Based on interview and record review, the facility failed to protect a resident from injury when the resident was left unattended in a bed which was not in the lowest position, and without a fall mat on the floor. The resident fell out of bed, sustained a laceration to the left side of the forehead and an acute left femoral neck fracture (a type of hip fracture of the thigh bone, just below the ball of the ball-and-socket hip joint). (Resident B) The facility also failed to ensure staff providing care were using/following the care sheet or electronic record which provides information on safety precautions put in place, resulting in Resident C had to be lowered to the floor, for 2 of 3 residents reviewed for accidents. (Resident B and C) The deficient practice was corrected on 9/12/23, prior to the start of the survey, and was therefore past noncompliance. Findings include: 1. During a phone interview, on 9/19/23 at 10:04 a.m., the Power of Attorney (POA) for Resident B indicated Resident B was dressed and prepped for a full body mechanical lift, which should have had two people to perform. After the resident was dressed, the other staff member should have remained in the room with Resident B. The POA indicated she felt the facility was not following protocol and the resident sustained injury during the lift and indicated she was dropped during a Hoyer [mechanical lift] transfer. She did not see her [the resident] having the strength to roll out of bed. During an interview, on 9/19/23 at 1:02 p.m., Resident 7 (Roommate for Resident B) indicated she was awake when Resident B fell. The CNA came in, got her ready, and put the Hoyer pad under her then left the room to get the lift. She did not know why she did not bring it with her, they usually did, but she heard a thud like a basketball hitting the floor. Another aide who was working on the hall, must have seen her on the floor. She was the one who responded. The record for Resident B was reviewed on 9/19/23 at 11:13 a.m. Diagnoses included, but were not limited to, dementia, unspecified fracture of unspecified femur, and fracture of unspecified part of neck of right femur subsequent encounter for closed fracture with routine healing status after a partial hip replacement procedure. A care plan, with a problem start date of 6/11/17, indicated Resident B was at risk for falls related to, but not limited to, dementia, impulsive and polyneuropathy (simultaneous malfunction of many peripheral nerves throughout the body). The interventions included the bed was to be in the lowest position when the resident was in the bed. A physician's order, with a start date of 4/20/22, and end date of 9/15/23, indicated .Mattress on floor next to bed when in bed .every shift The Medication and Treatment Record was signed off by the nurse, on the day of the fall, to indicate the mattress/mat was present on the floor at the bedside, when the nurse checked Resident B. A Care Sheet (resident care profile), provided by LPN 2 on 9/19/23, at 1:31 p.m., indicated .Bed in lowest position when resident is in the bed A nursing note, dated 9/8/2023 at 7:36 a.m., indicated .CNA called writer et [and] said resident is on the floor. Writer went in et saw resident lying on her left side bleeding from her L [left] forehead. Had 3x.5 cm [centimeter] cut; Pressure applied to stop bleeding. As per aide, resident rolled out of bed as she reached out to get Hoyer lift [full body mechanical lift] to transfer resident A radiology report, dated 9/8/23, indicated Resident B had an acute left femoral neck fracture. An Incident Report to the Indiana State Department of Health, dated 9/8/23, indicated the resident was found on the floor next to the bed. The resident had a laceration to the forehead and was complaining of hip pain. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated .I [CNA 1 name] was getting Resident B dressed for the day. After dressing the resident, the lift pad was placed under her, and she was left laying on her back .I believe she tried to get up from the bed when I went to get a spotter/the nurse to help me with the Hoyer lift. When I stepped out and return, she was laying on the floor The statement was unsigned and undated. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B had been witnessed moving in the bed unassisted. The statement was signed by LPN 4 on 9/8/23. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B was witnessed moving by herself in bed and there were times where she had witnessed Resident B sitting up in bed and the resident would attempt to get out of bed herself. She would have her legs out of bed sitting upright as if she was going to stand and try to get up. The statement was signed by Staff 5 on 9/11/23. A statement provided by the Executive Director, on 9/20/23 at 11:40 a.m., indicated Resident B was observed independently moving her body and repositioning herself. The statement was signed by LPN 6 on 9/15/23. During an interview, on 9/19/23 at 1:29 p.m., the Director of Nursing indicated the CNAs could find safety information on their care sheets. They could also pull up the information electronically. During an interview, on 9/19/23 at 2:10 p.m., the Director of Nursing indicated staff were supposed to follow the care plan and the CNA was supposed to follow the care sheet. During a telephone interview, on 9/19/23 at 2:20 p.m., CNA 1 indicated she was getting Resident B up and dressed. She put the full body mechanical lift sling under Resident B after she dressed her. She left the room to get a spotter (second person to assist with the lift transfer) and when she returned Resident B was on the floor. She indicated the bed was not high at all, maybe medium, she left Resident B lying on her back in the bed. She believed the resident tried to get up. She did not have the CNA care/assignment sheet, she did not know they (the facility) had them and she did not know where to find them. It was her first time working the night shift and the front hall. The resident did not have a mat on the floor beside her bed when she entered the room. During an interview, on 9/19/23 at 2:46 p.m., LPN 3 indicated when she responded to the fall for Resident B, the bed was at hip height (her hip height) and indicated the bed was to be in a low position when the resident was in bed. She also indicated the mat was on the floor at the bedside during the shift; she did check it during her shift. A document, titled Employee Communication Form, provided by the Executive Director on 9/20/23 at 11:40 a.m., indicated .Res [resident] was left unattended without fall precautions being put back in place, that resulted with res falling out of bed The document was signed by CNA 1 and the Assistant Director of Nursing on 9/12/23. 2. The record for Resident C was reviewed on 9/19/23 at 12:50 p.m. Diagnoses included, but were not limited to, unspecified dementia with other behavioral disturbance, essential hypertension, and generalized muscle weakness. A care plan, initiated on 12/30/21, indicated the resident required assistance with activities of daily living (ADLs) including transfers. An intervention, initiated on 7/7/22, indicated the resident was to be an assist x 2 with transfers (two people were needed to transfer the resident). A nurses' note, dated 7/5/23 at 10:26 a.m., indicated .Resident being assisted from toilet to wheelchair and started to sit down before in contact with wheelchair. Staff lowered her to floor to prevent injury. Resident assisted off floor and into wheelchair and then bed. No injuries noted. ROM [range of motion] WNL [within normal limits]. Denies pain. Did not hit head On 9/19/23 at 1:29 p.m., a care plan policy and safety intervention policy were requested of the Director of Nursing. During an interview, on 9/19/23 at 2:10 p.m., the Director of Nursing indicated the facility did not have a policy on safety interventions and she provided the care plan policy. During a telephone interview, on 9/19/23 at 2:50 p.m., CNA 7 indicated it was her first day. She was working the other side and she did not have Resident C on her assignment. She heard Resident C yelling for help and thought it was an emergency, so she responded. She was not aware of how the resident transferred and thought she was a limited transfer. She transferred the resident with a gait belt to toilet, she changed the resident on the toilet, and put on socks with the gripper (nonskid). When she went to transfer the resident back to the chair, the resident said she was going to fall. CNA 7 called for another CNA, in the hall, and together they gently lowered the resident to floor and then got the nurse. She indicated she did not have a resident care sheet, it was electronic. During an interview, on 9/20/23 at 8:54 a.m., the Executive Director (ED) indicated the resident care profile were to be carried on the CNA along with a gait belt. CNA care profiles are in a three (3) ring binder at each nursing station. The CNAs knew where to find them, even clinical resource group (corporate as needed pool of employees) are educated in training on where they can be found for all facilities. He and management complete rounds in the morning and check to be sure gait belts and care sheets are with the CNAs. A current policy, titled IDT Comprehensive Care Plan Policy, dated as last reviewed on 8/2023 and received from the Director of Nursing on 9/19/23 at 2:10 p.m., indicated .It is the policy of this facility that each resident will have an interdisciplinary comprehensive person-centered care plan developed and implemented .The care plan must include .resident specific interventions based on the residents needs and preferences to promote the psychosocial well-being. Physician's orders are considered part of the comprehensive plan of care The deficient practice was corrected by 9/12/23 after the facility implemented a systemic plan that included the following actions: The facility investigated the incident involving Resident B, disciplined CNA 1, educated the staff on fall prevention, began audits on safety precautions in place for all residents with fall risks, and ensured Resident B received medical care as well as follow up care and monitoring. This Federal Tag relates to Complaint IN00417153. 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice and to notify the physician with a change of condition for 2 of 2 residents reviewed for catheter care. (Resident 49 and 290) Resident 49 was not provided care to address concerns which developed after a urinary catheter was placed which led to a hospitalization with intravenous antibiotic intervention for the development of sepsis. Findings include: 1. The record for Resident 49 was reviewed on 9/30/22 at 10:55 a.m. Diagnoses included, but were not limited to, sepsis (life-threatening response to infection), paraplegia, chronic respiratory failure, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe), subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), gastrostomy (opening into the stomach from the abdominal wall) and paraplegia (paralysis of the legs and lower body). The facility document, titled Admit Discharge Report, dated 8/1/22 to 10/31/22, indicated Resident 49 was discharged /transferred to the hospital on 9/10/22. A care plan, dated of 9/16/22, indicated Resident 49 was readmitted to the facility with a UTI (Urinary Tract Infection) and directed staff to report concerns for urinary tract infection such as acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine and blood in urine. The care plan further directed staff to: a. Administer antibiotic as ordered. b. Provide assistance for catheter care. c. Change catheter per MD order. d. Keep catheter system a closed system as much as possible. e. Manipulate tubing as little as possible during care. f. Position bag below level of bladder. g. Avoid obstructions in the drainage. h. Store collection bag inside a protective dignity pouch. i. Do not allow tubing or any part of the drainage system to touch the floor. Physician's orders, dated 9/16/22, included, but were not limited to, a. Catheter orders: to change Foley catheter and urinary drainage bag as needed for dislodgement, leakage, or occlusion. b. Catheter orders to change Foley catheter monthly Size: 16 Fr (French) - 10 ml (milliliter) bulb. Once a Day on the 15th of the month. c. Catheter orders for Foley catheter care. Nurse to record output every shift. d. Catheter orders to change catheter bag weekly on Sunday. A hospital Discharge summary, dated [DATE], indicated the resident was treated for sepsis and catheter associated urinary tract infection (occurs when germs (usually bacteria) enter the urinary tract through the urinary catheter and cause infection). The facility document, titled Healthcare Associated Infection Report, dated 8/22, indicated a total of 12 types of infection with an infection rate of 4.5 percent. The facility document, titled Surveillance Log of Resident infections and antibiotic use, indicated, on 9/17/22, Resident 49 was started on Cefepime antibiotic for sepsis and urinary tract infection. The surveillance log indicated Resident 49 had a Healthcare-Associated Infection (HAI). A review of the nurse progress notes, from 9/9/22 at 10:42 p.m., until 9/10/22 at 2:11 p.m., indicated Resident 49 had no urine output, no bladder scan completed and no call to the provider to notify of concerns of no urine output. A nurse progress note, dated 9/10/22 at 2:11 p.m., indicated the resident had no output of urine after a Foley placement. Blood was noticed in Resident 49's catheter tube. The Nurse Practitioner was notified and directed staff to remove Foley and reinsert Foley due to possible swelling. Upon reinsertion of the Foley catheter, blood had begun to flow from penis. The NP directed staff to send Resident 49 to the emergency room for evaluation. A nurse progress note, dated 9/10/22 at 2:43 p.m., indicated Resident 49 was transferred to the hospital. A nurse progress note, dated 9/10/22 at 11:29 p.m., indicated the hospital notified the facility Resident 49 was admitted to the intensive care unit with the diagnosis of sepsis. A nurse progress note, dated 9/10/22 at 6:00 a.m., indicated Resident 49 had 16 Fr/30 cc Foley catheter inserted at the end of 2nd shift on 9/9/22. No output was noted from the resident's Foley catheter at the time of this entry. The progress note indicated a reinsertion was attempted of the Foley catheter with no effective results and staff would continue to monitor. The progress note lacked indication the provider was notified. A nurse progress note, dated 9/16/22 at 5:25 p.m., indicated Resident 49 had returned to the facility after hospitalization at 5:00 p.m. A nurse progress note, dated 9/16/22 at 1:56 a.m., entered at as a late entry on 9/17/22 at 2:03 a.m., indicated Resident 49 was on intravenous antibiotic Cefepime and had a midline placed in the left upper extremity. A nurse progress note, dated 9/23/22, indicated Resident 49 was on intravenous antibiotic for sepsis and urinary tract infection. During an interview, on 10/5/22 at 11:05 a.m., the Assistant Director of Nursing (ADON) indicated Resident 49 was hospitalized from [DATE] to 9/16/22 for the treatment of septic shock caused by urinary catheter related urinary tract infection. Resident 49 had Enterobacter urinary tract infection. The catheter was placed, on 9/9/22, for the treatment of a pressure ulcer. During an interview, on 10/5/22 at 12:15 p.m., the Director of Nursing (DON) indicated Resident 49 had a hospital admission due to bacteremia related to catheter associated infection. The DON and Corporate Regional Director of Clinical Services indicated a nurse made insertion of a catheter attempt twice and left it in place with no urine output. At around 2:00 p.m., a nurse found blood in the catheter tube and notified the Nurse Practitioner (NP). The RN had no documentation of the output of urine after Foley placement and later noticed blood in urine tube of the Foley catheter. When the catheter was originally placed and the staff did not get urine return, the nurse should have notified the provider and completed a bladder scan. The DON and Corporate Regional Director of Clinical Services indicated no documentation was completed until after 2:00 p.m., and the staff should have checked within 6 to 8 hours for urine return. A resident could be at risk each time a catheter was attempted or placed. During an interview, on 10/6/22 at 9:50 a.m., Nurse Practitioner (NP) 22 indicated staff should notify the provider if there was no urine output for an 8-hour shift and complete a bladder scan if available, straight catheterization, or insert a Foley catheter. She was not notified until after 2:00 p.m., with the concern about blood in the catheter tubing and the resident was at risk for hospitalization due to repeat catheterizations and no urine output for more than 16 hours. During an interview, on 10/6/22 at 11:18 a.m. the Infection Preventionist (IP) indicated the facility did have residents who had recurrent UTI's, who had catheters. He had provided education to staff on Hand Hygiene and Peri care, also staff were provided with skills validation regarding catheter insertion and catheter cares. He found no trends related to urinary tract infections within the facility. When Resident 49 was admitted to the hospital or readmitted to the facility, he would review the diagnoses and follow up as indicated related to infections. During the review of the surveillance records, no trends were found for UTI. No formal audits were completed on catheters and infections. At least one resident in the last month developed a UTI with a catheter. Nursing staff were given skills validation for catheter insertion upon hire and nursing assistants are given education on peri care. During an interview, on 10/6/22 at 1:30 p.m., the Executive Director (ED) indicated nursing staff could look on the Electronic Medical Record (EMR) for information on how to perform a procedure. 2. During an observation, on 9/29/22 at 12:03 p.m., Resident 290's catheter was in place and the Foley catheter bag hung on the right side of the wheelchair, at waist level. The urine was dark yellow in color and no dignity bag covered the catheter bag. During an interview, on 9/29/22 at 12:03 p.m., a family member indicated Resident 290 had a catheter placed while in the hospital because he had urinary retention after surgery. Resident 290 had a trial for the catheter removal but required staff to reinsert it because Resident 290 was suffering from significant abdominal pain. She had observed on multiple occasions the catheter bag was hung too high to drain. During an observation, on 9/30/22 at 2:10 p.m., Resident 290's Foley catheter tubing was located under the brace of the right leg with the Foley catheter bag hung on the right side of the recliner chair. The record for Resident 290 was reviewed on 10/3/22 at 8:30 a.m. Diagnoses included, but were not limited to, retention of urine, dementia, right patella fracture, open reduction internal fixation (ORIF) (surgery used to stabilize and heal a broken bone) of right knee and difficulty walking. An admission Minimum Data Set (MDS) assessment, dated 9/28/22, indicated Resident 290 had a severe cognitive impairment, moderately impaired vision, and required a total assist with activities of daily living (ADL's) and mobility. A care area assessment (CAA), dated 09/28/22, indicated Resident 290 triggered for an indwelling catheter related to post-op urinary retention. Resident 290 had a failed trial of a catheter removal and had the catheter reinserted. A care plan, dated 9/25/22, indicated Resident 290 was admitted with an indwelling urinary catheter related to post-op urinary retention and was at risk for infection. The care plan directed staff to use approaches to avoid obstructions in the drainage, change the catheter per MD order and do not allow tubing or any part of the drainage system to touch the floor. The care plan directed staff to keep catheter system a closed system as much as possible and manipulate tubing as little as possible during care. Resident 290's care profile, printed on 9/30/22 at 6:30 a.m., indicated he had a Foley catheter and denuded skin to the groin and penile area. A physician's orders report, dated 10/1/22 to 10/5/22, included, but were not limited to, the following orders: a. On 9/22/22, change Foley catheter monthly, size 16 French (Fr) with 10 ml balloon on the 21st of each month. b. On 9/22/22, change Foley catheter and urinary drainage bag as needed for dislodgement, leakage, or occlusions. c. On 9/22/22, Foley Catheter care, nurse to record output every shift. d. Change Foley catheter drainage bag weekly. A nurse progress note, dated 9/23/22 at 1:07 a.m., indicated Resident 290 had a 16 Fr 10 cc Foley catheter upon admission. A nurse progress note, dated 9/24/22 at 12:43 p.m., indicated Resident 290 had an 18 Fr Foley catheter. A nurse progress note, dated 9/25/22 at 10:39 p.m., indicated Resident 290 had an 18 Fr Foley catheter. A nurse progress note, dated 9/27/22 at 7:28 p.m., indicated Resident 290 did not have urinary output and an 18 Fr Foley catheter was re-anchored. Obtained 600 cc of clear urine. A nurse progress note, dated 9/28/22 at 1:01 p.m., indicated Resident 290's tip of penis was red and swollen and night staff saw him tugging and pulling on the Foley. A nurse progress note, dated 9/28/22 at 4:00 p.m., indicated Resident 290 passed a small amount of urine, complained of abdominal discomfort, irritation of penis and groin. A nurse progress note, dated 9/28/22 at 4:10 p.m., indicated Resident 290 had a new intervention initiated with discontinue of Foley catheter. A nurse progress note, dated 9/28/22 at 7:03 p.m., indicated Resident 290 had abdominal distention and no urine output, an 18 Fr Foley catheter re-anchored. A nurse progress note, dated 9/28/22 at 9:22 p.m., indicated Resident 290 upon assessment at the beginning of the shift was complaining of severe abdomen pain. The abdomen was very distended and hard to touch. Resident 290 indicated he could not urinate. A bladder scan was done and read 800 cc of urine in the bladder. The resident's groin area was very red, swollen and painful to touch. A Foley catheter 18 Fr/10 cc was inserted. Urine return noted of 1200 cc of bloody urine return. The procedure was painful to Resident 290. A Treatment Administration History, dated from 9/22/22 to 10/5/22, indicated Resident 290: a. Had no urine output on 9/26/22, from 10:30 p.m., to 6:30 a.m. b. A small amount of urine output, on 9/27/22, for the shift from 6:30 a.m. to 2:30 p.m. c. On 9/27/22, for 2:30 p.m. to 10:30 p.m., indicated discontinued, and no urine output was documented. d. On 9/28/22 at 10:57 p.m., indicated 600 ml urine output. An acute care visit physician progress note, dated 9/28/22, indicated Resident 290 had a Foley catheter for urinary retention and had periods of pulling and manipulating on the Foley catheter due to his cognitive impairment. The progress note further indicated new orders were given to remove Foley and monitor for urine output. A progress note indicated Resident 290 was scheduled for an appointment with Urology on 9/28/22 and had been rescheduled for 10/5/22. During an interview, on 10/5/22 at 12:34 p.m., the Director of Nursing (DON) indicated Resident 290 had a catheter in place for urinary retention. On 9/27/22 at 10:30 a.m., an order was placed to remove the catheter and reinsert/re-anchor if no urine output. The physician's order did not indicate a time frame for notification of no urine output. She had concerns about the lack of documentation of the removal of Resident 290's catheter and amount of urine output. Resident 290's progress note, on 9/27/22 at 7:28 p.m., indicated the resident had no urine output and a catheter was reinserted with 600 cc of urine returned. During an interview, on 10/5/22 at 1:50 p.m., the Medical Records staff and Director of Nursing (DON) indicated Resident 290 had a conflict with having an orthopedic and urology appointment on the same date and time. Medical Records staff spoke to the Nurse Practitioner, on 9/27/22 at 10:30 a.m., and entered the order for the removal of the catheter and notified the nurse on duty to remove the catheter and monitor urine output. The DON indicated the staff should have used nursing judgement and used a nursing assessment. During an interview, on 10/6/22 at 9:50 a.m., Nurse Practitioner (NP) 22 indicated her expectation for staff would be to notify the provider if there was no urine output after removing a catheter in an eight-hour shift. Staff did not notify her of concerns for no urine output. Her expectation would be for staff to notify the provider, complete a bladder scan if available, attempt a straight catheterization or reinsert a Foley catheter if needed. A current policy, titled Resident Change of Condition Policy, dated as revised 11/18, indicated all changes in resident condition will be communicated to the physician and family, timely and effective intervention takes place. The policy directed staff to communicate any sudden or serious change in condition manifested by a marked change in physical or mental behavior. The policy directed staff to document in the medical record all nursing actions and interventions. A current policy, titled Urinary Catheter Insertion, with a review date of 12/12, directed staff to confirm physician order, including catheter and balloon size. The policy further directed staff to check the catheter and tubing for drainage. The policy lacked indication of monitoring for urinary output and reporting concerns to provider. A current policy, titled Indwelling Urinary Catheter Care, Emptying Drainage Bag, and Catheter Removal, with a review date of 12/12, lacked indication of monitoring for urinary output and reporting concerns to provider. This Federal tag relates to Complaint IN00388366. 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to thoroughly assess and document a resident's change in respiratory status, to notify the physician of signs of respiratory distress and when a BIPAP/CPAP (machine used to help with breathing) was not available for a resident who was at risk for respiratory complications and required a hospitalization (Resident 293), and to ensure the humidification was used and wore correctly, infection control measures were in place by labeling and storing equipment appropriately for tracheostomy care (a tube surgically placed in the throat to assist with receiving air into the lungs) (Resident 49) and failed to obtain a physician's order to provide care and treatment and machine maintenance for a continuous positive pressure (CPAP) machine (Resident 67) for 3 of 4 residents reviewed for respiratory care. Findings include: 1. During an observation and interview, on 9/29/22 at 1:53 p.m., Resident 293's door was closed. The resident was found lying in bed with the head of the bed at a 75 degree angle. The resident's eyes were closed and she was positioned with her hips past the crease in bed, head on the wall, and right leg hanging over the side of the bed. An oxygen concentrator was on at 4 liters per minute (LPM), there was no label on the tubing or the BIPAP/CPAP. She was observed to have abdominal retractions and audible grunting was heard with breathing. Staff were requested to come to the room. The Infection Preventionist (IP) indicated the oxygen concentrator was on at 4 LPM, no label was on the oxygen tubing and the resident was in a poor position. During observation and interview, on 9/29/22 at 03:49 p.m., Resident 293's door was closed, and resident was observed lying in bed with nasal cannula on the bedside table and out of reach of the resident. Oxygen concentrator was set at 1.5 LPM. Resident was attempting to communicate but the words were nonsensical, abdominal retractions were noted. IP verified oxygen concentrator settings and nasal cannula was not on, he indicated Resident 293 must have taken the oxygen off. During an observation, on 9/30/22 at 8:26 a.m., the resident's door was closed and she was observed to be seated at the side of the bed. Her nasal cannula and tubing were on the dirty floor. The oxygen concentrator was set at 2.5 LPM. The resident had a deep moist cough, mouth breathing and bilateral lower extremity edema from her toes to her knees. The resident seemed to be confused and tried to communicate but words were nonsensical. During an observation, on 9/30/22 at 2:36 p.m., the resident was observed lying in bed with head of bed at a 30 degree angle. Her head was positioned on the wall, her hips pass the crease in bed and her legs were dangling over the exit side of bed. The oxygen was set on 2.5 liters via nasal cannula. The BIPAP/CPAP mask and tubing were lying under the bed on the dirty floor. During an observation, on 10/3/22 at 9:32 a.m., Resident 293's door was closed. She was found lying in bed with the head of bed up at an 80 degree angle, her eyes were closed and a loud grunting noise was heard with each breath with expiratory wheeze. The resident had oxygen on via nasal cannula at 2.5 LPM. The oxygen tubing was not labeled. During an observation, on 10/3/22 at 12:33 p.m., with Registered Nurse (RN) 24, Resident 293's door was observed to be shut. She was found to be hallucinating and was nonsensical, moving her arms and legs up and down. The resident was moving her hands up and down and appeared to be sewing her gown. Her BIPAP mask was on the floor, audible wheezes with retractions were observed with an elevated respiratory rate over 30. The nasal cannula was found lying on the bed. The record for Resident 293 was reviewed on 10/4/22 at 8:30 a.m. Diagnoses included, but were not limited to, sepsis, chronic obstructive pulmonary disease (COPD) (lung disease which block airflow and make it difficult to breathe), obstructive sleep apnea and congestive heart failure (CHF) (condition in which the heart doesn't pump blood as well). An admission MDS (Minimum Data Set) assessment, dated 9/29/22, indicated Resident 293 had a moderate cognitive impairment. A Care Area Assessment (CAA), dated 9/29/22, indicated the resident triggered for required total assist with activities of daily living (ADL's) and had diagnoses which could impact ADL's and mobility which included sepsis, COPD and heart failure. A care plan, dated 9/25/22, indicated the resident had a risk for impaired gas exchange related to COPD with shortness of breath while lying flat and obstructive sleep apnea (OSA). The Care Plan directed staff to assess vital signs and lung sounds as needed, BIPAP as ordered, elevate the head of the bed to alleviate shortness of breath while lying flat, monitor oxygen saturations as needed, nebulizer treatments as ordered, observe for nonverbal signs of anxiety such as furrowed brows, pacing, change in mental status, and behaviors, to observe for verbal signs of stress and anxiety, the resident used oxygen at 2 LPM. A resident profile, printed on 9/30/22 at 6:30 a.m., indicated the resident used oxygen at 2 LPM via nasal cannula, but lacked direction for staff to elevate head of bed. A hospital Discharge summary, dated [DATE] at 12:09 p.m., indicated Resident 293 had discharge diagnoses of severe sepsis, OSA treated with BIPAP/CPAP, diabetes, urinary tract infection, atrial fibrillation, and acute kidney injury. The summary indicated for the resident to wear her BIPAP/CPAP at nighttime. A Respiratory Administration History Report, dated 9/23/22 to 10/3/22, indicated Resident 293 was admitted to the facility, on 9/23/22, and orders included, but were not limited to, the following: a. Elevate head while in bed to alleviate shortness of breath while lying flat related to COPD diagnosis. b. A BIPAP. A review of the administration history indicated Resident 293 did not have an available BIPAP to use from 9/24/22 to 9/28/22. c. Oxygen continuously at 2 liters per minute (LPM). On 9/28/22, the history indicated Resident 293 was given oxygen at 4 LPM. d. Oxygen continuously at 4 liters per minute (LPM) per nasal cannula to keep oxygen saturations greater than 90 percent started on 10/3/22. A progress note, on 9/24/22 at 11:38 a.m., indicated a respiratory company was contacted with a new admission, BIPAP order and information given. The facility was waiting for a return call. A nurse progress note, dated 9/27/22 at 10:50 p.m., indicated the resident was not acting as usual, had increased confusion, frequency, urgency, tried to climb out of bed and she became combative. A urine sample was collected. A nurse progress note, dated 9/28/22 at 3:03 p.m., indicated the resident was complaining of shortness of breath and was yelling out incoherent statements. Oxygen saturation (measures the amount of oxygen in the body) were 85 percent (normal oxygen saturation level is between 95% and 100%). Increased oxygen via nasal cannula to 3 liters per minute and oxygen saturations rose to 88%. The staff worked with the resident on remaining calm and saturations were at 94%. The oxygen was decreased to 2 liters per minute (LPM) and oxygen saturations remained at 91 to 92%. A nurse progress note, dated 9/28/22 at 11:59 p.m., indicated the resident was found hanging off the side of the bed and staff lowered the resident to the floor. She was found to have a 2 inch by 2-inch skin tear noted to her right lower extremity. The physician and family were notified and the call light was placed within reach. A progress note, dated 9/28/22 at 12:28 p.m., indicated a respiratory company was contacted regarding BIPAP delivery and was still working on it. A nurse progress note, dated 9/29/22 at 4:17 p.m., indicated the resident had been combative during the shift, refused to wear oxygen or BIPAP mask and the resident remained confused and combative with care. A nurse progress note, dated 10/3/22 at 2:56 p.m., indicated the resident had been confused and combative with staff. The Nurse Practitioner was notified oxygen saturations were 88-91% and new order to utilize oxygen titration and BIPAP/CPAP as needed in addition to the nightly order. A new order of prednisone (oral steroid) was also written. A nurse progress note, dated 10/3/22 at 7:01 p.m., entered as a late entry on 10/4/22 at 2:34 a.m., indicated Resident 293 had trouble responding to verbal stimuli, was wheezing, and used extreme effort to breath. Respirations were short and labored with oxygen saturations 94% on 2 LPM, heart rate was 113. The nurse practitioner was notified and the resident was sent to hospital for evaluation. A Hospital History and Physical Report, dated 10/4/22 at 2:11 a.m., indicated Resident 293 was brought to the Emergency Department by Emergency Medical Services for altered mental status and hypoxia with oxygen saturations at 80 percent. Labs taken revealed a B-type natriuretic peptide BNP (hormone produced by your heart to indicate heart failure) of 800, Lactate of 8, and chest X-ray revealed low long volumes with diffuse opacities concerning for pulmonary edema. Resident 293 was admitted for Respiratory distress. The record review lacked indication the physician was notified Resident 293 did not have her CPAP to wear until 9/28/22, as ordered on 9/23/22, when discharged from the hospital. 2. During an observation and interview, on 9/29/22 at 12:25 p.m., Resident 49 was found lying in his bed with his head facing the wall. The mask of the humidified air was positioned onto the side of his neck. His humidified air, water canister, tubing, mask, yankauer suction tube and suction canister was not labeled. The water canister for the humidified air was empty with water pooled in the tubing. Licensed Practical Nurse (LPN) 25 indicated the mask was not on Resident 49's tracheostomy opening and his equipment was not labeled. During an observation and interview, on 9/29/22 at 12:39 p.m., Nursing Assistant (NA) 26 indicated the resident's humidified air mask was not on Resident 49 and it was the nurse's responsibility to ensure it was in place. During an observation and interview, on 9/29/22 at 2:19 p.m., LPN 25 indicated the resident was poorly positioned with his chin tucked to his chest and humidified air mask on his neck. All equipment should be labeled when opened. During an observation, on 9/30/22 at 10:15 a.m., Resident 49's respiratory equipment which included yankauer suction tube was dated 9/28/22. The humidified water bottle was not dated. The suction canister was not labeled or dated. During an observation, on 10/3/22 at 11:11 a.m., Resident 49's equipment which included suction tubing, water canister and nebulizer tubing was found to be not dated. The yankauer suction tube was dated 9/30/22. The canister for suctioning had roughly 60 cc of green, yellow colored liquid. The resident was lying in bed with his head facing the wall and humidifier air mask positioned on the side of his neck. During an observation and interview, on 10/3/22 at 11:17 a.m., the Director of Nursing (DON) indicated Resident 49's respiratory equipment was undated and not labeled. Her expectation would be for staff to ensure equipment was changed as directed and labeled appropriately. The humidified air was not over the Trach and the nursing staff and the NA could reposition as needed. Agency staff was working last night and could be the reason for items not being taken care of. The record for Resident 49 was reviewed on 9/30/22 at 10:55 a.m. Diagnoses included, but were not limited to, sepsis (life-threatening response to infection), paraplegia, chronic respiratory failure, tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe (trachea) to help you breathe), subarachnoid hemorrhage (bleeding in the space between the brain and the surrounding membrane), gastrostomy (opening into the stomach from the abdominal wall), paraplegia (paralysis of the legs and lower body). A care plan, dated 9/25/22, indicated Resident 49 was readmitted and had a problem with Pseudomonas in his trach. The care plan directed staff to document and notify MD of any abnormal findings, observe for continued or worsening symptoms of trach infection (increased secretion's, increased odor from trach site, increased temp), observe for adverse side effects of antibiotic (GI upset, nausea, diarrhea, rash) and to administer antibiotic as ordered. Physician's orders included, but were not limited to, per standard of practice with sterile water and normal saline assess trach site every shift for redness, swelling, drainage and warmth, change yankauer suction tip, change trach ties and change trach inner cannula (Size 8XLT) During an interview, on 10/3/22 at 12:02 p.m., the Infection Preventionist (IP) indicated Resident 49 had a hospitalization recently related to Tracheitis (bacterial infection of the windpipe). The resident's equipment had dates from the previous week. There was a concern if staff were not changing the equipment which could cause a spread of infections or cause an infection in Resident 49. Nursing staff are responsible for changing equipment. During an interview, on 10/4/22 at 8:20 a.m., Registered Nurse (RN) 14 indicated it was hard to tell whether a resident was raised to a 30-45 degree angle. His legs were elevated, his middle was creased and his head was elevated the same as his feet, more like a 10 degree angle. A thick air loss mattress was used. She had not checked on the resident yet this morning. There were concerns his trach had yellow/green colored dried mucous on the cannula with water pooling in the tube and the filter appeared dirty. All equipment should be labeled. During an interview, on 10/4/22 at 1:35 p.m., the DON indicated nursing staff should be labeling patient equipment items as needed. Resident 49 was to be properly positioned with his humidified air mask positioned over his tracheostomy. Not having the humidified air on could dry up secretions for Resident 49 and he could be at risk for of infection if the resident equipment was not stored, changed and labeled. 3. During the initial tour of the facility, on 9/30/22 at 9:55 a.m., Resident 67's CPAP machine was observed on the bedside table with the nose piece laying on the bedside table surface uncovered and not bagged. During a random observation, on 10/3/22 at 10:34 a.m., Resident 67's CPAP machine was observed on the bedside table. The nose piece was not bagged or covered. The record for Resident 67 was reviewed on 10/3/22 at 10:21 a.m. Diagnoses included, but were not limited to asthma, chronic obstructive pulmonary disease and obstructive sleep apnea. A progress note, dated 10/2/22 at 4:30 p.m. indicated Resident uses Bi-Pap or C-Pap. Resident 67 had no care plans for the use of a CPAP machine. There was no order for a CPAP or any orders for cleaning or maintenance for the machine. There was no documentation of times the CPAP was applied or removed. During an interview, on 9/30/22 at 10:15 a.m., Agency Nurse (AN) 8 indicated she did not know if Resident 67 used a CPAP or not, there was no order in the electronic record. A current policy, titled CPAP Therapy, undated and provided by the Director of Nursing on 10/4/22 at 2:21 p.m., indicated .Procedure: Verify doctor's orders .Cleaning the Machine: gently wash .rinse .air dry .clean and inspect .Filter maintenance .two filters 3.1-47(a)(6)