:07 AM, the [NAME] indicated the lunch menu included chicken Caesar salad. On 03/09/2023 at approximately 11:30 AM, the [NAME] was observed preparing lunch for R27 in which they added three pieces of chicken and approximately a palm size of the prewashed salad to the food processor. The [NAME] took the food processor bowl and added the puree mix directly to the plate for R27. The [NAME] was asked how they measure the food to ensure appropriate meal portion. The [NAME] indicated they eyeball the meal portion. The [NAME] explained the portion for R27 was 1 ounce per years of life and R27 was two years old, so the serving portion for R27 was two ounces. On 03/10/2023 at 8:30 AM, the Director of Food Services explained eyeballing was not an appropriate measurement and there were different measuring tools available in the kitchen to measure portion sizes. The Director of Food Services indicated Speech Therapy explained to them R27 was to receive one tablespoon per years of life for their meal portion. The Director of Food Services verbalized not measuring meal portions could mean residents were receiving food portions which were either too much or too little. On 3/10/2023 at 9:32 AM, a Speech Therapist indicated R27 was on an intensive feeding program and the current recommendation was for R27 to consume breakfast and lunch. The Speech Therapist indicated they were working closely with the Registered Dietician and rule of thumb regarding portion sizes for R27 was one tablespoon per years of life. The Speech Therapist explained the resident was one year old and was to receive one tablespoon of each food item being served. The Speech Therapist verbalized this was communicated to the kitchen staff. The Speech Therapist indicated not measuring the meal portion could lead to weight gain and impact the hunger satiety cycle for R27. On 03/10/2023 in the morning, a Registered Dietician (RD) confirmed the meal portion for R27 was one tablespoon per years of life. The RD explained if the resident was receiving a Caesar salad, R27 should have received one tablespoon of the chicken and one tablespoon of the salad.

Based on observation, interview, and document review, the facility failed to ensure 1) expired food items from the dry storage and refrigerator were discarded and 2) dishwasher was in good repair. The failed practices had the potential to impact the well-being of the residents through potential consumption of expired food items and breaches in infection control due to ineffective disinfection of dishes. 1) On 03/07/2023 at approximately 8:15 AM, the following expired food items were identified in the dry storage: - Flour with an expiration date of 08/15/2022 - [NAME] sugar with an expiration date of 09/16/2022 - Powdered sugar with an expiration date of 05/2021 On 03/07/2023 in the morning, the Director of Food Services confirmed the expiration date of the flour, brown sugar, and powdered sugar. On 03/07/2023 at approximately 8:15 AM, the following expired food items were identified in the refrigerator: -Chobani peach yogurt with an expiration date of 05/2021 -One bag of cinnamon sticks with an expiration date of 12/18/2022 On 03/07/2023 in the morning, the Director of Food Services confirmed the expiration date of the Chobani peach yogurt and bag of cinnamon sticks. On 03/10/2023 at 8:30 AM, the Director of Food Services indicated they were responsible for clearing out expired food items from the dry storage and refrigerator. The Director of Food Services explained the residents could get sick if they were to consume expired food items. The facility's policy titled Dry Goods Storage and policy titled Refrigerated Storage; both were last revised on 01/03/2019 revealed new food stock was stored behind old stock, so the older items were used first. 2) On 03/07/2023 in the morning, during the kitchen tour, the facility dishwasher was identified as a chlorine sanitizer, low temperature machine. The following attempts were made to test the chlorine level after completion of the rinse cycle: -Attempt one: Chlorine strip did not have a color change -Attempt two and three: Chlorine strip turned a light gray indicating a value of 10 with normal range being 50-100 On 03/07/2023 in the morning, the Director of Food Services indicated they performed the chlorine strip test that morning and the range was within normal. On 03/09/2023 at approximately 11:07 AM, the Director of Food Services indicated the dishwasher was still under repair as there was tubing which was deteriorating and needed to be replaced. On 03/10/2023 at 8:30 AM, the Director of Food Services indicated the staff member washing the dishes was responsible for ensuring the chlorine test was done before breakfast, lunch, and dinner. The Director of Food Services explained the potential outcome of the dishwasher not being within good repair meant dishes were not being disinfected properly, which meant bacteria could still be present on the dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure the nursing staff did not sign off on the medication administration record before administering the medication in PODS 1, 2, and 3. Failure to accurately document the medication administration could potentially result in medication errors, falsified medication records, altered therapeutic benefits, medication underdosing or overdosing, and adverse reactions. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including gastrostomy status, gastroparesis (delayed stomach emptying) and gastro-esophageal reflux disease with esophagitis. On 03/09/2023 at 7:53 AM, during medication pass observation, a Registered Nurse 2 (RN2) in POD 2 prepared R11's medications. RN2 signed off the medication administration and saved the record right after preparation, which indicated the medications were successfully administered. After completing the documentation, RN2 proceeded to R11's room to administer the six medications. On 03/09/2023 at 8:13 AM, RN2 checked the gastrostomy tube (GT) placement and administered the medications one at a time. R11's GT leaked during administration. Two medications were not completely administered and RN2 called the charge Registered Nurse (CRN) for assistance. The CRN indicated the GT was clogged. On 03/09/2023 at 11:15 AM, RN2 confirmed the medication administration record (MAR) was signed off right after the medications were prepared. RN2 explained was unsure if the MAR could still be corrected. RN2 indicated it should not have been documented as given when some of the medications were not administered due to GT clogging or leaking. RN2 indicated the facility provided education related to medication administration upon hire in 2022. On 03/09/2023 in the morning, the Assistant Director of Nursing (ADON) indicated the protocol was to sign off the MAR right after the medications were administered. The ADON explained the staff could click yes upon administration but not save the record until the administration was completed. The ADON indicated there could be a way to edit the documentation, but the protocol was to document right after the medications were administered. Resident 13 (R13) R13 was admitted on [DATE], with diagnoses including gastrostomy status and gastro-esophageal reflux disease. On 03/09/2023 at 8:56 AM, during medication pass observation, a Registered Nurse 3 (RN3) in POD 1 prepared R13's medications. RN3 signed off the medication administration and saved the record right after the preparation, which indicated the medications were successfully administered. RN3 proceeded to R13's room and administered the four medications. On 03/09/2023 at 11:22 AM, RN3 confirmed the medication administration record was signed off after the medications were prepared but not after they were administered. RN3 indicated was aware the administration record should have been signed off right after the medications were administered but was distracted. Resident 2 (R2) R2 was admitted on [DATE] and readmitted on [DATE], with admitting diagnoses including gastrostomy status and gastroesophageal reflux disease. On 03/09/2023 at 9:15 AM, Registered Nurse 4 (R4) in POD 3 prepared R2's 10 medications, signed off the medication administration and saved the record, which indicated the medications were successfully administered. RN3 proceeded to R2's room and administered the medications via GT. On 03/09/2023 at 11:30 PM, RN4 acknowledged the MAR should have been signed off right after the medications were administered, not during or after the medications were prepared. On 03/09/2023 at 11:56 AM, the Director of Nursing (DON) indicated the standard of practice was to document right after the medication was administered, not before. The DON indicated there could be a circumstance where the medication was not successfully administered and required assessment and reporting. The DON indicated staff were expected to document after the task was done and completed to maintain accuracy. A facility policy titled Medication Administered through an Enteral Tube revised 12/11/2019, documented the facility staff should take all the measures required by facility policy and applicable law to document necessary medication/treatment administration information when medications were given or administered after medication administration.

Based on interview and document review, the facility failed to ensure an allegation of physical abuse by a staff member towards a resident was reported to the State Agency in a timely manner for 1 of 1 resident. The failure to report incidents timely may place the facility residents at risk for abuse. Findings include: The facility policy Abuse-Dependent Adult/Child, revised on 07/02/2014, when an alleged or suspected case of mistreatment, neglect, injury of unknown source or abuse was reported the Administrator/Director of Nursing would notify the State Agency within 24 hours of when the abuse was reported. On 01/05/2023 the facility Administrator acknowledged the facility did not report the allegation of abuse to the State Agency within the required time frame. The facility submitted an initial and final report to the State Agency on 10/10/2022, 48 hours after they were aware of the alleged incident on 10/08/2022.