**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure physician-ordered laboratory and intravenous treatment was administered as ordered; and failed to ensure the physician was notified of a critical laboratory result for 1 of 3 sampled residents (#22). This deficient practice resulted in the resident not receiving the prescribed and appropriate treatment needed, resulting in further decline.Findings include:Resident #22 was admitted on [DATE], with diagnoses of malignant neoplasm of the upper lobe right bronchus or lung, malignant pleural effusion, and pneumonia. The care plan dated November 19, 2024, revealed that the resident was at malnutrition status related to diagnoses of emphysema, pneumonia, dementia, acute on chronic respiratory failure with hypoxia, and malignant neoplasm of the right lung. Interventions included diet and supplements as ordered. A 5-day Minimum Data Set (MDS) assessment dated [DATE], included that the resident was cognitively intact and did not have signs of delirium, psychosis, or behaviors. The assessment included the resident required supervision or touching assistance for rolling right to left, sitting to lying, and lying to sitting on the side of the bed.The late entry consultation note dated November 25, 2024, revealed the resident preferred only soups and reported some difficulty with swallowing. Assessments included debilitation, dysphagia, dehydration, and weakness.A Speech Therapy daily note dated November 25, 2024, included that a care coordination was completed with nursing, dietary, and a phone call was placed to the family regarding the resident's refusal of oral nutrition and hydration. The note also included that the resident had no signs or symptoms of aspiration on honey-thick liquid; and that the resident accepted soup and a Magic Cup.An alert note dated November 26, 2024, included that the resident's family complained the resident was not eating enough. According to the documentation, speech therapy recommended thickened liquids to avoid aspiration. Further, the documentation included that the resident refused to have thickened liquids and that he was refusing food. -Regarding IV Sodium ChlorideA physician progress note dated November 27, 2025, included that the resident was cachectic, weak, had poor appetite, and was not eating much.A provider's assessment note dated November 27, 2024, revealed the resident was very thin-appearing and was considering hospice at the time of discharge, and that the resident wanted to get better and stronger. Per the documentation, intravenous (IV) normal saline at 75 cc (cubic centimeter) per hour for one day was ordered.A physician order dated November 27, 2024, included Sodium Chloride Solution 0.9% Use 75 milliliters/hour (ml/hr) intravenously (IV) for 24 hours for dehydration for 1 Day.A provider assessment dated [DATE], included the resident was resting comfortably and denied any changes, nausea, or vomiting, and that he was getting a little bit better. It also included that the staff will start an IV line and give him 1L (liter) of fluids. A physician progress note dated November 29, 2024, revealed that the resident was cachectic and weak. Per the documentation, the IVF (intravenous fluid) was running. A general progress note dated November 29, 2024, revealed that a 26-gauge subcutaneous needle 6mm (millimeter) was placed in the right lower abdomen and that the physician was aware. Review of the Medication Administration Record (MAR) for November 2024 revealed that sodium chloride solution at 100 ml/hr was administered on November 27 for the 6:00 p.m. shift. However, the MAR documented 9 indicating to see nurses notes for sodium chloride solution from November 28 through 29 at 5:00 a.m. shift; and, X from November 29 at 6:00 pm shift through November 30. However, review of the clinical record revealed no evidence that the sodium chloride solution was administered as ordered by the physician from November 28 through November 30, 2024.The clinical record also revealed no documentation of any reason why sodium chloride solution was not administered, and that the physician was notified.The alert note dated December 2, 2024, included that on November 28, 2024, at approximately 4:00 p.m., the nurse attempted to place an IV for IV fluids without success. The documentation included that the resident's family was in the room at that time, and that the nurses present encouraged the resident and family to encourage fluids. The clinical record review revealed no documentation of further attempts to insert the IV, and that sodium chloride solution was administered as ordered. There was also no evidence found in the clinical record that the order of IV sodium chloride solution was discontinued by the physician.However, this order was not transcribed onto the MAR for December 2024. There was no evidence found in the clinical record that sodium chloride solution was administered as ordered on December 1, 2024. -Regarding laboratory orderA provider's assessment note dated November 27, 2024, revealed the resident was very thin-appearing and was considering hospice at the time of discharge, and that the resident wanted to get better and stronger. Per the documentation, an immediate (STAT) Complete Blood (CBC), Comprehensive Metabolic Panel (CMP), Magnesium, and Vitamin D, along with a urinalysis (UA) were ordered.The physician order dated November 27, 2024 included a STAT order for CBC, CMP, urinalysis, and vitamin D and magnesium levels. Despite being a STAT order, the Laboratory and Diagnostic Administration Record for November 2024 revealed that the laboratory order for CBC, CMP, vitamin D, and magnesium was documented as completed only on November 28, 2024. A laboratory result with a report date of November 30, 2024, at 9:39 p.m. for a CBC with differential, platelet, magnesium, and vitamin D revealed a critical value for Potassium of 8.7 mmol/L (millimole/Liter). The normal range for potassium was 3.6 to 5.3 mmol/L.Despite the documentation of a critical value for potassium, there was no evidence found in the clinical record that the physician was informed of the critical laboratory results. A Physical Therapy daily note dated November 30, 2024, included that during treatment, the resident was very lethargic and slow responding.The general progress note dated December 1, 2024, at 3:00 p.m. revealed the resident was lying in bed and was not responding to verbal stimuli. Per the documentation, the carotid pulse was checked, and the resident did not have a pulse; and that the resident had an advanced directive of DNR (do not resuscitate). It also included that the Medical Doctor and the nursing manager were notified. An interview was conducted on August 7, 2025, at 12:05 PM with a Registered Nurse (RN, staff #89) who stated she was present on the day resident #22 died but was not assigned to the resident. She described it as an absolute happenstance that she found the laboratory results. The RN said that she called the physician immediately-within two hours of the resident's death-but does not recall the exact time. She stated that the nurse assigned to resident #22 was a Licensed Practical Nurse (LPN, staff #18). The RN also said that the facility was aware that resident #22 was dying and described the resident as looking like a skeleton. She expressed concern that the laboratory did not notify the nurse of the critical potassium value and stated she does not understand how the critical lab result was missed.An attempt was made to conduct a phone interview with the LPN (staff #18) on August 11, 2025, but was unsuccessful because the phone number was disconnected. An interview was conducted on August 12, 2025, at 12:30 PM with an LPN (staff #43) who stated that when a physician orders IV therapy, she explains the procedure to the resident, inserts the IV, and starts the medication as ordered. She said that the Respiratory Therapy (RT) team was certified to place IVs and had equipment to locate veins. She also said that if she was unable to insert the IV, she would ask another nurse to try, and if that nurse was also unsuccessful, she would contact the RT team; and she documents all related information in the progress notes. The LPN stated that if a laboratory test was ordered, she fills out the lab slip; and, for STAT (immediate) orders, she calls the lab directly and marks the test in the Treatment Administration Record (TAR) once the sample is collected. She said that if a critical result is received, the lab contacts the nurse, who then notifies the physician and waits for further instructions; and that she follows all physician orders and informs both the resident and their family. The LPN said that lab results were maintained in the electronic medical record and appear automatically under the laboratory tab once reported. She said that nurses can also write progress notes linked to lab results. The LPN further stated that it was unacceptable for the lab to delay drawing STAT samples; and in such cases, she contacts the lab repeatedly until the sample is drawn, notifies the provider and the Director of Nursing (DON), and documents the issue in the progress notes. During the interview, the clinical record was reviewed with the LPN, who confirmed that there was no documentation of IV placement on November 28, 2024, and the only lab result in the record was a CBC with differential, magnesium, and vitamin D, collected on November 30, 2024, and reported the same day. She stated that the potassium level was 8.7, which she described as pretty high. The LPN also stated that the resident should have been sent to the hospital or treated to lower the potassium level, and the physician should have been notified. However, there was no documentation in the clinical record showing that the physician was informed of this result.An interview was conducted on August 12, 2025, at 11:16 p.m. with a Registered Nurse (RN/staff #5) who stated that if a physician orders an IV, he would attempt to insert it himself. he said that if unsuccessful after 2-3 attempts, he would ask another nurse to try; and, if that nurse was also unable to insert the IV, they would contact Respiratory Therapy (RT) to place a midline, as the RT manager has access to an ultrasound machine. He stated that the provider would be notified and all actions would be documented in the clinical record, and that any unsuccessful IV attempts should also be documented. Regarding STAT lab orders, the RN said that he would call the lab to place the order, complete a requisition form, and wait for lab staff to arrive. He stated that all STAT labs must be called in and that he would receive an order number during the call. He said that once the lab sample was drawn, he marked it as completed in the electronic medical record (EMR). He stated that lab results were typically available within 2 to 6 hours and appear under the laboratory tab in the EMR; and, when STAT results are available, he sends a screenshot to the provider to ensure a prompt response. He said that if a nurse receives a critical lab result, they should text the provider, and if there was no reply within 5 minutes, follow up with another text and continue to monitor the laboratory tab in the electronic record. The RN said that he has never experienced delays with STAT labs being picked up and has never had to wait days for results. He stated that all events, including IV issues, doctor notifications, and lab results, should be documented in the progress notes. During the interview, the RN reviewed the clinical record and stated there was no documentation showing the physician was notified of IV issues on November 28, 2024. He said that a STAT order for CBC, CMP, urinalysis, and magnesium was placed on November 27, 2024, but the sample was not collected until November 30, 2024. He further stated that the STAT lab order from November 27, 2024, was likely never called in and that he could not find any documentation indicating that the nurse on duty took action on the order. He said that a STAT lab order dated November 30, 2024, was collected at 8:20 a.m., received by the lab at 9:44 a.m., and the results were available just before midnight. However, there was no documentation that the provider was notified of the results.In an interview with the Director of Nursing (DON/staff #16) conducted on August 12, 2025, at 1:24 p.m., the DON stated that no laboratory samples were drawn on November 28, 2024. She said the physician entered the lab order on November 27, 2024, at 5:13 p.m., and the nurse completed the lab slip at 1:19 a.m. on November 28, 2024. The DON also stated that IV fluids were started on November 27, 2024, at a rate of 75 mL per hour and were later increased to 100 mL per hour.A follow-up interview was conducted with the Director of Nursing (DON/staff #16) on August 12, 2025, at 2:45 p.m. The DON stated that a STAT order means it should be completed as soon as possible, and that critical results were those that fall outside the normal range. The DON said that, depending on the test, critical lab results should be addressed promptly based on the resident's clinical condition. However, the facility does not have a specific timeframe for acting on critical lab results. The DON stated that the current process for orders was that once a physician enters an order, the nurse must confirm it. The DON said that previously, orders might not be seen right away unless someone was reviewing the system, and that the expectation was that if something was ordered, it should be completed. During a review of the clinical record, the DON confirmed that IV saline (sodium chloride solution) was started on November 27, 2024, for resident #22; the IV line appeared to have been lost, and a subcutaneous line was started on November 29, 2024. The DON said that there was no documentation showing that the physician or administration had been informed. Regarding the lab orders, the DON said the physician entered the lab order on November 28, 2024, and the nurse completed the lab slip. However, the DON said that the lab did not draw the sample until November 30, 2024, at 9:20 a.m., and the facility did not receive the results until 10:39 p.m. that night. The DON stated that a potassium level over 8 was considered critical, and not reporting such a result does not meet her expectations. The DON said that the result should have been reported to the physician as soon as staff saw it; and, STAT lab orders, staff should be actively checking for results, and the lab should call the facility with critical values. Additionally, the DON said staff should have informed the physician during their shift if they were unable to start an IV for resident #22, and also should have informed the physician if they were unable to obtain the STAT lab sample. Further, the DON stated that both staff and physicians need to document these issues more thoroughly. The DON stated that the only policies she could provide were those related to reporting medications not administered, timeliness of obtaining lab samples, and timeliness of reporting lab results. She said the facility does not have a specific policy on the development or implementation of procedures and policies.A policy and protocol named Specimen Collection: Lab and Diagnostic Test Results - Clinical Protocol, with an effective date of January 1, 2024, revealed that the physician will identify and order diagnostic and lab testing based on the resident's diagnostic and monitoring needs, and the staff will process test requisitions and arrange for tests. This document included a nurse who will identify the urgency of communicating with the attending physician based on physician request, the seriousness of any abnormality, and the individual's current condition.A policy and protocol named Medications: Administering Medications, noted as Policies and Procedures in effect on January 1, 2024, revealed that medications are administered in accordance with prescriber orders, including any required time frame. This document included that medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). A policy and protocol named Documentation: Charting and Documentation noted as Policies and Procedures in effect on January 1, 2024 revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record and that documentation of procedures and treatments will include care-specific details, including: a. the date and time the procedure/treatment was provided; b. the name and title of the individual(s) who provided the care; c. the assessment data and/or any unusual findings obtained during the procedure/treatment; d. how the resident tolerated the procedure/treatment; e. whether the resident refused the procedure/treatment; f. notification of family, physician, or other staff, if indicated; and g. the signature and title of the individual documenting.A policy named Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program noted as Policies and Procedures in effect on January 1, 2024 revealed that residents have the right to be free from neglect and that the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the objective to develop and implement policies and protocols to prevent and identify neglect of residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and review of policy, the facility failed to ensure one resident (#127) received care and services to restore and/or maintain continence. The sample size was 18. The deficient practice could adversely impact the resident's dignity and result in bowel and bladder continence not being maintained. Findings include: Resident #127 admitted to the facility on [DATE] with diagnoses including fracture of sacrum, subsequent encounter for fracture with routine healing, intervertebral disc degeneration, lumbar region and retention of urine. An indwelling catheter care plan dated 02/14/23 related to acute neurogenic bladder had a goal to be/remain free from catheter-related trauma. Interventions included to monitor/document for pain/discomfort due to catheter. The 5-day Minimum Data Set assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status, indicating intact cognition. She required extensive 2+ person physical assistance for most activities of daily living and she had an indwelling catheter. A physician's order dated 02/22/23 at 2:52 p.m. included for removal of Foley catheter for voiding trial. Instructions indicated that if the resident did not void in 6 hours, to have a bladder scan. If the residual urine was more than 350 milliliters (mL), [utilize] a straight catheter. After two straight catheterizations, call the MD to verify possible replacement. One time a day for 1 day. However, review of the resident's indwelling catheter care plan did not include evidence that that the care plan was revised or updated to reflect the Foley removal, voiding trial, bladder scan or straight catheterization. The Medication Administration Record (MAR) documentation dated 02/22/23 revealed a code 2 in the space provided for Foley removal. Per the Chart Codes key on the last page of the MAR, code 2 indicated the resident had refused. Review of an electronic MAR (eMAR) administration note dated 02/23/23 at 12:01 p.m. included that the Foley had been removed for a voiding trial the previous day and that the resident had been unable to void. The note indicated [the Foley] had been reinserted. However, review of the clinical record provided no evidence of documentation to indicate whether or not the resident had received bladder scans and/or straight catheterization. In addition, the nursing documentation did not include the amount of residual urine visualized on the bladder scan and/or the amount of urine that had been removed. Further review of the clinical record did not include documentation to evidence that the provider had been notified that the resident had been unable to urinate. On 2/25/23 at 7:30 p.m. an alert progress note included that the Foley had been discontinued per the resident's request at 12:30 p.m. to trial prior to discharge. According to the note, the resident had not voided at (sic) 7:00 p.m., so the resident was bladder scanned, 100 cc (mL) [was visualized]. The resident had no discomfort at that time. However, review of the physician's orders did not indicate that an order to discontinue the Foley had been obtained. Further review did not include bladder scanning, residual monitoring and/or straight catheterization. Review of the Point of Care (POC) Certified Nursing Assistants (CNA) tasks dated 02/25/23 at 11:19 p.m. indicated that the resident was provided limited assistance to the toilet. However, review of the clinical record did not include nursing documentation to indicate whether or not the resident was able to void and/or approximately how much. A physician's order dated 02/26/23 at 6:00 p.m. revealed for bladder scanning every 6 hours. If more than 300 mL, [administer] straight catheterization. Every 6 hours for monitoring. The order was discontinued on 02/27/23. Review of the February 2023 MAR bladder scanning documentation included: -02/26/23 at 6:00 p.m. 500 mL was visualized on a bladder scan. -02/27/23 at 0000 [midnight] 650 mL of urine was visualized. -02/27/23 at 6:00 a.m. 0 mL was noted. However, further review of the clinical record did not indicate whether or not the resident had received straight catheterization. In addition, there was no documentation to indicate that the provider had been notified. On 02/27/23 at 10:45 a.m. an interview was conducted with resident #127. She stated that her Foley had been removed for bladder retraining. She stated that on Saturday (02/25/23) evening she had complained about bladder pain/feeling of urgency. She stated that she complained about increasing bladder pain to her night nurse (Licensed Practical Nurse/staff #112). She stated that staff #112 told her around 2:00 a.m. that someone would replace the Foley in the morning. She stated that she was given oxycodone (opioid analgesic) for the pain. She stated that the following morning (02/26/23) she received straight catheterization. She stated that on the night of 02/26/23, she woke up around 2:30 - 3:30 a.m. with back and bladder pain. She stated that she told her CNA (staff #32) that she needed her bladder drained again. She said however, the nurse did not come in and that no one drained her bladder. She stated that around 4:15 a.m. she was assisted to the commode by staff #32 to have a bowel movement. She said that when she sat on the commode, she actually urinated on her own. An interview was conducted on 02/28/23 at 7:46 a.m. with a CNA (staff #32). She stated that on 02/25/23 the resident was bladder scanned at 7:00 p.m. and about 100 mL was viewed. She stated that the resident asked for pain medication around midnight and that she reported it to the nurse. She stated that she was told the resident could not have pain meds at that time because she had received them around 9:00 o'clock. She stated that the nurse told her to just let him know when the resident asked again. She stated that the resident used her call light again about 2:00 a.m. She stated that she went into the resident's room with staff #112 to speak with the resident and give her the pain medication. She stated that she did not hear the nurse ask the resident where her pain was. She stated that the resident told the nurse that she had not peed yet, but that she did not complain of bladder pain. She stated that she and the nurse encouraged the resident to continue drinking water and if she still wasn't urinating to call again and let them know. She stated that staff #112 did not bladder scan the resident at 2:00 a.m. because the resident did not ask for it. She stated that she did not know whether nurses usually asked residents if they would like to have a bladder scan. She stated that around 6:30 - 7:00 a.m., staff #112 scanned the resident's bladder and that 600 mL (more or less) was visualized. She stated that staff #112 asked her to go into the resident's room with him after the morning report to straight catheterize the resident. She stated that about 1,000 mLs were removed. On 03/01/23 at 10:12 a.m. an interview was conducted with a Licensed Practical Nurse (LPN/staff #112). He stated that he thought the resident's Foley catheter had been discontinued on the 25th. He stated that the day shift told him. He stated that he told the resident/encouraged her to remember to drink water and that she had said she would try. He stated that the resident was able to use a commode with assistance. He stated that the CNA told him that the resident was peeing. He stated that no amount of urine was measured or monitored. He stated that he told the resident that he would provide bladder scanning/straight catheterization if needed. He stated that the resident asked for pain medication at 10:00 p.m., but did not say where her pain was. He stated that he completed a bladder scan at 2:00 a.m. and that he thought he measured 138 mL. He stated that he may not have documented it. He stated that he gave the resident a pain pill and she slept through the night. He said that in the morning he checked on her again. He stated that the resident was starting to feel pressure. He stated he bladder scanned her and visualized 586 mL of residual urine. He stated that he and the CNA provided straight catheterization between 6 and 7 a.m. and removed 1,000 mL of urine. He stated that he did not see an order for bladder scanning. He stated that he documented these notes in a notebook, but not in the computer. An interview was conducted on 03/02/23 at 9:40 a.m. with an LPN (staff #53). She stated that Foleys were removed generally first thing in the morning, then the protocol was to place the resident on bladder scanning every 6 hours. She stated that the nurses will document this on the MAR. She stated that in between bladder scans, the resident will be given fluids, taken to the restroom and placed on the toilet. She stated that if the bladder scan revealed the resident had more than 350 mL of residual urine, the resident would be straight cathed (sic), and after 2 straight caths, the physician would be notified. She stated that if the resident still had not voided by the 3rd time, the Foley would be reinserted and the resident would follow up with urology. She stated that nursing will notify the physician prior to removing the Foley and obtain an order for removal. She stated that the other orders were standing protocol in the facility. She stated that if the Foley was removed, documentation should be in the clinical record to indicate such. She stated that further documentation would include bladder scanning, residuals greater than 350 mLs, whether the resident was straight cathed, whether or not they were able to void and whether the provider was notified. She stated that the residents do not have to ask for bladder scanning. She stated that if a resident was unable to urinate but did not receive bladder scanning and/or straight catheterization the risks to the resident might include infection, pain and fullness in the abdomen. She stated that in her opinion, the maximum amount of urine a bladder would hold would be about 1,000 mL and that the resident would be extremely uncomfortable. She stated that she would document that amount in the progress notes, absolutely. On 03/02/23 at 3:54 p.m. an interview was conducted with the Director of Nursing (DON/staff #52). She stated that the facility policy stated that if a resident has had a Foley catheter discontinued, and they do not void within 6 hours, the resident will be bladder scanned. She stated that if the urine residual is more than 350 mL, the resident will be straight cathed. She stated that after 2 straight caths, the MD will be contacted for possible replacement. She stated that a physician's order must be obtained to discontinue a Foley. She stated that the Foley removal should trigger the bladder scanning and monitoring every 6 hours, etc. She stated that the resident's care plan should be updated to reflect the voiding trial. She stated that bladder scanning/monitoring for residuals would be documented on the MAR or Treatment Administration Record. She stated it would not meet her expectation for a Foley to be removed without documentation for bladder scans, residuals or voiding because that is the expectation. She stated that risks to the resident would include urine retention, discomfort, pain, bladder rupture, or urinary tract infection. She stated that if a bladder scan revealed 0 mL of urine after 12 hours she would expect nursing to call the doctor. She stated that if a resident was straight cathed and produced 1,000 mL of urine, she would expect the output to be documented - that's a full bladder. The Post Foley Catheter Bladder Management policy, dated 03/2023, included if the [resident] does not void in 6 hours, bladder scan. If residual urine is more than 350 mL, straight cath. After 2 straight caths, call MD to verify possible replacement.