**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #1's brief was changed, and she was put back in bed after she was transferred to her wheelchair on [DATE] at 8:45 AM until approximately 6:00 PM which resulted in skin breakdown on her sacral area. This failure could place residents at risk of not receiving adequate care, harm, or injuries. Findings included: Review of Resident #1 face sheet dated [DATE] reflected a [AGE] year old female admitted on [DATE] and discharged on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia following nontraumatic subarachnoid hemorrhage (difficulty with speaking due to brain bleed), tracheostomy status (surgical procedure that creates an opening in windpipe to help with breathing), chronic respiratory failure (condition where lungs are unable to adequately exchange oxygen and carbon dioxide over a prolonged period), muscle wasting and atrophy (loss of muscle tissue, size and strength), muscle weakness, other lack of coordination, and nontraumatic subarachnoid hemorrhage (bleeding in the brain without external trauma). Review of Resident #1's initial care plan dated [DATE] reflected Resident #1 had pressure ulcer or potential for pressure ulcer development on sacrum related to bed bound status and poor nutritional station. Goal included pressure ulcer will show signs of healing and remain free from infection by / through review date, and Resident #1 will have intact skin, free of redness, blisters or discoloration by/through review date Interventions included roll left and right, sit to lying, and lying to sitting on side of bed. Review of Resident #1's MDS 5-day assessment dated [DATE] reflected Resident #1 had a short-term and long-term memory problem. Review of functional abilities reflected at admission Resident #1 was dependent of for all ADLs (eating, oral hygiene, toileting hygiene, shower/bathing). Further review reflected Resident #1 was dependent for chair/bed-to-chair transfers, going from sitting to lying position, and rolling left and right and. Review also reflected that resident was always incontinent of bowel and bladder. Review of MDS skin conditions reflected Resident #1 had no pressure ulcer/injury upon admission and was at risk for developing pressure injuries or ulcers. Review reflected resident had other open lesions or rashes and moisture associated skin damage. Review of Resident #1's initial admission record dated [DATE] reflected Resident #1 used alternating air mattress and pressure re-distributing overlay mattress. Resident #1 was admitted alert to person, but was not alert to place or time and was unable to follow simple commands. Further review reflected resident was incontinent of bowel and bladder and required briefs. Skin problems noted upon admission included traumatic tongue wound prior to admission and surgical site from ankle fracture. Review of Resident #1's skin assessment dated [DATE] reflected Resident #1 had a traumatic tongue wound prior to admission and surgical site to right ankle. There were no other skin issues noted on the assessment. Review of grievance resolution form dated [DATE] reflected Resident #1's family had concerns regarding frequency of checks and new redness to perineal area. Resolution reflected that the DON spoke with family and implemented check and change for frequent rounding. Review of visual/bedside Kardex (electronic health record) report for Resident #1 dated [DATE] reflected under the skin section resident needed monitoring/remining/assistance to turn or reposition. Review reflected Resident #1 required 2 person mechanical lift for all transfers. Review of POC (plan of care) response history for Resident #1 reflected incontinence care was marked as provided on [DATE] at 3:32 AM and 11:41 PM. Review reflected incontinence care was marked as not provided on [DATE] at 11:38 AM. Review of 1 hour checks for Resident #1 reflected sections titled Check, Change, Suctioning and Trach Care. Review for 09-05-2025 hour checks reflected change was not selected between 9:00 am and 6:00 PM. Note on the document reflected Qhour Checks: Please indicate care provided during rounding. Review reflected Resident #1 was checked each hour between 9:00 am and 6:00 pm. Review reflected resident had suctioning completed at 12:00 AM, 4:00 AM, 8:00 AM, 12:00 PM, 4:00 PM,6:00 PM, 7:00 PM, 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review reflected tracheostomy care was provided at 4:00 AM, 8:00 AM, 10:00 AM (nebulizer treatment), 2:00 PM (nebulizer treatment), 6:00 PM (nebulizer treatment), 7:00 PM (nebulizer treatment), 8:00 PM, 9:00 PM, 10:00 PM and 11:00 PM. Review of occupational therapy treatment encounter note dated [DATE] reflected OT checked Resident #1's brief and it was dry and fresh. Review reflected OT then transferred Resident #1 with mechanical lift from bed to geriatric chair. OT then informed ADON that Resident was in chair with mechanical lift sling beneath her. Observation of facility recorded camera footage for Resident #1 room dated [DATE] revealed footage started at 5:53 AM and ended at 6:30 PM. Observation revealed mechanical lift was taken into Resident #1's room by OT at 8:45 AM. OT exited Resident #1's room at 9:07 AM. Observation of footage revealed a mechanical lift was not returned into Resident #1's room until 5:45 PM. Observation of Resident #1 video camera footage dated [DATE] at 10:48 AM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:00 PM revealed Resident #1 sat in a geriatric chair in the room. Observation of Resident #1 video camera footage dated [DATE] at 6:55 PM revealed Resident #1 was transferred from geriatric chair to bed. Observation of picture dated [DATE] at 6:07 AM reflected sacral area (area at the base of the spine) revealed a shallow, broken skin that was light pink with spots of darker red and white flakey skin on the gluteus area. A darker spot shallow opening in the skin was observed in the fold of the gluteus. Review of change of condition evaluation dated [DATE] reflected upon discharge Resident #1 had a rash to right buttock and left buttock. Review of the hospital notes dated [DATE] reflected Resident #1 had wound care evaluation on [DATE]. Resident #1 was admitted with small area of partial skin thickness injury from moisture and from flaky skin loss due to fungal irritation. Orders placed for groin, perineal and perianal/wound areas to decrease fungal irritation. During an interview on [DATE] at 11:49 AM, the FM stated that Resident #1 was no longer at the facility and FM had requested Resident #1 be sent to the hospital. The FM stated that on [DATE] Resident #1 was left in her wheelchair for hours and had not been changed. The FM stated that there was a camera in Resident #1's room and Resident #1 was not transferred into bed until other family arrived on [DATE]. During an interview on [DATE] at 3:27 PM, the OT stated that he transferred Resident #1 from bed to wheelchair on [DATE] in the morning. The OT stated that he checked Resident #1's brief prior to transfer and that Resident #1 was dry and did not observe any skin redness. The OT stated that after Resident #1 was placed in the geriatric chair he notified ADON as ADON was right outside Resident #1's room. The OT stated that usually therapy did not put resident back in wheelchair after assisting them unless nursing staff specifically asked. The OT stated, it sounds like she was up in the chair all day from what I was told. The OT stated he was unsure where he heard this information from or who. During an interview on [DATE] at 3:29 PM, CNA B stated she was familiar with Resident #1. CNA B stated that Resident #1 was not able to talk and wore briefs. CNA B stated that she noticed normal irritation on Resident #1's perineal area and denied any open areas or bleeding. CNA B stated normal irritation was some redness. CNA B stated that she put barrier cream on Resident #1 during brief changes for the redness. CNA B stated the last time she worked with Resident #1 was the day she went to the hospital ([DATE]). CNA B stated that any changes or open areas observed were reported to the nurse immediately. CNA B stated Resident #1 had an extra list that every time she was changed or checked the staff were required to mark off on a piece of paper. During an interview on [DATE] at 4:08 PM, CNA A state she recalled working with Resident #1 and providing care for Resident #1. CNA A stated that the last time she worked with Resident #1 was on [DATE] during the 6:00 PM to 6:00 AM shift. CNA A stated when she arrived Resident #1 was sitting in the geriatric chair in her room. CNA A stated when she arrived CNA C tried to put Resident #1 in the bed, but the mechanical lift's battery was dead. CNA C stated she charged the battery and the put Resident #1 into bed. CNA A stated she changed Resident #1's brief and the only skin issues were some redness, but it was not open or bleeding. CNA A stated that any new redness or open areas would be reported to the charge nurse. During an interview on [DATE] at 4:21 PM, CNA C stated she was familiar with Resident #1. CNA C stated that she took over the shift on [DATE] around 3:00 PM for CNA D. CNA C stated that she was unsure why CNA D did not tell her that Resident #1 was in the geriatric chair. CNA C stated Resident #1 never came out of her room and it was her first day getting up out of bed. CNA C stated that she did not know Resident #1 was out of bed in the geriatric chair that day. CNA C stated Resident #1's family would notify staff if they needed something and they did not call CNA C until around 5:30 PM because they wanted Resident #1 to be transferred in bed. CNA C stated that she tried to use the mechanical lift, but the battery was dead and she went to find another mechanical lift, but they were being used. CNA C stated it was after 6:00 PM and she let the next shift know Resident #1 needed to be transferred and then left. CNA C stated that prior to 5:30 PM she had not seen Resident #1 during the shift and did not provide care to Resident #1. CNA C stated that CNA D told her all the residents had already been changed. CNA C stated that Resident #1's FM told her that Resident #1 had been in the chair all day. CNA C stated she wished CNA D told CNA C that Resident #1 was in the chair before CNA D left the shift so Resident #1 could have been transferred back in bed. During an interview on [DATE] at 6:45 PM CNA E stated she normally works 6:00 am to 6:00 pm shifts. CNA E stated she was familiar with Resident #1 and had worked with Resident #1 several times. CNA E stated the most recent time she worked with Resident #1 was when she was going to leave her shift and the night she needed help to put Resident #1 in bed. CNA E stated that she had changed Resident #1's brief and did not observe any open area or bleeding. CNA E stated that residents who required a mechanical lift to transfer would have to be laid back down in bed to have their brief changed. CNA E stated residents cannot be left in a chair for nine hours as the resident could be really soaks and get a skin rash or they could slip out of the chair and fall. CNA E stated that rounds were done every two hours and during rounds residents were checked and changed and laid down for a nap with they were up. CNA E stated changes in a Resident's skin would be reported to the nurse. During an interview on [DATE] at 1:29 PM, RN F stated she was the wound care nurse. RN F stated that residents who required mechanical lift should be checked on at least every two hours and this included checking their brief and more frequently if needed. RN F stated perineal care cannot be performed in a chair and the resident would have to be transferred with the mechanical lift to complete perineal before bed. RN F stated residents who required a mechanical lift were not able to reposition themselves and would be more vulnerable for skin breakdown. RN F stated that it was not okay for a resident to be in a chair for 9 hours and not changed for 9 hours. RN F stated a resident that was left in a chair for hours could have issues with their skin integrity and that risk for skin breakdown. RN F stated that residents need to be turned and have perineal care. RN F stated that she was familiar with Resident #1 and that she had some redness in her perineal area and it was blanchable (skin turns pale or white when pressure is applied and then returns to normal color). RN F stated Resident #1's last skin assessment was done on [DATE] and she had redness to her sacral area, but it was not open. During an interview on [DATE] at 2:08 PM, RN G stated that residents who required a mechanical lift to transfer were supposed to sit in their wheelchair between one to two hours at a time, but no more than 2 hours. RN G stated 9 hours was way too long and that the position could be challenging for a resident. RN G stated that perineal care could not be done unless a resident was transferred via mechanical lift back to their bed. RN G stated residents who used a mechanical lift for transfers were at a higher risk for skin breakdown and are often incontinent which can mean skin is more prone to breakdown. RN G stated he worked with Resident #1 on [DATE] from 6:00 pm to 6:00 am. He stated that he did not provide any perineal care or incontinent care and that the aides provided that care. RN G stated that he worked with CNA A and that she did not report any changes in skin to him. RN G stated during his shift rounds were conducted hourly for Resident #1 and that he and CNA A alternated the rounds. RN G stated that any changes would have been reported to the DON or ADON. During an interview on [DATE] at 3:07 PM, LVN H stated that resident who required the mechanical lift to transfer were usually laid back down in bed to give their bottom a rest, but the resident required incontinent or perineal care every two hours. LVN H stated it was not okay for a resident to be in a wheelchair for nine hours as sitting on their bottom would not allow for good circulation. LVN H stated residents who used a mechanical lift to transfer were at a higher risk for skin breakdown. During an interview on [DATE] at 3:31 PM, CNA D stated that she worked with Resident #1 on [DATE] and she left early. CNA D stated that Resident #1 was in her room most of the day. CNA D stated the last time she saw Resident #1 was before breakfast time and she did not see Resident #1 after breakfast at all as CNA D left around 10:00 am or 11:00 am. CNA D stated she did not change Resident #1's brief during her shift on [DATE]. CNA D stated she worked with Resident #1 in previous days and she did not observe any skin breakdown or redness that she could recall. CNA D stated she never transferred Resident #1 in or out of bed. CNA D stated the amount of time residents remain in their wheelchair depended on what therapy said how long the resident could tolerate. CNA D stated that nine hours was too long to be in the chair and stated I bet it is uncomfortable. CNA D stated Resident #1 would have to be transferred with the mechanical lift to have her brief changed in bed. CNA D stated rounds were done at least every two hours and during that time residents were turned and their brief was checked. CNA D stated when she checked on Resident #1 during rounds she was usually went and needed to be changed. CNA D stated it was everyone's responsibility to ensure that a resident was transferred back into bed. CNA D stated any skin changes would be documented and reported to the charge nurse. During an interview on [DATE] at 4:11 PM, the ADON stated that Resident #1's family requested that she be checked on every hour for tracheostomy care and suctioning and in general to ensure Resident #1 was okay. The ADON stated on [DATE] therapy, aides and the ADON were in Resident #1's room. The ADON stated she did not change Resident #1's brief on [DATE]. The ADON stated therapy provided perineal care for Resident #1 on [DATE] and that it was around 10:30 AM or 11:00 AM. The ADON stated that CNA D was the aide for half the shift and then CNA C took over. The ADON stated that Resident #1 was in the geriatric chair when her family arrived and they asked to have her put to bed around 5:00 PM. The ADON stated that Resident #1's family around after lunch time. The ADON stated they were not able to transfer Resident #1 at that time because the mechanical lift battery died and the other lifts were being used so she informed the family the next shift would be notified. The ADON stated that she did not know if any transfers occurred for Resident #1 between 11:00 am to 5:00 pm. The ADON stated she assumed the check off for Resident #1 was for the nurses until she looked at the document and saw it had check and change. The ADON stated that Resident #1 would have had to be transferred from her wheelchair to her bed within an hour to be changed. The ADON stated that typically residents who rely on mechanical lift to be transferred are in the wheelchair for a couple of hours and then they are put in bed, laid down and changed. The ADON stated if a resident cannot verbalize that they want to stay in bed or get back up staff will leave the resident laying down to rest and then get them back up. The ADON stated that residents who required the mechanical lift for transfers were at a high risk for skin breakdown. The ADON stated if they are sitting on that spot of a long time they have decrease circulation and boney areas have pressure. The ADON stated that it was not acceptable for a resident to be in the wheelchair from 10:00 am to 5:00 pm. The ADON stated she left around 6:30 pm on [DATE] and that night shift went into Resident #1's room around 6:00 pm and transferred her. During an interview on [DATE] at 4:35 PM, the NP stated that she saw Resident #1 the day after she admitted to the facility. She stated that it was not generally okay for Resident #1 to sit in a wheelchair for nine hours unless Resident #1 was verbally able to say she did not want to get into bed. The NP stated that Resident #1 was not able to verbalize her needs when she saw Resident #1. The NP stated Resident #1 was a higher risk for skin breakdown because she was not able to care for herself. The NP stated that Resident #1 was able to move around a bit, but required a mechanical lift to transfer. The NP stated at her visit Resident #1 had not been out of bed. The NP stated if Resident #1 sat in a chair she could have had breakdown and irritation for nine hours and for sure MASD was possible. The NP stated redness would have most likely occurred. During an interview on [DATE] at 4:51 PM, the DON stated that Resident #1 was dependent on the mechanical lift for transfers. The DON stated that typically when a resident was in a wheelchair it was for a max of two hours unless therapy has cleared the resident for [NAME] time or they have wound care. The DON stated that she expected Resident #1 to be transferred with the mechanical lift to bed for any type of care they might have needed. The DON stated that residents who were dependent on mechanical lift for transfers were at higher risk for skin breakdown and if they were not used to being up. The DON stated that the resident could also be at a risk if they were incontinent and if they urinated the entire time they were up in the chair. The DON stated that it did not meet her expectation that resident be up in a wheelchair for nine hours. The DON stated it was ultimately the responsibility of the charge nurse to ensure the resident was transferred up to the wheelchair or laid down. The DON stated the house checks came about because on [DATE] the family was concerned regarding perineal care. Resident #1 was assessed by wound care and had slight excoriation (irritation) on her perineal area and frequent rounding was implemented. The DON stated that it was designed for the nurse or CNA to check and/or change Resident #1 and to see if she needed anything or was okay. The DON stated that staff checked off if they performed care listed for Resident #1. The DON stated that she interviewed staff and staff sated that they went in and did checks and changes with Resident #1 on [DATE]. The DON stated that some staff said they forgot to check it off, but she could only speak to what the staff told her. The DON stated no change of condition was reported to her prior to Resident #1 going out to the hospital and it was by family request that she went to the hospital on [DATE]. The DON stated Resident #1 returned within 4 hours and family refused any care and requested she be sent out again to the hospital. The DON stated that when she spoke with Resident #1's family they referenced [DATE] and that Resident #1 was up in the chair all day. The DON stated that it was reported to her about Resident #1 being in the chair mid-morning on [DATE]. During an interview on [DATE] at 5:15 PM, the ADM stated that there were hour checks for Resident #1 because her family had concerns about frequency of checks and wanted continuous care and more one-on-one level. The ADM stated that from his understanding and based on the logs she was checked on hourly. The ADM stated that staff were expected to see if the resident or family needed anything and if Resident #1's brief was dry. The ADM stated that when he tried to speak with Resident #1 she could not respond verbally. The ADM stated on [DATE] therapy put Resident #1 in her wheelchair and she had not been put in a chair before. The ADM stated that staff reported she was more responsive and able to use her call light after she was up. The ADM stated that when he reviewed the hourly check he believed there was a gap on that particular day. The ADM stated that he did not know how long Resident #1 was in her chair that day and stated he knew she was in chair a good part of the day and did not think she was in the chair for nine hours. The ADM stated that Resident #1 used a mechanical lift to transfer and would have expected staff to have transfer her from her wheelchair to provide care as they could not do if she was in her chair. The ADM stated the risk of Resident #1 being in her chair for an extended time was skin breakdown, pressure, ulcers, pain and being uncomfortable in general. The ADM stated that he did not think Resident #1 was able to make her needs known. Review of facility policy dated 02/2025 titled Resident Rights reflected residents had the right to be treated with consideration, respect, and full recognition of his or her dignity and individuality. Review of facility in-services for last sixty days [DATE], [DATE] and [DATE] reflected no in-services were conducted on rounding or check and change rounding for Resident #1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for one (Resident #1) of three residents reviewed for respiratory care. The facility failed to ensure nurses were documenting the oxygen flow rate or response to oxygen therapy for Resident #1. The facility failed to have an ongoing system of monitoring Resident #1 as her oxygen saturations dropped below 92% on several occasions, she could no longer participate in therapy, her CO2 lab value was 40 (normal range was 23-31), and she continued to be short of breath days prior to hospitalization on 04/12/25 where she was diagnosed with acute and chronic hypoxic (low levels of oxygen in your body tissues) and hypercapnic (an excess of carbon dioxide in the blood stream) respiratory failure and CHF exacerbation. This deficient practice could place residents at risk for inadequate care, respiratory distress, and hospitalization. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), unspecified heart disease, and dependence on supplemental oxygen. Review of Resident #1's admission MDS assessment, dated 03/31/25, reflected a BIMS of 15, indicating she was cognitively intact. Section O (Special Treatments, Procedures, and Programs) reflected she required oxygen therapy. Review of Resident #1's admission care plan, dated 03/24/25, reflected she had asthma and COPD with an intervention of monitoring for s/sx of acute respiratory insufficiency: anxiety, confusion, restlessness, SOB at rest. Review of Resident #1's preadmission clinicals, dated 03/17/25, reflected she was on continuous use of oxygen at 2 liters for chronic respiratory failure. Review of Resident #1's physician order, dated 03/25/25, reflected O2 at 2-4 L/Min prn to keep sats >= 90% and avoid 4 liters if possible as she retained CO2. Review of Resident #1's lab results, dated 04/09/25, reflected a critically high CO2 level of 40 (Reference Range: 23-31 mEq/L). Review of Resident #1's NP note, dated 04/09/25, reflected the following: Chief Complaint: abnormal lab, increased SOB, pain . [Resident #1] reports increased dyspnea (shortness of breath), which she notes began around the same time she started using an inhaler . She is currently on 3 L of oxygen and uses a BiPAP machine due to hypercapnia. She mentions that her oxygen levels dropped during the night, and she has been experiencing difficulty taking deep breaths, describing it as laborious. . Physical Exam: General: Dyspneic, in bed, color wnl Resp: Oxygen saturation 91-95% on 3 liters of oxygen, diminished breath sounds throughout, decreased to 87% on 2 liters; no wheezing auscultated; labored breathing noted. Review of Resident #1's IDT Care Plan Review, dated 04/10/25, reflected the following: Additional Comments: [Resident #1] and FM A were concerned about the level of O2 she has been on and said that they would like her to go back to using 2 liters of O2 rather than 4. . Therapy Services Plan of Care: [OT B] participated care plan for [Resident #1] with IDT and [FM A] in order to communicate regarding recent change in condition (extreme fatigue and headache) and decreasing oxygen saturation (79%), resulting in limited participation in therapy this week, functional levels and treatment outcomes prior to this week with strength, balance, and hygiene focus, and frequency in OT and PT. Review of Resident #1's NP note, dated 04/11/25, reflected the following: Chief Complaint: abnormal urine, hypoxia . Nursing reported that [Resident #1]'s oxygen saturation was 84% this morning but is currently 92%. She is using BiPAP but is unhappy with the current mask size and request a medium-sized mask. DON was notified of [Resident #1] asking for a different mask and this was obtained almost immediately . She is still feeling more SOB than her baseline and CXR was ordered and completed and showed no acute cardiopulmonary disease. Physical Exam: Resp: Labored, expiratory wheezing throughout. Additional Notes: Chronic obstructive pulmonary disease with acute lower respiratory infection Worse/Exac: - Oxygen sat 91-92% on 3 liters during visit. - Increased prednisone dosage: starting at 40 mg daily for 3 days, then titrating down by 10 mg every 3 days. - Initiated Brovana and budesonide via Nebulizer twice a day. - Continues on DuoNeb 4 times a day and albuterol every 4 hours as needed. - Continue on roflumilast. - Discontinued AirSupra as nebulizers provide more effective medication delivery. - Patient advised to avoid exertion and use BiPAP as needed to alleviate shortness of breath. - Can wear bipap all the time for now to assist with CO2 retention. - Follow-up scheduled for Monday to assess patient's condition and response to treatment. - Instructed to ask to go the hospital if she feels like she's not getting better or is getting worse. . New lower extremity edema - may need diuretics with elevated CO2 and treating UTI will f/u Monday. Heart Failure - Now with edema which is new today. [Resident #1] has a history of mild congestive heart failure. Review of Resident #1's x-ray results, dated 04/11/25, reflected the following: There is no abnormal radiopaque foreign body. The cardiac silhouette is enlarged. There is no pneumothorax visible. There is no radiographic evidence of pulmonary edema. There is no radiographic evidence of pneumonia. IMPRESSION: There is no radiographic evidence of acute disease. Review of Resident #1's Infection Surveillance assessment, dated 04/11/25, reflected she had a new or increased cough, and her oxygen saturation was less than 94% on room air or a reduction in oxygen saturation of >3% from baseline with an onset of 04/10/25. She was started on Cipro (antibiotic) on 04/11/25. Review of Resident #1's progress note, dated 04/12/25 at 5:37 AM and documented by LVN C, reflected the following: CNA notified this nurse that [Resident #1] was experiencing difficulty breathing. Upon immediate assessment, [Resident #1] was noted to be in respiratory distress with O2 saturation at 54% on pulse oximeter. [Resident #1] observed with labored breathing and cyanosis (blue/purple in color) to lips. 911 was called immediately. EMS arrived promptly and initiated oxygen therapy; [Resident #1]'s O2 saturation improved to 97% following their interventions . Review of Resident #1's progress notes, from 03/24/25 - 04/12/25, reflected the nurses were not documenting the flow rate she was receiving or her response to the oxygen therapy. Review of Resident #1's hospital paperwork, dated 04/12/25, reflected the following: [Resident #1] had noticed worsening shortness of breath for the last 2-3 days . [Resident #1] was requiring increasing oxygen requirements, had to increase her O2 to 4L, received IV furosemide. . Carbon Dioxide - 39 . Final Result: Findings of CHF/volume overload. . [Resident #1] admitted to the ICU with acute and chronic hypoxic and hypercapnic resp failure and CHF exacerbation. During a telephone interview on 05/27/25 at 4:29 PM, FM A stated on multiple occasions, Resident #1 would tell the NP, I do not feel good, I feel like I need to go to the hospital. She stated the NP would respond, I cannot stop you from going to the hospital, but I think you should wait. She stated she was notified on occasions where her oxygen saturations would drop in the 80's (percent). She stated because she had COPD, they were used to them dropping low, but when they did, she was always sent to the hospital in the past. She stated she knew it was common for someone with COPD to develop CHF and that was what she was worried about because the last time Resident #1 was hospitalized , the doctor had told her she had the beginning stages of CHF. She stated instead of trying to treat what was wrong, they (facility staff) just kept increasing the liters of oxygen she was receiving. She stated at the facility, the NP would tell her everyone with COPD had CHF, and she believed that was not a reason to not treat her. She stated she received a call on 04/12/25 at 5:30 AM informing her Resident #1 was being sent to the hospital. She stated she was diagnosed with full-blown CHF with fluid on her heart and lungs. She stated the doctor at the hospital told her if Resident #1's oxygen had dropped below 88 (percent) at any time, she should have been sent to the hospital. She stated the facility did not take Resident #1 seriously, she was suffocating and drowning with the fluid build-up. She stated Resident #1 was currently at a rehab facility and would not be returning to (facility). During a telephone interview on 05/28/25 at 12:07 PM, the MD stated ideally, it would be important to document how many liters of oxygen a resident was on because it would be hard to treat a resident without knowing. She stated if a resident had a critical lab value for their CO2 levels, it would depend on what condition they were in as to what she would have done next. She stated if the resident had diagnoses of COPD or hypoxia, she would have evaluated their mental status at that time and if they were continuing to complain of shortness of breath. She stated if a resident was in hypercapnic failure, their mental status would normally be altered, and oxygen saturations would be low. She stated Resident #1 had requested a new mask which they (staff) obtained for her. She stated despite placing the new mask, she could have continued to deteriorate due to underlying issues such as pneumonia. She stated her severe obesity could play a part for how she was compensating for her hypercapnia failure, but they (staff) did the right thing by changing the mask. She stated with Resident #1 continuing to have her oxygen desaturating and with the critical level of her CO2, it would have been prudent to have sent her to the ER for further assessments/care. During an interview on 05/28/25 at 12:25 PM, Resident #1's NP stated it would sure help and make it nice for nurses to document how liters of oxygen a resident was receiving so they could tracker her oxygen saturations and on how many liters. She stated symptoms of a high CO2 level would be increased confusing, increased shortness of breath, low oxygen saturation, and lethargy. She stated some people tend to run high (CO2 levels) and it more so depended on how they were presenting. She stated in some people, an increase in CO2 could lead to death. She stated if a resident was taking off their bipap or cpap or not wearing it regularly, it could make their CO2 levels increase. She stated she was never notified of Resident #1 taking off her bipap. She stated for someone with COPD, you wanted to keep it on the lowest level of oxygen possible with still maintaining 92 percent saturations, as you did not want an unnecessary amount of oxygen. She stated Resident #1 was normally on 2-3 liters of oxygen. She stated on 04/11/25, a nurse told her she had been at 84% that morning, so she started her on prednisone (worked as an asthma treatment). She stated that same day (04/11/25), Resident #1 was more wheezy, short of breath, and more anxious. She stated if someone was short of breath, that would be the reason they were more anxious. She stated any kind of decline in someone's health could make heart failure worse, including increased levels of CO2. She stated she had not ordered for Resident #1 to be sent to the hospital sooner because sometimes going to the hospital could be worse for the residents. She stated she never told Resident #1 she could not go to the hospital. She stated her blood work had been okay, chest x-rays were fine, she started her (on 04/11/25) an antibiotic for a possible UTI, and ordered prednisone. During an interview on 05/28/25 at 2:28 PM, OT B stated Resident #1 started presenting with fatigue and headache on 04/08/25. She stated that was also when her oxygen saturations started being affected (dropping). She stated she started to not want to get out of bed and they could not encourage her to get up . She stated the nursing staff knew, and she brought it up in her care plan meeting on 04/10/25. During an interview on 05/28/25 at 3:03 PM, the DON stated the nurses would probably document the amount of liters of oxygen a resident was receiving in their skilled nursing note. She stated it was important to document so they would know how they were doing each day. She stated if a resident had abnormal lab values, she would always follow the provider's orders. She stated the NP was very involved in Resident #1's care because she was here so often. She stated her CO2 level was elevated, but because her COPD was so severe, it was not too abnormal to see that. She stated her chest x-rays had been normal and believed the next step would be starting Lasix. She stated she knew her oxygen saturations were dipping from time-to-time, but that was to be expected, especially in therapy. She stated she believed they (staff) were managing her symptoms pretty well. She stated she would expect the nurses to monitor Resident #1's oxygen saturations more often, especially if they were lower than 92 percent. She stated she believed they were doing that but should have absolute been documented in her EMR. She stated not monitoring her oxygen saturations more often could lead to a decline in her health. She stated symptoms of hypercapnia were higher CO2 levels and shortness of breath, but hypercapnia was usually figured out by blood levels which were only done in the hospital. During an interview on 05/28/25 at 3:16 PM, LVN D stated she worked with Resident #1 the day before she went to the hospital on [DATE]. She stated she remembered her oxygen saturations being in the 80's that morning and she notified the NP. She stated she could not remember how many liters of oxygen she was receiving. She stated whenever someone had low oxygen, she would re-check it and re-check it. She stated she had been fairly new to the facility and was still learning their EMR system and admitted she failed to document when she re-checked her oxygen saturation levels and the oxygen flow rate . She stated in her opinion, Resident #1 did not seem to be struggling to breathe or having a change in condition that day. Review of the facility's undated Oxygen Administration Policy reflected the following: It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. The purpose of oxygen therapy is to provide sufficient oxygen to the blood stream and tissues. . 16. Document all appropriate information in medical record. A. Oxygen therapy B. Respiratory assessment findings C. Method of oxygen delivery D. Flow Rate E. Resident's response

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of four residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1 was administered her prescribed Keppra (anticonvulsant), Buprenorphine (for pain), and Buspirone (for depression and anxiety) until five hours after the scheduled administration time on 04/22/25 causing her to be in increased pain, anxiety, and continuous spasms in her legs. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral palsy (a group of disorders that affect movement and muscle tone or posture), major depressive disorder, post-traumatic stress disorder, chronic pain, and generalized anxiety disorder. Review of Resident #1's quarterly MDS assessment, dated 03/06/25, reflected a BIMS score of 15, indicating she was cognitively intact. Review of Resident #1's quarterly care plan, dated 01/14/25, reflected she was taking anti-anxiety and anti-depressant medication with an intervention of giving anti-anxiety and anti-depressant medications as ordered by the physician. Review of Resident #1's physician order, dated 01/07/25, reflected Buprenorphine HCl - Give one film sublingually every 12 hours for pain. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Buprenorphine was scheduled for 8:00 AM but not was administered until 1:01 PM by the ADON. Review of Resident #1's physician order, dated 02/18/25, reflected Buspirone HCl Oral Tablet - 10 MG - Give two tablets by mouth two times a day related to major depressive disorder and generalized anxiety disorder. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Buspirone was scheduled for 8:00 AM but not was administered until 12:55 PM by the ADON. Review of Resident #1's physician order, dated 04/17/25, reflected Keppra Oral Tablet - 250 MG - Give one tablet by mouth one time a day for anticonvulsants. Review of Resident #1's MAR Audit, dated 04/22/25, reflected her Keppra was scheduled for 8:00 AM but not was administered until 12:55 PM by the ADON. During an interview on 04/29/25 at 9:29 AM, Resident #1 stated medications were administered late very often. She stated she had not received her morning medications yet. She stated it was frustrating because not getting her medications on time, especially her Cerebral Palsy medications, truly affected her. She stated one day a week prior, morning medications were not administered until 1:00 PM. She stated she could not function or get out of bed. She stated she was in so much pain, was extremely anxious, and her legs would not stop jerking uncontrollably which was very uncomfortable. She stated she felt like she was going to have a panic attack just waiting for her medications. During a telephone interview on 04/29/25 at 1:04 PM, NP A stated some medications were not as time sensitive as others. She stated usually missing a dose by an hour or two would not be that big of a deal. She stated regarding Resident #1 and her diagnoses and the medications she was on, not getting her medications until five hours after they were scheduled could definitely cause her a lot of pain, anxiety, and for her legs to have increased jerking/spasming. She stated anxiety was one of her main issues and she hoped being administered medications that late was a rare occasion. During a telephone interview on 04/29/25 at 1:38 PM, NP B stated usually scheduled medications were to be administered within an hour before or an hour after the scheduled time. If a resident did not receive their medication until after a five-hour timeframe from the scheduled time she would expect for them to be in increased pain, primarily. During an interview on 04/29/25 at 2:15 PM, the ADON stated he did not normally pass medications. He stated he was new to the facility and did pass medications on 04/22/25. He stated he probably was late with administering the medications because he was training with the DON. He stated he was not running on time due to him explaining all the medications to the residents. He stated medications should be administered punctually. He stated normally the orders have a window (timeframe), but Resident #1's medications did not. He stated it was more important that she received the medications than not get the medications. He stated not getting the medications all together would be a more serious situation. During an interview on 04/29/25 at 2:47 PM, the DON stated her expectations on medication administration was that they were administered effectively per the residents' MAR. She stated she wanted to make all the medication times liberalized so that the timeframe would be, for example, between 7:00 AM and 12:00 PM for morning medications. She stated on 04/22/25 it was the ADON's first day being trained all the medication cart. She stated he was trying to explain all of the medications to the residents, and she realized they ran late with the administration . She stated a negative outcome of receiving medications late could be increased pain or anxiety. She stated, however, Resident #1 was always experiencing pain and anxiety. Review of the facility's Medication Administration Policy, revised 11/13/18, reflected the following: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. . Medications are administered within (60 minutes) of scheduled time . Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide accurate and timely pharmaceutical services to meet the needs of each resident, in that: Three residents (Resident #1, Resident #2, Resident #3) out of six reviewed had not consistently received medications ordered to meet their needs. The facility failed to acquire and administer prescribed drugs as ordered; Resident #1 had not received all doses of his Triamcinolone Cream as ordered, Resident #2 had not received all doses of her sleep-aide medication (Temazepam) and pain medication (Norco) as ordered, and Resident #3 had not received all doses of her pain medication (Morphine Sulfate) as ordered. This failure resulted in unnecessary discomfort and pain, psychosocial distress, and insomnia (trouble falling asleep, staying asleep, or getting good quality of sleep). Findings Included: 1.Record Review of Resident #1s face sheet, dated 11/16/23, reflected a [AGE] year-old admitted on [DATE] from Acute Care Hospital after a diagnosis of Chronic Obstructive Pulmonary Disease (a respiratory disorder that requires ongoing medical attention) exacerbation (a temporary worsening). Resident #1 face sheet reflected a diagnosis of Quadriplegia (paralysis of both arms and both legs), that he was blind in one eye, had a history of Psoriasis (skin condition that causes red, scaley itchy patches and has high rate of recurrence in those afflicted), and had an anxiety disorder. Record review of Resident #1s Care Plan entry dated 10/10/2023 reflected Focus: Potential for behavioral problems AEB (as evidenced by) verbal complaints about facility as well as adjustments to medications per resident's request with later statements that medications are not being given the way he requested. Record review of Resident #1s Care Plan entry dated 10/06/2023 reflected Focus: Resident #1 has adjustment issues due to admission and medication administration and prefers to have medications given by nurses. Record review of Resident #1s Order Summary Report dated 11/16/2023 reflected that Triamcinolone Acetonide External Cream 0.5% was ordered on 10/03/2023 by the Physician to be applied to affected areas (where his rash was present) two times a day. The order was active on investigation date and had been ongoing since it was initially ordered on 10/03/2023. Record review of EMAR for November 2023 reflected that the Triamcinolone Cream Acetonide External Cream 0.5% was not applied on 11/02/2023, that it was applied one time on 11/03/2023, that it was not applied 11/11/2023, 11/12/2023, 11/13/2023, and that one dose was applied on 11/14/2023. Resident #1 was observed and interviewed on 11/16/2023 at 11:00 AM Resident #1 was observed to have red scaly rash to chest, arms, shoulders, and back. Resident #1 stated the rash itched a lot and made him feel miserable. Resident #1 stated the rash was very itchy. Resident #1 stated he had not been able to get his Triamcinolone Cream applied as it was ordered. Resident #1 stated it was ordered by the doctor to be applied two times a day and he had been told many times by the nursing staff that the cream was not available. Resident #1 was unable to give specific dates and scheduled doses that were missed but stated it happens all of the time. I blame the facility. They don't order my medications on time and then it is time to give them, and they (the medications) aren't here. 2.Record review of Resident #2s face sheet dated 11/16/2023 reflected an [AGE] year-old admitted on [DATE] from Acute Care Hospital with diagnoses of Pain in Unspecified Joint, Insomnia (difficulty falling asleep, staying asleep, and/or the quality of sleep is poor), Polyneuropathy (the malfunction of nerves throughout the body, symptoms include burning and/or pins-and needles type of pain, numbness, lack of sensation), Cognitive deficit (difficulty remembering, speaking, and understanding), and Alzheimer's Disease (a progressive disease that destroys memory and other mental functions). Record review of Resident #2s Care Plan dated 06/15/2023 reflected the resident has chronic pain. The interventions for chronic pain dated 06/15/2023 included Administer analgesia medication as per orders. Anticipate need for pain relief and respond immediately to any complaint of pain. Record review of Resident #2 Order Summary Report dated 11/16/2023 reflected that Norco, generic name Hydrocodone/Apap (Hydrocodone, the opioid component and Apap also known as Acetaminophen, the Tylenol component) 10/325 (strength) was ordered by Physician on 03/15/2023 as one tablet by mouth four times daily. The order was active and had been ongoing since initial order date. The scheduled times for administration were listed as: 07:00 AM, Noon, 4:00 PM, and 8:00 PM. Record review of Resident #2 Order Summary Report dated 11/16/2023 reflected that Temazepam 15 mg by mouth at bedtime was ordered by Physician on 05/16/2023 and was active and had been ongoing since initial order date. The scheduled time for Temazepam was 7:00 PM. Record review of Resident #2 EMARs for September, October, and November 1-16, 2023 revealed the following missed doses: September 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 09/11/2023 at the 07:00 AM, Noon, and 4:00 PM dosage times. The record review of the EMAR and nurses' notes for these time periods had not indicated the reason that the dosages were not given. October 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 10/02/2023 noon dose; on 10/05/2023 at noon, on 10/26/2023 at 8:00 PM, and on 10/31/2023 at noon. The record review of the EMAR and nurses' notes for these time periods had not indicated the reason that the dosages were not given. November 2023 -Hydrocodone/Apap 10/325 one tablet was missed on 11/03/2023 at noon. The record review of the EMAR and nurses' notes for this time-period had not indicated the reason that the dosage was not given. -Temazepam 15 mg was not given on 11/07/2023. A code 7 was entered on the EMAR and CMA A initials were reflected on EMAR for this dose which corresponded to Other/See Nurses' Notes. The record review of the EMAR and nurses' notes for this time-period did not reflect a reason that the dose was not given. An interview was attempted with Resident #2 on 11/16/2023 at 2:30 PM, Resident #2 verbalized that she wanted to take a nap and did not wish to be bothered with an interview. An interview with FM of Resident #2 was conducted by telephone on 11/16/2023 at 2:30 PM. The FM stated that it was important that Resident #2 get her pain medication, Norco (an opioid analgesic, hydrocodone, combined with acetaminophen), and her sleep aide medication, Temazepam (a benzodiazepine, a medication that is used to help with relaxation) on time and consistently as Resident #2 had taken these medications for many years. Both medications had the potential for physical dependence to be developed in the user. The FM stated that Resident #2 has had opioid-withdrawal symptoms when she had not received her pain medication on time and consistently. The FM stated that Resident #2 relied on Temazepam to help her sleep. The FM stated that Resident #2 had missed a dose or two of Norco in September 2023, had missed a dose or two in October 2023, and had missed a dose on 11/07/2023. The FM further stated that in the past few months she was told by (unknown) facility staff (on unknown date) that the facility did not have Resident #2's pain medication, that they had run out. The FM of Resident #2 stated that she was told by (unknown) facility staff member that the reason that the medication runs out at times was due to a lack of communication. The FM of Resident #2 was unclear what this meant. The FM of Resident #2 stated that she could not indicate who had failed to communicate, but this was the reason given to her by an unknown facility staff member. The FM of Resident #2 stated that she was told another time in the past few months (by unknown staff, unknown date) that they could get the sleeping pill out of the emergency kit (a locked emergency drug kit where nurses pulled medications that have just been ordered and/or were otherwise unavailable). The FM of Resident #2 stated that this was done, however, Resident #2 still had to wait a long time before she received the medication at 2:00 - 3:00 am. The FM of Resident #2 stated that these events have caused stress to Resident #2. The FM of Resident #2 stated that she had observed Resident #2 in the facility when she experienced withdrawal symptoms from not having received her Norco. The FM of Resident #2 stated that Resident #2 was distressed on another occasion as she did not get sleep the night before, attributed to not receiving her Temazepam as scheduled. The FM of Resident #2 stated that Resident #2 experienced withdrawal symptoms of headache, restlessness, and agitation when she had not received her Norco. The FM of Resident #2 stated that when the Temazepam was given late or not at all, Resident #2's sleep pattern was interrupted which caused her to be in a bad mood the next day. During the interview with FM of Resident #2, it was stated that she felt that the medication was not being reordered timely and this had caused the facility to run out. 3.Record review of Resident #3s Face Sheet dated 11/16/2023 reflected an [AGE] year-old admitted to the facility on [DATE] from Acute Care Hospital. The record review of Resident #3 Face Sheet reflected that Resident #3 diagnoses of Chronic Pain Syndrome (everyday symptoms beyond pain alone, including anxiety and depression, and must be treated), Anxiety, and Depression. An interview was conducted with Resident #3 on 11/16/2023 at 2:45 PM. Resident #3 stated that she has had Morphine Sulfate (an opioid analgesic) scheduled for her pain condition. Morphine Sulfate was a drug which could lead to physical dependence and cause symptoms of withdrawal in someone who had taken it routinely. Resident #3 stated that she had not always received her pain medication and had missed a dose five times in the past few months. Resident #3 stated that she had chronic pain related to a prior hip and leg surgery. Resident #3 stated that her pain level was a 5-6 out of a 1-10 scale (10 being the worst pain experienced, 1 being no pain) all of the time, even when she received her Morphine Sulfate as scheduled. Resident #3 stated that her pain level had risen on the pain scale when she had not received her pain medication. Resident #3 stated that she had required scheduled dosing to keep her comfortable enough to get through each day at a 5-6 pain level. Resident #3 added that she was not the only resident who had not received their pain medication. Resident #3 offered that she was familiar with Resident #2 and witnessed when Resident #2 had not received her pain medication on one occasion and she that she had witnessed Resident #2 when she screamed at the nurse due to the pain medication being unavailable. Resident #3 stated that she had witnessed Resident #2 Family Member being very upset when she was told that Resident #2's pain medication was not available. Resident #3 stated that she had witnessed them both being upset, loud, and angry, when they blamed the staff verbally for not having provided a scheduled dose of pain medication to Resident #2. Resident #3 stated that she had chosen not to say anything to the facility staff about her own missed doses as she felt that it would not have done any good. Resident #3 stated that she felt it was the fault of the CMAs that she had missed doses of her medication, that the CMAs had not been mindful of getting the medication reordered. Resident #3 stated that it seemed that the events of missed doses usually happened on the weekends. Record review of Order Summary Report dated 11/16/2023 for Resident #3 reflected that Morphine Sulfate ER (extended release, pain relief effect lasted longer) 10 mg by mouth two times a day was ordered by Physician for pain on 07/01/2022, was an active order and had been ongoing since it was first ordered. The medication was scheduled for 07:00 AM and 7:00 PM. Record review of EMAR for month of August 2023 reflected that on 08/02/2023, the morning dose and the evening dose were not given. A code 2 was reflected on the EMAR and initialed by LVN A for the AM dose not given and a code 7 on the EMAR and initialed was reflected by CMA B for the PM dose not given. A code 2 indicated Hold/See Nurses Notes and a code 7 indicated Other/See Nurse Notes; the number codes corresponded to a key found on the EMAR reviewed. No nurses' notes were found which indicated why the medications were held for this time-period. Record review of the EMAR codes dated 08/01/2023 - 11/16/2023 reflected that a checkmark along with initials of person who had administered medications appeared in entry boxes where medications had been administered. This same system was present on all EMARS reviewed when medications were administered. An interview was conducted with the DON on 11/16/2023 at 3:40 PM the DON stated that when a medication was not available, there was the capability to have a medication sent over stat (promptly) from the pharmacy. The DON stated she was aware of one dose of Resident #2's Temazepam which had not been given and when she was informed, she was able to get the medication sent over stat (promptly) from the pharmacy. The DON stated medications were reordered five days before they ran out. The DON stated controlled medications (those with stricter federal regulations to have them controlled) such as Temazepam, Morphine Sulfate, and Norco are audited at each medication cart each morning and medications that needed to be reordered were flagged. The DON stated that medications that needed triplicate prescriptions (an added measure of security to prevent drug diversion; Morphine Sulfate and Norco/Hydrocodone require a paper prescription in triplicate) are ordered by Nurse Practitioner A or Nurse Practitioner B right away when they are needed. Record review of the facility policy Medication Ordering and Receiving from Pharmacy Provider dated 11/13/2018 stated that Schedule II (a I-IV number assigned to a controlled drug based on risk for abuse) controlled substance medications, such as Morphine Sulfate and Hydrocodone/Apap , are reordered when a seven-day supply remained to allow for transmission of the required original written prescription to the pharmacist. The policy reflected that other medications should be reordered seven days in advance to assure an adequate supply was on hand. The policy also reflected that the Administrator, Director of Nursing, and provider pharmacy establish a daily delivery and pick-up schedule for medication orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to change Resident #1's foley catheter bag or collect a specimen from him for urinalysis according to physician orders. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including morbid obesity, spinal stenosis (a condition where the space for the spinal cord and nerves in the spine becomes narrow causing pressure and pain), and muscle wasting and atrophy (wasting away). Resident #1 was discharged from the facility on 09/13/23. Review of Resident #1's admission MDS assessment, dated 08/21/23, reflected a BIMS score of 11, indicating a moderate cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter. Review of Resident #1's admission care plan, dated 09/21/23, reflected he had an indwelling catheter related to urinary retention with an intervention of changing the catheter bag and tubing as ordered and monitoring/recording/reporting to MDS for s/sx of UTI: pain, burning, tinged urine, cloudiness, etc. Review of Resident #1's NP note in his EMR, dated 08/31/23, reflected a UA C&S was ordered due to sedimentation (crystals, bacteria, or blood exiting through the urine) noted to indwelling foley catheter and purulent (discharge) drainage to urethra (a tube that connects the urinary bladder to the urinary meatus (opening of the urethra) for the removal of urine from the body) noted. Review of Resident #1's physician order, dated 08/31/23, reflected to change the urinary catheter bag one time only for increased sedimentation for one day. Review of Resident #1's physician order, dated 08/31/23, reflected a UA C&S one time only for penile discharge and increased urinary sedimentation for one day. Review of Resident #1's TAR in his EMR, from August of 2023, reflected the UA C&S was not collected nor was the urinary foley catheter bag changed as ordered. Review of Resident #1's TAR in his EMR, from September of 2023, reflected staff documented they were monitoring for signs and symptoms of a UTI. Review of Resident #1's NP note in his EMR, dated 09/05/23, reflected UA and C&S not collected, reordered. Sedimentation noted and purulent drainage from urethra noted. Ordered for nursing to exchange tubing and bag for foley catheter. Review of Resident #1's laboratory results, on 10/11/23, reflected his urine was collected on 09/06/23 by the facility, the laboratory received the urine on 09/07/23, and the results were reported to the facility on [DATE]. The results reflected Resident #1 had a UTI. Review of Resident #1's physician order, dated 09/09/23, reflected an order for Cefepime HCl Infection Solution Reconstituted 2 GM. Use 2 gram intravenously two times a day for Pseudomonas aeruginosa (an infection requiring antibiotics) more than 2,000,000 for 10 days untiled finished. During a telephone interview on 10/11/23 at 11:26 AM, Resident #1's NP stated she did put in orders for a change of his foley catheter bag as well as collecting a sample of urine for a UA on 08/31/23 due to sediment in in his foley catheter tubing and bag. She stated her expectations were that these orders were followed through when they were ordered. She stated on 09/05/23 she noticed neither order had been followed and she re-wrote the orders. She stated she was not sure why they weren't followed through, as there was no documentation indicating Resident #1 had refused. She stated she normally wrote orders for the changing of a foley catheter bag when she wanted to ensure it was draining properly and to be able to monitor more closely if the sedimentation was decreasing or not. She stated not changing the foley catheter right away as ordered would not affect the treatment but would hinder the effectiveness of monitoring appropriately. She stated not ensuring a UA was conducted right away, as it was ordered to be done, would not have exacerbated or worsened the UTI symptoms, but would put a delay in treatment. During an interview on 10/11/23 at 2:22 PM, the IDON stated if the NP's orders should have been followed through the same day unless the resident refused. She stated if the order was not a STAT order for the collection of specimens for a UA, her expectations would be that it was at least collected by the same night so that specimens could be sent to the lab the following morning. She stated a negative outcome of not following NP orders promptly could result in a delay in treatment. Review of the facility's Medications and Treatment Orders Policy, revised May of 2007, reflected it focused on following medication orders and did not address UA or foley catheter physician orders.