**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure safe and comfortable temperatures were maintained in residents' bedrooms by failing to repair one of eight rooftop air-conditioning (A/C) units resulting in temperature readings between 89.8- and 90.0-degrees Fahrenheit (F) on 06/23/2025, for one resident (#5) of twenty sampled residents. These failures resulted in physical discomfort for a dependent resident and the likelihood of significant harm due to unsafe temperatures exceeding 81-degrees Fahrenheit. Findings included: During the tour of the facility on 06/23/2025 at 8:32 a.m. Resident #5 was observed in a private bedroom. Upon entering the room, noticeable uncomfortable room air temperature was identified due to excessive warmth with palpable humidity present. A fan, approximately 18 inches, was observed operating on an over the bed table. Resident #5 was observed in a low bed, in a curled position, eyes open, observed to be watching the television in the corner of the room. Two windows, that were approximately the length of the bed, were observed to be open approximately 1 inch. The room was observed to have no wall cooling A/C units. An air vent was observed to be located in the ceiling, right inside the resident's room door. During this tour, there was no noticeable cool air flow. During this tour, Resident #5 was noted not interviewable and could not speak of his temperature preferences. A review of Resident #5's admission Record revealed a re-admission date of 05/23/2025. The diagnosis information included, but not limited to: Severe intellectual disabilities, acute and chronic respiratory failure; contracture, unspecified joint, cognitive communication deficit, muscle weakness (generalized); and need for assistance with personal care. Review of a progress note dated 06/04/2025 at 4:13 p.m. revealed Resident #5 was unable to speak on behalf of self. It showed, Social Determinations of Health note by the Minimum Data Set Coordinator: Resident is unable to respond regarding ethnicity. Resident is unable to respond regarding race. Language: English. Residents do not need or want an interpreter to communicate with doctor or health care staff. Resident is unable to respond to lack of transportation. How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy: Resident unable to respond. How often do you feel lonely or isolated from those around you: Resident unable to respond. On 06/23/2025 at 10:33 a.m., an interview was conducted with the Maintenance Director. He stated the facility had three ground unit air conditioners (A/C) and eight rooftop A/Cs. He stated, Yes, they are all keeping temperatures. He stated he checks the working order of the A/Cs by using the thermal gun, pointing it at the vents for temperature. He said he did this about once per month. On 06/23/2025 at 10:47 a.m., observations were conducted of Resident #5's room with the Maintenance Director. The windows were observed open in the same position. The Maintenance Director stated he was unaware of the warmth of the room, and he did not know why the residents' windows were open. He was observed to close the windows. When asked if he had a tool to measure the temperature in the room, he said he did and he was observed to leave to retrieve it. During the Maintenance Director's absence, at 10:50 a.m. Staff C, Licensed Practical Nurse (LPN) was observed outside of Resident #5's room, she confirmed she was assigned to Resident #5. When asked about the temperature in Resident #5's room, she said, it was warm in the room. She said, It has been like that for about one month. All of them are aware. On 06/23/2025 at 11:55 a.m., the Maintenance Director returned with a thermal temperature gun. He pointed the thermal gun at the ceiling and the reading on the tool was 90.0 degrees Fahrenheit. He pointed the thermal gun at the floor, approximately two and a half feet from Resident #5's bed, and the reading on the tool was 89.8 degrees Fahrenheit. The Maintenance Director said, It is very warm, we can see about moving him. On 06/23/2025 at 11:13 a.m. an interview was conducted with Staff C, LPN. When asked if and how the temperature was monitored in Resident #5's room, she stated she did not know how to take temperatures. She stated they were aware of it. She said, for maintenance issues, they enter maintenance requests electronically through a portal. An interview was conducted with Staff A, Certified Nursing Assistant (CNA) on 06/23/2025 at 11:38 a.m. She stated the Maintenance Assistant and Director knew about the warm temperatures in Resident #5's room. She said, He (The Maintenance Director) has been aware of it. I asked them if they are going to do anything about it. She said, (referring to Resident #5) you can go in there and he will be hot visibly, but he will say he is cold. Staff A stated, hot visibly, meant sweat. She stated the resident has a ten-word vocabulary and would not go in there expecting him to answer. On 06/23/2025 at 11:48 a.m., the Maintenance Director stated they were going to move Resident #5 out of the room today and they were currently working on another room for him. He stated this was the first time he had taken temperatures in the resident's room. He said his goal for the temperature level was to be no more than 82 degrees or below. On 6/23/2025 at 12:00 p.m., a telephone interview was conducted with the Maintenance Assistant. He stated (Resident #5)'s room was hooked up to a roof top unit; it should be cooling. When asked his expectation for the temperature of the air coming out of the vent in the room, he stated he would expect the temperature of the air coming out of the vent to be 75 degrees. He stated he was unaware of any problems in the last 30 days with Resident #5's room, hallway, or the A/C unit serving the area. He stated, Not that I am aware of. He stated, Yes he should be aware of any problems. He said, For the temperature in the room, the goal is to be 74 to 75 degrees; the maximum, believe it to be 80 degrees. He stated he had not received any concerns about warm temperatures in the resident's room. He stated, Not that I am aware of. When asked about the temperature obtained from (Resident #5's) room, the floor at 89.9 degrees Fahrenheit, the ceiling at 90.0 degrees Fahrenheit, he said, that is not suitable for a resident in there; it is definitely too hot. The Maintenance Assistant stated he had measured the temperature coming out of the vent at the end of last month but had not written it down. A second observation of air vent temperature located in Resident #5's room and vents in the hallway near Resident #5's room was conducted on 06/23/2025 at 12:10 p.m. with the Maintenance Director. The following was observed: Resident #5's doorway ceiling vent air output temperature reading was 87.4 degrees Fahrenheit. The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 84.2 degrees Fahrenheit. The ceiling vent air output for the vent in the hall outside of room [ROOM NUMBER] was 86.4 degrees Fahrenheit. Observed outside of the resident's room was a thermostat on the wall which read a temperature of 79 degrees Fahrenheit, with a setting of 74 degrees Fahrenheit. The Maintenance Director was observed to remove the cover of the thermostat and lower the setting to 72 degrees Fahrenheit. A review of the facility's electronic communication log dated 04/01/2025 through 06/23/2025 revealed there were no listings for concerns of temperature submitted by staff. On 06/23/2025 at 2:15 p.m., an interview was conducted with the Director of Nursing (DON). She reported she had not been in (Resident #5's) room. She stated she had not noticed the temperature in the hall (near Resident #5's room) being warm. When asked what she would expect a staff member to do if they noticed a warm temperature in a resident room, she said, first find out if it is a preference; report it to management and maintenance that there may be a problem. On 06/23/2025 at 3:15 p.m., Staff C, LPN, was observed sitting at the nursing station between the 100 and the 200 halls, she was using a piece of paper to fan herself. She stated, it is very hot here, the west side is cooler. She stated, This is the east side. I have noticed it getting warm in May. When asked if she had reported the warm temperature, she stated Yes, everyone knows it is warm, it is an older building. On 06/23/2025 at 3:20 p.m. Staff E, CNA was observed standing at the nurses' station between the 100 and 200 halls. She confirmed she was assigned rooms in the 200 hall. She said regarding Resident #5's room, It is hot in his room; I think I had him last week. The Maintenance Assistant said they were working on it. An observation was conducted at this time of a digital wall clock on the wall at the end of the nursing station. The temperature of the wall clock read 83.3 degrees Fahrenheit. Staff E, CNA, said, the wall clock will register over 80 degrees frequently. On 06/23/2025 at 3:30 p.m., an interview was conducted with Staff F, Housekeeper. She confirmed she performed housekeeping on certain days of the week. She said regarding the temperature in Resident #5's room, Sometimes the room is cooler, sometimes warmer. I do not know if there is air conditioning in here (pointed to the ceiling). Staff F stated lately it has been warmer. On 06/24/2025 at 11:30 a.m., an observation and interview confirmed Resident #5 had been moved to another room. The Maintenance Director stated the roof top A/C unit, which was responsible to source the cool air for Resident #5's room, the fan was running, but he was not sure if it was cooling. He stated the thermostat in the hall was set at 72 degrees and the temperature in the hall had been between 76- and 77-degrees during frequent checks this morning. He stated he was told the A/C technician cannot come out today and is going to call back and see if another technician can come out. During the interview, the temperature in the room felt warm and the air coming from the vent was at a sparse rate. The Maintenance Director stated this air vent was sourced by the roof top A/C unit. He immediately used his thermal temperature gun, pointed at this air vent and obtained a temperature of 87 degrees Fahrenheit. Another temperature measurement was obtained inside the middle of Resident #5's room, by pointing the thermal temperature gun at the ceiling, which measured 87 degrees Fahrenheit, and then mid-floor, which measured 85 degrees Fahrenheit. The Maintenance Director confirmed air temperatures were not checked routinely. He stated they only checked if the A/C system goes out, then there would be frequent temperature checks done. On 06/24/2025 at 1:14 p.m. an interview was conducted with the Nursing Home Administrator (NHA). When asked if the facility had a policy for testing temperatures in the building, or what the process was to ensure temperatures were appropriate, the NHA said, if we have a loss of A/C, then we take temperatures, on a daily, weekly, monthly basis. She stated they just walk through. The NHA did not provide documentation to show they were monitoring temperatures. The NHA stated they can monitor temperatures by looking at the thermostats on the walls, and staff can tell if it is warm. The NHA stated she was not aware of an A/C unit that was not working. The NHA said, No, not that I'm aware of, no one had brought anything to me, and no one had voiced concerns about temperatures. The NHA stated for staff reporting maintenance issues, she said, they should use (the electronic communications) system, she stated it is a reporting system where you can put work orders in. She stated all staff had access to the generic login. She stated all staff were trained in the Electronic Communication System. The NHA said, Yes, they were trained on hire. I don't know the last time they were trained; I have to go look. The NHA stated her expectation for temperatures in resident rooms was to be between 71 and 81 degrees, unless it is resident preference to have it warmer. The NHA stated they were waiting on a technician to fix the roof-top unit located near 200 hall. The NHA stated she was not aware of Resident #5's room being warm. The NHA said, No. I have been in that room two-three times a week doing spot checks. The HNA stated she was in there and the window was not open. The NHA stated the window being open would have brought more heat inside. The NHA stated her expectation was when maintenance becomes aware of a non-functional A/C unit, they should get quotes and get it fixed. On 06/23/2025 at 12:40 p.m. the Maintenance Director was requested to provide the policy and procedure for monitoring temperatures in the building, and the policy and procedure for how staff communicate concerns to the maintenance personnel. The policies were not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 4/29/25 at 9:17 a.m., Resident #7 was observed lying in bed. The resident's bottom teeth were covered with a yellow/tan colored substance and a watery, tan colored liquid was observed in the resident's mouth. An intravenous (IV) pole was standing between the bed and window and hanging from the pole was an empty IV medication bag, labeled with the residents name, name of the medication Zerbaxa, and tubing wrapped around the wings of the pole. The IV medication was dated 4/28/25 and not running. Review of Resident #7s medical record showed a medication list from an acute care facility, printed on 4/17/25 at 10:46 a.m., revealing the resident was to receive ceftolozane-tazobactam 1.5-gram (g) in sodium chloride 0.9%, 100 milliliter (mL) IV piggyback (IVPB) - Infuse 1.5g into a venous catheter every 8 (eight) hours for 35 doses. Last time this was given: April 17, 2025, at 6:05 a.m. Review of Resident #7s Admit/Readmit Assessment, effective 4/17/25 at 5:15 p.m. revealed a temperature reading of 98.5 degrees Fahrenheit taken 4/17/25 at 2:36 p.m., a blood pressure and pulse taken on 4/17/25 at 5:07 p.m. and 5:08 p.m., a weight of 139.0 pounds taken on 3/9/22 at 1:44 p.m. (previous admission), respiration rate of 18 taken 3/13/22 at 3:47 a.m. (previous admission), and a height on 3/6/22 at 2:06 p.m. (previous admission). Review of Resident #7s April Medication Administration Record (MAR), printed on 4/30/25 at 11:45 a.m., revealed an order for Cetfolozane-Tazobactam Intravenous solution reconstituted 1.5 (1-0.5) gram (GM) (Ceftolozane Sulfate - Tazobactam Sodium) - Use 1.5 gm intravenously three times a day for urinary tract infection (UTI) for 35 administrations. The order was started on 4/17/25 at 10:00 p.m. and discontinued on 4/29/25 at 9:03 a.m. The MAR had X documentation for the 6:00 a.m. and 2:00 p.m. doses on 4/17/25, allowed for 35 doses to be administered, three doses daily on 4/18/25 to 4/28/25 (11 days) and one dose each on 4/17/25 and 4/29/25, the 35th dose to be administered on 4/29/25 at 6:00 a.m., the rest of the order was marked with X. The MAR included the following dosage documentation with corresponding chart codes related to the administration of the resident's antibiotic: - 4/17/25 at 10:00 p.m. - 1 = Absent from home without meds. - 4/18/25 at 6:00a.m. - 1 = Absent from home without meds. - 4/18/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/19/25 at 10:00 p.m. - no documentation. - 4/24/25 at 6:00 a.m. - 5 = Hold/See Progress Notes. - 4/24/25 at 2:00 p.m. - 5 = Hold/See Progress Notes. - 4/26/25 at 6:00 a.m. - no documentation. - 4/28/25 at 6:00 a.m. - no documentation. The MAR showed the resident missed 8 of the 35 ordered doses. Review of Resident #7s progress notes included the following notes related to the missed doses of Ceftolozane-Tazobactam Intravenous solution: - 4/18 at 1:36 p.m.: Medication unavailable at this time. Not available in [electronic medication dispenser]. MD (Medical Doctor) and representative (RP) aware. No signs/symptoms (s/s) of any adverse reactions. No new orders. Pharmacy to deliver. Plan of care ongoing. - The notes revealed no progress note was written on 4/19/25 for the resident. - 4/24/25 at 8:19 a.m.: Med on hold, MD notified. - 4/24/25 at 8:22 a.m.: Resident antibiotic (ABT) on hold. MD notified. - 4/24/25 at 2:53 p.m.: MD ordered put in hold the medication. - 4/26/25 showed no progress note was written regarding the 6:00 a.m. dose. - 4/28/25 showed no progress notes was written on that day. A progress note written on 4/29/25 at 9:15 a.m. showed Review of resident's IV medication. Resident received the 35 required doses of the medication. Medication was discontinued. Will follow up with [Infectious Disease] ID. Review of Resident #7's Order Summary Report, active as of 4/30/25 at 11:43 a.m. showed an order Discontinue (D/C) PICC line. Therapy complete, dated 4/29/25. A note, effective 4/29/25 at 1:30 p.m. regarding the Normal Saline flush of Resident #7s Central line/ peripherally inserted central catheter (PICC)/Midline revealed line has been removed. The report did not reveal an active order for Ceftolozane-Tazobactam. An interview was conducted with Staff L, Licensed Practical Nurse/Unit Manager (LPN/UM) on 4/30/25 at 1:15 p.m. The staff member stated, regarding Resident #7's Ceftolozane-Tazobactam, knowing the medication was hard to get from pharmacy due to the cost and the facility was only able to get a couple of days at a time. Staff L, LPN/UM reported there was a time the Director of Nursing (DON) was pre-approving it daily and if it was not available the doctor was to be notified. The staff member stated she was unaware of the physician holding the medication (4/24 doses) and stated wonder if it wasn't some of the nurses who don't speak well put the note in. The LPN/UM reviewed the resident's MAR and stated it did not look like the resident received the ordered 35 doses. The staff reported Staff E, LPN/Infection Preventionist (IP), counted the doses up yesterday and told her the resident received the 35 doses. An interview was conducted with Staff F, LPN on 4/30/25 at 1:31 p.m. The staff member reported administering all of Resident #7's IV antibiotics. The staff member reported not having the medication until pharmacy delivered it and there would have been no reason why the staff member would not have administered them. An interview was conducted with Staff E, LPN/IP on 4/30/25 at 1:40 p.m. The staff member reported starting to work for the facility on 4/17/25. The staff member confirmed Resident #7 was to receive the IV antibiotic Ceftolozane-Tazobactam for 35 doses and the facility had a hard time getting the medication from pharmacy. The staff member reported the facility kept adding doses to the end because of the missed doses. Staff E, LPN/IP stated the original order was for it to end on the 25th of April and the physician extended it out to the 29th. Staff E, LPN/IP stated All I know the nurses said the resident finished the IV's. She reported being unable to pull the MAR and spoken with Infectious Disease (ID) and the physician on the 29th. Staff E, LPN/IP reported informing ID and the physician that according to staff, the resident completed the 35 doses of the antibiotic, and the Assistant Director of Nursing (ADON) spoke with the physician and received an order to pull the IV line. During the interview, at 1:51 p.m. the ADON came into Staff E's office and said she had not spoken with the physician, the DON had spoken with him. The DON stepped into the office and said Staff L, LPN/UM spoke with the physician while in the DON's office. Staff E, LPN/IP reviewed Resident #7's MAR and confirmed No he did not the resident had not received the ordered 35 doses of antibiotic. The DON stated Staff E, LPN/IP came to her and said the resident had all the doses and Staff L, LPN/UM had gotten the order to pull the IV line. The DON reviewed the resident's MAR and said the facility was aware now the resident had not received the 35 doses and the physician was notified of the medication error. Review of Resident #7s MAR showed an order, started on 4/30/25 at 2:45 p.m., to Insert PICC [peripherally inserted central catheter] line. May use 1% lidocaine for insertion. One time only for medication administration for 2 days. A general nurse's note, created 4/30/25 at 3:03 p.m. by Staff E and effective 4/30/25 at 12:54 a.m., revealed Call placed to Nurse Practitioner (NP) regarding resident IV therapy. Resident requires 8 more doses of ABT. Discussed with NP and order was given to have PICC line reinserted and to give resident remaining required doses. Call made to RP by ADON with verbal consent to have PICC line reinserted. IV Team called and will be out to reinsert line. Resident to follow up with ID next Thursday. On 4/30/25 at 4:36 p.m., Resident #7 was observed lying on right side. The observation did not show a new IV catheter had been placed. Review of the MAR showed a new order for Ceftolozane-Tazobactam was to start on 4/30/25 at 10:00 p.m. The review revealed the resident missed 4 doses of the 8 already missed due to the facility not ensuring 35 doses had been administered and discontinued the PICC line requiring the resident to have another inserted before completing the doses of IV antibiotics. 3. Review of the facility's Incident Log revealed a medication error occurred on 3/28/25 at 5:50 p.m. with Resident #4. Review of Resident #4's admission Record revealed the resident was admitted on [DATE] and 3/7/25. The record included diagnoses not limited to intraspinal abscess and granuloma, unspecified local infection of the skin and subcutaneous tissue, unspecified organism sepsis, unspecified disorder involving the immune mechanism, osteomyelitis of vertebra lumbar region, and chronic myeloproliferative disease. The resident was transferred to the hospital on 4/19/25 for uncontrolled pain. Review of Resident #4's progress notes revealed the following: - 3/27/25 at 2:58 p.m.: an order was entered for Daptomycin Intravenous Solution Reconstituted 500 mg. - 3/27/25 at 11:04 p.m.: Resident continue with IV treatment. No adverse reactions noted. PICC line on right arm, patent and intact. No redness or swelling noted. Flushed according medical orders. - 3/28/25 at 5:50 p.m.: Resident accidentally received Cefepime HCl (hydrochloride) Intravenous Solution 1 gram/50 milliliter. Family at bedside notified. DON notified. MD states to monitor resident for changes. MD states to perform 24 hour neuro checks. Resident denies pain or discomfort. Resident did not have signs of adverse reactions. Neuro in normal range. - 3/28/25 at 11:00 p.m.: Resident observed resting in bed. Resident denies pain or discomfort. Resident has no signs or symptoms of distress. Neuro check are with in normal range. - The progress notes did not contain a note written on 3/29/25. Review of Neurological Assessment Flow Sheet read *Med Error only for 24 hr neuro check. The instructions printed on top of the sheet showed neurological assessments to include level of consciousness, motor function (hand grasps), pain response, vital signs, pupil response, extremities (movement) and observations were to bed completed every 15 minutes for 2 hours, every 60 minutes for 4 hours, and every 8 hours for 16 hours. The sheet showed level of consciousness, pupil response, hand grasps, extremities, and vital signs continued as instructed every 15 minutes for 2 hours, every 30 minutes for 2 hours, every 60 minutes for 4 hours, stopping at 12:45 a.m., 6 hours and 45 minutes after the incident. The documentation did not reveal the neurological assessment had continued every 8 hours for 16 hours on 3/29/25. During an interview on 4/29/25 at 10:53 a.m., the DON reported having the position of DON for 2.5 weeks and provided one Investigation Statement regarding Resident #4's medication error. The DON stated Staff K, LPN was assisting another nurse, Staff M, LPN with hanging the IV medication for Resident #4, as Staff M, LPN was not IV certified and Staff K, LPN was. The DON stated Staff M, LPN gave Staff K, LPN the wrong medication. The DON reviewed the Investigation Statement from Staff K, LPN and stated the form was not filled out correctly, the incident was supposed to have been investigated, statements completed by those involved, and education should have been done. The DON reported she had not received education related to medication rights from the previous DON. An interview was conducted on 4/29/25 at 11:12 a.m. with Staff L, LPN/UM. Staff L, LPN/UM reported not finding out about the incident until the next day. Another nurse, Staff M, LPN, who wasn't IV certified, asked Staff K, LPN to hang the medication. Staff M, LPN had the medication all set up for Staff K, LPN and Staff K, LPN, had not checked it before administration. An interview was conducted on 4/30/25 at 6:35 p.m. with the Nursing Home Administrator/Risk Manager (NHA/RM). The NHA reported being informed of the incident when it occurred with the previous DON informing her that education had started. The NHA stated nurses are supposed to be IV certified, not all of them are and did not know if Staff M, LPN had been certified. An interview was conducted on 4/30/25 at 6:45 p.m. with Staff K, LPN. The staff member reported Resident #4 was not on assignment the day of the incident and the error was on him. Staff M, LPN couldn't hang the antibiotic, wasn't IV certified, and came to the staff member a couple of times. Staff K, LPN stated Staff M, LPN had the medication bag and tubing and told the staff member all that had to be done was to hang it. Staff K, LPN did not verify if the medication bag had been spiked prior to receiving it. Staff K, LPN reported asking the other staff member to verify the medication was for the B-bed. Staff K, LPN stated, I should have pulled my own stuff and the medication ran for approximately 5 minutes. Staff K, LPN reported taking over the resident and apologized to the family. Staff K, LPN reported talking to the family a couple of times to update on condition, wrote a statement day of the incident, started neuro checks. Review of the policy titled Medication Administration, undated, revealed the following: Medications are administered by licensed nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The policy instructed staff to correct any discrepancies and report to the nurse manager. The compliance guidelines instructed staff: - 10. Review MAR to identify medication to be administered. - 11. Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, route, and time. - 17. Sign MAR after administered. For those medications requiring vital signs, record the vital signs onto the MAR. Review of the policy titled Abuse, Neglect, and Exploitation, undated, showed the following: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, in misappropriation of resident property. The policy defined neglect as failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy Explanation and Compliance Guidelines included: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Established policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, dementia management, and resident abuse prevention; and d. Establish coordination with the QAPI program. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. III. Prevention of Abuse, Neglect, and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: . B. Identifying, correcting, and intervening in situations in which abuse, neglect, exploitation, and/ or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms; C. Assuring an assessment of resources needed to provide care and services to all residents is included in the facility assessment; D. Identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents both needs and behaviors which might lead to a conflict or a neglect. IV. Prevention of Abuse, Neglect, and Exploitation A. The facility will have written procedures to assist staff in identifying the types of abuse - mental/ verbal abuse, sexual abuse, physical abuse, and deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: . 8. Failure to provide caring needs such as feeding, bathing, dressing, turning and positioning. Based on observations, interviews, and record review, the facility failed to ensure residents were free from neglect related to 1.) not providing physician ordered tube feeding and not providing assistance to get out of bed for 13 days, leading to a decline in functionality for one resident (#7) out of 12 sampled residents and 2.) failing to administer medications in accordance with physician orders for two residents (#7 and #4) out of twelve sampled residents. Findings included: 1. An observation and interview was conducted on 4/30/25 at 10:47 a.m. with a family member of Resident #7. The family member said she was concerned because the resident's tube feeding was supposed to be running all day, and she had been in a few times and it was not running. She said she was worried he was not getting the nutrition he needed. The family member said she talked to staff a few times and was told the pump for the tube feed was broken. She said the tube feed had not been running when she got to the facility that day and the day prior it ran for a while, then the pump broke. She said after a little bit, someone got it running again. The family member also stated Resident #7 had not been out of bed in the almost two weeks. She said when the resident came to the facility he was able to transfer and walk with assistance, but now he had gotten so much weaker. She said he was supposed to be there for rehab and then go home. The family member said she is now concerned Resident #7 won't be able to improve and go home. Review of admission Records showed Resident #7 was admitted on [DATE] with diagnoses including sepsis, unspecified organism, pneumonitis due to inhalation of food and vomit, acute respiratory failure with hypoxia, and protein-calorie malnutrition. Review of Resident #7's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 3008), dated 4/17/25, showed the resident ambulates with assistive device, transfers with 2 assistants, and is partial weight-bearing on the left and right sides. Review of Resident #7's Care Plan showed a focus area of Resident requires assist with ADLs [activities of daily living] R/T [related to] impaired mobility, dated 4/18/25. Interventions included substantial/maximum assistance with bed mobility and lying to sitting on the side of the bed and dependent for chair to bed and bed to chair transfers. Another focus area was PEG [percutaneous endoscopic gastrostomy] tube is utilized for all medications/nutrition and fluids, dated 4/18/25. Interventions included feeding/water flushes per doctor orders. Review of Resident #7's orders showed: #1 Nutren Renal Oral Liquid. Give 250 ml (milliliters) via g-tube four times a day for Nutritional Supplement. Start date 4/17/25. Discontinued 4/18/25. #2 Enteral Feed Order. Every shift for dysphasia. Nutrin 2.0 60 ml/hr (hour) x 20 hrs. Up at 6 a.m. and down at 2 a.m. Start date 4/18/25. Discontinued 4/19/25. #3 Enteral Feed Order. Every shift for dysphasia. Nutrin 2.0 60 ml/hr x 20 hrs. Up at 6 a.m. and down at 2 a.m. Start date 4/19/25. Discontinued 4/21/25. #4 Enter Feed Order. Five times a day. Nutren 2.0 bolus 1 can 5 times a day with 75 cc (cubic centimeters) water bolus. Start date 4/21/25. Discontinued 4/24/25. #5 Enteral Feed. In the morning for dysphasia Nutrin 2.0 60 ml/hr x 20 hrs up at 6 a.m. and one time a day for dysphasia Nutrin 2.0 60 ml/hr x 20 hrs down at 2 a.m. Dated 4/24/25. Review of Resident #7's progress notes showed the first note was entered into the medical record at 5:19 p.m. on 4/17/25, indicating the resident arrived prior to that time. Review of Resident #7's April 2025 Medication Administration Record (MAR) showed the resident did not receive enteral feeding on 4/17/25. The feeding at 9:00 p.m. on 4/17/25 was documented as 5 meaning Hold/See Progress Notes. The progress notes did not have any documentation as to why the enteral feeding was not provided. According to the MAR, the resident received his first enteral feeding at 9:00 a.m. on 4/18/25, over 15 hours after admission to the facility. The resident received another feeding at 1:00 p.m. on 4/18/25, and order #1 for bolus feeding was discontinued. Order #2 for continuous feeding to hang at 6 a.m. and take down at 2 p.m. was signed off for the night shift on 4/18/25, and it was discontinued. The MAR showed order #3 for continuous feeding was signed off for all shifts on 4/19/25 and 4/20/25 and for the morning shift on 4/21/25, but was not signed off on the evening shift of 4/21/25. Order #3 was discontinued on 4/21/25. Order #4 was documented as completed twice on 4/21/25 and five times each on 4/22/25 and 4/23/25. The order was discontinued the morning on 4/24/25. There is no order in place or documentation to show the resident received any tube feeding on 4/24/25. Order #5 began on the morning of 4/25/25 and was signed off as the tube feed being hung at 6:00 a.m. on 4/25/25, 4/27/25, 4/28/25, 4/29/25, and 4/30/25. On 4/26/25, the tube feed was not signed off as being hung and there is no documentation stating why it was not administered as ordered. An interview was conducted on 4/30/25 at 11:16 a.m. with Staff F, Licensed Practical Nurse (LPN). She stated she cared for Resident #7 on 4/29/25 starting at 7:00 a.m. She said when she came on shift, Resident #7's tube feed was not hanging. She confirmed it was supposed to be hung at 6:00 a.m. and didn't know why it wasn't hung up and why it was signed off. She said she did not notify anyone she just hung the tube feed around 10:00 a.m. and turned it on. Staff F, LPN said she did not know why the resident had been switched back and forth between continuous and bolus feedings. She said she did not think the pump was broken, she just didn't think the staff knew how to use it correctly. An observation was conducted on 4/30/25 at 10:47 a.m. of Resident #7 lying in bed. The tube feed pump was next to the bed and there was no tube feed hanging and the pump was turned off, although it was documented it had been hung at 6:00 a.m. on 4/30/25. An interview was conducted on 4/30/25 at 5:41 p.m. with the facility's Registered Dietician (RD). She said from her understanding, Resident #7 has switched from continuous pump feeding to bolus feeds and back again because the facility had issues with the pump. She said they do weekly weights on tube feed residents and Resident #7 was 145 pounds on admission 13 days ago and 142 pounds on 4/30/25. She said he was on a medication for edema, but in general, tube feed residents should never lose weight. The RD said not getting the required food intake can lead to a lot of problems. She said Resident #7 looks worse now than when she saw him after admission. She said the resident not getting the proper amount of nutrition and possible missing tube feedings could have led to the weakness he had been having, it certainly doesn't help. The RD said Resident #7 had gone down since he had been at the facility. An interview was conducted on 4/30/25 at 2:49 p.m. with the facility's Director of Nursing (DON). She said the facility was not notified of the type of tube feed Resident #7 was on until he arrived and it was a less common type. She said they did not have a tube feed pump available at the time he arrived due to an influx of tube feed residents. She said they found a pump in the back for the resident, but it was an older type. She said they also found a case of Nutrin renal containers in the facility after he arrived and that is why they were doing bolus feedings instead of continuous feed. She said the bags of tube feeding arrived and he began continuous tube feeding on the second day. An interview was conducted on 4/30/25 at 11:42 a.m. with Staff H, Occupational Therapy Assistant (OTA). Staff H, OTA said there is not a reason Resident #7 cannot get out of bed. She said he used a full body mechanical lift and the nursing staff should have been getting him up. Staff H, OTA said she took a wheelchair to the resident's room a week ago, but someone must have taken it out. She said the resident had been receiving therapy in bed due to nursing staff not having him up in a chair. A follow-up interview was conducted on 4/30/25 at 12:00 p.m. with Staff F, LPN. She said she had not seen Resident #7 out of bed since he had been in the facility. She said they were waiting on therapy and she didn't know if therapy had gotten him up or not. An interview was conducted on 4/30/25 at 12:05 p.m. with Staff J, Certified Nursing Assistant (CNA). She said she regularly took care of Resident #7. She confirmed the resident had not been out of bed and that was due to him not having a wheelchair. A follow-up interview was conducted with Staff H, OTA and the Director of Rehabilitation (DOR). Staff H, OTA said she had no idea where the wheelchair went that therapy provided to Resident #7. She said nursing should not have been waiting on therapy to get the resident out of bed, they should have been getting him up daily. The DOR said therapy does not tell nursing if they can or cannot get a resident out of bed. He said therapy did an evaluation of the resident and let nursing know the level of assistance needed. The DOR said Resident #7 needed a full body mechanical lift to get up and nursing should have been getting him out of bed. An interview was conducted on 4/30/25 at 5:38 p.m. with Staff I, Physical Therapist (PT). Staff I, PT reviewed Resident #7's initial evaluation on 4/17/25 and his current evaluation on 4/30/25. He said Resident #7 declined in his functionality since his admission. Staff I, PT said on 4/17/25 the resident completed sit to stand transfers with moderate assistance and on 4/30/25 he was totally dependent. He said on 4/17/25, the resident was able to ambulate 6 feet using a 2-wheel walker with moderate assistance and on 4/30/25 the resident was unable to do the task. The physical therapy evaluation provided noted Resident #7's decline in function. Staff I, PT said if a resident does not get out of bed it can cause their muscles to atrophy and the resident can weaken and decline in function. An interview was conducted on 4/30/25 at 6:44 p.m. with the Nursing Home Administrator (NHA). The NHA said she would expect staff to be following physician orders. She said she had not been aware of issues with Resident #7's tube feed, antibiotics not being administered correctly, or him being left in bed until today. She said the issues will be addressed. On 4/30/25, the DON stated the facility did not have the requested polices on getting residents out of bed or tube feedings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure pain management was provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (#35) out of three residents sampled for pain. Findings included: An interview was conducted with Resident #35 on 8/8/22 at 1:09 p.m. He stated he was in so much pain last night (8/7/22) at 11:00 p.m. He described his pain as 10/10 on the pain scale. Resident #35 stated he was not able to get his pain medication, because there wasn't any available. He stated this has happened to him four or five times. The resident began to get upset and cry explaining this and stated when this happens it hurts so bad, he feels like he could die. The resident stated he was given Tylenol and it doesn't do anything for his pain. He stated he was not able to get pain medication until lunchtime today (8/8/22). He stated at lunch the nurse was able to give him two tablets to combined to get his normal dose. The resident couldn't recall the name of the pain medication he normally receives. A review of admission records indicated Resident #35 was readmitted on [DATE] with an initial admission of 4/22/21. The resident had diagnoses including quadriplegia, chronic kidney disease, tracheostomy, pressure ulcer, atherosclerotic heart disease, and chest pain. A review of orders revealed the following: Fentanyl patch 75 micrograms (mcg)/hour (hr) 72 hour. Apply 1 patch transdermal every 72 hours for pain. Document site and remove per schedule. Order date was 8/9/22. Oxycodone HCL 10 milligrams (mg). Give 1 tablet by mouth every 3 hours as needed (PRN) for non-acute pain. Order date was 8/8/22. Acetaminophen tablet 650 mg. Give 1 tablet by mouth every 4 hours as needed for general discomfort. Order date was 8/4/22. Gabapentin capsule 100 mg. Give 1 capsule by mouth every 8 hours for never pain. Order date 8/4/22 (This was previously given via a feeding tube.) An order, dated 2/23/22, was in place to access and document pain level every shift using pain scale. A pain management evaluation was ordered for 8/8/22 A previous pain management evaluation was completed for Resident #35 on 1/8/22. The evaluation showed the resident has a terminal disease process and was able to verbalize his pain. The evaluation indicated the pain was chronic, occurring all the time at a severe level (7,8,9,10 on pain scale.) A care plan is in place for: risk for pain related to actual pain, quadriplegia, pressure areas, poor mobility and contractures. The care plan goal is for resident to be kept comfortable daily through next review. Interventions included: contact Medical Doctor (MD) for pain not relieved by current order, medications per MD order, pain assessment completed and reviewed quarterly and PRN, assist resident with re-positioning or other non-pharmacological aspect of pain relief. Resident #35's Minimum Data Set (MDS) dated [DATE] was reviewed. Section C, Cognitive Patterns, indicated the resident has a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. Resident #35's electronic Medication Administration Record (eMAR) was reviewed. The eMAR indicated Resident #35 was given Oxycodone 10 mg on 8/7/22 at 3:45 a.m., 9:48 a.m., 1:25 p.m., and 5:25 p.m. The Oxycodone was not administered again until 8/8/22 at 11:53 a.m. This shows an 18.5 hour gap between administrations of Oxycodone that is ordered every 3 hours as needed. The eMAR indicated Resident #35 was administered Acetaminophen 8/7/22 at 11:17 p.m., noting it was ineffective. The resident was again given Acetaminophen on 8/8/22 at 3:19 a.m., again noting it was ineffective. On 8/8/22 at 11:00 a.m. a one-time order was entered for two 5 mg tablets of Oxycodone for pain, this was administered on 8/8/22 at 11:53 a.m. The resident resumed his normal ordered dosage of one 10 mg tablet on 8/8/22 at 2:20 p.m. A review of the July 2022 and August 2022 eMAR indicated Resident #35 takes his PRN (as needed) Oxycodone around the clock daily with Acetaminophen not being utilized. A review of Resident #35's progress notes did not indicate any additional nursing notes regarding ineffective pain control, notification of the doctor, or notification of the pharmacy. Resident #35's Controlled Drug Receipt/Record/Disposition Forms were reviewed. The forms revealed the delivery of Oxycodone to the facility on 7/26/22, with the medication card running out on 8/7/22 at 1:15 p.m. An interview was conducted with Staff B, Licensed Practical Nurse (LPN,) on 8/9/22 at 4:00 p.m. Staff B stated Resident #35 receives his pain medication routinely every 3 hours. Staff B stated he has never run out of the resident's Oxycodone on his shift. He stated some shifts may have issues due to waiting on the pharmacy to deliver, but if the card is empty, they should be able to get the medication from the medication dispensing machine on the north unit. He stated when the medication card is down to only have 5-6 pills left, the nurse is supposed to notify the pharmacy. He said he didn't have any way to confirm a nurse before him notified the pharmacy or not. An interview was conducted with Staff O, LPN on 8/9/22 at 4:06 p.m. She sated there is a medication dispensing machine in the medication room on the north unit. She said to access the Oxycodone the nurse would need an Emergency Drug Kit (EDK) code from the pharmacy. She stated the pharmacy can be reached in the middle of the night if needed. She also stated the pharmacy can tell the nurse if there is Oxycodone in the machine. She said she has never seen it out of Oxycodone. On 8/10/22 at 11:41 a.m. the west hall medication card was inspected with Staff C, LPN. Staff C confirmed Resident #35 currently had two cards of Oxycodone that were both delivered on 8/8/22. She stated one card now has 19 pills remaining and one card is full. Narcotics counts were verified in the narcotics book. Staff C stated the medication card shows the resident currently has 180 pills left on this prescription. Staff C stated as long as the resident has pills left on their prescription, the nurse can get an access code from the pharmacist at any time to get Oxycodone out of the medication dispensing machine. She stated the only reason a resident can run out of medication is because no one ordered it, or the nurse didn't follow up. Staff C explained when the medication card gets to the last row, indicated in red, the nurse knows to reorder the medication. She stated she would know if it was reordered because a small sicker on the top is pulled off and faxed to the pharmacy, if the sticker is gone the medication was ordered. She confirmed the pharmacy will deliver narcotics every day of the week. An interview was conducted with the Director of Nursing (DON) on 8/1/22 at 2:03 p.m. She confirmed Resident #35 receives his PRN Oxycodone every 3 hours. She stated if the medication cards are out, staff should check the medication dispensing machine to see if it is in and get a code from the pharmacy. She stated, if the machine was out of the medication, the doctor would be notified. She stated he should never go without his pain medication. She confirmed the process is to reorder medication when the card has 7 pills remaining. After hearing the situation from the night of 8/7/22 and the morning of 8/8/22, she stated on Sunday night, 8/7/22, the doctor should have been notified or the pharmacy should have been called. The DON also stated, if [Acetaminophen} gave multiple times and it's ineffective should have notified the doctor. She stated the nurse taking care of Resident #35 on Sunday night was an agency nurse, but she should have still had access to the medication dispensing machine. She said all agency nurses are orientated to the building and where things are. She confirmed the nurse should have been able to get the Oxycodone. An interview was conducted with facility's Consultant Pharmacist on 8/11/22 at 2:58 p.m. She stated there is no reason Resident #35 shouldn't have been able to receive pain medication on the weekend. She stated the pharmacy does stat runs if there is something needed that can not wait until the next delivery. An interview was conducted with Staff T, Pharmacist currently working in the pharmacy. Staff T reviewed Resident #35's medication orders and deliveries. She stated there was a refill requested on 7/26/22 and 60 pills were delivered the same day. She also stated she can see where a new Oxycodone prescription for Resident #35 was sent in from a doctor on 8/8/22 at 10:45 a.m. She stated the resident was due for a new prescription. Staff T stated the card on 7/26/22 indicated to the facility there were no refills remaining and a new prescription was needed. She stated the facility should have requested a new prescription at that time. She stated this request was not put in until Sunday, 8/7/22. Staff T said the pharmacy received the request on Sunday and it was delivered Monday. She confirmed it is the facility's responsibility to follow-up and get new prescriptions. Staff T reviewed the stock of the facility's medication dispensing machine. She stated the machine had 5 mg tablets in stock and the resident's prescription was for 10 mg. She stated the doctor could have been called at any time for a prescription for two 5 mg tablets to be given. Staff T stated there would have been no issue with the nurse being able to access the Oxycodone in the middle of the night on 8/7/22. Staff T stated she is able to see Monday morning (8/8/22) an order was put in for two 5 mg tablets of Oxycodone and access to the medication was provided by the pharmacy. An interview was conducted with the Nursing Home Administrator on 8/11/22 at 3:50 p.m. The NHA stated they are looking for a Pain Management doctor to come to the facility. She agreed Resident #35 should never have to go without pain medication. She confirmed nurses are responsible for tracking medication and requesting refills. A facility policy titled, Pain Management Program, was reviewed. The policy stated, Effective pain recognition and management requires an ongoing facility-wide commitment to resident comfort, to identifying and addressing barriers to managing pain, and to addressing any misconceptions that residents, families, and staff may have about managing pain. It also stated, If resident is assessed for unrelieved pain, the nurse will notify the attending physician to obtain an order for appropriate pain management.