**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure expired medications were removed and discarded from the active supply in the medication storage room and 1 of 3 medication carts. The deficient practice had the potential to compromise the effectiveness of the medication. Findings include: On 02/25/2025 at 03:15 PM, an inspection of the facility's medication room with a Registered Nurse (RN) was completed. A box of disposable single-dose prefilled tip-lok syringes, each containing one 10 mcg/0.5 mL Hepatitis B vaccine for use from birth through [AGE] years of age was stored on the top shelf inside the medication refrigerator, with an expiration date of 02/17/2025. On 02/25/2025 at 03:27 PM, the RN confirmed the box of disposable single-dose prefilled tip-lok syringes each containing one 10 mcg/0.5 mL Hepatitis B vaccine for use from birth through [AGE] years of age was expired and should have been removed from the active supply to prevent administration. On 02/25/2025 at 03:40 PM, in the presence of an RN on Oasis-hall, the medication cart was inspected. A punch card which contained the as needed medication, Ondansetron HCL F/C 4mg tablets for R1 was observed stored with the active medications. The medication had expired on 01/23/2025. On 02/25/2025 at 03:46 PM, the Registered Nurse (RN), confirmed the Ondansetron HCL F/C 4mg tablets were expired and should have been discarded for resident safety. On 02/25/2025 at 03:58 PM, the RN explained the expired medication, Ondansetron HCL F/C 4mg tablet, had not been given to R1 in January or February per the medication administration record. On 02/26/2025 in the afternoon, the DON and the Administrator explained the nurses and the pharmacist had just checked for expired medications the week before and thought all expired medications had been appropriately removed and discarded. On 02/27/2025 at 03:03 PM, the Director of Nursing (DON), also verified the Ondansetron HCL F/C 4mg tablets and the box of disposable single-dose prefilled tip-lok syringes each containing one 10 mcg/0.5 mL Hepatitis B vaccine for use from birth through [AGE] years of age were expired and should have been discarded for resident safety. The facility pharmacy policy titled 5.3 Storage and Expiration Dating of Medications and Biologicals, with the revision date of 08/01/24, revealed the facility would ensure medications and biologicals with an expiration date on the label and 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 interview, record review, and document review, the facility failed to ensure 1) justification for off-label (the practice of prescribing a drug for a different purpose other than the condition for which the drug was approved) antibiotic use was documented and prolonged antibiotic regimen was re-evaluated by the inter-disciplinary team (IDT) for 4 of 12 sampled residents (Residents 1, 7, 5 and 10) and 2) facility staff and providers were educated on the facility's antibiotic stewardship program (ASP). The deficient practice had the potential to place residents at risk for antimicrobial resistance. Findings include: Implementation of ASP Resident 1 (R1) R1 was admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral palsy and Lennox-Gastaut syndrome with status epilepticus. A physician's order dated 03/23/2024, documented to give Erythromycin Ethyl succinate reconstituted suspension 200 milligrams (mg) per 5 milliliters (ml) or 200 mg/5 ml, give 5 ml via gastrostomy tube (G-tube) every eight hours for gastrointestinal (GI) motility. No stop date. Resident 7 (R7) R7 was admitted on [DATE], with diagnoses including cerebral palsy and congenital hydrocephalus. A physician's order dated 03/14/2024, documented to give Erythromycin Ethyl succinate 200 mg/5 ml reconstituted suspension, give 10 ml via G-tube four times a day for GI motility. No stop date. Resident 5 (R5) R5 was admitted on [DATE] and readmitted on [DATE], with diagnoses including spastic quadriplegic cerebral palsy and other seizures. A physician's order dated 09/02/2024, documented to give Erythromycin Ethyl succinate 200 mg/5 ml reconstituted suspension, give 5 ml four times a day for GI motility. No stop date. Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anoxic brain damage related to asphyxiation due to hanging. A physician's order dated 04/17/2024, documented to give Erythromycin Ethyl succinate 200 mg/5 ml reconstituted suspension, give 7.5 ml four times a day for GI motility. No stop date. On 02/25/2025 at 2:36 PM, the Director of Nursing (DON)/Infection Preventionist (IP) indicated the facility utilized the Mc Geer criteria (a set of evidence-based guidelines used to determine appropriate antibiotic therapy use) for its antibiotic stewardship program (ASP). The medical record reflected Residents 1, 7, 5 and 10 did not have active infections, antibiotic orders did not meet the Mc Geer criteria, and the medical record lacked documented justification for the non-recommended antibiotic starts for Residents 1, 7, 5 and 10. The medical record lacked documented evidence the prescriber provided a documented purpose for the off-label use of Erythromycin (an antibiotic) for Residents 1, 7, 5 and 10. The medical record lacked documented evidence the IDT which included nursing staff, pharmacist and physicians, re-evaluated the prolonged and off-label antibiotic regimen for Residents 1, 7, 5 and 10 such as evaluating risks versus benefits. On 02/25/2025 at 3:12 PM, the IP indicated it had been the long-time practice of the pediatrician to order Erythromycin to improve GI motility to facilitate bowel movements (BM) for residents with vomiting issues. The IP indicated the pediatrician preferred Erythromycin to an enema (a procedure which involved introducing a solution into the rectum to stimulate BM). On 02/25/2025 at 3:22 PM, the IP acknowledged the following: 1) Erythromycin was an antibiotic which was being used off-label for Residents 1, 7, 5, and 10; 2) antibiotic orders for Residents 1, 7, 5 and 10 had an indefinite duration or no stop date; 3) the antibiotic regimen for Residents 1, 7, 5 and 10 were considered prolonged spanning several months; 4) antibiotic starts for Residents 1, 7, 5 and 10 did not meet the Mc Geer criteria and 5) the IDT which included the IP, pharmacist, and physician had not discussed, mentioned nor questioned the pediatrician's practice of prescribing Erythromycin for GI motility during IDT or quality assurance and performance improvement (QAPI) meetings. On 02/25/2025 at 3:30 PM, the IP indicated needing time to review the medical record for Residents 1, 7, 5 and 10 to determine whether there was evidence of nurse-physician discussions, re-evaluation of the residents' antibiotic regimen by the IDT which included examining risks versus benefits or whether the physician had written a justification for the off-label, prolonged, non-recommended use of Erythromycin for Residents 1, 7, 5 and 10. On 02/26/2025 at 8:36 AM, Registered Nurse 1 (RN1) indicated being employed for 10 years and RN 2 for more than 10 years. RN1 and RN 2 indicated being familiar with Residents 1, 7, 5 and 10 and were likewise familiar with the pediatrician's practice of off-label use of Erythromycin for residents with BM issues. RN1 and RN 2 explained the facility had a bowel protocol wherein a stool softener was used first, progressing to a laxative and resorting to a rectal suppository when a BM had not been achieved. The RNs indicated the pediatrician rarely ordered an enema but preferred to use Erythromycin to stimulate GI motility. The RNs indicated never questioning the pediatrician's orders. On 02/26/2025 at 8:45 AM, the IP indicated having reviewed the medical record for Residents 1, 7, 5 and 10 and confirmed there was no evidence the prescribing physician provided a written justification for the off-label, prolonged, non-recommended (does not meet Mc Geer criteria) prescribing of Erythromycin for Residents 1, 7, 5 and 10. According to the IP, 12 months' worth of pharmacy regimen review documents reflected the pharmacist had not addressed nor questioned the physician's antibiotic orders. Finally, the IP confirmed there was no documentation the IDT had re-evaluated the antibiotic regimen which included discussions regarding benefits outweighing risks for Residents 1, 7, 5 and 10. Education and Training On 02/26/2025 at 8:40 AM, RN1 and RN 1 indicated not being familiar with the facility's ASP. The RNs indicated not being well-versed on the Mc Geer criteria and verbalized not receiving training regarding Mc Geer criteria and the facility's ASP. On 02/26/2025 at 11:53 AM, the DON/IP indicated being responsible for providing education and training to nurses and providers. The IP indicated staff were provided infection control in-services on admission and annually, but the in-service did not include antibiotic stewardship. The IP corroborated the RNs interview regarding staff not been educated on the facility's ASP. On 02/26/2025 at 1:04 PM, the Administrator indicated there were four physicians with prescribing privileges in the facility. The Administrator indicated the General Orientation for Independent Contractors listed all topics the physicians were provided education on which included the ASP program. The Administrator indicated the Medical Director signed the orientation form on 07/12/2013, the pediatrician signed the orientation form on 01/16/2014, the physician assistant signed the orientation form on 01/03/2014 and the pulmonologist had no signed orientation form. On 02/26/2025 at 1:16 PM, the Administrator and the IP indicated being hired after 2014 so the Administrator and IP could not speak to the content, level and depth of ASP education the physicians were provided in 2013 and 2014. The IP indicated it was fair to say the education provided to the physicians on the facility's ASP was outdated and should have been re-done. On 02/26/2025 at 1:20 PM, the IP indicated the facility's current ASP was not being fully implemented and should be tightened and improved through education particularly with regards to following Mc Geer criteria and documentation requirements when antibiotic orders do not align with the Mc Geer criteria. The IP indicated the non-implementation of the ASP placed residents at risk for developing antimicrobial resistance and receiving unnecessary medications. The ASP policy dated 01/01/2017, documented the ASP would promote appropriate use of antibiotics at the same time reducing adverse effects associated with antibiotic use. The policy was designed to limit antibiotic resistance while improving treatment efficacy and resident safety. The core elements of stewardship include leadership, drug expertise, action to implement recommended practices, and education for clinicians, nursing staff and families regarding antibiotic resistance. The facility used the Mc Geer revised guidelines to determine if the resident's status met the minimum criteria for initiating antibiotics.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure comprehensive care plans were completed for 1) gastrostomy (GT) venting, 2) prophylactic antibiotics and 3) hypertension (HTN) with multiple antihypertensive medications for 3 of 14 sampled Residents (Resident 11, 13 and 22). The deficient practice had a potential for staff not to provide personalized care for residents. Findings include: 1) Resident 11 (R11) was admitted on [DATE], with diagnoses including pervasive developmental delay and GT dependent. On 01/30/2024 at 9:27 AM, in R11's room at the head of the bed on an intravenous (IV) pole, was a 30 milliliter (ml) open syringe with a tubing attachment. The 30 ml. syringe had no plunger and was attached to a plastic tubing to keep it above the level of the head of the resident. The syringe and the attached tubing contained residual tube feeding (TF) liquid. On 01/30/2024 at 9:39 AM, the registered nurse (RN) indicated the setup is for venting the resident's stomach after a TF regimen and the purpose is to let gastric air release preventing regurgitation and abdominal discomfort. R11 physician's order dated 12/18/2023, documented Enteral Feed order four times a day, flush with 300 ml water after feeding - run over 1 hour. A nursing progress note dated 01/29/2024 at 6:11 PM documented, stomach distended, g-tube venting as needed. Tolerated all feeds and medications. Meds given as scheduled as ordered. A nursing progress note dated 12/18/2023 at 2:36 PM, documented at approximately 2:37 PM, it was noted Resident's abdomen was very distended and hard to the touch in all quadrants. Resident was vented for 30 mins with minimal relief and an output of approximately 10ml. Due to abdominal distention, tube feeding was held for the duration of day shift. Resident does not seem to be in any physical distress. Will continue to monitor. R11's Comprehensive Care Plan lacked documented evidence of interventions and monitoring for the procedure of venting of the patient's stomach after tube feeding. On 01/31/2024 at 3:07 PM, the assistant director of nursing (ADON) confirmed the GT venting process should be included in R11's comprehensive care plan. Care interventions and monitoring for the resident's need for gastric venting to alleviate abdominal discomfort should have been included in the care plan. 2) Resident 13 (R13) was admitted on [DATE] with diagnoses including acute lymphoblastic leukemia and autistic disorder. R13's medical file revealed a physician's order dated 06/10/2023 at 9:00 AM, documented Sulfamethoxazole-Trimethoprim (Bactrim) Oral Suspension 200-40 milligram (mg)/5 milliliter (ml), give 160 mg via gastrostomy (GT) every 12 hours every Saturday, Sunday for Prophylaxis, give 160 mg = 20 ml. Review of physician's progress notes from 06/2023 to current documented, continue with Bactrim 2x per day Saturday/Sunday, no end date per Hematology/Oncology. R13's medication administration record revealed the resident had been consistently receiving the antibiotic as prescribed. The Comprehensive Care Plan for R13 documented the following: Start Date - 12/3/2023 Target Completion - 12/9/2023 Completed date - 12/23/2023. Start Date - 9/1/2023 Target Completion - 9/8/2023 Completed date - 9/14/2023. Start Date - 6/1/2023 Target Completion - 6/8/2023 Completed date - 6/17/2023. All completed comprehensive care plans lacked documented evidence of a focus problem and interventions for the diagnosis and use of the medication Bactrim. On 02/01/2024 at 3:36 PM, the director of nursing (DON) confirmed the Bactrim was for leukocytopenia and should have been included in the resident's comprehensive care plan. 3) Resident 22 (R22) was admitted on [DATE], with diagnoses including essential hypertension and traumatic brain injury. Review of R22's physician's orders revealed the following antihypertensive medications: 1) Order Date: 01/04/2024, Propranolol Hydrochloride Oral Solution 20 milligrams (mg)/5 milliliter (ml), give 40 mg via G-Tube every 8 hours for blood pressure (BP) management. Check vitals prior to administration. Hold for systolic blood pressure (SBP) less than (<) 90 and heart rate (HR) < 60. 2) Order Date: 12/22/2023, Catapres-TTS-3 Patch Weekly 0.3 mg/24hour (CloNIDine Hydrochloric patch), Apply 1 patch transdermally one time a day every Friday for hypertension - no parameters needed. 3) Order Date: 11/14/2022, CloNIDine HCl Tablet 0.1 mg, give 0.1 mg via G-Tube every 12 hours as needed for hypertension, do not give if HR is less than 60. 4) Order Date: 4/28/2023, Lisinopril Oral Tablet 10 mg, give 10 mg via G-Tube one time a day for hypertension hold if SBP is < 95. On 01/31/24 at 2:14 PM, the assistant director of nursing (ADON) reviewed R22's medical record and confirmed the lack of a person-centered comprehensive plan. The ADON indicated a care plan should have been created for the diagnosis of hypertension and the appropriate interventions for the antihypertensive medications. The facility policy titled Care Plans revised 09/27/2018, documented the facility shall develop, for each resident, a comprehensive care plan. Resident care plan should include a description of the services that will be provided to the resident to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being.

Deficiency Text Not Available

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure splints were applied to hand contractures as ordered and documented for 1 sampled residents (Resident 2), and a physician order for a splint application was obtained for 1 sampled residents (Resident 6). The deficient practice could have the potential to exacerbate existing medical conditions, impede rehabilitation progress, and increase the risk of further complications, such as restricted joint mobility, muscle atrophy, prolonged recovery times, and diminished overall quality of life for the affected residents. Findings include: Resident # 2 (R2) R2 was admitted on [DATE], with diagnoses including hypoxic ischemic encephalopathy, tracheostomy status, and reduction deformity of the brain. A physician's order dated 11/16/2023, documented bilateral wrist and hand finger orthosis (WHFO) to be donned daily for up to 4 hours at 1000 (10:00 AM) and doffed at 1400 (2:00 PM) daily for tone management and contracture prevention. On 01/30/2024 at 9:42 AM, R2 was in bed in a supine position, non-verbal, with eyes closed. Contractures on the upper extremities were noted with no splints in place. On 01/30/2024 at 11:06 AM, R2 was in bed in the supine position, with no splints in place. On 01/30/2024 at 12:37 PM, R2 was in bed; there was no splint in place. The Medication Administration Record (MAR), dated 01/30/2024 and 01/31/204, documented the bilateral splints were applied. The Administration History documented the splints were applied and removed on the following occasions: -01/30/2024 at 9:14 AM, the splints were applied. -01/30/2024 at 1:30 PM, the splints were removed. -01/31/2024 at 9:18 AM, the splints were applied. On 01/31/24 at 9:39 AM, R2 was in bed; no splints were in place. On 01/31/2024 at 9:54 AM, a Licensed Practical Nurse (LPN) assigned to R2 on 01/30/2024 and 01/31/2024, verified and confirmed the splints were not applied, but it was documented in the MAR the splints were applied. The LPN explained the process was to verify the splint orders, implement them, and document them after the task was completed. The LPN indicated the Occupational Therapist (OT) was responsible for applying and removing the splints. On 01/31/2024 at 10:00 AM, an OT explained the splints required an order and were normally applied from 10:00 AM to 2:00 PM as ordered. The OT indicated the CNA, Licensed Nurses and therapists were responsible for applying and removing the splints. The OT indicated the rehabilitation services had their own documentation, but the Licensed nurses were responsible for documenting it in the MAR. On 01/31/2024 at 10:34 AM, the Director of Nursing (DON) explained the Licensed nurses, Certified nursing Assistants and therapists were responsible for the application and removal of the splints as ordered. The DON indicated the expectation was to implement the orders timely and to accurately document if splints were applied or not. On 01/31/2024 at 11:36 AM, the Assistant Director of Nursing (ADON) confirmed the LPN documented in the MAR splints were applied at specific times, and the Licensed Nurses were expected to appropriately document ensuring the splints were in place. Resident 6 (R6) R6 was admitted on [DATE] and readmitted on [DATE], with diagnoses including hypoxic ischemic encephalopathy, generalized idiopathic epilepsy, and epileptic syndromes. On 01/30/2024 at 10:48 AM, R6 was seated on the tilted wheelchair, wearing a chest harness, hip/lap seat belt, and a rubberized ankle foot orthosis (AFO) on bilateral lower extremities. The Physical Therapist Progress Note dated 06/20/2023, documented the bilateral AFOs were donned for three hours. R6 medical records lacked documented evidence a physician order was obtained and transcribed for the utilization and management of AFO, chest harnesses, and hip/lap seat belts until 01/31/2024. On 01/31/24 at 3:24 PM, the Director of Rehabilitation (DOR) confirmed there was no order in place for the utilization of R6's AFOs, chest harnesses, and hip/lap seat belts to provide a stable surface with support to maintain upright posture and provide weight shifting and pressure relief. The DOR indicated the physical therapist (PT) was responsible for obtaining and transcribing an order but was unsure if an order had been placed for R6. The DOR indicated a physician order was required before any application of orthotics. On 02/02/2024 at 11:24 AM, the PT indicated the AFOs were first applied on 06/20/2023, and were currently donned up to this time. The PT explained was unaware the order should have been obtained and transcribed before application since there was an order for therapy. A facility policy titled Splint-Care of Resident dated 04/03/2012, documented to obtain physician orders for applications and the frequency of use schedule.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a physician's order was obtained for gastrostomy (GT) venting for 1 of 14 sampled residents (Resident 11). The deficient practice has the potential for nursing interventions not being communicated with the physician and preventing the physician from being aware of the current status of the patient. Findings include: Resident 11 (R11) R11 was admitted on [DATE], with diagnoses including pervasive developmental delay and GT dependent. On 01/30/2024 at 9:27 AM, in R11's room at the head of the bed on an intravenous (IV) pole, was a 30 milliliter (ml) open syringe with a tubing attachment. The 30 ml. syringe had no plunger and was attached to a plastic tubing to keep it above the level of the head of the resident. The syringe and the attached tubing contained residual tube feeding (TF) liquid. On 01/30/2024 at 9:39 AM, the registered nurse (RN) indicated the setup is for venting the resident's stomach after a TF regimen and the purpose is to let gastric air release preventing regurgitation and abdominal discomfort. R11 physician's order dated 12/18/2023, documented Enteral Feed order four times a day, flush with 300 ml water after feeding - run over 1 hour. A nursing progress note dated 01/29/2024 at 6:11 PM documented, stomach distended, g-tube venting as needed. Tolerated all feeds and medications. Meds given as scheduled as ordered. A nursing progress note dated 12/18/2023 at 2:36 PM, documented at approximately 2:37 PM, it was noted Resident's abdomen was very distended and hard to the touch in all quadrants. Resident was vented for 30 mins with minimal relief and an output of approximately 10ml. Due to abdominal distention, tube feeding was held for the duration of day shift. Resident does not seem to be in any physical distress. Will continue to monitor. R11's Physicians Orders lacked documented evidence an order for GT venting was obtained. On 01/31/2024 at 3:07 PM, the assistant director of nursing (ADON) confirmed the GT venting process should have had a physician order. The ADON indicated the facility utilizes two types of procedures to relieve gas discomfort for residents with GT's. One was with the use of an open syringe and the second was with the use of a [NAME] bag (a bag which allows gas to escape after feeding). The facility policy titled [NAME] Bags for Gastrostomy Tube Feedings (undated), documented Purpose: to provide means of relieving gastric pressure. Needed Supplies: Physician's Order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure prophylactic antibiotics had a justification for usage for 1 of 14 sampled Residents (Resident 13). The deficient practice had the potential to prevent implementation of proper care and monitoring interventions based on the antibiotic justification. Findings include: Resident 13 (R13) R13 was admitted on [DATE] with diagnoses including acute lymphoblastic leukemia and autistic disorder. R13's medical record revealed a physician's order dated 06/10/2023 at 9:00 AM documented, Sulfamethoxazole-Trimethoprim (Bactrim) Oral Suspension 200-40 milligram (mg)/5 milliliter (ml), give 160 mg via gastrostomy (GT) every 12 hours every Saturday, Sunday for Prophylaxis Give 160 mg = 20 ml. Review of physician's progress notes from 06/2023 to current documented, continue with Bactrim 2x per day Saturday/Sunday, no end date per Hematology/Oncology. Review of nursing progress notes 06/2023 to current, lacked documentation as to why R13 was on antibiotic. R13's medical record lacked a diagnosis for the use of the antibiotic and laboratory work up or indications to monitor the resident associated with the use of the prophylactic antibiotic. R13's medication administration record revealed the resident has been consistently receiving the antibiotic as prescribed. A Pharmacy Recommendation Review dated 11/27/2023 documented, upon reviewing the medical record no diagnosis for the use of Bactrim. Recommendation is to provide documentation that supports the clinical rationale for antimicrobial use. The physician's signature and date were blank. On 02/01/2024 at 3:36 PM, the Director of Nursing (DON) confirmed the Bactrim was for leukocytopenia and should have been the indication from when the antibiotic was initiated. The DON confirmed the Pharmacy recommendation from November 2023 should have been followed through and confirmed with the physician. The facility policy titled Antimicrobial Stewardship Program dated 01/01/2017, documented when prescribing antimicrobials, the physician should provide complete orders including the following elements: Indication for use.

Based on observation, interview and record review, the facility failed to ensure a surveillance device was in working condition to provide additional visual monitoring for the facility. The failure had the potential for decreased monitoring of the facility and lack of tools for reviewing incidences. Findings include: A tour of the facility revealed wall mounted surveillance cameras strategically located to monitor common areas of the lobby, dining/multipurpose area, and hallways. The cameras provided monitoring of the doors which serves as the entrance and exits for the facility. On 02/01/2024 at 3:36 PM, the Director of Nursing (DON) toured the information technology (IT) room where the camera monitor and recording devices were installed. The DON indicated the cameras aid the facility in terms of monitoring activities for both residents and staff in the common areas. The DON acknowledged the cameras were monitored by the use of a smartphone application. The DON indicated the access to the camera feeds is limited to the Administrator, the DON, and the Director of Maintenance. The DON confirmed the only way of determining functionality of the camera is through accessing the application or actual visualization of the camera monitor. On 02/01/2024 at 4:10 PM, the assistant director of nursing (ADON) indicated not knowing where monitors for the surveillance camera were located and would not be able to determine if the camera was fully operational. On 02/01/2024 in the morning, the housekeeper and two Registered Nurses indicated knowing there were several cameras located in the facility. The interviewed staff confirmed not knowing where the camera feeds were sent and would not be aware if the cameras were working or not. On 02/02/2024 at 11:50 AM, the DON and the Administrator indicated the key to the IT room was on a general house key where most staff could have accessed the room, but staff normally do not go inside for they have no reason to. The Administrator confirmed there was no standard frequency set in accessing the application to assess functionality of the surveillance camera. The Administrator acknowledged the surveillance camera would have been a good tool in investigating incidences that had occurred in the facility. The DON and Administrator agreed the camera should have been monitored for functionality. On 02/02/2024 at 3:07 PM, the Director of maintenance indicated using the camera monthly to remotely assess for environment safety checks. The Director indicated going inside the IT room about four to five days to obtain tools or supplies. The Director confirmed there could have been days the camera was down, and the staff would not be able to determine if it was functional. The Director acknowledged having the camera visible to staff could immediately identify any breakdowns and reported to be serviced when needed. The facility policy titled Utility Systems Risk Management Plan revised 06/22/2010, documented the policy is to design and install utility systems that meet patient care and operational needs. It is designed to ensure operational reliability, assess risk, respond to failures, assure performance and testing of critical components before use and train users and operators of the utility systems components, thus promoting a safe, controlled, and comfortable environment. Objective: The facility identifies and documents inspection and maintenance activities for all operating components of utility systems in the inventory. The facility identifies and documents the frequencies for inspecting, testing, and maintaining all operating components of the utility systems, based on criteria such as manufacturers' recommendations, risk levels and/or organizational experience.

Based on observation, interview, record review, and document review, the facility failed to ensure the medication carts were locked when unattended. The deficient practice could have jeopardized the safety of both staff and residents, as unsecured medication carts increase the risk of unauthorized access to potent medications, medication errors, theft, or misuse, posing serious health hazards and compromising the overall well-being of individuals within the facility. Findings include: A facility policy titled Storage and Expiration of Medications, dated 01/01/2013 documented the facility should ensure the resident medications were locked. A pharmacy Consultation Report dated 01/25/2024, documented during the medication and cart review, it was noted the medication cart was left open and unattended. On 02/01/2024 at 3:09 PM, the medication cart in the Oasis hallway was parked, unlocked and unattended. An unsampled resident from Springs Hall wandered in the lobby and Oasis hallway. A Registered Nurse RN) assigned to the medication cart was not around, and there were no other staff in the hallway until the Administrator came by and locked the medication cart. On 02/01/2024 at 3:15 PM, an RN explained was assigned to Oasis and Springs Hall. The RN indicated the medication cart should have been locked when unattended to prevent unauthorized individual to access the medications. On 02/01/2024 at 3:21 PM, the Assistant Director of Nursing (ADON) indicated the medication cart should have been locked at all times when unattended for resident's safety. The ADON indicated the RN had previously received education ensuring the medication cart would be locked. On 02/01/2024 at 3:33 PM, the Director of Nursing (DON) indicated the medication carts should have been locked when unattended for safety. The DON indicated the facility had residents who wandered and were at risk for accidental ingestion of the medications. On 02/02/2024 at 8:00 AM, observed the medication cart for respiratory therapy was parked in the hallway and was not locked. The cart was unattended for 13 minutes with two certified nursing aides and a physical therapist observed passing by the unlocked cart. On 02/02/2024 at 8:13 AM, the respiratory therapist (RT) confirmed the cart was left open and should be kept locked. The RT indicated the cart key was not handed down during shift change. On 02/02/2024 at 8:19 AM, the RT informed the DON and a key to the cart was provided to the RT. The DON acknowledged any cart with medications stored in it, has to be locked at all times. The facility policy titled General Dose Preparation and Medication Administration revised 01/01/2013, documented facility should ensure that medication carts are always locked when out of sight or 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 nail care was provided for a dependent resident for 1 of 12 sampled residents (Resident 10). The failure to trim the resident's nails as ordered could have resulted in injuries to the skin. These injuries include scratching, infections, the spread of diseases, damages to the gastrostomy or tracheostomy, irritation, and inflammation at the incision sites. Findings include: Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including cerebral palsy (impaired muscle coordination), gastrostomy status (GT), dependence on a respirator, behavioral and emotional disorders, and a lack of expected normal physiological development in childhood. A Care Plan dated 02/26/2020, documented R10 had potential and actual impairments to skin integrity due to incontinence, impaired mobility, and a communication deficit. The intervention included avoiding scratching and keeping fingernails short. A Care Plan dated 03/25/2020, documented avoid scrubbing and pat dry sensitive skin. Check nail length, trim and clean on bath day and as necessary. The History and Physical dated 09/25/2022, documented R10 was very active, became frustrated, and would grab at R10's tracheostomy or grab the GT when upset. R10 experienced significant severe agitation on occasion. R10 had very sensitive skin and intermittent dermatitis around the GT site. On 01/24/2023 at 3:39 PM, R10 was in bed, awake, active and non-verbal. R10 had long fingernails and was unintentionally scratching self, due to constant movement of the hands. The Skin Monitoring: Comprehensive Certified Nursing Assistant (CNA) Shower Review, documented R10's fingernails were trimmed on 01/25/2023. On 01/27/2023 at 11:00 AM, R10 was awake and active, fingernails were long. A Respiratory Therapist (RT) confirmed R10's fingernails were long, and the nail edges were uneven. The RT indicated the nails should have been trimmed because it was risky for the heat moisture exchanger (HME) to be pulled out or injure the surrounding skin as R10 was very active. On 01/27/2023 at 11:30 AM, a Registered Nurse (RN) confirmed R10's fingernails should have been trimmed. The RN explained the fingernail trimming should be done during shower days or bed bath and R10 was provided a bed bath on Wednesday 01/25/2023. The RN verified and confirmed it was documented R10's nails were trimmed but indicated it was not done. The RN instructed the Certified Nursing Assistant (CNA) assigned to R10 to trim R10's fingernails. On 01/27/2023 at 11:32 AM, a CNA confirmed R10's fingernails were long with uneven edges. On 01/27/2023 at 12:10 PM, the Assistant Director of Nursing acknowledged the Skin Monitoring: Comprehensive CNA Shower Review documented R10's fingernails were trimmed on 01/23/2023 and 01/25/2023 but was not performed. On 01/27/2023 in the afternoon, the Director of Nursing indicated the staff were expected to trim a resident's nails as scheduled and document only what had been performed or completed. A facility policy titled Activities of Daily Living dated 05/28/2019, documented care and services provided as person-centered care. The facility would provide services related to activities of daily living and would be included in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and document reviews, the facility failed to ensure a physician's order was followed and appropriately documented when medication or treatment was not provided for 1 of 12 sampled residents (Resident 5). Failure to follow a physician's order could potentially lead to further complications, such as infection or delayed healing. Findings include: Resident 5 (R5): R5 had been admitted on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy status, tracheostomy status, and hypoxic ischemic encephalopathy (brain injury). The Brief Interview of Mental Status, dated 11/29/2022, documented a score of 99, which meant R5's cognitive status could not be completed due to impairment. R5's functional status, dated 11/29/2022, documented R5's total dependence on staff. A physician's order dated 12/28/2022, documented Desitin external cream to be applied topically to the GT site twice daily at 9:00 AM and 9:00 PM for skin redness. The Medication Administration Record dated 01/26/2022, documented Desitin cream was administered on 01/25/2023 at 9:00 AM. On 01/26/2023 at 8:29 AM during medication pass, a Registered Nurse (RN) administered the scheduled eight medications, except the Desitin external cream. On 01/26/2023, at 11:30 AM, a Registered Nurse 1 (RN1) explained that right after the medication pass observation, the Desitin cream was administered to R5's GT site. When the surveyor asked RN1 to check the Desitin Cream medication, RN1 had difficulty locating the medication. RN1 was asked again if the Desitin cream was applied to R5's GT site, and RN1 revealed it was not applied because there was still cream on R5's GT site upon checking. RN1 acknowledged that the Desitin cream was not administered and should not have been documented as applied. On 01/26/2023 at 11:45 AM, a Registered Nurse 2 (RN2) indicated the physician order should have been followed. RN2 explained before the application of any treatment, the GT site should have been cleansed first. RN2 explained if the GT site's skin redness and inflammation were not treated effectively, it could potentially lead to further complications such as delayed healing or infection. On 01/26/2023 at 1:00 PM, the Director of Nursing (DON) indicated the staff were expected to follow the physician orders. The DON explained if the medication was not administered, there should have been a reason, and the physician should have been notified. On 01/27/2023 at 09:45 AM, the Nurse Practitioner (NP) indicated the staff were expected to follow the physician order to treat the skin. The NP indicated failure to follow orders and properly document could potentially cause infection. The NP indicated the resident's condition may not improve or may worsen, requiring additional medical intervention or prolonging the recovery process. A facility policy titled General Dose Preparation and Medication Administration, dated 01/01/2013, indicated the facility should comply with applicable laws and the State Operations Manual when administering medications. The facility should document necessary medication administration or treatment information when medication is given or applied.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and document review, the facility failed to ensure dressings were changed as ordered and documented appropriately for 2 of 12 sampled residents (Residents 1 and 5). Failure to maintain proper dressing care as ordered could potentially lead to several risks, such as skin breakdown, pressure injuries, infection, discomfort, and pain. Findings include: Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including tracheostomy status, gastrostomy status, scoliosis (abnormal twisting and curvature of the spine) and cerebral palsy (impaired muscle coordination). The Brief Interview of Mental Status dated 11/21/2022, documented a score of 99, which indicated R1's cognitive status could not be completed due to impairment. R1's functional status dated 11/21/2022, documented R1's required total dependence on staff. A physician order documented to apply Optifoam in the crease on the right side of the abdomen daily at night for skin protection. On 01/25/2023 at 2:30 PM, R1 was in bed, contracted, and unable to communicate verbally. An observation revealed Optifoam dressing was dated 01/23/2023 and had the initials of the nurse who applied the dressing. It was also noted there was scarring from previous skin openings present on R1's abdominal crease. The Registered Nurse on duty confirmed the dressing was soiled and dated 01/23/2023 and documented it was changed on 01/24/2023. The RN acknowledged the order for skin protection for R1's abdominal crease should have been followed and appropriate documentation should have been completed by the night nurse on duty. The Medication Administration Record documented, the Optifoam dressing was changed on 01/24/2023, even though the old dressing was dated 01/23/2023. On 01/25/2023 at 9:19 AM, during a telephone interview, a night Registered Nurse (RN) explained during the morning endorsement, the Optifoam was clean, the reason why it was not changed and documented as being applied. The night RN stated was new to the facility and was unaware of what to document if the Optifoam was not applied but acknowledged the physician order should have been followed. On 01/26/2023 at 2:00 PM, the Director of Nursing (DON) indicated the staff were expected to follow the physician orders and to notify the physician if the dressing was not changed or clarify the order. The DON indicated if the dressing was not changed, it should be documented as not changed. The DON acknowledged the RN documented the dressing had been changed, but it had not been. On 01/27/2023 at 09:45 AM, the Nurse Practitioner indicated the staff were expected to follow the physician order for skin protection as ordered for R1. The NP indicated failure to maintain proper dressing care can potentially cause harm by reopening the skin and developing a wound. The NP indicated the nurse should document only what was done. Resident 5 (R5) R5 was admitted on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy status, tracheostomy status and hypoxic ischemic encephalopathy. The Brief Interview of Mental Status dated 11/29/2022, documented a score of 99, which indicated R10's cognitive status could not be completed due to severe impairment. R5's functional status dated 11/29/2022, documented R5's total dependence on staff. A Care Plan dated 04/04/2020, documented R5 was at risk for skin breakdown. The interventions included to administer medications as ordered. Administer treatments as ordered and monitor effectiveness. A Comprehensive Certified Nursing Assistant Shower Review dated 01/20/2023 documented a wound lesion on the right elbow during assessment. A physician order dated 01/16/2023, documented Medihoney wound burn dressing to be applied to right elbow topically for wound management twice a day at 8:00 AM and 8:00 PM. On 01/26/2023 at 8:29 AM, R5 was in bed and a wound dressing on the right elbow was dated 01/24/2023. The Medication Administration Record indicated the Medihoney wound burn dressing was applied on 01/25/2023 and 01/26/2022 by the same RN assigned to R5. On 01/26/2023 at 1:30 PM, the RN indicated the dressing was applied as ordered however, upon checking the dressing on R5's right elbow, it was dated 01/24/2023. The RN explained the dressing was not changed on 01/25/2023 and 01/26/2023 because it still looked clean. The RN acknowledged the physician order was not followed as ordered. The RN indicated the physician should have been notified if the dressing was not applied and to appropriately document the dressing was not changed. The RN verbalized the importance of following the physician order or communicating for clarification. On 01/26/2023 in the morning, another RN indicated If the physician order was to be followed or if not to clarify. The RN explained the risk would be the redness and inflammation would not be effectively treated, potentially leading to further complications such as infection or delayed healing. On 01/27/2023 at 09:45 AM, the Nurse Practitioner (NP) indicated the staff were expected to follow the physician order to treat R5's skin as ordered. The NP indicated failure to follow orders and properly document can potentially cause harm. Additionally, the patient's condition may not improve or may worsen, potentially requiring additional medical intervention or prolonging the recovery process. A facility policy titled Skin Care Program/Wound Care Program dated 10/2018, indicated the facility would enhance the participant's quality of life by maintaining or restoring the resident's skin integrity. The programs would implement preventative measures through ongoing monitoring of participants at risk for skin breakdown. Based on skin findings, appropriate preventative measures would be implemented. Nursing would monitor the resident for wound healing based on physician order.

Based on observation, interview, record review, and document review, the facility failed to ensure the medication cart was locked and the key was secured and not attached to the narcotics drawer when unattended. Failure to keep the medication cart locked and the narcotics key secured when unattended could result in easy access to the medications or narcotics, leading to theft, drug diversion, and the risk of accidental ingestion. Findings include: On 01/24/2023 at 10:09 AM, a medication cart in unit 1 was found to be unlocked and unattended, with a set of keys attached to the narcotics drawer. A nurse was notified and searched for the Registered Nurse (RN) who was responsible for the unattended medication cart. On 01/24/2023 at 10:14 AM, an RN assigned to the medication cart explained while in a resident's room, had forgotten to lock the medication cart and left the key attached to the narcotics drawer. The RN confirmed the medication cart had been left unattended and unlocked and the key attached to the narcotic drawer. The RN explained the medication cart should not be left unlocked and keys should be secured when unattended to prevent unauthorized access to the medications, including the narcotics. On 01/25/2023 at 11:00 AM, the Director of Nursing (DON) indicated that staff were expected to lock the medication carts when unattended to secure the medications and narcotics from unauthorized access and for the safety of the residents. A facility policy titled Medication Storage dated 08/2022, indicated medication carts and cabinets should be locked when unattended. A facility policy titled General Dose Preparation and Medication Administration dated 01/01/2013, indicated the facility should ensure the medication carts were always locked when out of sight or unattended.

Based on observation, interview, and document review, the facility failed to ensure lunch was served at proper temperature. The failure to ensure meals were served at proper temperature had the potential to put the resident at an increased risk of food safety. Findings include: On 01/24/2023 at 11:48 AM, the cook was preparing the lunch tray for one resident. The cook indicated there was one resident receiving a lunch tray since the other residents were on tube feedings, not eating orally, or currently at school. The cook was preparing chicken nuggets, green beans, fresh orange cubes, and a juice for the lunch tray. The temperature of the food was as follows: -Chicken nuggets-165 degrees Fahrenheit -Green beans-167 degrees Fahrenheit -Bowl of oranges cut into cubes-44 degrees Fahrenheit - Cup of Juice-41 degrees Fahrenheit The cook and the Dietary Manager indicated the hot foods needed to be over 165 degrees Fahrenheit and the cold food items should be 41 degrees Fahrenheit or below for meal service. The cook and the Dietary Manager confirmed the oranges cubes taken from the refrigerator were not 41 degrees Fahrenheit or below. The Refrigerated Storage policy revised 01/03/2019, documented all refrigerated food must be maintained at a temperature of 41 degrees Fahrenheit or below. The Proper Temperatures for Meal Preparation and Service policy (undated) documented the holding temperature of fruit was a minimum of 41 degrees Fahrenheit.

**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) residents' significant weight changes were identified and reassessed for 7 out of 12 sampled residents (Resident #3, #6, #9, #11, #16, #1, and #10), and 2) a Registered Dietitian (RD) recommendation was processed timely for 1 of 12 sampled residents (Resident #13). The failure to identify, monitor, and reassess the weight of a resident receiving gastrostomy tube (GT) feeding had the potential of overfeeding or underfeeding which could lead to the imbalance of nutrient intake. The failure to process a resident's RD recommendation timely for a tube feed change had the potential to put the resident for further nutritional risks. Findings include: The Significant Weight Change policy revised 01/29/2019, documented if the resident's weight change was more than five pounds, the resident would be reweighed, and the weighing process would be witnessed by the licensed nurse on duty. The reweigh would be documented. The licensed nurse would notify the physician, family, and the consultant dietitian. Resident with an unplanned significant weight loss or weight gain would require a nutritional review and re-assessment by the consultant dietitian. A significant weight change would be 2% in one week, 5% in 30 days, 7.5% in three months, and 10% in six months. The Nutritional Assessment policy revised 03/01/2010, documented all residents would be reviewed during each consultant dietitian's facility visit. The consultant dietitian would be notified when residents experience a change in condition with nutritional risk indicates. A revised nutritional assessment would be completed at that time. Resident considered at nutritional risk include but are not limited to significant weight loss, vomiting, diarrhea, and residents' requiring nutritional support. Resident #3 (R3) R3 was admitted on [DATE], with diagnoses including fusion of the spine, scoliosis, and abnormalities of gait and mobility. A Physician Order dated 07/14/2020, documented R3 weighed on admission and then weekly. A Care Plan revised 03/09/2022, documented R3 had a swallowing problem (dysphagia) related to oral motor deficits. The goal for R3 was to maintain weight and nutritional balance. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R3 documented the following weights in pounds (lbs.): March 2022 Weight-72.6 lbs. (03/23/2022) Weight-79.9 lbs. (03/28/2022) April 2022 Weight-34.4 lbs. (04/04/2022) Weight-69.9 lbs. (04/13/2022) Weight-31.63 lbs. (04/18/2022) Weight-70.7 lbs. (04/25/2022) May 2022 Weight-73.4 lbs. (05/02/2022) Weight-33.9 lbs. (05/09/2022) Weight-76.6 lbs. (05/18/2022) July 2022 Weight-76.34 lbs. (07/04/2022) Weight-76.02 lbs. (07/11/2022) Weight-35.4 lbs. (07/22/2022) August 2022 Weight-82.9 lbs. (08/03/2022) Weight-81.4 lbs. (08/15/2022) Weight-72.4 lbs. (08/22/2022) Weight-81.8 lbs. (08/29/2022) September 2022 Weight-84.8 lbs. (09/12/2022) Weight-31.7 lbs. (09/19/2022) Weight-88 lbs. (09/26/2022) October 2022 Weight-83.6 lbs. (10/24/2022) Weight-85.8 lbs. (10/31/2022) November 2022 Weight-78.1 lbs. (11/07/2022) Weight-85.8 lbs. (11/14/2022) Weight-84.9 lbs. (11/21/2022) The Weights and Vital Summary revealed the following significant weight changes: -significant weight gain of 7.3 lbs. (10%) in one week on 03/28/2022 -significant weight loss of 45.5 lbs. (56.9%) in one week on 04/04/2022 -significant weight gain of 35.5 lbs. (103.1%) in nine days on 04/13/2022 -significant weight loss of 38.3 lbs. (54.7%) in five days on 04/18/2022 -significant weight gain of 39.1 lbs. (123.6%) in one week on 04/25/2022 -significant weight loss of 39.5 lbs. (53.8%) in one week on 05/09/2022 -significant weight gain of 42.7 lbs. (125%) in nine days on 05/18/2022 -significant weight loss of 40.6 lbs. (53.4%) in 11 days on 07/22/2022 -significant weight gain of 47.5 lbs. (134%) in 12 days on 08/03/2022 -significant weight loss of 9 lbs. (11%) in one week on 08/22/2022 -significant weight gain of 9.4 lbs. (12.9%) in one week on 08/29/2022 -significant weight loss of 53.1 lbs. (62.6%) in one week on 09/19/2022 -significant weight gain of 56.3 lbs. (177.6%) in one week on 09/26/2022 -significant weight loss of 7.7 lbs. (8.9%) in one week on 11/07/2022 -significant weight gain of 7.7 lbs. (9.8%) in one week on 11/14/2022 The medical record lacked documented evidence R3 was reweighed when a significant weight change occurred on the following days: -03/28/2022 -04/04/2022 -04/13/2022 -04 /18/2022 -04/25/2022 -05/09/2022 -05/18/2022 -07/22/2022 -08/03/2022 -08/22/2022 -08/29/2022 -09/19/2022 -09/26/2022 -11/07/2022 -11/14/2022 The medical record lacked documented evidence R3's significant weight change was acknowledged, and the RD reassessed the resident after significant weight change occurred on the following days: -03/28/2022 -04/13/2022 -04 /18/2022 -04/25/2022 -05/18/2022 -07/22/2022 -08/03/2022 -08/22/2022 -08/29/2022 -09/19/2022 -09/26/2022 -11/07/2022 On 01/25/2023 at 10:40 AM, the Director of Nursing (DON) indicated resident weights were done by the Certified Nursing Assistants (CNAs) every week. The DON indicated resident weights from the scale were in kilograms (kg) and the CNAs would need to covert the weight to lbs. before entering the weight in the resident's Electronic Health Record (EHR). The DON indicated sometimes the CNAs enter weights in kg instead of lbs. which would then show a significant weight change. The DON indicated the DON was responsible for monitoring the weekly weights by Thursday for weight variances and to request the CNAs to do a reweigh. The DON acknowledged the weight changes, kg's entries, or entry errors were not always caught in resident's EHR so reweighs were not identified and done. On 01/26/2023 in the morning, two Certified Nursing Assistants (CNAs) indicated the residents were weighed weekly on their scheduled shower days at the beginning of the week on Mondays or Tuesdays. The CNAs indicated they would write the weight in the weight binder at the nurse's station, and covert the kg weight obtained from the scale to lbs. before entering the weight in the residents' EHR. The CNAs indicated the DON, or the Assistant Director of Nursing (ADON) would notify them if a reweigh for a resident was required and the reweighs were to be obtained the same day when they were told to reweigh the resident. On 01/26/2023 at 12:46 PM, the ADON indicated weights were obtained weekly by the CNAs on resident shower days at the beginning of the week. The ADON explained the DON and ADON would audit the resident weights when they can, but it may not be after the weights were obtained earlier in the week. The ADON indicated if there were any discrepancies in the resident's weight, a reweigh would be done within a day to verify the significant weight change and the RD would be notified. On 01/27/2023 at 9:30 AM, the Nurse Practitioner indicated the staff were expected to weigh the resident per policy and there should have been follow through to ensure assessment and interventions in place for resident's safety. On 01/27/2023 at 11:36 AM, the Registered Dietitian (RD) indicated residents were weighed weekly and the CNAs would enter the resident weights in the residents' EHR. The RD indicated the RDs would review the resident weights when doing their monthly resident assessment charting, RD consultations, or when a significant weight change for a resident occurs. The RD indicated the nursing staff, and the DON were monitoring the residents' weight weekly, identify any significant weight changes, and obtain reweighs within 24 hours if a significant weight change occurred. The RD indicated the nursing staff would notify the RD when a resident has a significant weight change and for the RD to assess. The RD explained the significant weight change was 5% in a month, 7.5% in three months, and 10% in six months. The RD indicated a nutritional reassessment would be required if the resident had a significant weight gain or loss and nutritional interventions would be put in place if required. The RD acknowledged a reweigh should have been done for R3's weight obtained on 03/28/2022 which revealed a 7.3 lbs. (10%) significant weight gain in one week. The RD indicated a nutritional reassessment for the significant weight change should have been completed to address the weight change and the reweigh would have determined if nutritional interventions were required. The RD acknowledged a reweigh should have been done for R3 on 04/04/2022, 04/18/2022, 05/09/2022, 07/22/2022, and 09/19/2022 to verify the significant weight changes and if nutritional interventions were required once the reweighs were verified. The RD indicated the weights may have been entered incorrectly and may have been the kg weights not converted to lbs. The RD indicated reweighs should have been done for R3 on 04/13/2022, 04/25/2022, 05/18/2022, 08/03/2022, 08/29/2022, and 09/26/2022 to verify the significant weight changes. The RD indicated the weights following the weights that may have been entered in kg would trigger for significant weight change so a reweigh should have been completed. The RD indicated the reweighs would determine if nutritional interventions were required. The RD acknowledged a reweigh should have been done for R3's weight obtained on 08/22/2022 which revealed a significant weight loss of 9 lbs. (11%) in one week. The RD indicated a nutritional reassessment for the significant weight loss should have been completed to address the weight change and the reweigh would have determined if nutritional interventions were required. The RD acknowledged a reweigh should have been done for R3's weight obtained on 11/07/2022 which revealed a 7.7 lbs., (9.8%) significant weight loss in one week. The RD indicated a nutritional reassessment for the significant weight loss should have been completed to address the weight change and the reweigh would have determined if nutritional interventions were required. Resident #6 (R6) R6 was admitted on [DATE], with diagnoses including traumatic brain injury and cerebral palsy. A Care Plan revised 05/08/2018, documented R6 had a nutritional problem or potential nutritional problem related to gastrostomy tube dependent. The intervention was to weight R6 on scheduled days. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R6 documented the following weights in lbs.: May 2022 Weight-40.1 lbs. (05/10/2022) Weight-90 lbs. (05/31/2022) June 2022 Weight-178.6 lbs. (06/21/2022) July 2022 Weight-177 lbs. (07/05/2022) Weight-89.76 lbs. (07/12/2022) November 2022 Weight-84.2 lbs. (11/15/2022) Weight-89.7 lbs. (11/22/2022) Weight-93.6 lbs. (11/24/2022) December 2022 Weight-89.7 lbs. (12/29/2023) January 2023 Weight-88.2 lbs. (01/03/2023) Weight-95.26 lbs. (01/19/2023) The Weights and Vital Summary revealed the following significant weight changes: -significant weight gain of 49.9 lbs. (124%) in three weeks on 05/31/2022 -significant weight gain of 88.6 lbs. (98.4%) in three weeks on 06/21/2022 -significant weight loss of 87.24 lbs. (49.2%) in one week on 07/12/2022 -significant weight gain of 5.5 lbs. (6.5%) in one week on 11/22/2022 -significant weight gain of 3.9 lbs. (4.3%) in two days on 11/24/2022; gained 9.4 lbs. (11.1%) in nine days on 11/24/2022 -significant weight gain of 7 lbs. (7.9%) in 16 days on 01/19/2023 The medical record lacked documented evidence R6 was reweighed when a significant weight change occurred on the following days: -05/10/2022 -05/31/2022 -06/21/2022 -07/05/2022 -01/19/2023 The medical record lacked documented evidence R6's significant weight change was acknowledged, and the RD reassessed the resident after significant weight change occurred on the following days: -05/10/2022 -05/31/2022 -06/21/2022 -07/05/2022 -07/12/2022 -11/24/2022 -01/19/2023 On 01/27/2023 at 11:36 AM, the RD acknowledged reweighs should have been done for R6 on 05/10/2022, 05/31/2022, 06/21/2022, 07/05/2022, 11/24/2022, and 01/19/2023 to verify the significant weight loss or gain. The RD indicated the reweighs would determine if nutritional interventions were required. The RD indicated some of the weights may have been entered incorrectly by the nursing staff. The RD acknowledged a nutritional reassessment was not done on 11/24/2022 when R6 had a trending significant weight gain of 3.9 lbs. (4.3%) in two days and 9.4 lbs. weight gain (11.1%) in nine days. The RD indicated R6 should have been reassessed by the RD the same week but was not assessed until 12/19/2022. The RD acknowledged a reweigh should have been done on 01/19/2023 when R6 had a significant weight gain of 7 lbs. (7.9%) in 16 days to verify the weight change. The RD indicated a nutritional reassessment should have been done to evaluate the resident to determine if nutritional interventions were required. Resident #9 (R9) Resident #9 (R9) was admitted on [DATE], with diagnosis including cerebral palsy, seizures, and gastrostomy. A Physician Order dated 09/01/2018, documented weight on admission and then weekly. A Physician Order dated 09/02/2018, documented dietary evaluation on admission, monthly, and as needed. A Care Plan revised 10/05/2020, documented R9 had a swallowing problem (dysphagia) related to cerebral palsy. The goal for R9 was to maintain weight and nutritional balance. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R9 documented the following weights in lbs.: January 2022 Weight-108.9 lbs. (01/11/2022) Weight-115.9 lbs. (01/19/2022) February 2022 Weight-106 lbs. (02/16/2022) Weight-50.3 lbs. (02/23/2022) Weight-110 lbs. (03/01/2022) May 2022 Weight-109.12 lbs. (05/18/2022) Weight-99.88 lbs. (05/24/2022) July 2022 Weight-99.88 lbs. (07/19/2022) August 2022 Weight-64.7 lbs. (08/03/2022) Weight-103.7 lbs. (08/10/2022) [DATE] Weight-101 lbs. (01/03/2023) Weight-107.8 lbs. (01/11/2023) The Weights and Vital Summary revealed the following significant weight changes: -significant weight gain of 7 lbs. (6.4%) in eight days on 01/19/2022 -significant weight loss of 55.7 lbs. (52.5%) in one week on 02/23/2022 -significant weight gain of 59.7 lbs. (118.7%) in six days on 03/01/2022 -significant weight loss of 9.24 lbs. (8.5%) in six days on 05/24/2022 -significant weight loss of 35.18 lbs. (35.2%) in two weeks on 08/03/2022 -significant weight gain 39 lbs. (60.3%) in one week on 08/10/2022 -significant weight gain of 6.8 lbs. (6.7%) in eight days on 01/11/2023 The medical record lacked documented evidence R9 was reweighed when a significant weight change occurred on the following days: -01/19/2022 -02/23/2022 -03/01/2022 -05/24/2022 -08/03/2022 -08/10/2022 -01/11/2023 The medical record lacked documented evidence R9's significant weight change was acknowledged, and the RD reassessed the resident after significant weight change occurred on the following days: -01/19/2022 -02/23/2022 -03/01/2022 -05/24/2022 -08/03/2022 -08/10/2022 -01/11/2023 On 01/27/2023 at 11:36 AM, the RD acknowledged reweighs should have been done for R9 on 01/19/2022, 02/23/2022, 03/01/2022, 05/24/2022, 08/03/2022, 08/10/2022, 01/11/2023 to verify the significant weight loss or gain. The RD indicated the reweighs would determine if a nutritional reassessment and interventions were required. The RD indicated some of the weights may have been entered incorrectly and were questionable when the nursing staff entered the weights. Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including epilepsy, lack of expected normal physiological development in childhood, and cerebral palsy. A Physician Order dated 08/06/2019, documented R11 to be weighed on admission and then weekly. A Care Plan revised 09/18/2020, documented R11 required a gastrostomy tube [NAME] button related to oral aversion. The goal was for R11 to maintain adequate nutritional and hydration status as evidenced by stable weight and no signs and symptoms of malnutrition. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R11 documented the following weights in lbs.: May 2022 Weight-92.84 lbs. (05/17/2022) Weight-42.2 lbs. (05/23/2022) Weight-95 lbs. (05/30/2022) August 2022 Weight-92.4 lbs. (08/30/2022) September 2022 Weight-42 lbs. (09/06/2022) Weight-92.84 lbs. (09/13/2022) October 2022 Weight-93.5 lbs. (10/04/2022) Weight-100.3 lbs. (10/10/2022) Weight 99.8 lbs. (10/18/2022) Weight-96.5 lbs. (10/25/2022) Weight 89.7 lbs. (10/31/2022) November 2022 Weight-89.3 lbs. (11/07/2022) Weight-98.3 lbs. (11/14/2022) Weight-89.5 lbs. (11/22/2022) The Weights and Vital Summary revealed the following significant weight changes: -significant weight loss of 50.64 lbs. (54.5%) in six days on 05/23/2022 -significant weight gain of 52.8 lbs. (125%) in one week on 05/30/2022 -significant weight loss of 50.4 lbs. (54.5%) in one week on 09/06/2022 -significant weight gain of 50.84 lbs. (121%) in one week on 09/13/2022 -significant weight gain of 6.8 lbs. (7.3%) in six days on 10/10/2022 -significant weight gain of 6.3 lbs. (6.7%) in two weeks on 10/18/2022 -significant weight loss of 6.8 lbs. (7%) in six days on 10/31/2022 -significant weight gain of 9 lbs. (10%) in one week on 11/14/2022 -significant weight loss of 8.8 lbs. (8.9%) in eight days on 11/22/2022 The medical record lacked documented evidence R11 was reweighed when a significant weight change occurred on the following days: -05/23/2022 -05/30/2022 -09/06/2022 -09/13/2022 -10/10/2022 -10/18/2022 -10/31/2022 -11/14/2022 -11/22/2022 The medical record lacked documented evidence R11's significant weight change was acknowledged, and the RD reassessed the resident after significant weight change occurred on the following days: -05/23/2022 -05/30/2022 -09/06/2022 -09/13/2022 -10/10/2022 -10/18/2022 -10/31/2022 -11/22/2022 On 01/27/2023 at 11:36 AM, the RD acknowledged R11's reweighs should have been done on 05/22/2022, 05/30/2022, 09/06/2022, 09/13/2022, 10/10/2022, 10/18/2022, 10/31/2022, and 11/22/2022 to verify the significant weight loss or gain. The RD indicated the reweighs would determine if nutritional reassessment and interventions were required. The RD indicated some of the weights may have been entered incorrectly and were questionable when the nursing staff entered the weights. The RD acknowledged R11 should have been reassessed on 10/10/2022 and 10/18/2022 when the resident had a trending significant weight gain of 6.3 lbs. (6.7%) in two weeks. The RD confirmed R11 did not have a nutritional reassessment when the significant weight gain occurred. The RD confirmed R11 was assessed on 09/25/2022 and 10/24/2022 when the monthly assessment was done. Resident #16 (R16) R16 was admitted on [DATE], with diagnoses including cerebral palsy, gastrostomy, and lack of expected normal physiological development in childhood. A Physician Order dated 11/04/2020, documented R16 to be weighed on admission and then weekly. A Care Plan revised 11/06/2020, documented R16 had a swallowing problem (dysphagia) related to cognitive function. R16's goal was to maintain weight and nutritional balance. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R16 documented the following weights in lbs.: March 2022 Weight-89.95 lbs. (03/29/2022) April 2022 Weight-95 lbs. (04/05/2022) Weight-86.2 lbs. (04/12/2022) Weight-862 lbs. (04/19/2022) Weight-90.6 lbs. (04/26/2022) May 2022 Weight-96 lbs. (05/10/2022) Weight-41.7 lbs. (05/24/2022) September 2022 Weight-90.3 lbs. (09/20/2022) Weight-41.2 lbs. (09/27/2022) October 2022 Weight-92.18 lbs. (10/03/2022) December 2022 Weight-90.2 lbs. (12/12/2022) Weight-24.6 lbs. (12/13/2022) Weight-88.44 lbs. (12/26/2022) The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R16 documented the following weights in lbs.: -significant weight gain of 5.05 lbs. (5.6%) in one week on 04/05/2022 -significant weight loss of 8.8 lbs. (9.2%) in one week on 04/12/2022 -significant weight gain of 775.8 lbs. (900%) in one week on 04/19/2022 -significant weight loss of 771.4 lbs. (894%) in one week on 04/26/2022 -significant weight loss of 54.3 lbs. (56.6%) in two weeks on 05/24/2022 -significant weight gain 46.7 lbs. (112%) in one week on 05/31/2022 -significant weight loss of 49.1 lbs. (54.4%) in one week on 09/27/2022 -significant weight gain of 50.98 lbs. (123.7%) in six days on 10/03/2022 -significant weight loss of 65.6 lbs. (72.7%) in one day on 12/13/2022 -significant weight gain of 63.84 lbs. (259.5%) in 13 days on 12/26/2022 The medical record lacked documented evidence R16 was reweighed when a significant weight change occurred on the following days: -04/05/2022 -04/12/2022 -04/19/2022 -04/26/2022 -05/24/2022 -09/27/2022 -10/03/2022 -12/13/2022 -12/26/2022 The medical record lacked documented evidence R16's significant weight change was acknowledged, and the RD reassessed the resident after significant weight change occurred on the following days: -04/05/2022 -04/12/2022 -04/19/2022 -04/26/2022 -05/24/2022 -05/31/2022 -09/27/2022 -10/03/2022 -12/13/2022 -12/26/2022 On 01/27/2023 at 11:36 AM, the RD acknowledged R16's reweighs should have been done on 04/05/2022, 04/12/2022, 04/19/2022, 04/26/2022, 05/24/2022, 05/31/2022, 09/27/2022, 10/03/2022, 12/13/2022, and 12/26/2022 to verify the significant weight loss or gain. The RD indicated some of the weights may have been entered incorrectly and were questionable when the nursing staff entered the weights. The RD acknowledged R16 was not reweighed and reassessed on 04/05/2022 when the resident had a significant weight gain of 5.05 (5.6%) in one week and significant weight loss of 8.8 lbs. (9.2%) in one week on 04/12/2022. The RD indicated the reweighs would determine if nutritional assessment and interventions were required. The RD indicated the R16's was assessed on 04/04/2022 and 05/13/2022 during the monthly assessment which did not address the significant weight change. Resident #13 (R13) R13 was admitted on [DATE], with diagnoses including spastic quadriplegic cerebral palsy, gastrostomy status, failure to thrive, other pervasive developmental disorders, hydrocephalus in disease classified elsewhere. A Physician Order dated 11/11/2022, documented enteral feeding Compleat Pediatric 1.0, 250 milliliter (mL) over one hour three times a day. A Physician Order dated 11/11/2022, documented enteral feeding of Compleat pediatric 0.6 250 mL over 1 hour one time a day. The Weight and Vitals Summary from 01/01/2016-01/31/2023 for R13 documented the following weights in lbs.: December 2022 Weight- December 2022 Weight-57.8 lbs. (12/19/2022) Weight- 59.1 lbs. (12/28/2022) January 20223 Weight-58.4 lbs. (01/02/2023) Weight-59.3 lbs. (01/09/2023) Weight-60.5 lbs. (01/16/2023) Weight-61.2 lbs. (01/23/2023) A Dietary Progress Note dated 01/23/2023, documented R11 had significant weight gain for one, three, and six months. Would recommend tube feed decrease to Compleat Pediatrics 225 mL four times a day to run over one hour. The RD Consultation Form dated 01/23/2023, documented R13 was plotting at the 90th percentile body mass index (BMI) for their age. The RD's recommendation was to have a tube feed reduction to Compleat Pediatric 225 mL four times a day. The physician signed off on the RD recommendation on 01/24/2023. R13's medical record lacked documented evidence the RD recommendation on 01/13/2023 was implemented. On 01/27/2023 at 11:36 AM, the RD indicated RD recommendations would be processed by the nurses and would expect the nurses to process and implement RD recommendation within 24-72 hours. The RD indicated they would follow-up on the RD recommendation the following month when they assess the resident again to ensure the RD recommendation were processed. The RD confirmed R11's RD recommendation on 01/23/2023 for a decrease in tube feed due to weight gain was not in place. The RD indicated the physician signed off on the RD recommendation already, but the orders did not reflect the correct tube feed order. The RD explained R11 would continue to gain weight when the RD recommendation was not followed, and the resident would not achieve their nutritional goals because the RD recommendation was not being used. On 01/27/2023 at 12:57 PM, the DON indicated RD recommendations would be processed and implemented when the physician approves the order within 24 -72 hours. The DON acknowledged the RD recommendation on 01/23/2023 was not processed and should have been processed by the nurse on duty on 01/24/2023. Resident 1 (R1) R1 was admitted on [DATE], with diagnoses including tracheostomy status, gastrostomy status, scoliosis, and cerebral palsy. The Brief Interview of Mental Status dated 11/21/2022, documented a score of 99, which means R1's cognitive status could not be completed due to severe impairment. R1's functional status dated 11/21/2022, documented R1's required total dependence on staff. R1's Weight Summary revealed R1's weight was not consistently monitored. R1's medical record lacked documented evidence the weight was not followed through, and nutritional assessment was completed. 10/03/2022 - 82.28 lbs. 10/10/2022 - 38.6 lbs. 11/28/2022 - 83.0 lbs. 11/07/2022 - 74.4 lbs. 10/31/2023 - no weights taken 10/24/2022 - 81.8 lbs. 12/05/2022 - 83.77 lbs. 12/12/2022 - 82.94 lbs. 12/19/2022 - no weights taken 12/26/2022 - 84.7 lbs. 01/2/2023 - 82.06 pounds (lbs.) R3's medical record lacked documented evidence R3 was reweighed when a significant weight change occurred, and nutritional assessment was done promptly. On 01/25/2023 at 10:40 AM, the DON indicated was responsible for monitoring the weekly weights by Thursday for weight variances and to request the CNAs to do a reweigh. The DON acknowledged the weight changes, kg's entries, or entry errors were not always caught in resident's EHR so reweighs were not identified and done. Resident 10 (R10) A Care plan dated 02/26/2020, documented R10 had a swallowing problem (dysphagia) related to oral motor control. The goal was R10 would maintain weight and nutritional balance through the review. All staff were informed of R10's special dietary and safety needs, R10 received GT feeds only at this time. A Care plan revised 02/26/2020, documented R10 required tube feeding related to dysphagia, with the goal R10 would maintain adequate nutrition and hydration status, keep weight stable, and show no signs and symptoms of malnutrition or dehydration. R10's Weight Summary lacked documented evidence the weight was consistently taken: 1/24/2023 - 76.7 lbs. 1/17/2023 - 76.12 lbs. 1/10/2023 - 75.5 lbs. 01/02/2023 - no weights taken 12/27/2022 - 75.68 lbs. 12/20/2022 - 74.8 lbs. On 01/27/2023 at 9:30 AM, the Nurse Practitioner indicated the staff were expected to weigh the residents weekly per policy, and there should have been follow-through to ensure assessment and interventions were in place for the resident's safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3 (R3) R3 was admitted on [DATE] with diagnoses including fusion of the spine, scoliosis, and abnormalities of gait and mobility. A Care Plan revised 04/11/2022, documented R3 required tube feeding related to Dysphagia. The interventions were to check for tube placement and gastric contents/residual volume per facility protocol and record and provide local care to G-Tube site as ordered and monitor for signs and symptoms of infection. A Physician Order dated 09/27/2022, documented to change the gastrostomy tube ([NAME] button) every three months and as needed when broken, clogged, or dislodged. R3's medical records lacked documented evidence the care and management of the gastrostomy site were implemented. Resident #11 (R11) R11 was admitted on [DATE], with diagnoses including acute hematogenous osteomyelitis, epilepsy, and cerebral palsy. A Care Plan revised 09/18/2020, documented R11 required a gastrostomy tube ([NAME] button) related to oral aversion. The intervention was to provide local care to the gastrostomy tube site as ordered and monitor for signs and symptoms of infection every shift and as needed. R11's medical records lacked documented evident the care and management of the gastrostomy site were implemented. On 01/25/2023 in the morning, the RN indicated the residents on tube feedings were required to have physician orders for care and management. The RN confirmed R3 and R11 did not have orders for tube feeding care and management. On 01/25/2023 in the morning, the DON confirmed a physician order was not in place for gastrostomy site cleaning monitoring for signs of infection or irritation and ensuring that the tube was functioning properly and securely in place. Based on observation, interview, record review, and document review, the facility failed to ensure physician orders were obtained and the orders were implemented for gastrostomy site care to cleanse, assess, and monitor the surrounding skin for redness and infection for 6 out of 12 sampled residents (Residents 5, 10, 23, 15, 3 and 11). This failure could potentially lead to risks such as infection, blockage, leakage, displacement, inflammation or skin irritation, medication complications, and gastrointestinal issues. Findings include: A facility policy titled Gastrostomy Tube (GT) Feeding via low-Profile GT (such as MIc-Key or mini-one), Site Care and Replacement (undated), indicated to provide care for the insertion site. Toleration of tube feeding, and site assessments were addressed in daily nursing notes. The stoma site was to be inspected after feedings and medication to ensure there was no gastric leakage. The skin around the stoma was cleaned with warm water and soap using a cotton tip applicator or soft cloth. The feeding port was cleaned once per shift to remove any buildup of oil or food. Resident 5 (R5) R5 was admitted on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy status and tracheostomy status. The Brief Interview of Mental Status dated 11/29/2022, documented a score of 99, which means R10's cognitive status could not be completed due to impairment. R5's functional status dated 11/29/2022, documented R5's total dependence on staff. A Care Plan dated 02/27/2020 documented the need for R5 tube feeding for [NAME] Button due to difficulty swallowing (dysphagia). The interventions included providing local care at the GT site as ordered every shift and monitoring for signs and symptoms of infection. On 01/26/2023 at 8:29 AM, during medication pass, a Registered Nurse 1 (RN1) administered the scheduled medications. R5's GT site and surrounding skin were not assessed or cleansed following medication administration. R5's Treatment Administration Record (TAR) lacked documented evidence the care and management orders for the utilization of GT, stoma monitoring and cleaning of the site were implemented and followed. On 01/26/2023 at 11:00 AM, Registered Nurse 2 (RN2) indicated the GT care and management required an order. RN2 confirmed there was no GT care and management order for R5. RN2 indicated the order was vital as a guide for the resident's care and to document if the task or treatment was completed. On 01/26/2023 at 1:30 PM, RN1 indicated if a resident had a GT or jejunostomy tube (JT), the incision site should be observed for infection and should be cleansed to prevent complications. The RN confirmed there was no order in place to care for the GT incision site. On 01/26/2023 in the afternoon, the Director of Nursing (DON) explained the facility had routine orders for the care and management of the GT or JT. The DON indicated if a resident was admitted with GT or JT, the routine orders for enteral feedings should be transcribed and reflected in the resident's treatment administration record. The DON explained GT or JT site should be cleansed and monitored each shift. The DON confirmed there were no orders for site care and management in place for R5's GT. Resident 10 (R10) R10 was admitted on [DATE] and readmitted on [DATE], with diagnoses including gastrostomy status, dependence on respirator and unspecified lack of expected normal physiological development in childhood. A Care Plan dated 09/17/2021, documented R10 required tube feeding related to dysphagia (difficulty swallowing). The interventions involved to monitor and provide care to GT. A Care Plan dated 09/17/2021, documented R10 was at risk for infection related to GT site irritation and inflammation. The interventions involved to monitor for signs and symptoms of infection and monitor incision and insertion site. On 01/26/23 at 9:21 AM, during medication pass, RN1 did not clean R10's GT site following medication administration. RN1 indicated the order for care and management was required for the resident. RN1 confirmed there was no order in place for R10. R5's TAR lacked documented evidence the care and management orders for the utilization of GT, stoma monitoring and cleaning of the site were implemented and followed. On 01/26/2023 at 10:00 AM, the Director of Nursing (DON) explained the facility utilized the standard routine admission orders and should be transcribed in the TAR. The appropriate orders based on the resident's assessment for proper care and monitoring should be carried out as ordered. The DON confirmed a physician order was not in place for R5's GT site cleaning monitoring for signs of infection or irritation and ensuring that the tube was functioning properly and securely in place. The DON explained GT or JT site should be cleansed and monitored each shift. The DON confirmed there were no orders for site care and management in place for R5's GT. Resident 15 (R15) R15 was admitted on [DATE] and readmitted on [DATE], with diagnoses including anoxic brain damage, tracheostomy, and gastrostomy. <Info added from earlier citation. The Brief Interview of Mental Status dated 11/23/2022, documented a score of 99, which means R1's cognitive status could not be completed due to severe impairment. R15's functional status dated 11/23/2022, documented R1's required total dependence on staff. On 01/25/2023 at 11:30 AM, a Registered Nurse indicated an order was required for GT site care and management and confirmed there was no order in place. R15's TAR lacked documented evidence the care and management orders for the utilization of GT, stoma monitoring and cleaning of the site were in place and carried out. 01/25/2023 at 11:55 AM, another RN explained there should have been an order for GT site care and monitoring and flushing in order to monitor and remind the staff of the tasks and to document in the TAR. 01/26/2023 in the morning, the DON indicated there should have been an order to clean and monitor the GT site and management for the GT site. Resident 23 (R23) R23 was admitted on [DATE], with diagnoses including gastrostomy status, tracheostomy status and traumatic brain injury. The Brief Interview of Mental Status (undated) documented a score of 99, which means R1's cognitive status could not be completed due to severe impairment. R23's functional status (undated), documented R1's required total dependence on staff. On 01/26/23 at 9:01 AM, during medication pass, RN1 did not clean and inspect R15's gastrostomy site following medication administration. On 01/26/2023 at 10:00, the DON confirmed a physician order was not in place for R23's GT site cleaning, monitoring for signs of infection or irritation, and ensuring that the tube was functioning properly and securely in place. The DON explained GT or JT site should be cleansed and monitored each shift. The DON confirmed there were no orders for site care and management in place for R5's GT.

Based on interview, record review, and document review, the facility failed to provide evidence of good faith attempts to resolve the issues of documenting and identifying inaccurate weights which triggered significant weight changes in the Quality Assessment and Assurance (QAA) Committee meetings. The failure to address the documenting and identifying the accuracy of the resident weights could potentially lead to negative outcomes of addressing and assessing residents' nutritional status. Findings include: On 01/24/2023 through 01/27/2023, twelve resident record reviews were conducted during the survey process. The 12 resident record reviews revealed eight out of 12 residents had inaccurate weights documented in the electronic health record (EHR), no attempts to correct the inaccurate weights or obtain reweighs or assess the resident for significant weight changes were documented. The monthly QAA Committee Minutes from January 2022 through January 2023 lacked documented evidence of addressing the issues with the inaccuracy of the weights entered in residents' EHR and the process of identifying the triggered significant weight changes. The facility could not provide documented evidence of attempts to resolve the inaccuracy of weights that were entered in residents' EHR at the facility. On 01/25/2023 at 10:40 AM, the Director of Nursing (DON) indicated the resident weights were an on-going issue since the DON started at the facility five years ago. The DON explained the weighing scales in the facility were in kilograms (kg) due to the pediatric population. The DON indicated the Certified Nursing Assistants (CNAs) were required to convert the kg weight to pounds (lbs.) before entering the weight in the residents' EHR which did not happen at times. The DON indicated the kg would be entered by the nursing staff which would trigger for a significant weight change because it was not converted to lbs. The DON indicated it was the responsibility of the DON to monitor the weights on a weekly basis for weight discrepancies but sometimes the weight discrepancies and errors were not identified. The DON indicated if there were weight discrepancies, the DON would tell the nursing staff to obtain a new weight for the resident. On 01/26/2023 in the afternoon, two CNAs indicated the weight on the scales were taken in kg and they would need to convert the kg weight to lbs. before entering the weight in the EHR. The CNAs indicated the DON would notify them if a resident needed a reweigh which would be obtained the same day. On 01/27/2023 at 11:36 AM, the Registered Dietitian (RD) indicated the DON would monitor the weights and the two consultant RD's would check the weights monthly to do the resident assessments. The RD indicated the resident weights were not always accurately entered in the residents' EHR which would trigger for significant weight gain or loss. The RD indicated they would see the resident had lost 20 -30 lbs. in a week which probably meant the weight was inaccurate or the CNA forgot to do the kg to lbs. weight conversion. The RD indicated the accuracy of the weights had been an on-going issue since working at the facility for the past two years. On 01/27/2023 at 2:32 PM, the Administrator indicated the physician and DON were aware of the on-going issues with the accuracy and the documentation of weights. The Administrator indicated the nursing staff have been told to make sure they obtain accurate weights and document weights correctly in the residents' EHR. The Administrator indicated it had been an issue for the CNAs to convert the kilogram (kg) weight obtained from the scale and convert it to pounds (lbs.) before entering the weight in the EHR. The Administrator indicated management would verbally tell the CNAs to obtain the weights accurately and document in lbs. when the clinical team would see that weights were not correctly documented. The Administrator indicated the physician would verbally tell the DON and the Administrator the inaccuracy of the weights and the DON and Administrator would go tell the CNAs to document the weights correctly. The Administrator confirmed there was no documented evidence the QAA Committee Team made attempts to plan and resolve the residents' weight issues of documenting and identifying inaccurate weights. The Performance Improvement Program Manual revised 10/01/2018, documented the facility was involved in defining and improving how the organization cares for the residents. The performance improvement efforts were to ensure delivery of the best possible care to the residents. The program provided a mechanism and process which was designed to identify opportunities to improve care and services by measuring, assessing, and improving care in a systematic and ongoing manner. The Performance Improvement System was intended to be a confidential, internal process, and documents generated were intended to be internal documents. The Performance Improvement Program was to guide all components of the organization towards obtaining resident outcomes of the highest quality and provide services that meet or exceed the expectations of the residents and their families.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure the Quarterly Assessments were completed timely for 16 of 24 sampled residents (Residents #22, #21, #4, #2, #11, #8, #7, #23, #12, #14, #19, #18, #20, #15, #6, and #9). The failure to timely assess the residents resulted in the lack of care management for residents. Findings include: 1) Resident #22 (R22) was admitted on [DATE], with diagnoses including seizures, gastrostomy, failure to thrive, and unspecified developmental delays. R22's medical record revealed a Quarterly Assessment was in progress. The facility's Minimum Data Set (MDS) Summary Report revealed the Quarterly Assessment Reference Date (ARD) for R22 was 12/03/2022. The assessment was 41 days overdue. 2) Resident #21 (R21) was admitted on [DATE], with diagnoses including hypoxic ischemic encephalopathy, tracheostomy, gastrostomy, and cerebral palsy. R21's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R21 was 12/21/2022. The assessment was 23 days overdue. 3) Resident #4 (R4) was admitted on [DATE], with diagnoses including cerebral palsy, developmental disorder of speech and language, and epilepsy. R4's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R4 was 12/10/2022. The assessment was 34 days overdue. 4) Resident #2 (R2) was admitted on [DATE], with diagnoses including deformities of brain, gastrostomy, tracheostomy, and seizures. R2's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R2 was 11/25/2022. The assessment was 49 days overdue. 5) Resident #11 (R11) was admitted on [DATE], with diagnoses including epilepsy, lack of expected normal physiological development in childhood, and cerebral palsy. R11's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R11 was 11/26/2022. The assessment was 48 days overdue. 6) Resident #8 (R8) was admitted on [DATE], with diagnoses including blindness, epilepsy, and cerebral palsy. R8's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R8 was 11/30/2022. The assessment was 44 days overdue. 7) Resident #7 (R7) was admitted on [DATE], with diagnoses including gastrostomy, seizures, and cerebral palsy. R7's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R7 was 11/24/2022. The assessment was 50 days overdue. 8) Resident #23 (R23) was admitted on [DATE], with diagnoses including traumatic brain injury. R23's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R23 was 11/14/2022. The assessment was 60 days overdue. 9) Resident #12 (R12) was admitted on [DATE]. R12's diagnoses were not available. R12's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R12 was 11/26/2022. The assessment was 48 days overdue. 10) Resident #14 (R14) was admitted on [DATE], with diagnoses including autistic disorder, gastrostomy, and speech disturbances. R14's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R14 was 11/30/2022. The assessment was 44 days overdue. 11) Resident #19 (R19) was admitted on [DATE], with diagnoses including tracheostomy, gastrostomy, and seizures. R19's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R19 was 12/01/2022. The assessment was 43 days overdue. 12) Resident #18 (R18) was admitted on [DATE], with diagnoses including acute and chronic respiratory failure, brain damage, and tracheostomy. R18's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R18 was 11/30/2022. The assessment was 44 days overdue. 13) Resident #20 (R20) was admitted on [DATE], with diagnoses including severe intellectual disabilities, gastrostomy, and cerebral palsy. R20's medical record revealed a Quarterly Assessment was export ready. The facility's MDS Summary Report revealed the Quarterly ARD for R20 was 11/23/2022. The assessment was 51 days overdue. 14) Resident #15 (R15) was admitted [DATE], with diagnoses including anoxic brain damage, tracheostomy, and gastrostomy. R15's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R15 was 11/23/2022. The assessment was 51 days overdue. 15) Resident #6 (R6) was admitted on [DATE], with diagnoses including traumatic brain injury and cerebral palsy. R6's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the admission ARD for R6 was 12/23/2022. The assessment was 21 days overdue. 16) Resident #9 (R9) was admitted on [DATE], with diagnoses including cerebral palsy, seizures, and gastrostomy. R9's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R9 was 12/23/2022. The assessment was 21 days overdue. On 01/27/2023 in the morning, the Director of Nursing indicated the facility did not have a MDS Coordinator for almost a year and the MDS assessments were not completed. On 01/27/2023 at 9:29 AM, the MDS Coordinator indicated the resident MDS assessments were to be completed at the time of admission, quarterly, annually, and when a significant change occurred. The MDS Coordinator explained the facility had 14 days from the ARD to complete the quarterly assessment for the residents. The MDS Coordinator indicated the facility followed the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual for MDS submissions. The MDS Coordinator indicated the facility did not have a MDS Coordinator for a long period of time in 2021-2022 so there was a lot of catching up on MDS assessments when they first stated in June of 2022. The MDS Coordinator acknowledged the MDS quarterly assessments for the above listed residents were not submitted within 14 day of the ARD and were late. On 01/27/2023 at 2:32 PM, the Administrator indicated the facility did not have a MDS Coordinator from June 2021-May 2022. The Administrator indicated the facility was behind on the MDS resident assessments because there was no MDS staff from June 2021-May 2022. The Administrator indicated the current MDS Coordinator had to catch up on the late MDS resident assessments when they started. The Administrator acknowledged the MDS assessments were not submitted on time. The CMS RAI Manual Version 3.0, Chapter Five: Submission and Correction of the MDS Assessment, dated 10/2019, documented MDS assessments would be submitted within 14 days of the MDS completion date. The quarterly assessment is due every quarter unless the resident is no longer in the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and document review, the facility failed to ensure the Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) System within the 14-day timeline for 18 of 24 sampled residents (Residents #22, #21, #4, #2, #11, #8, #7, #23, #12, #14, #19, #18, #20, #15, #6, #9, #5, and #74), The failure to timely assess the residents resulted in the lack of care management for residents. Findings include: 1) Resident #22 (R22) was admitted on [DATE], with diagnoses including seizures, gastrostomy, failure to thrive, and unspecified developmental delays. R22's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly Assessment Reference Date (ARD) for R22 was 12/03/2022. The assessment was 41 days overdue. 2) Resident #21 (R21) was admitted on [DATE], with diagnoses including hypoxic ischemic encephalopathy, tracheostomy, gastrostomy, and cerebral palsy. R21's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R21 was 12/21/2022. The assessment was 23 days overdue. 3) Resident #4 (R4) was admitted on [DATE], with diagnoses including cerebral palsy, developmental disorder of speech and language, and epilepsy. R4's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R4 was 12/10/2022. The assessment was 34 days overdue. 4) Resident #2 (R2) was admitted on [DATE], with diagnoses including deformities of brain, gastrostomy, tracheostomy, and seizures. R2's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R2 was 11/25/2022. The assessment was 49 days overdue. 5) Resident #11 (R11) was admitted on [DATE], with diagnoses including epilepsy, lack of expected normal physiological development in childhood, and cerebral palsy. R11's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R11 was 11/26/2022. The assessment was 48 days overdue. 6) Resident #8 (R8) was admitted on [DATE], with diagnoses including blindness, epilepsy, and cerebral palsy. R8's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R8 was 11/30/2022. The assessment was 44 days overdue. 7) Resident #7 (R7) was admitted on [DATE], with diagnoses including gastrostomy, seizures, and cerebral palsy. R7's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R7 was 11/24/2022. The assessment was 50 days overdue. 8) Resident #23 (R23) was admitted on [DATE], with diagnoses including traumatic brain injury. R23's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R23 was 11/14/2022. The assessment was 60 days overdue. 9) Resident #12 (R12) was admitted [DATE]. The diagnoses for R12 were not available. R12's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R12 was 11/26/2022. The assessment was 48 days overdue. 10) Resident #14 (R14) was admitted on [DATE], with diagnoses including autistic disorder, gastrostomy, and speech disturbances. R14's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R14 was 11/30/2022. The assessment was 44 days overdue. 11) Resident #19 (R19) was admitted on [DATE], with diagnoses including tracheostomy, gastrostomy, and seizures. R19's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R19 was 12/01/2022. The assessment was 43 days overdue. 12) Resident #18 (R18) was admitted on [DATE], with diagnoses including acute and chronic respiratory failure, brain damage, and tracheostomy. R18's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R18 was 11/30/2022. The assessment was 44 days overdue. 13) Resident #20 (R20) was admitted on [DATE], with diagnoses including severe intellectual disabilities, gastrostomy, and cerebral palsy. R20's medical record revealed a Quarterly Assessment was export ready. The facility's MDS Summary Report revealed the Quarterly ARD for R20 was 11/23/2022. The assessment was 51 days overdue. 14) Resident #15 (R15) was admitted on [DATE], with diagnoses including anoxic brain damage, tracheostomy, and gastrostomy. R15's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R15 was 11/23/2022. The assessment was 51 days overdue. 15) Resident #6 (R6) was admitted on [DATE], with diagnoses including traumatic brain injury and cerebral palsy. R6's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the admission ARD for R6 was 12/23/2022. The assessment was 21 days overdue. 16) Resident #9 (R9) was admitted on [DATE], with diagnoses including cerebral palsy, seizures, and gastrostomy. R9's medical record revealed a Quarterly Assessment was in progress. The facility's MDS Summary Report revealed the Quarterly ARD for R9 was 12/23/2022. The assessment was 21 days overdue. 17) Resident #5 (R5) was admitted on [DATE], with diagnoses including epilepsy, tracheostomy, and gastrostomy. R5's medical record revealed a Significant Change Assessment was in progress. The facility's MDS Summary Report revealed the Significant Change ARD for R5 was 12/23/2022. The assessment was 21 days overdue. 18) Resident #74 (R74) was admitted on [DATE], with diagnoses including traumatic brain injury and gastrostomy. R74's medical record revealed an admission Assessment was in progress. The facility's MDS Summary Report revealed the admission ARD for R74 was 11/24/2022. The assessment was 51 days overdue. On 01/27/2023 in the morning, the Director of Nursing indicated the facility did not have a MDS Coordinator for almost a year and the MDS assessments were not completed. On 01/27/2023 at 9:29 AM, the MDS Coordinator indicated the facility had 14 days from the ARD to complete and transmit the MDS to CMS. The MDS Coordinator indicated the facility did not have a MDS Coordinator for a long period of time in 2021-2022 so there was a lot of catching up on MDS assessments when they first stated in June of 2022. The MDS Coordinator acknowledged the MDS quarterly, significant change, and admission assessments for the above listed residents were not transmitted within 14 day of the ARD. The MDS Coordinator indicated the transmission dates were late and not submitted on time. On 01/27/2023 at 2:32 PM, the Administrator indicated the facility did not have a MDS Coordinator from June 2021-May 2022. The Administrator indicated the facility was behind on the MDS resident assessments because there was no MDS staff from June 2021-May 2022. The Administrator indicated the current MDS Coordinator had to catch up on the late MDS resident assessments when they started. The Administrator acknowledged the MDS assessments were not submitted on time. The CMS RAI Manual Version 3.0, Chapter Five: Submission and Correction of the MDS Assessment, dated 10/2019, documented MDS assessments would be submitted within 14 days of the MDS completion date.

Based on observation, interview, and document review, the facility failed to ensure 1) opened food items were labeled and dated, 2) expired items were discarded, and 3) spoiled produce item was discarded. The failure to label and date food items, and discard expired items had the potential to serve foods to the residents at an increased risk of food safety. Findings include: On 01/24/2023 at 7:59 AM, during the initial kitchen tour of the kitchen revealed the following: 1) Opened items unlabeled and undated included: Dry storage: - Bottle of crystal sprinkles Freezer: -Bag containing hot dog buns -Bag of bread rolls -Bag of assorted popsicles -Bag of beef patties -Large plastic bag containing three opened bags of frozen vegetables Countertop: -Spice tray with 14 bottles of assorted spices Refrigerator: -Bag of shredded mozzarella cheese 2) Expired food items: Refrigerator: -Container of oat yogurt opened and dated 01/11/2023 with manufacturer's instruction to use within seven days of opening -Carton of liquid eggs opened and dated 12/28/2022 with manufacturer's instruction to use within seven days of opening 3) Spoiled produce Refrigerator: - Whole head of lettuce wrapped in plastic was discolored and browned On 01/24/2023 in the morning, the kitchen inspection was conducted with the Dietary Manager and the cook. The Dietary Manager confirmed the opened items were not labeled and dated. The Dietary Manager indicated opened food items should be labeled and dated to ensure food safety. The Dietary Manager confirmed the opened container of oat yogurt and liquid eggs were opened but was not aware of the manufacturer's instructions to use within seven days of opening. The Dietary Manager indicated the kitchen should have followed the manufacturer's instructions to use within seven days of opening and discarded after the seventh day to ensure food safety. The [NAME] acknowledged the lettuce in the refrigerator was no longer edible and should have been discarded. The Refrigerated Storage policy revised 01/03/2019, documented opened foods should be dated. The Freezer Storage policy revised 01/03/2019, documented frozen food should be labeled with the date it was placed in the freezer. The Dry Goods Storage policy revised 01/03/2019, documented all products that have been opened should be labeled and dated.