Every finding on record at Gulf Shores Rehabilitation and Healthcare Center

Based on interview and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Residents #1) of 5 residents reviewed for accidents and supervision. The facility did not provide Resident #1 with adequate supervision while wandering. Resident #1 entered another resident's room and obtained a regular textured food item leading to Resident #1 choking and dying on 08/03/2026. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/03/26 and ended on 08/04/26. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of sustaining serious injury, harm, and death. The findings included: Record review of Resident #1's face sheet, dated 08/05/2026, was a [AGE] year-old male admitted to the facility on [DATE]. He had diagnosis of dysphagia (difficulty or discomfort when swallowing foods, liquids, or even saliva) and unspecified intellectual disabilities (a diagnosis used for people over the age of five when a doctor or tester suspects an intellectual disability but cannot measure its severity). Record review of Resident #1's care plan, dated 05/02/25, reflected the resident had an ADL self-care performance deficit r/t disease process. Interventions included: Eating, the resident was able to feed self and needed staff assistance with setup. Resident #1 was non-adherent to diet due to his variation in cognition and poor impulse control. Interventions included: monitor/document/report PRN any s/sx of dysphagia. Resident#1's care plan did not include any intervention that specifically addressed this behavior. Record review of Resident #1's quarterly MDS assessment, dated 06/17/26, reflected a Brief Interview for Mental Status scored 00, indicating severe cognitive impairment. Section K (Swallowing/Nutritional Status) reflected a mechanically altered diet - required change in texture or liquids for example pureed food, thickened liquids while a resident. Resident #1 was able maneuver a wheelchair 150 feet on wheelchair with supervision. Record review of Resident #1's Wander Assessment, completed on 06/12/26, reflected a score of 22 indicating he was at high risk for wandering. Record review of Resident #1's physician's order, dated 07/07/26, indicated Resident #1 had a puree texture and thickened liquid diet. Record review of Resident #1's progress note created by LVN B dated 08/03/26 at 12:58 p.m., reflected Resident #1 was found by the WCN C in Resident #2's room unresponsive in his wheelchair with a cake like food on his lap and cake like texture in his mouth. CPR was initiated and EMS was activated. Resident #1 was unable to regain a pulse and was pronounced (when a qualified professional like a doctor, nurse or paramedic check for signs of life, and officially declare that life has ended) on 08/03/26. during a dining room observation on 08/05/26 at 12:10 p.m., reflecting accurate meal/liquid texture provided based on physician orders and observation of supervision completed by staff and no incidents of choking observed. During a telephone interview on 8/5/26 at 12:11 p.m., CNA A stated she transferred Resident #1 from bed and assisted Resident #1 to the nurses station at 11:25am on 08/03/26. During a telephone interview on 8/5/26 at 2:00 p.m., WCN C stated on 08/03/26 at 11:44am, she found Resident #1 unresponsive in his wheelchair in Resident #2's room. WCN C stated that she saw something like cake inside Resident #1's mouth and took some out. WCN C stated that she called for help from LVN C and CPR was initiated and 911 was called. During an interview on 8/6/26 at 11:00 a.m., Resident #2 stated he did have a muffin in his room that was no longer there when he returned to his room on 08/03/26 after Resident #1 was taken from his room. Resident #2's BIMS score was 11, which indicated moderate cognitive impairment. During an interview on 08/07/2026 at 10:33 AM, the DON stated that Resident #1 had a previous behavior of wandering into residents' rooms seeking food, with no behavior noted since May 2025. The DON stated that on 2025 Resident #1's diet was changed to double portion because he thought resident was still hungry. The DON stated he was not sure what caused Resident #1 to be unresponsive but stated based off the food in his mouth he could have choked. Record review of facility's policy titled, Wanderer Management, reflected it is the policy of this facility that all residents are afforded adequate supervision to provide the safest environment possible. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/03/26 and ended on 08/04/26. The administrator was made aware of past non-compliance on 08/06/26 at 6:43 p.m. The facility had corrected the noncompliance before the survey began. 5 LVNs, 5 CNAs, 1 RN, 1 CMA, 1 Housekeeping, 1 SW from multiple shifts during 08/05/26 thru 08/07/26 were interviewed and reflected understanding of recent in-services that were provided on 08/03/26 and stated they covered the following topics and procedures including accidents/hazard and reporting, care planning resident behaviors, AED used for codes and supervision of residents, had been trained the DON confirmed recent in-services and understanding. Facilities corrective actions completed after Resident #1 expired on 08/03/26 included: Facility completed self-report to HHSC on 08/03/26 Facility completed a review to identify any other at risk residents and identified 1 resident, Resident #3. Resident #3 was transferred to a sister facility's secure unit for increased supervision due to poor safety awareness. Resident #3 was wandering into offices and residents' rooms looking for sodas and other belongings and occasionally looking for food. No other residents who were on a puree diet, able to propel a wheelchair and eat on their own were identified to be in the facility at time of entrance on 08/05/26. Facility in serviced staff on choking prevention, dysphagia precautions, meal supervision, accident/hazard reporting, care planning, resident behaviors, AED used for codes, and supervision of residents on 08/03/26. Facility staff were aware of in-service provided and were aware of the procedures to follow for residents who wander and have a special diet in place. Competency quiz for 18 of 37 nursing staff done on 8/4/26 - as per the DON this was ongoing and staff were being in-serviced before their next shifts, and stated they will also be reviewing the competency quiz during their next monthly meeting on 08/07/26. 17 Staff questionnaires dated 08/04/26 asked various staff of any observation of residents entering and eating food that was not theirs. Only 1 resident was identified, Resident #3. As per the DON staff will also be asked this questionnaire prior to the start of their next shift.

Based on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained one each resident that were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's MAR for June 2026 was appropriately and accurately completed to reflect Resident #1's behaviors, for which he was given PRN medication. This failure could place residents at risk for improper care. The findings included: Record review of Resident #1's face sheet, dated 06/16/2026, revealed a [AGE] year-old male with an original admission date of 05/30/2024, and a current admission date of 03/17/2026. Resident #1's pertinent diagnoses included Panic Disorder (an anxiety disorder characterized by frequent and unexpected panic attacks, which were sudden waves of intense fear or discomfort) and Major Depressive Disorder (a persistent feeling of sadness and loss of interest).Record review of Resident #1's Quarterly MDS assessment, dated 03/12/2026, revealed a BIMS score of 15, which indicated intact cognition. The Quarterly MDS assessment also revealed Resident #1 rejected care daily. Record review of Resident #1's current care plan, initiated 01/31/2026 and revised 05/27/2026, revealed a focus for Resident #1 had a behavior problem with interventions to include anticipate and meet Resident #1's needs, and intervene as necessary. Resident #1 had a care plan focus for the use of anti-anxiety medication, initiated 06/26/2024 and revised 06/15/2025. Interventions included administer anti-anxiety medication as ordered, monitor and record occurrences of target behavior symptoms and document per facility protocol. Record review of Resident #1's physician's orders, started 08/31/2024, revealed an active order for behavior monitoring for anti-anxiety every shift: 0. None, 1. Afraid, 2. Agitated, 3. Angry, 4. Anxious, 5. Mood Change, 6. Noisy, 7. Restless, 8. Withdrawn/Depressed, 9. Crying, 10. Combative. The physician's order summary also revealed an order for Alprazolam (an anti-anxiety medication), started 06/01/2026, 0.25 MG tablet, give one tablet by mouth every 8 hours as needed for anxiety x 14 days. Record review of Resident #1's June 2026 MAR, revealed Alprazolam, 0.25 MG tablet, every 8 hours as needed for anxiety was administered 06/01/2026 at 4:03 PM, 06/02/2026 at 4:00 PM, 06/03/2026 at 9:39 AM, 06/04/2026 at 9:57 AM, 06/04/2026 at 11:55 PM, 06/06/2026 at 11:48 AM, 06/10/2026 at 2:15 AM, 06/14/2026 at 11:42 AM. The June 2026 MAR also revealed - 0 (No Behavior) was document for behaviors each time the medication was administered. In an interview on 06/17/2026 at 12:01 PM, LVN-B stated Resident #1 was non-compliant because he refused care frequently, and his room was a mess because he was a hoarder and he did not like for anyone to touch his things. It would cause him increased anxiety and agitation. LVN-B stated when a resident had a behavior, the staff would try to redirect them, as well as notified the DON and the doctor of the behavior. She stated if a PRN anti-anxiety medication was administered there would be progress or communication note done. LVN-B stated there were areas which were clicked off in PCC (electronic charting system) regarding the medication and the behavior, and after they clicked through the areas it automatically got transcribed on the Resident's MAR and an administration progress note. She stated the behaviors should be documented on the MAR by the nurse administering the medication, and after reviewing the MAR, LVN-B stated the post medication communication note was being done, but the behaviors were not being documented on the MAR. She stated she was not sure why she, or the other nurses, had not been documenting the behaviors into the MAR. In an interview on 06/17/2026 at 12:36 PM, LVN-C stated behaviors were documented in an orders administration progress notes and in the MAR. She stated she was the nurse who gave Resident #1 the prn Alprazolam on 06/01/2026 because those were her initials on the MAR, but she did not document the behavior on the MAR because the other nurse who worked with her on 06/01/2026 was supposed to document it for her. LVN-C stated one nurse administered the medication and the other nurse completed the documentation of the behaviors on the MAR, so this was why it showed someone else's signature other than her own for the behaviors section. LVN-C stated it was still wrong because the other nurse documented 0 - No Behaviors when the medication was administered.In an interview on 06/17/2026 at 1:05 PM, the DON stated the nurse who observed the behavior and administered the PRN medication should be the one who documented the behavior in the residents' MARs. He stated this was one of the ways resident's behaviors were track when a PRN anxiety medication was being administered. After reviewing Resident #1's MAR the DON stated the behaviors were not being documented in the MAR.In an interview 06/17/2026 at 1:24 PM, the Administrator stated she had already reviewed Resident #1's MARs prior to the interview. She stated she realized the nursing staff was not documenting the resident's behaviors appropriately, and she had already started an in-service with the nurses regarding correct and adequate documentation in the residents' MARs. She stated she discussed with the nurses if it had been an accident and just occurred once, it would not have been such a big deal, but they were obviously not documenting any of Resident #1's behaviors in the MAR when they were administering the PRN anti-anxiety medications. The Administrator stated she would look for a recent or current policy regarding documentation on the MARs.

Based on observation and interview the facility must ensure that the resident environment remains as free of accident hazards as is possible 1.The facility failed to ensure the shower door in the 500 hall was closed shut and locked after use. 2.The facility failed to ensure the chemical storage closet in the 400 hall was closed shut was locked after use. 3.The facility failed to ensure the supply closet door in the 200 hall was locked which contained an unlocked electrical fuse box. These failures have the potential to result in serious injury. The findings included: In the initial facility observation on 04/27/26 at 9:53 AM the chemical room door of the 400 wing was left wide open containing cleaning agents for the kitchen and cleaning supplies with no staff in the hallway to monitor. In observation of the 500 wing the shower room was left unlocked after use which contained cleaning agents for hair and body the a resident with mental cognitive issues could ingest and result in harm. In observation of the 200 wing the supply closet door was left unlocked and it contained an electrical fuse box that had no lock on it. In an interview on 04/27/26 at 10:15 AM with HK B she stated she must have forgotten to close and lock the door to the chemical storage closet after she went in to grab cleaning supplies. HK B stated she knew it was very dangerous to leave the door to the chemical room unlocked as a resident who might have Alzheimer's or dementia could wander in and drink chemical that could make them sick and possibly die. The HK stated she would start to double-check the chemical door when she uses it and when she passes by it to make sure it was locked. The last in-service on resident hazards was 2 weeks ago. In an interview on 04/27/26 at 10:36 AM with CNA C stated she works the 500 hall was taking a resident back to the room after their shower and left the door open while transporting the resident. CNA C stated leaving the door open posed danger to a resident that has dementia or Alzheimer's as they could go in slip and fall and injure themselves, lock themselves in and possibly ingest cleaning solutions like shampoo. The CNA stated she had been employed for two week and just had training on accidents and hazards and will be more careful by closing and locking the shower room door. CNA C stated she will be checking the doors of room that need to be locked to ensure the safety of the resident. In an interview on 04/27/2026 10:48 AM with CNA D she stated she and the ADON are the only ones that have a key to the supply room that had the fuse box in it and it was their responsibility to ensure the door was always closed and locked. CNA D stated she must have left the door unlocked after she grabbed supplies. CNA D stated she understands how dangerous it was to leave the door unlocked as a cognitively impaired resident could go in lock themselves in and open the fuse box get electrocuted. The last time an in-service was given on accidents and hazards was two weeks ago. CNA D stated she will make it a point to check the door to make sure it was locked every time she passed the door. CNA D stated the last in-service on accidents and hazards was about 3 weeks ago. In an interview on 04/27/2026 10:54 AM at with CNA E she stated she was the CNA for the 200 hall and does not know the supply room was left unlocked but stated it was normally always locked. CNA E stated the ADON and CNA D are the only ones that have a key and can open and lock the door. CNA E stated she knew that it was dangerous for a resident to go in that room because it has a fuse box and the resident can get electrocuted. CNA E stated she will try to check all door that should be locked in the hall she works. The last time she had a in-service was about a month ago. In an interview on 04/27/26 at 10:59 AM with the ADON she stated she and CNA D are responsible for securing the door be lock to the supply room with the fuse box. The ADON stated she the back up to CNA D in case she cannot be found or wasout of the facility. The ADON stated all doors to supply rooms and Shower rooms must remain locked as it posed a hazard to residents that have Alzheimer's or dementia as they can lock themselves in ingest harmful chemicals, slip and could fall possibly injuring themselves and with the fuse box in the supply room possibly electrocuting themselves. The ADON stated she and the DON will be conducting in-services to reeducate all staff on the importance of locking doors to rooms that residents should not have access to. In an interview on 04/27/2026 at 11:11 AM with the DON he stated all doors to shower room and supply room must be always locked as this could pose a hazard to any resident with cognitive impairment. The DON stated all CNAs and nurses have keys to shower rooms and the supply room with the fuse box only CNA D and the ADON have a key, and all staff should be checking doors to ensure these rooms cannot be accessed by residents. The doors are to be checked at every shift by the nurses and CNAs during every round or after-use. In an interview with the Administrator04/27/2026 6:37 PM she stated for she normally does daily rounds all day long, but she was not here that morning. The Administrator stated she had a backup team to go around and secure doors are locked but could not say why the doors were left open. The Administrator stated it was the responsibility of all the staff members to ensure all doors are locked to shower rooms, the chemical room, and the supply room that contained the fuse box. The administrator stated leaving the doors unlocked could cause the resident harm like a slip and fall resulting in a major injury, a resident with mental cognitive problems could possibly drink the chemicals in the chemical room, and in the shower room get cut with razors or drink cleaning agents, and lock themselves for in without staff knowing. The Administrator stated maintenance man went around fixing any broken locks that were on the maintenance report log that the staff logs anything that needs fixing. The Administrator stated she would be purchasing keypads for all the doors that need to be locked to ensure only staff can enter. There was an in-service done today with all staff to ensure all doors checked upon pass and after use. Record review of the facility's Hazardous Areas, Device and Equipment policy dated 07/2017 indicated: All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. 2. any element of the resident environment that has the potential to cause injury and that was accessible to a vulnerable resident was considered hazardous.

Based on interview and record review, the facility failed to allow the resident's representative the right to exercise the resident's rights to the extent those rights are delegated to the representative for 1 resident (Resident #1) of six residents reviewed for resident rights. The facility failed to ensure that decisions made by the resident's representative were recognized and carried out as the resident's decisions, consistent with the authority established by court order or resident delegation, in accordance with applicable law. This failure could place residents at risk of their rights being violated.Findings included:Record Review of Resident#1's Face Sheet04/27/26 revealed he was 97 years-old, and was admitted to the facility on [DATE] with diagnoses of Dementia (A End stage renal disease (permanent, stage 5 chronic kidney failure where kidneys function at less than 15% of normal, requiring dialysis or a kidney transplant to sustain life)group of thinking an social symptoms that interferes with daily functioning), Restlessness and Agitation, and Hypertension. The Face Sheet also revealed Resident #1 had a family member listed as the responsible party.Record review of Resident #1 care plan revealed the resident has impaired cognitive function/dementia or impaired thought processes related to diagnosis Dementia. The care plan revealed interventions are to monitor, document, report as needed any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, and mental status. Record review of Resident #1's Annual MDS, date 03/10/26, revealed Resident #1 had impaired vision could see large print but not regular print, BIMS of 3 (indicating a severe cognitive impairment), on antipsychotic and antidepressant, requires help with ADLs, and uses a wheelchair. In Observation on 04/27/26 at 10:37 AM of Resident #1 revealed the resident awake sitting in his wheelchair watching tv was dressed in clean clothes but looked flustered. The resident had problems hearing the questions the state surveyor was asking and started talking about his daughter not coming to see him. The interview was unsuccessful due to the inability of Resident #1 to understand and hear the questions. In an interview with 04/27/2026 at 12:15 pm with the RP of Resident #1 she stated she is a part time evening employee of the facility and did not understand why the BOM did not try contacting her there. The RP stated the BOM told her that Resident #1's fee for living in the facility increased from 780.00 to 1217.79 per and had inquired a balance of 1600.00. The FM stated the resident had a BIMS of 3 and felt Resident #1 could not make that type of decision for himself. The RP stated she did not think the signature on the address change of his retirement check was his. The RP stated the BOM said there was a witness, CNA A, who was present while she acquired the signature. The RP feels that it was foraged because the signature was in print and Resident signed in cursive. The RP stated the CNA A told her she was not in the room with the resident and BOM when he allegedly signed the form in his room, so CNA A did not witness the signature. In an interview on 04/27/26 at 5:00 PM with CNA A she stated she was not a witness to the signing of the retirement income check address change form and never witnessed the form being signed and all the BOM did was pass by her waving the form in the air stating she had finally got a signature. CNA A never witnessed Resident #1 sign the form. CNA A stated the Resident #1 stated cognitive mental status was not good and at times could not remember what he did yesterday but could follow commands you gave him. CNA A stated she could not say for sure if Resident #1 could understand what he was signing if he had signed the form presented to him by the BOM. In an interview on 04/27/2026 at 5:30 with the BOM she stated all residents have a personal fund to keep their 75.00 allowed by the state after the stay in the facility is paid for. The BOM stated anytime there is an increase in their income which is their social security income, and any other retirement income the charges for the facility are increased by the state. The BOM stated RP kept the extra retirement check until March 2026, but in April of 2026 the facility was able to get the retirement income due to the address form being signed by Resident #1. The BOM stated Resident #1 was only being charged about 750.00 a month till 12/01/2025 when the state changed it on 12/31/2025 because the state found out about the additional income which was from his retirement so the fee for residence at the facility increased. The BOM stated that the FM had kept the money and had made payment arrangements with a promissory note to pay for the remaining balance for the months that were not covered by the residents' Social Security Income. The FM was told that she could make payments online as well. The BOM stated a RP is needed when the resident cannot voice his wants and needs. The BOM stated she was always concerned about resident rights and had the first meeting with the FM where they discussed she was going to get the resident to sign the change of addresses so the facility could receive the retirement check. The BOM usually would ask MDS nurse about new residents but did not ask the MDS nurse about Resident #1 because he could say he wanted to stay here. The BOM stated she assumed he was making his needs known and had the address change form for the retirement check to come to the facility. The BOM stated the only time the facility is involved with financial matters is when the resident is not paying the full amount and would find a family member to make that informed decision. The BOM stated she tried to get hold of the RP multiple times by phone and was aware she was an employee and worked the night shift. The BOM stated she spoke with Resident #1 in the hallway about signing the form to change the mailing address of the retirement check and stated CNA A witnessed her as she waved the paper in the air and stated, he signed it. The BOM stated she understands it is policy and procedure is to get the RP to sign or a family member if the resident appoints them. The state informed the facility the resident had additional income after recertification done on 10/07/2025. Resident #1 owes for December an amount of $56.15 and January 2026 of 1217.79. The BOM stated she understood if the BIMS is high the resident may sign for themselves but if the BIMS was low the resident is not cognitive enough to make an informed decision. The BOM stated she did not ask anyone or inform herself about the Resident #1 BIMS. The BOM stated there is no way of tracking this type of trend where residents have additional income, so she had not come across this scenario before. In an interview with Administrator04/27/2026 6:23 PM, she stated the resident can make a decision for him and felt Resident #1 he could make the decision for himself regardless of the BIMS low score. The Administrator stated the resident was owing money because FM was not sending the payments she agreed to pay. The Administrator stated the state had to deem the resident incompetent by court and have no RP for the facility to consider have taken financial responsibility and to take over the income of the residents. The Administrator stated normally you go to court legally with a psychologist and medical doctor and proceed to go through the courts to deem a resident incompetent. The Administrator stated she will go over and education on following policy and procedure. Give 30-day notice for discharge according to policy and procedure. The Administrator stated it is not a normal process to get consent from the resident with a low BIMS score. The FM works here in the evenings, and she takes him to dialysis at times because he does not like the ambulance so she usually can take him. The administrator stated the resident knows what he likes and doesn't like and when the ambulance shows up he says no and stated he liked staying at the facility and is why the form was presented to him to be signed by him. The administrator stated she has tried to work with the FM but she cannot keep the money and should pay the amount owed. The administrator stated she and BOM had meeting with her and why the facility was requiring payment so Resident #1 stayed in facility. In review of the facility financial policy and procedure dated 03/05/26 Financial admission Policy and Collection Procedures: Policy statement: it is the policy of the policy of Nexion Health that facility admission procedures be followed to ensure that the correct financial obligations for all charges are established before admission. Facility personnel should never tell a resident that they will not have to pay for services. Guidelines: The procedure set forth in this policy will be the responsibility of the business office manager unless otherwise designated. It is the responsibility of the Administrator to ensure that these procedures are followed. Adherence to the following procedures will assist facility personnel in meeting the Days in Sales (DSO) and cash Collection goals that have been established by senior management. Change of address for other income sources such as pension, retirement, VA, etc. require other methods of completion.

Based on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 (Resident #39) of 6 residents reviewed for privacy.The facility failed to ensure the WCN provided privacy for Resident #39 while performing her wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy. Findings included:Record review of Resident #39's face sheet dated 02/18/26 reflected a [AGE] year-old-female with an original admission date of 07/24/24. Diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities) and type 2 diabetes (insufficient insulin production in the body). Record review of Resident #39's physician orders dated 2/18/26 reflected: Cleanse wound with wound cleanser with 4x4 gauze, pat dry with 4x4 gauze, apply medical grade honey (sterilized honey designed for safe and effective therapeutic use, particularly for wound care and skin healing) and apply bordered gauze (specialized wound dressing designed to provide protection and convenience in wound care) daily and as needed for unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [thick, dry, leathery layer of dead tissue that forms over a skin wound, burn, or infection] in the wound bed) wound to right buttock. During an observation of wound care on 02/18/26 beginning at 2:05pm, the WCN set up the supplies needed next to Resident #39's bed. The WCN closed the door but did not close the privacy curtain, leaving Resident #39 exposed to her roommate, who was in the room, during the wound care process. In an interview on 02/18/26 at 2:24pm, the WCN stated she should have closed Resident #39's privacy curtain to ensure dignity. The WCN stated it could make the resident feel less dignified and feel shame for being exposed. The WCN stated that since Resident #39's roommate was in the room at the time of wound care and privacy should have been maintained. The WCN stated she realized she forgot to provide privacy in the middle of wound care but did not stop to close the privacy curtain. In an interview on 02/19/26 at 1:44pm, the DON stated that the WCN should have provided privacy during Resident #39's wound care. The DON stated the residents have the right to privacy even in their own room. The DON stated the residents could become embarrassed and feel uncomfortable if privacy and dignity were not ensured. Record review of the facility's Resident's Rights policy revised on 04/2017 reflected: b. Be treated as individuals in a manner that supports their dignity; c. Be assured choice and privacy and the opportunity to act autonomously, take risks to enhance independence, and share responsibility for decisions

Based on observation, record review, and interview, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 2 (Resident #39 and Resident #27) of 5 residents reviewed for infection control and transmission-based precautions, policies, and practices. The facility failed to ensure the WCN performed hand hygiene between glove changes after providing personal care to Resident #39. The facility failed to ensure the WCN wore EBP during Resident #39's wound care as indicated in the physician's orders The facility failed to ensure Resident #39's wound did not come in contact with a contaminated, soiled surface during wound care. The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds or greater after completing Resident #39's wound care. The facility failed to ensure Resident #27's urinary catheter tubing was not on the floor on 02/17/26. The facility failed to ensure Resident #27 had an order for EBP due to his urinary catheter. These failures could place residents at risk of infection through cross contamination of pathogens and infectious diseases. Record review of Resident #39's face sheet dated 02/18/26 reflected a [AGE] year-old-female with an original admission date of 07/24/24. Diagnoses included Alzheimer's disease (progressive brain disorder that slowly destroys memory and thinking skills), dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities) and type 2 diabetes (insufficient insulin production in the body). Record review of Resident #39's physician orders reflected: Cleanse wound with wound cleanser with 4x4 gauze, pat dry with 4x4 gauze, apply medical grade honey (sterilized honey designed for safe and effective therapeutic use, particularly for wound care and skin healing) and apply bordered gauze (specialized wound dressing designed to provide protection and convenience in wound care) daily and as needed for unstageable (full thickness tissue loss where the depth of the wound or bed sore is completely obscured by eschar [a thick, dry, leathery layer of dead tissue that forms over a skin wound, burn, or infection] in the wound bed) wound to right buttock dated 2/18/26. Enhanced Barrier Precautions every shift dated 02/11/26 Record review of Resident #39's care plan initiated on 02/12/26 reflected:Special Instructions: Enhanced Barrier Precautions Resident #39 had a pressure injury ulcer to the buttock r/t disease process of Alzheimer's, incontinence, and dependence on staff for repositioning in bed and w/c. Interventions included follow facility policies/protocols for the prevention/treatment of skin breakdown. During an observation of wound care for Resident #39 on 02/18/26 beginning at 2:05pm, the WCN removed her gloves after setting up Resident #39's wound care supplies and did not perform hand hygiene before putting on new gloves. The WCN entered Resident #39's room to perform wound care and did not put on a gown and gloves as stated in the physician's orders, the EBP sign by Resident #39's door, and the care plan. While Resident #39's wound was exposed, the WCN allowed Resident #39's soiled brief to touch Resident #39's wound bed throughout the wound care process therefore, contaminating the wound bed after it was cleaned. After the wound care was completed, the WCN removed her gloves after performing wound care, and washed her hands for approximately 15 seconds. In an interview on 02/18/26 at 2:33pm, the WCN stated she forgot to perform hand hygiene after removing her gloves. The WCN stated she was nervous, and she should have sanitized her hands before putting on new gloves. The WCN stated she forgot to put on her gown before performing Resident #39' s wound care and stated EBP was important to follow, so residents were protected from any germs from staff that could be transmitted to the residents. The WCN stated the wound could get infected as residents with open wounds were more compromised to illness. The WCN stated she did not realize Resident #39's wound was touching her brief during wound care. The WCN stated Resident #39's wound could get infected if bacteria got into the wound. The WCN stated hands should be washed for approximately 21 seconds or to sing the alphabet once. The WCN stated proper hand hygiene was important to prevent the spread of infection and disease. In an interview on 02/19/26 at 1:35 PM, the DON stated staff should be performing proper hand hygiene between every glove change. The DON stated that hand hygiene was the best way to stop the spread of infection. The DON stated the WCN should have worn EBP during Resident 39's wound care. The DON stated EBP should be worn with residents who have chronic wounds, g-tubes, or urinary catheters. The DON stated staff knew that EBP was to be used because signage was put on the resident's door, and it was also in the care plan and orders. The DON stated Resident #39's open wound should not have come in contact with any potentially dirty surface. The DON stated that if the wound was exposed to any microorganisms, the wound could get an infected, worsen, or have delayed healing. The DON stated that the WCN was new and was probably nervous. The DON stated that the WCN did have orientation prior to starting the wound care position with no concerns. The DON stated the WCN should have had assistance during wound care to ensure Resident #39 was properly held during wound care, so the wound did not come in contact with any dirty surface. The DON stated that if help was not available, a barrier should have been placed between the resident and the dirty surface to prevent cross-contamination and infection. The DON stated staff were taught to lather their hands for 20 seconds or sing the Happy Birthday song twice. 2.) Record review of Resident #27's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. His diagnoses included benign prostatic hyperplasia with lower urinary tract symptoms (a common, non-cancerous enlargement of the prostate gland in older men that compresses the urethra, causing lower urinary tract symptoms), hydronephrosis (swelling of one or both kidneys due to build up of urine), obstructive and reflux uropathy (urine flow is blocked and causes urine to back up into the kidneys causing kidney damage), chronic kidney disease (when the kidneys are damaged and can't filter blood as well as they should), unspecified intellectual disabilities (a condition that involves limitations on intelligence, learning and everyday abilities necessary to live independently), and cognitive communication deficit (difficulty with communication). Record review of Resident #27's significant change MDS dated [DATE] reflected a BIMS score of 99 which indicated he was unable to complete the interview and his cognitive skills for daily decision making score was 3 which indicated he was severely cognitively impaired and rarely/never made decisions. Record review of Resident #27's physician's order summary report reviewed on 02/17/26 reflected no order for EBP in relation to Resident #27's urinary catheter. Observation of Resident #27 on 02/17/26 at 11:51 am reflected Resident #27 was in the dining room in his wheelchair. Resident #27's urinary catheter tubing was observed extending from the bottom of his pants to the urinary drainage bag that was hung on the cross bar under his wheelchair. The urinary catheter tubing did not have a protective plastic cover on it and was touching the floor. Observation of Resident #27's room on 02/7/26 at 2:48 pm reflected no EBP sign on or around the door and no PPE available inside or outside of the room. In an interview on 02/19/26 at 1:35pm the DON stated EBP should be worn with residents who had chronic wounds, gastric tubes, or urinary catheters. The DON stated staff knew that EBP was to be used because signage was put on the resident's door and it was also in the care plan and orders. The DON stated urinary catheter tubing should not touch the floor and if the tubing was on the floor it could cause infection and possibly hospitalization. Record review of the facility's urinary catheter care policy dated January 2023 and revised June 2025 reflected in part: Purpose The purpose of this procedure is to prevent catheter-associated urinary tract infections.General Guidelines1. Following aseptic insertion of the urinary catheter, maintain a closed drainage system Use Enhanced barrier precautions.Infection Control1. Use Enhanced Barrier precautions when handling or manipulating the drainage system.2. b. Be sure the catheter tubing and drainage bag are kept off the floor.Equipment and Supplies The following equipment and supplies will be necessary when performing this procedure:6. Gown, gloves & mask (Follow Enhanced-Barrier Precautions.)

Based on interviews and record reviews, the facility failed to ensure residents were free of any significant medication errors for one of ten residents (Resident #6) reviewed for medication errors. 1.a. The facility failed to ensure MA A administered Resident #6's blood pressure altering medication on 02/10/26, 02/11/26, 02/16/26, and 02/17/26 when his blood pressure was within the required parameters per the physician's order. b. The facility failed to ensure RN B administered Resident #6's blood pressure altering medication on 02/14/26 when his blood pressure was within the required parameters per the physician's order. These failures could place residents who receive blood pressure altering medications at an increased risk for complications such as decreased blood pressure, decreased pulse, exacerbation of symptoms and disease process, and potential hospitalization. Record review of Resident #6's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] and most recently admitted on [DATE]. His diagnoses included end stage renal disease (the kidneys lose the ability to remove waste and balance fluids) with dependence on renal dialysis (process of filtering blood through a machine to remove excess water and toxins in the blood when the kidneys no longer function), essential (primary) hypertension (high blood pressure), unspecified protein calorie malnutrition (a state of inadequate nutrient intake), and dementia (loss of memory, language, problem solving and other thinking abilities which significantly impair a person's ability to perform daily activities). Record review of Resident #6's quarterly MDS dated [DATE] reflected a BIMS score of 3 which indicated severe cognitive impairment. Record review of Resident #6's physician order summary report reflected the following order: Losartan Potassium Oral Tablet 100 MG. Give 1 tablet by mouth one time a day for HTN. Hold medication for SBP (top number) less than 110 MM HG. Record review of Resident #6's February 2026 medication administration record reflected the following: On 02/10/26 at 7:53 am, Resident #6's blood pressure was 122/52. MA A documented she did not administer Resident #6's AM dose of Losartan due to VS outside of parameters for administration when his blood pressure was within the required parameters per the physician's order. On 02/11/26 at 10:35 am, Resident #6's blood pressure was 116/50. MA A documented she did not administer Resident #6's AM dose of Losartan due to VS outside of parameters for administration when his blood pressure was within the required parameters per the physician's order. On 02/14/26 at 10:50 am, Resident #6's blood pressure was 110/56. RN B documented she did not administer Resident #6's AM dose of Losartan due to VS outside of parameters for administration when his blood pressure was within the required parameters per the physician's order. On 02/16/26 at 11:13 am, Resident #6's blood pressure was 126/55. MA A documented she did not administer Resident #6's AM dose of Losartan due to VS outside of parameters for administration when his blood pressure was within the required parameters per the physician's order. On 02/17/26 at 10:18 am, Resident #6's blood pressure was 113/55. MA A documented she did not administer Resident #6's AM dose of Losartan due to VS outside of parameters for administration when his blood pressure was within the required parameters per the physician's order. In an interview on 02/19/26 at 10:00am, MA A looked at the order for Resident #6's blood pressure medication and stated the hold parameters for it was blood pressure under 110 systolic (top number of blood pressure) and under 60 diastolic (bottom number of blood pressure). When asked to check again, she stated she did not realize the physician had changed the hold parameters and had removed the diastolic blood pressure hold. MA A stated she should have administered Resident #6's Losartan Potassium on 02/10/26, 02/11/26, 02/16/26, and 02/17/26 because his blood pressure was not within the physician ordered parameters to hold it. MA A stated it was important to give medications as ordered because the residents needed the medications. If medications were not given as prescribed, it could cause the resident complications. In an interview on 02/19/26 at 1:35 pm, the DON stated it was important for medications to be given per the physician's orders to ensure there were no negative side effects and so the medication was effective. Record review of the facility's Medication Administration policy dated 07/08/24 and revised June 2025 reflected in part: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation 4. Medications are administered in accordance with prescriber orders, including any required time frame.

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent mistreatment, abuse, neglect, and exploitation of residents, and misappropriation of residents' property for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not inappropriately touch and kiss Resident #1. This failure could place residents at risk for abuse and psychological harm.Findings include:Record review of Resident #1's face sheet dated 07/16/25 reflected a [AGE] year-old-male with an original admission date of 04/16/25. Resident #1 had diagnoses which included bipolardisorder (mental health condition characterized by extreme mood swings), seizures (sudden surge of electrical activity in the brain that can cause involuntary movements), blindness in right eye, and anxiety (feeling of worry, nervousness, or unease). Record review of Resident #1's quarterly MDS dated [DATE], reflected a BIMS of 15 which indicated the resident was cognitively intact). Functional abilities included setup or clean-up assistance (Helper provides verbal cues/and/or touching/steadying and/or contact guard assistance as resident completed an activity. Assistance may be provided throughout the activity or intermittently) with showering/bathing self. Partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, hold, or supports trunk or limbs, but provided less than half the effort) with toileting hygiene, upper body dressing, and personal hygiene. Substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with lower body dressing. Record review of Resident #1's progress notes dated on 04/29/25 reflected:Resident verbalized a female staff member was inappropriately touching and kissing him. Resident verbalized female staff member gave him her personal phone number, and resident proceed to engage in conversation with employee. Resident verbalized he would text her and request pictures of her and employee would send him photos of herself. Facility performed a head-to-toe assessment, Trauma Informed Assessment performed, called the Local Authority, Called the Ombudsman, and Nurse Practitioner was notified and gave orders for STD Panel (RPR, HIV, CHLAMYDIA, GONORRHEA, HERPES, SYPHILIS, & HEPATITIS) and monitor for any s/s of behaviors and distress for 72 hours. Resident did not warrant the need for hospitalization and refused to be sent to hospital for evaluation. Will continue to follow plan of care.Record review of Resident #1's care pan dated 04/19/25 reflected:The resident has a behavior problem r/t bipolar, depression & anxiety. Hx of confabulating stories, accusative behavior towards team members and homosexual, with poor impulse control and short temper, accusing staff of stealing from him, refusing staff to enter room to provide care, using profanity towards staff and constantly verbalizes he has a lawyer and is building his case for monetary compensation: Hx of cocaine abuse. Resident with history of nightmares at night due to him being kidnapped in Mexico 10 years ago. on 4/29/25, Resident #1voices female staff member was sexually inappropriate with him, and he let her as he is a man and could not resist. States he requested her phone number and pictures of her as well.Interventions include: The resident will have no evidence of behavior problems by review date. Administer medications as ordered. Monitor/document for side effects andeffectiveness. Anticipate and meet the resident's needs.Explain all procedures to the resident before starting and allow the resident to adjust to changes. Head to toe assessment and labs In an interview on 07/15/25 at 1:38pm, Resident #1 stated on the first day he got to the facility, he was about to take a shower, and he told CNA A he could shower himself but stated CNA A went in the shower room and helped him shower anyways. Resident #1 stated during the shower, CNA A began to give him oral sex. Resident #1 stated me as a man, I liked it. Resident #1 stated this continued for the first two weeks after arriving to the facility. Resident #1 stated he did not report the incident until two weeks later to the ADM. Resident #1 stated he was not scared and enjoyed it at the time. Resident #1 did not elaborate further on alleged incident. Resident #1 stated he asked CNA A for her number, and she gave it to him. Resident #1 stated they began to text, and he asked CNA A for a picture. Resident #1 showed this State Surveyor his phone and the text thread with a picture of what appeared to be a mirror selfie of a female with tattoos located on the arm and leg seen in the picture, no face was visible in the picture as it was covered by the phone. Resident #1 did not state if he knew CNA A prior to being admitted to the facility. Record review of Resident #1's text messages reflected:Resident #1: What's up beautifulAlleged CNA A: Hey, what's up just seeing thisResident #1: Can you send me another picture I deleted the one you sent meAlleged CNA A: It will have to be later I don't have the correct phone with meResident #1: Okay thanksResident #1: It feels good outsideAlleged CNA A: Does it I haven't been outsideAlleged CNA A: HelloResident #1: Sorry I fell asleepResident #1: Send me a picture of youAlleged CNA A: I have to wait till I get homeResident #1: OkayAlleged CNA A dated, Sunday April 27th at 2:35pm: Picture of a female with no face visible wearing a bra and underwear, with visible tattoos on the forearm and leg. In an interview on 7/16/25 at 9:38am, the SW stated she had just arrived to work when Resident #1 came up to her and stated he needed to talk with her. The SW stated Resident #1 reported to her he was getting inappropriate pictures from CNA A, and she was coming on to him. The SW stated Resident #1 stated CNA A tried to kiss him and gave him unwanted advances. The SW stated she immediately informed administration. The SW stated Resident #1 spoke to the ADM and the DON and showed them the inappropriate picture of a female that was texted to him. The SW stated Resident #1 stated she sent multiple pictures but there were no other pictures on the phone and the phone number on the text message was not the same number listed for CNA A. The SW was unable to identify if the female in the picture was CNA A as the face was not visible. The SW stated Resident #1 did not appear fearful, did not appear to be in any distress, and did not verbalize feeling unsafe. The SW stated later, during Resident #1's head-to-toe assessment, Resident #1 reported to the DON and the ADM another story. Resident #1 stated he was receiving oral sex from CNA A; Administration reported the alleged incident to the state survey agency. The SW stated she was not present during the head-to-toe assessment, and she did not know exactly what was said but stated Resident #1 changed his story from CNA A kissing him or trying to kiss him, to receiving oral sex and he did not report it because he is a man, and he couldn't tell her no. The SW stated no other residents came to her or expressed being inappropriately cared for or touched by CNA A or any other staff members. The SW stated the resident stated the advances were happening in his room. In an interview on 07/16/25 at 12:11pm, the DON stated during a morning meeting, the SW came to inform them Resident #1 had made an allegation stating he received inappropriate pictures of CNA A. The DON stated he and the SW went to speak to Resident #1 and showed him a text thread on his phone. The DON stated in the text message, Resident #1 asked for a picture. The DON stated the picture shown was of a female in front of a mirror with the phone partially covering her face and she was in her underwear. The DON stated the resident claimed there were other pictures but he deleted them and was going to ask for more so he could show his lawyer. The DON stated even though in the picture, her face was partially covered by the phone, it could have been CNA A. The DON stated he could not identify the female in the picture by the tattoos. The DON stated the police were called immediately (police report observed). The DON stated while the police were at the facility, that was when Resident #1 insinuated he and CNA A had oral sex by motioning it without saying it. The DON stated Resident #1 stated CNA A touched him, and they kissed in his room and motioned with gestures they had oral sex. The DON stated the resident stated it happened just the one time. The DON stated the police officer saw the picture and recognized the female as possibly being CNA A as CNA A had run ins with the law. The DON stated the phone number used in that text, was later confirmed to be CNA A's phone number. The DON stated the CCS for the facility called the number used in the text and CNA A answered the phone and identified herself by name when asked who she was. The DON stated CNA A denied the allegations between her and Resident #1 and could not answer why Resident #1 had her number or picture. The DON stated no other residents had a concern about the care CNA A provided. In an interview on 7/16/25 at 12:21, the ADM stated Resident #1 informed the SW CNA A was having an inappropriate relationship with him. When the ADM spoke to Resident #1, he stated CNA A was sucking his dick. The ADM stated Resident #1 was not fearful. The ADM stated the resident reported to the SW kissing was going on in his room and CNA A was sending him pictures but did not report about the oral sex. The ADM stated the police were called, CNA A was immediately suspended, and an investigation was conducted. The ADM stated no other residents stated they were abused or inappropriately touched by CNA A or any staff member. CNA A was terminated an no longer employed by the facility. In a phone interview on 7/16/25 at 12:31pm, the CCS stated she was contacted by the facility and informed about the situation with Resident #1 and CNA A. The CCS stated the ADM stated there was an allegation of emotional distress. The CCS stated the number used in the text messages where the picture was found was not a number the facility had listed for CNA A. The CCS stated since the picture did not show a face, the staff were unable to positively identify the female in the picture was CNA A. The CCS stated however, she called the number on the text thread and when the person answered the phone, they identified themselves as CNA A. The CCS stated she did not know what CNA A looked like and could not identify her as the female in the picture. In an in anonymous interview, CNA A seemed flirtatious with the male residents and giggly with the female residents. CNA A was not professional, and CNA A would present herself different with the male residents like the boundary wasn't there for her. They reported CNA A's behavior to many people including the ADON and was not sure what came about it and could not identify who they told or when the complaints were made. They felt CNA A was doing stuff she was not supposed to be doing. CNA A would sometimes take a long time with Resident #1. When they would check on what was taking CNA A so long, she would be in the room combing Resident #1's hair or CNA A stated she was just providing care. In an interview on 7/16/25 at 1:59pm the ADON stated CNA A was an okay employee and stated Resident #1 claimed she was a good CNA. The ADON stated staff never came to her about concerns with CNA A and the care she provided. The ADON stated CNA A would take a long time when providing care to residents but could not say if it was with male or female residents but believed CNA A was just slow because she was new to the facility. The ADON stated she did not work closely with CNA A and could not say if she was inappropriate with residents. The ADON stated Resident #1 claimed CNA A was sending him inappropriate text messages or pictures. The ADON stated she could not see the face in the picture and could not positively identify if it was CNA A. The ADON stated she could not recall if Resident #1 stated it happened once or not. The ADON stated no other residents expressed concern or complained about CNA A's care. In a second anonymous interview revealed CNA A seemed to be flirtatious with Resident #1. CNA A's behavior was reported to multiple nurses which included the ADON but did not know if anything was ever done. CNA A would take hours on Resident #1 and CNA A would say she was either combing their hair or providing some kind of care. CNA A would brag about getting texts from Resident #1, but CNA A never stated she had a sexual relationship with Resident #1 and denied any inappropriate behavior. Information about CNA A texting Resident #1 was not reported. In a phone interview on 7/16/25 at 2:51pm, CNA A stated she remembered Resident #1 and stated he would request her to provide care to him because she cared for him the right way and would bathe him right. CNA A stated she never sent text messages or pictures to any resident, CNA A denied any inappropriate behavior and stated she did have tattoos but did not identify them. Attempted interview with the local authorities on 07/16/25 at 4:04pm, 07/16/25 at 4:08pm, and 07/16/25 at 4:40pm were unsuccessful. Record review of the Police Report dated 4/29/25, reflected the call log confirmed the phone number in Resident #1's text message belonged to CNA A. Record review of the facility's Abuse Prohibition Policy dated 06/02/25 reflected: IntentEach resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Sexual abuse includes, but is not limited to, rape, sexual harassment, sexual coercion or sexual assault.Identifying Sexual Abuse and Capacity to ConsentA resident's consent to sexual activity is not valid if obtained from a resident who lacks the capacity to consent, or if the consent was obtained through intimidation, fear or coercion. 1. Sexual abuse is non-consensual sexual contact of any type with a resident, as defined at 42 CFR S483.5. Sexual abuse includes, but is not limited to:a. unwanted intimate touching of any kind especially of breasts or perineal area;b. all types of sexual assault or battery, such as rape, sodomy, and coerced nudity;c. forced observation of masturbation and/or pornography; andd. taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g. posting on social media). This wouldinclude, but is not limited to, nudity, fondling, and/or intercourse involving a resident.2. Generally, sexual contact is nonconsensual if the resident either:a. appears to want the contact to occur, but lacks the cognitive ability to consent; orb. does not want the contact to occur.4. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexualabuse.

Based on interviews and record review, the facility failed to ensure that all alleged violations involving the reasonable suspicion of a crime were reported immediately to a law enforcement entity for its political subdivision, within two hours if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (Resident #1 ) of 5 residents reviewed for abuse/neglect.The facility failed to report to the local law enforcement agency within the allotted time frame of 24 hours on 01/27/2025 around 8:53 AM when LVN A observed red/yellow discoloration on Resident #1's left breast and areola.This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.The findings included:Record review of Resident #1 face sheet dated 07/07/2025 revealed Resident #1 was a [AGE] year-old- female who was initially admitted on [DATE]. Resident #1 was admitted with diagnoses of Alzheimer's disease (cognitive impairment) and dementia (cognitive impairment) and altered mental status.Record review of Resident #1's Comprehensive MDS dated [DATE] revealed Resident #1 had a long-term and short-term memory problem which meant severely cognitively impaired and was dependent on staff for ADLs.Record review of Resident #1's Care Plan date implemented 11/03/2024 and revision date on 03/02/2025 have actual impairment of my skin integrity r/t Diabetes, protein calorie malnutrition, B&B incontinence 1/27/2025 Discoloration to right chest down to breast. 1/27/25Resident noted tightly crossing arms over chest area, at risk for self-inflicted bruising. Goal: My area of discoloration to left chest and breast will be resolved by review date. I will maintain intact skin through the review date. Interventions: 1/18/25 Staff in-serviced by DOR on proper transfer techniques and handling residents. Resident sleeps with arms crossed in fetal position and is at risk for bruising. or changes and report to DS if abnormal. Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocol for treatment of skin impairment. Incontinent care as needed. Apply barrier cream as needed. Keep skin clean and dry. Use lotion on dry skin. Monitor (specify meds/treatments) for potential side effects compromising skin integrity. Notify MD/NP/PA/RP of impairments of skin integrity. Pillow will be given to resident and placed over chest to minimize resident from applying pressure to chest area to prevent bruising. Skin checks weekly. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface.Record review of Resident #1's Skin Observation tool dated 01/27/2025 at 08:53AM revealed Area of red/yellow discoloration from left chest down to left breast and areola. Skin 100% intact 20cm X 7.5cm X 0cm.Record review of the facility's Provider Investigation Report regarding Resident #1 revealed incident date 01/27/2025, Facility Nurse performed a head-to-toe assessment and noted red and fading yellow discoloration to the left chest wall and left breast and areola skin intact 20 cm x 7.5 cm x 0. Resident in not apparent pain. No physiological or psychological distress noted. Resident within her normal baseline.During an interview on 07/07/2025 around 2:21PM, the Administrator stated the bruise on Resident #1 did not look suspicious, however on 01/27/2025 could not definitively rule out abuse as the investigation was ongoing. The Administrator stated once she attained all the details regarding Resident #1's left chest bruise, she concluded that the injury may have stemmed from possible gait belt usage. The administrator stated she the facility's protocol would be to initially treat the skin irregularity as abuse and would notify HHSC and local law enforcement immediately. The Administrator stated she did know recall why she did not notify the local law enforcement as it is one of her initial steps. The Administrator stated the reason she notifies the local law enforcement was due to being on her facility policy and procedures in accordance with state regulations. The Administrator gave no definitive answer when questioned what could happen if the local law enforcement is not notified of an allegation of abuse. The Administrator reiterated she may have forgotten to notify local law enforcement regarding Resident #1's bruise, and continued to state the bruise was not suspicious, however since Resident #1 was cognitively impaired she was unable to verbalize how the skin discoloration occurred. The Administrator stated she reports all allegations of abuse and neglect to the appropriate state agencies and local law enforcement, however for this incident she did not, but will for future incidents. Record review of the facility's gait belt transfer in-service dated 1/27/25 was reviewed.Record review of the facility's Abuse Prohibition Policy in-service dated 1/27/25 was reviewed.Record review of the facility's Abuse Prohibition Policy reviewed dated 6/2/25 revealed,Reporting/Response: 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective action depending on the results of the investigation. The Abuse Coordinator will report allegations of abuse, neglect, with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries or unknown source and misappropriation within 24 hours of the allegation.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents, for one of four residents (Resident #2) reviewed for accidents and supervision.The facility failed to ensure CNA A used a gait belt to transfer Resident #2 from the wheelchair to bed on 07/06/2025.This failure could place residents at risk for falls, injuries and a decline in health.Findings include:Record review of Resident #2's face sheet, dated 07/07/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included lack of coordination, muscle wasting and atrophy (breakdown of tissue), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, abnormalities of gait and mobility, and lack of coordination.Record review of Resident #2's Quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15, which meant Resident #2 was cognitively aware. Resident #2 needed substantial/maximal assistance for chair/bed-to-chair transfer. Resident #2 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis.Record review of Resident #2's care plan focus date initiated 10/10/2024 and revised on 01/25/2025, The resident has an ADL self-care performance deficit r/t Left hemiplegia (weakness to extremities) and hemiparesis (paralysis to one side of the body) TRANSFER: The resident requires Total assistance) by (X1) staff to move between surfaces. Encourage the resident to use bell to call for assistance.During an observation 07/06/2025 at 3:27PM CNA A entered Resident #2's room and assisted Resident #2 by pushing Resident #2's wheelchair to the right side of her bed. CNA A then locked the wheelchair brakes and proceeded to stand in front of Resident #2. Upon initial observation there was observable left sided deficit on Resident #2's left leg and right leg. CNA A then proceeded to assist Resident #2 to stand and observed CNA A use arm strength to transfer Resident #2 from wheelchair to bed. During Resident #2's transfer, Resident #2 pivoted to her bed and observed visible struggle while she staggered when pivoting from wheelchair to bed. Resident #2 was observed to have compromising balance as she was observed to be struggling while transferring to her bed. Resident #2 was successful in transferring to the bed. Throughout the transfer CNA A did not utilize a gait belt.During an interview on 07/06/2025 AT 3:40PM, CNA A stated she should have used a gait belt to assist Resident #2 to transfer onto her bed. CNA A stated she was unaware Resident #2 had a stroke or had left sided weakness, while Resident #2 struggled to transfer into the bed. CNA A was asked if she utilized a gait belt when transferring Resident #2, CNA A stated she did not use a gait belt due to not having a gait belt with her. CNA A stated she left her gait belt in a different hall but usually keeps it on her person. CNA A stated she did not use a gait belt because she had left the gait belt in her assigned hallway. CNA A stated she was supposed to use a gait belt for transfers but did not have access to it as it was in a destination that was not near Resident #2's room. CNA A stated by not using a gait belt Resident #2 could have fallen and was fortunate that she did not fall. CNA A stated going forward she would ensure to always keep a gait belt with her and would utilize the gait belt when she transferred any resident. CNA A stated she could not recall when she was last educated about resident transfers.During an interview on 07/07/2025 at 1:27PM the DON stated he was made aware of the observation by CNA A. The DON stated initially, the physical therapy department will conduct a transfer mobility in-service when needed. The DON stated CNA A should have used a gait belt when transferring Resident #2 from wheelchair to the bed, as not only a safety precaution but also to maintain Resident #2's wellbeing. The DON stated the therapy department would work with the CNAs on proper body mechanics when transferring a resident. The DON stated the nursing staff would notify the CNAs on what level of transfer assistance is warranted for each resident. The DON stated CNA A may have compromised Resident #2's well-being as Resident #2 may have fallen. The DON stated CNAs should use a gait belt with all mobile residents as a precautionary safety measure. The DON stated all CNAs were supposed to keep a gait belt on their persons. The DON gave no definitive answer when asked who was responsible for training staff on transferring precautions/procedures. The DON stated going forward he would conduct an impromptu in-service regarding gait belt transfers.Record review of the facility's CNA A's Restorative Nurse Aide Competency Checklist dated 4/18/2025 revealed CNA A was checked off on 2. Gait: b. Proper use of gait belt.Record review of the facility's Safe Patient Handling and Moving Protocol reviewed on 06/18/2025 documented,General considerations: Utilize gait belt during all weight bearing transfer activity. Please note that the gait belt will loosen slightly when the resident rises.One Person Transfer: To be utilized when transferring resident who can bear weight through at least one lower extremity and require the assistance of 1 person.- Place the gait belt around the resident's waist securely .reach around the resident and grasp the belt in the mid back area (avoid grasping on the sides due to risk for injury) .once the resident is seat/positioned safely, remove the gait belt.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection for one (Resident #2) of five residents reviewed for infection control, in that:CNA A, on 07/06/2025, did not remove her contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to initiating Resident #2's perineal care. Additionally, CNA A failed to perform hand hygiene and gloves changes while performing incontinent care.These failures could place residents at risk for contamination and infection.The findings included:Record review of Resident #2's face sheet, dated 07/07/2025, revealed a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 diagnoses included lack of coordination, muscle wasting and atrophy (breakdown of tissue), hemiplegia (paralysis of one side of body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side, abnormalities of gait and mobility, and lack of coordination.Record review of Resident #2's Quarterly MDS, dated [DATE], revealed Resident #2 had a BIMS score of 15, which meant Resident #2 was cognitively aware. Resident #2 needed substantial/maximal assistance for chair/bed-to-chair transfer and was dependent on staff for toileting hygiene, however, gave no specificity on how many staff members were required for transferring within the MDS document. Resident #2 was coded to have neurological deficits of cerebrovascular accident, transient ischemic attack or stroke and hemiplegia or hemiparesis.Record review of Resident #2's care plan focus date initiated 10/10/2024 and target date 09/21/2025, The resident has (bladder and bowel incontinence r/t CEREBRAL INFARCTION, UNSPECIFIED. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. BRIEF USE: The resident uses disposable briefs. Change (Q 2hrs) and prn. Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. INCONTINENT: Staff to perform incontinent care during daily care and as needed. Wash, rinse anddry perineum. Change clothing PRN after incontinence episodes. Monitor/document for s/sx UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns.During an observation 07/06/2025 at 3:27PM while Resident #2 was in bed, CNA A applied clean gloves, lowered the head of bed using the bed remote, then closed Resident #2's curtain, unlatched Resident #2's brief, retrieved clean wipes, and began to clean perineal area with same contaminated gloves she used to touch the multiple surfaces. CNA A the proceeded to assist Resident #2 to turn to her left side, attained additional cleansing wipes and cleaned the visible bowel movement on Resident #2's buttock. CNA A then rolled the brief within itself and threw the contaminated brief and soiled gloves in the trash. CNA A then proceeded to apply clean gloves without any hand hygiene, and attained a clean brief and transfer sheet, and placed both items under Resident #2's buttocks, followed by turning Resident #2 onto her back, and latching the brief attachments to close the brief. CNA A did not perform any hand hygiene prior to, during, nor after incontinent care, nor did she perform any contaminated glove change when cleaning Resident #2's labial area to buttock area.During an interview on 07/06/2025 at 3:50PM CNA A stated she should have performed gloves removal followed by hand hygiene prior to unlatching Resident #2's brief straps. CNAA stated she should have removed contaminated gloves and performed hand hygiene after touching Resident #2's environment due to those surfaces having germs. CNA A stated she should have removed her contaminated gloves and performed hand hygiene after she cleaned Resident #2's perineal area, prior to turning Resident #2 onto her left side, followed by applying clean gloves and cleaning Resident #2's buttock area. CNA A stated Resident #2 could potentially become sick or become septic from the introduction of germs and could had led to an UTI. CNA A stated UTIs are very bad especially for the geriatric community. CNA A stated Resident #2's health could be affected by an infection by potentially compromising Resident #2's health by depleting Resident #2's strength or weight loss, and these situations could have severe/detrimental effects on Resident #2's well-being. CNA A stated she was not given a competency check off regarding perineal care or hand hygiene nor does she recall being in-serviced about hand hygiene or perineal care.During an interview on 07/07/2025 at 1:27PM with the DON, the DON stated the facility follows the CDC recommendations regarding hand hygiene. The DON stated by CNA A touching multiple surfaces followed by performance of perineal care, Resident #2 could have potentially been exposed to infectious bacteria which could cause illness, UTI, or sepsis (infection). The DON stated CNA A should have removed her contaminated gloves that touched multiple surfaces and perform a form of hand hygiene. The DON stated CNA A should have performed hand hygiene prior, during, and after the completion of incontinent care. The DON stated CNA A once she completed cleaning Resident #2's perineal area, should have removed her contaminated gloves, performed hand hygiene, applied clean gloves, followed by cleaning Resident #2 bowel movement. The DON stated her ADONs administer competency skill check offs within the hiring process, and as needed. The DON stated CNA A had received perineal/incontinence competency check off prior to working independently within the facility.Record review of the facility's CNA A's Restorative Nurse Aide Competency Checklist dated 4/18/2025 revealed CNA A was checked off on 6. Bathing/Hygiene/Dressing (ADLs) with adaptive equipment.Record review of the facility 04/18/2025 Infection Control, Hand Hygiene, Track and Trending infection preventive measures, disinfecting equipment before and after use was reviewed and documented CNA A in attendance.Record review of the facility's Handwashing-Hand Hygiene Policy and Procedures date reviewed 1---2020 revealed,The facility considers hand hygiene the primary means to prevent the spread of infections 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: B. Before and after direct contact with residents; before moving from a contaminated body site to a clean body site during resident care; J. after contact with blood or bodily fluids; M. After removing gloves.Record review of the CDC guidelines Clinical Safety: Hand Hygiene for Healthcare Workers updated on 02/27/2024 revealed Know when to clean your hands,- Immediately before touching a patient.- Before moving from work on a soiled body site to a clean body site on the same patient- After touching a patient or patient's surroundings- After contact with blood, body fluids, or contaminated surfaces- Immediately after glove removal.

Based on observation and interview, the facility failed to post the daily nurse staffing data at the beginning of each shift in a prominent place, readily accessible to residents and visitors that included the facility name; the total number of hours worked per shift by the registered nurses, the licensed vocational nurses, and the certified nurse aides directly responsible for resident care for the facility for 43 of 43 days reviewed for staffing postings. The facility did not post current daily staffing information from 02/07/25 through 03/22/25. This failure could place the residents, families, and visitors at risk of not having access to information regarding the number of staff working each day to provide care on all shifts. Findings included: Observation on 03/22/25 at 8:50 a.m., Surveyor was conducting an observation of the facility and noticed the Nurse Staffing Data on the wall across from the nurse's station. The date on the Nurse Staffing Data form was 02/07/25. In an interview on 03/22/25 at 4:23 p.m., the DON said the HR person usually completed the form and posted it daily. The DON said the HR person had not worked for about a month, so they would have to hire someone for the HR department. The DON said he was responsible in her absence for completing the form and the posting, but he had been busy and did not keep up with the posting. The DON said he had sufficient staffing. Record review of the facility's policy for Posting Direct Care Daily Staffing Numbers03/2023 dated September 2022, reviewed on 03/2023 indicated: Our Facility will post on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents. Policy Interpretation and Implementation 1. Within two (2) hours of the beginning of each shift, the number of licensed nurses (RNs, LPNs, and LVNs) and the number of unlicensed nursing personnel (CNAs) directly responsible for resident care will be posted in a prominent location (accessible to residents and visitors) in a clear and readable format. 2. Directly responsible for resident care means that individuals are responsible for residents' total care or some aspect of the residents' care including, but not limited to, assisting with activities of daily living (ADLs), performing gastrointestinal feeds, giving medications, supervising care given by CNAs, and performing nursing assessments to admit residents or notify physicians of changes of condition. 3. Shift staffing information shall be recorded on the Nursing Staff Directly Responsible for Resident Care form for each shift. The information recorded on the form shall include the following: a. The name of the facility. b. The dated for which the information is posted. c. The resident census at the beginning of the shift for which the information is posted. d. Twenty-four (24) hour shift schedule operated by the facility. e. The shift for which the information is posted. f. Type (RN, LPN, LVN, or CNA) and category (licensed or non-licensed) of nursing staff working during that shift. g. The actual time worked during that shift for each category and type of nursing staff. h. Total number of licensed and non-licensed nursing staff working for the posted shift.

49157 Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #14, Resident #24, and Resident #37) of 8 residents reviewed for care plans. 1. The facility failed to ensure that Resident #14's care plan reflected the need for Enhanced Barrier Precautions regarding Resident #14's right chest wall dialysis catheter. 2. The facility failed to ensure that Resident #24's care plan reflected the fact that the resident frequently removed her own oxygen cannula and tubing and refused to wear it. 3. The facility failed to ensure Resident #37's care plan reflected Resident #37 had an arterial wound (painful injuries in your skin caused by poor circulation) to right heel. These failures could place residents at risk of not receiving the care and treatments necessary to achieve or maintain their highest practicable level of health and well-being. The findings included: 1. Record review of Resident #14's admission record reflected a [AGE] year-old male that was originally admitted to the facility on [DATE] and was readmitted on [DATE]. Resident #14's diagnoses included End Stage Renal Failure (a condition in which the kidneys no longer function), dependence on renal dialysis (a treatment used to remove waste and excess fluid from the blood), dementia (a group of symptoms that affect memory and thinking and interferes with daily life), and hypertension (high blood pressure). Record review of Resident #14's quarterly MDS dated [DATE] reflected a BIMS score of 5, which indicated that Resident #14 had severe cognitive impairment. Record review of Resident #14's order summary report reflected the following orders: -Monitor Perma catheter (a special intravenous tube that is used for hemodialysis that is inserted into a large vein in the neck or upper chest) to right upper chest wall dressing in place, if dislodged or soiled, cover with a clean dressing and inspect for s/s of infection qshift and pm. Note changes in skin color, temperature, and exudate from access. Report changes to physician. Order date: 10/12/24. -Monitor Perma catheter to right upper chest wall pressure dressing for excessive bleeding every shift upon return from dialysis and remove dressing morning after dialysis. Order date: 10/12/24. - Resident to receive dialysis 3 days a week on T-Th-Sat at [name of dialysis facility and phone number] under the care of [name of nephrologist]. Chair time 11:00am. Order date: 8/8/24. Record review of Resident #14's care plan reflected the following: Focus: The resident needs dialysis r/t renal failure at [name of dialysis facility] at 11:00am on T, Th, and Sat. Monitor Perma catheter to right upper chest. Date initiated: 4/6/23. Revision on: 11/2/24. Goal: The resident will have no s/s of complications from dialysis through the review date. Date initiated: 4/6/23. Revision on: 4/29/23. Goal: The resident will have immediate intervention should any s/s of complications from dialysis occur through the review date. Date initiated: 4/6/23. Revision on: 12/14/23. Interventions/ Tasks: Monitor/document/report PRN (as needed) any s/s of infection to access site: redness, swelling, warmth, or drainage. Date initiated: 4/6/23. The interventions/task section does not have an intervention for Enhanced Barrier Precautions related to the Perma catheter in his right upper chest wall. 2. Record review of Resident #24's Optional State Assessment MDS dated [DATE] revealed Resident #24 has a BIMS of 15, which means Resident #24 is cognitively intact. Record Review of Resident #24's physician orders on 12/2/24 at 4:00 PM revealed an order for Oxygen at 3 liters per minute via nasal cannula continuously. May titrate to 4 liters per minute to keep oxygen saturation above 90%. Observation on 12/1/24 at 1:58 PM revealed Resident #24's oxygen tubing hung over the side of her bed. The oxygen concentrator was on, and you could her the oxygen running through the tubing, but Resident #24 was not wearing her oxygen. In an interview on 12/1/24 at 1:58 PM, Resident #24 stated she puts her oxygen back on when she needs it, and she can tell when she needs it. In an interview on 12/2/24 at 2:45 PM, LVN-F stated that Resident #24 removes her oxygen frequently and wears it over or her or will hang it on her bed. In an interview on 12/4/24 at 12:45 PM, the DON stated Resident #24 takes her oxygen off repeatedly and wears on her head or hangs on her bed, and we should have care planned the fact she frequently removes it on her on. He also stated that DON, MDS and staff nurses were responsible for updating the care plans. 3. Record review of Resident #37's face sheet dated 12/03/24 reflected an [AGE] year-old-male with an original admitted [DATE]. Diagnoses included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), hypertension (high blood pressure), and atrial fibrillation (irregular and often very rapid heart rhythm). Record review of Resident #37's physician orders dated 11/20/24 reflected an arterial wound to right heel. Cleanse with NS, pat dry, apply skin prep (protective film or barrier), leave open to air, every day/shift. Record review of Resident #37's care plan initiated on 8/13/24 did not reflect Resident #37 had an arterial wound to right heel. Record review of Resident #37's quarterly MDS dated [DATE] reflected Resident #37 had a BIMS score of 9 (moderate cognitive impairment), had one arterial ulcer present, and was at risk of developing pressure ulcers/injuries. In an interview on 12/3/24 at 2:50pm the MDS Coordinator stated she was in charge of initial care plans and as conditions and needs of the resident changed, the DON, ADON, and nurses could make changes in care plan as needed. The MDS Coordinator stated she audited care plans quarterly, but the DON was in charge of ensuring overall accuracy. In reference to Resident #14's Enhanced Barrier Precautions, the MDS Coordinator stated, Our corporate people were back and forth on whether it should or should not be care planned. It would be a good idea to care plan EBP, but corporate never stated yes or no about care planning that (EBP). The MDS Coordinator stated Resident #37's arterial wound should have been care planned. In reference to Resident #37's wound, the MDS Coordinator stated it was important to have any wounds care planned so they can be monitored, and direct care staff could be aware of Resident #37's individualized plan of care and needs. The MDS Coordinator stated she was not sure how Resident #37 would be affected by not having his wound care planned. The MDS Coordinator stated when a resident had a new order or condition it was discussed in morning meetings, and she was in charge of updating the care plan but Resident #37's wound was overlooked. In an interview on 12/4/24 at 9:47am the DON stated Resident 37's wound should have been care planned to make sure everyone was aware of the wound and the plan of care. The DON stated it was an oversight. The DON stated nurses usually initiated the care plans, MDS would check it, and the DON oversees accuracy. The DON stated Resident #37 could be affected but the resident did have an order for wound care and was getting weekly skin assessments (verified through record review). The DON stated that even though the Enhanced Barrier Precautions were not care planned for Resident #14, the facility was using EBP for him and that there was a sign on the door to his room and PPE available in the hallway (verified through observation). The DON stated that he did not think the facility had done an in-service on care plans or revisions lately. Record review of the facility's Care Plans, Comprehensive Person-Centered policy dated 10/22 and reviewed 11/24 stated in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being; 9. Areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record review of the facility's Enhanced Barrier Precautions policy and procedure dated 4/1/24 reflected in part: EBP are indicated for residents with any of the following: Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with an MDRO. Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Because EBP do not impose the same activity and room placement restrictions as Contact Precautions, they are intended to be in place for the duration of the resident ' s stay in the facility or until the discontinuation of the indwelling medical device that placed them at higher risk. Communication to staff/ medical professionals: The facility will utilize postings outside the room and Point Click Care (the facility's electronic health record) to communicate to staff if a resident requires EBP. 50969

Based on interviews and record review, the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 8 residents (Resident #8) reviewed for physician notification. The facility failed to ensure RN A notified Resident #8's provider when RN A did not administer Resident #8's Tresiba as prescribed by the physician on 8 of 9 opportunities from 11/1/24 to 11/30/24. This failure could affect residents by placing them at risk of not receiving the therapeutic effects of medications, decline in health, and death. The findings included: Record review of Resident #8's admission record reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8's diagnoses included type 2 diabetes mellitus with hyperglycemia (persistently high blood sugar), type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage caused by persistently high blood sugar) and cognitive communication deficit. Record review of Resident #8's quarterly MDS dated [DATE] reflected a BIMS of 8 which indicated moderate cognitive impairment. Record review of Resident #8's order summary report reflected the following orders: Check blood sugar levels via accucheck one time a day related to type 2 diabetes mellitus with hyperglycemia ordered on 7/9/24. Tresiba FlexTouch Subcutaneous Solution Pen Injector 100 units/ml (Insulin Degludec) Inject 62 units subcutaneously one time a day for diabetes ordered on 11/1/24. Record review of Resident #8's November 2024 MAR reflected the following: An order for Tresiba FlexTouch Subcutaneous Solution Pen Injector 100 units/ml (Insulin Degludec) Inject 62 units subcutaneously one time a day for diabetes at 6:00am, ordered on 11/1/24 at 3:51pm. This medication was held by RN A on 11/3/24 (BS 108), 11/10/24 (BS 97), 11/11/24 (BS 84), 11/17/24 (BS 81), 11/18/24 (BS 101), 11/24/24 (BS 83), 11/25/24 (BS 91), and 11/28/24 (BS 106) which was 8 of 9 opportunities that RN A had to administer the medication. Attempts were made to contact RN A for interview on 12/3/24 at 3:33pm, 12/4/24 at 9:15am and 12:39pm by the state surveyor and on 12/04/24 at 09:43am, 12:36pm, and 12:37pm, by the DON with no success. In a telephone interview on 12/4/24 at 10:00am, LVN D stated Resident #4's Tresiba order stated to give 62 units every morning and there was not a hold parameter. LVN D stated the Tresiba was a pen, and the needles were changed every morning, though she did not recall an order to change it every morning. LVN D stated they were not able to automatically see the previous doses that were given or held in the MAR. LVN D stated if there was an order for insulin that did not have a hold parameter, but it was held anyway, it could cause the resident's sugar to go high and could result in complications such as kidney damage. LVN D stated if a medication was held, they would notify the physician right away and it was documented in the progress notes or in a communication to the physician. LVN D stated, If we did not notify the physician about holding medications, we could get into trouble. It could cause the resident to have hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). LVN D stated the last in-service on medication administration was 2-3 weeks ago. LVN D stated the nurses, charge nurses, and the DON are responsible for making sure the orders were accurate. LVN D stated if there was an order that was not accurate, they would notify the DON, the administrator, and the physician. LVN D stated an order could not be changed without notifying the physician. LVN D stated the last in service on SBAR and notification was not too long ago. In an interview on 12/4/24 at 12:15pm the DON stated he did not know why the Tresiba was held since there were no hold orders. The DON stated it was important to follow physician orders for the Tresiba administration to make sure Resident #8's sugar did not go higher, the medication had the desired effect, and the resident did not have any undesired consequences. The DON stated he and the ADON were responsible for making sure that orders made sense and were followed. The DON stated if a medication was held, the physician should have been notified by telephone at that time, and it was supposed to be documented in the progress notes right away. The DON stated the last in-service on medication administration was in October and nurses were checked off on medication administration during orientation. The DON stated every morning they would pull an orders report that would show all of the new orders and any orders that were placed on hold, but they did not have a report to tell them when medications were not given. The DON stated he did not recall seeing that there was a pattern with Resident #8's Tresiba being held. The DON stated information regarding medications, treatments, etc. were put into the 24-hour report to pass along to the next shift, but he did not recall hearing anything about Resident #8 not getting her Tresiba during morning meetings. In an interview on 12/4/24 at 2:43pm the MD stated he was not aware of Resident #8's Tresiba being held and he would have expected to have been notified when it was held. The MD stated if he had been notified that the medication was not given, he would have asked the nurse why it was held and provided clarification of his order. The MD stated if medications were not given when they were supposed to be, it could cause the resident to have complications. The MD stated that if he was not notified of medication issues, he would not know what was going on with the resident and would not be able to provide effective care and treatment for the residents. The MD stated he would talk with the DON and the nurse to find out why the medication was not given and why he was not notified. Record review of the facility's Change of Condition and Physician/Family Notification policy dated 8/11/20 and reviewed 5/17/24 reflected in part: Purpose: To ensure that resident's family and/or legal representative and physician are notified of resident changes that fall under the following categories: A need to significantly alter treatment. Procedure: When any of the above situations exist, the licensed nurse will contact the resident's family and their physician. Non-emergency notifications may be made [to the physician] the next morning if the situation occurs on the late evening or night shift. This applies to any day of the week including holidays. In a non-emergency situation, the primary physician will be called unless he/she has left an alternate name to call. Each attempt will be charted as to time the call was made, who was spoken to, and what information was given to the physician. Examples of significant changes: Medication error. Record review of the facility ' s Medication Administration Policy dated 4/1/19 and reviewed 7/8/24 reflected in part: 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident ' s attending physician or the facility's medical director to discuss the concerns.

Based on observation, interviews and record reviews the facility failed to ensure that the comprehensive care plan was periodically reviewed and revised by a team of qualified persons after each assessment, including both the comprehensive and quarterly review assessments for 1 (Resident #14) of 8 residents reviewed for care plan revision. The facility failed to update Resident #14 ' s care plan when he no longer had a urinary catheter. This failure could place residents at risk of not receiving the care and services necessary to meet their current needs and achieve or maintain their highest practicable level of health and well-being. The findings included: Record review of Resident #14 ' s admission record reflected a [AGE] year-old male that was admitted to the facility on [DATE] with an original admitted [DATE]. Resident #14 ' s diagnoses included End Stage Renal Failure (a condition in which the kidneys no longer function), dependence on renal dialysis (a treatment used to remove waste and excess fluid from the blood), dementia (a group of symptoms that affect memory and thinking and interferes with daily life), and hypertension (high blood pressure). Record review of Resident #14 ' s quarterly MDS dated [DATE] reflected a BIMS score of 5, which indicated that Resident #14 had severe cognitive impairment. Section H- Bladder and bowel reflected that Resident #14 did not have a urinary catheter present. Record review of Resident #14 ' s care plan reflected the following: Focus: The resident has a F/C (foley catheter) r/t obstructive uropathy d/t BPH (benign prostatic hypertrophy- a condition in which the prostate is enlarged). Date initiated 6/2/23. Revised on: 6/2/23. Record review of Resident #14 ' s EHR (electronic health record) reflected 2 documented care plan meetings dated 7/6/23 and 11/9/23 in which Resident #14 ' s urinary catheter was not reviewed. No other care plan meetings were documented in Resident #14 ' s EHR (Electronic Health Record). Observation on 12/1/24 at 3:20pm reflected that Resident #14 did not have a urinary catheter. In an interview on 12/3/24 at 2:50pm the MDS Coordinator stated she was in charge of initial care plans and as conditions and needs of the resident changed, the DON, ADON, and nurses could make changes in care plan as needed. The MDS Coordinator stated she audited care plans quarterly, but the DON was in charge of ensuring overall accuracy. In reference to Resident #14 ' s foley catheter, the MDS Coordinator stated that Resident #14 had the urinary catheter removed and replaced a couple of times but that it was discontinued on 9/10/24. The MDS Coordinator stated Resident #14 ' s last quarterly MDS was on 11/21/24 and that the urinary catheter was not marked on it, so it should have been discontinued on the care plan when Resident #14 was no longer using a catheter. The MDS Coordinator stated when a resident had a new order or condition it was discussed in morning meetings, and she was in charge of updating the care plan, but she missed Resident #14 ' s urinary catheter removal. In an interview on 12/4/24 09:47am the DON stated the nurses usually initiated the care plan, the MDS Coordinator would make any changes that were needed then the DON would look at it. The DON stated that Resident #14's urinary catheter should have been taken off the care plan when the orders were discontinued and that the MDS Coordinator or the DON would have been responsible for taking it off. The DON stated it was just oversite on their part as to why it was not taken off. Record review of the facility ' s Care Plans, Comprehensive Person-Centered policy dated 10/22 and reviewed 11/24 stated in part: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident. 13. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents ' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident ' s condition; d. At least quarterly, in conjunction with the required quarterly MDS assessment.

F-tag initiation Based on observations, interviews and record reviews, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 2 residents (Resident #24) reviewed for quality of care. 1. The facility failed to ensure Resident #24's implanted medi-port was accessed and flushed appropriately per policy and physician's orders. 2. The facility failed to ensure nurses documented the access and flush of the implanted med-port appropriately and accurately. 3. The facility failed to ensure the nurses were properly trained to access and flush the implanted med-port appropriately. These failures could place residents at risk for complications such as infection, blood clot, occlusion of catheter and/or infiltration. The findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female with an original admitted [DATE] and a current admitted [DATE]. Resident #24 had diagnoses which included, but are not limited to: Epilepsy (a seizure disorder), Intermittent Explosive Disorder (impulsive anger outbursts), Generalized Anxiety (anxiousness), Heart Failure, Unspecified Sequelae of Cerebral Infarction (long term effects of a stroke), Dysphagia and Gastrostomy. Record review of Resident #24's Optional State Assessment MDS dated [DATE] revealed resident had a BIMS score of 15, which indicated the residents was cognitively intact. Record review of Resident #24's Medication Administration Records and Treatment Administration Records revealed: **December 2024 MAR had no saline flush of implanted medi-port due until 12/31/24; **November 2024 MAR revealed Medi-port accessed via Huber needle on 11/2/24; **November 2024 MAR revealed normal saline flush of implanted medi-port scheduled for 11/20/24, but never signed that it was performed. **October 2024 MAR revealed Huber needle access scheduled for 10/02/24, but never signed that it was performed. **October 2024 MAR revealed normal saline flush of implanted medi-port scheduled and signed as completed for 10/31/24. **September 2024 MAR revealed Huber needle access scheduled for 9/2/24, but never signed that it was performed. **September 2024 MAR revealed normal saline flush of implanted medi-port scheduled and signed as completed 9/30/24. Record review of Resident #24's physician orders revealed the Huber needle order showed a revised date of 11/30/2024 with a new start date of 12/1/2024, and the normal saline flush was originally ordered on 8/31/2024, revised 8/22/2024, and put on hold on 9/12/2024. There were no new or revised orders after this to resume or restart the medi-port flush. Physician's orders also revealed there was never an order to flush the medi-port with heparin. Record review of Resident #24's progress note, dated 11/30/2024, revealed the physician had given orders to discontinue implanted medi-port flush due to high risk of infection due to Resident #24's lack of hygiene. Record review of Attendance/In-Service Records revealed a Medication Administration in-service was done with the nursing staff on 10/15/2024. Record review of Resident #24's care plan, initiated 8/27/24, revealed Resident #24 has an implanted port that could be used with physician's orders and access of a Huber needle. Observation 12/1/24 at 1:58 PM revealed an almost empty bottle of water at Resident #24's bedside. Resident #24's Foley Catheter hung on the bedside. The urine was yellow but clear. Observation also revealed the medi-port to the upper chest wall was not accessed at this time. Observation on 12/2/24 at 2:30 PM revealed almost empty Pepsi bottle and an almost empty large bag of candy and cookies in Resident #24's room, which reveals that resident is getting some form of nutrition and hydration. Interview with Resident #24 on 12/01/24 at 1:58 PM, she stated she was still not eating, except cream of wheat and tomato soup because no one was watching her eat. Resident #24 stated she thought she was dehydrated and had a urinary tract infection but could not drink water because it made her sick to her stomach unless it had Kool-Aid in it. She stated her urine has been dark. She stated she had some low back pain, but mostly her chronic lower extremity pain. She had a 3/4 eaten fruit cup as well as a large package of cookies at bedside that was approximately 3/4 empty, as well as a very large bag of candy that was probably 3/4 gone. Interview with Resident #24 on 12/02/24 at 02:30 PM, Resident #24 stated she told at least three nurses that her urine looked bad and she didn't want her kidneys to go out again. She was unsure of which three nurses she told. She stated she bought her own sodas to drink and sell, and she also keeps some in her fridge. Resident #24 stated she asked about IV fluids through her medi-port because she felt dehydrated, but they wouldn't do it for her. She stated they (the nurses at this facility) were supposed to be flushing her medi-port, but that the administrator told her they were not going to pay $500 for kits to flush her port if she was not going to let them do it correctly. Interview with CNA-E on 12/4/24 at 12:00 PM, she stated she has worked here approximately 1.5 years, so she knows this resident, and Resident #24 refused hygiene frequently. She refused 6-2, 2-10 and 10-6 shift. There was a specific CNA on 2-10 that she preferred to have perform her hygiene, and Resident #24 would only accept bed baths from that CNA. She was still scheduled for 10- 6 shift for shower or bed bath, but the other 2-10 CNA would give them if she was working. CNA-E stated Resident #24 had not complained about urinary tract infections or dehydration to her or anyone else she knew of. She stated the CNAs were the ones who emptied the foley, and if the urine was dark, the nurse was notified, but stated Resident #24's urine had not been dark or had an odor to it. Interview with LVN-F on 12/02/24 at 02:45 PM, she stated the Resident had not complained of low back pain, urinary tract infection or feeling dehydrated. She stated Resident #24 never requests specific snacks, Gatorade or Pedialyte and has never requested IV fluids from her or anyone else that she knows of. LVN-F also stated Resident #24 had not complained of urgency, burning or low back pain, and she bought her own Kool-Aid and sodas to drink, but she has never buys Gatorade or Pedialyte. LVN-F stated Resident #24 had no recent infections, to include urinary tract infections. LVN-F also stated no medications or treatments were withheld, and the Medi-port had only been accessed and flushed by RNs. Interview with RN-H on 12/2/24 1:58 PM, she stated Resident #24 had not voiced any concerns to the nurses about her foley or urine, as well as had not complained of any low back pain, urgency or frequency. She usually complained about lower extremity pain, but that was it. RN-H stated she had accessed the medi-port to flush it as ordered monthly. She stated she prepped the area first, held the port, felt for the center, accessed the port, pulled back to check for blood return, then flushed with normal saline and then heparin. She stated she did not know why the MARs showed the port and flush were being done on separate days/times because they are done together. She attempted to pull up the order on her computer but couldn't find the order because it was discontinued. She also stated she was not sure why any of the nurses would continue to access and flush the port if the order was discontinued or held. When asked to show the order for Heparin, she stated she was wrong, there was no order for Heparin, and they did not flush the port with Heparin. RN-H also looked and could not find the order to discontinue the saline flush, even though it was not showing up in her medications anymore. Interview with the DON on 12/02/24 at 03:13 PM, he stated Resident #24 had Medi-port prior to admission to this facility, and nursing had been flushing the port monthly since she had been here at the facility. He stated these should be documented on the Treatment Administration Record, but he would look to see if they were documented somewhere else. DON also stated that he is not sure why the flush is showing that it is being done on a different day than the port is being accessed because they are supposed to be done together. The DON looked at the order for the saline flush, which was put on hold when Resident #24 was admitted to the hospital in September 2024, and never could find an order to resume flushes when the Resident came back to the facility. He stated it was only supposed to be a three day hold, then resumed or renewed. He stated if the order was never resumed or renewed, the nurses would not have been able to sign, so something must be wrong with the order. He also stated he was not sure why there was a progress not to discontinue the flush. Interview with the DON on 12/4/24 at 12:45 PM, he stated the nurses were not trained, in-serviced or had annual skills checkoffs for implanted medi-port access or maintaining the medi-port. Record review of the facility's Intravenous Catheter Policy, updated 10/2022 and reviewed 01/2023, revealed under general guidelines, paragraph 1, facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy; 2 - staff may only insert catheter types for which they have adequate training and demonstrated skill. Record review of the facility's Intravenous Therapy Policy, with a revision date of 03/2022, revealed for a port that is not being accessed for infusing or intermittent medication administration, under the Frequency section, 4 - flush implanted venous ports not accessed for infusions with at least 10ml preservative-free 0.9% sodium chloride and 3-5ml heparin 100 units ml every 3 months for maintenance flushing or refer to manufacturer's instruction. Record review of the facility's Charting and Documentation Policy, revised 07/2017, revealed under Policy Interpretation and Implementation: 2 - the following information is to be documented in the resident medical record: objective observations, medications administered, treatment of services performed, changes in resident's condition, events involving the resident, progress or changes in the care plan goals or objectives.

Based on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #44) reviewed for accidents and hazards. The facility failed to ensure floor mats were in place beside Resident #44's bed . This failure could place residents at risk for an injury or a major injury. The findings include: Record review of Resident #44's face sheet, dated 12/02/24, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #44 had a diagnosis which included cerebral infarction (a serious that occurs when brain tissue die due to lack of blood flow to brain). Record review of Resident #44's Significant Change Minimum Data Set, dated dated dated [DATE] indicated she had severe cognitive impairment with unclear speech. Record review of Resident #44's care plan dated 11/26/24 indicated: The resident has had an actual fall 4/3/2024 unwitnessed fall-no injury 4/6/2024 unwitnessed fall- no injury 4/15/24 unwitnessed fall 4/15/24 intervention- fall mats Record review of Resident #44's December 2024 physician orders reflected there was no order for floor mat usage Record Review of Resident #44 Fall Risk Assessment/ Morse Fall Scale reflected 30 -a moderate risk or falling. Observation on 12/02/24 at 11:42 AM revealed Resident #44 was lying in bed with eyes closed. Resident #44 had a floor mat on the floor on the left side of her bed but not on her right side. Observation on 12/02/24 at 03:27 PM revealed Resident #44 was lying in bed on her right side with her eyes closed. Resident #44 has a floor mat on the floor on the left side of her bed but not on her right side. Interview with CNA C on 12/02/14 at 3:45 PM revealed the floor mats were to be in place to prevent any injury to the resident in case she rolled over and fell out of bed. CNA C stated it was the CNAs nurse and DON's responsibility to ensure the mats were in place. CNA C said she checked the Kardex which informed her the mat was required for the resident. CNA C said she did not notice the right floor mat was not in place since she just started her shift at 3:00 PM. CNA C said if Resident #44 fell on her right side she may acquire an injury. Interview with LVN B on 12/02/24 at 03:47 PM revealed the purpose of the floor mats were to prevent any major injury if Resident #44 fell out of bed. LVN B said Resident #44 should have a floor mat on each side of the bed. LVN B said she had not noticed the right floor mat was not in place and that's because she walked through that part of the area to move the oxygen concentrator and feeding pump. LVN B said it was the responsibility of all nursing staff to ensure the floor mats were in place on both sides of the bed. LVN B said if the mats were not in place and Resident #44 fell out of bed, she could acquire a major injury. Interview with the DON on 12/03/24 at 2:35 PM, the DON stated the floor mats were used to prevent injuries in case of a fall. The DON stated the floor mats should be at each side of the bed if the bed was centered in the room. The DON said nothing should be placed on top of the floor mats. The DON said the nurses and CNAs were responsible for monitoring the position of the floor mats. The DON stated the Resident could injure herself if the floor mat was not properly placed. Injuries could include bruising, skin tears, and fractures. The DON said he and the ADON conducted daily rounds to monitor preventive devices were placed correctly. Record review of the facility's Fall Prevention Program policy dated 06/10/24 reflected All residents will be assessed for the risk for falls at the time of admissions, on a quarterly basis, and upon significant change in condition thereafter. Based on the results of this assessment, specific interventions will be to minimize falls and avoid repeat falls and minimize falls resulting in significant injury 3. The following is a list of commonly used interventions that may be considered to minimize falls and injury . K. Utilizing adaptive equipment such as - walker, cane, grab bars, etc.

Based on interviews and record reviews, the facility failed to provide resident with he appropriate competencies and skills sets to provide nursing and related services to assure residents safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for 1 of 5 residents (Resident #24). The facility failed to ensure that nursing staff were educated on the steps and protocols to access and flush Resident #24's implanted medi-port. These failures could place residents at risk for complications such as infection, blood clot, occlusion of catheter and/or infiltration. The findings include: Record review of Resident #24's face sheet revealed a [AGE] year-old female with an original admitted [DATE] and a current admitted [DATE]. Resident #24 had diagnoses which included, but are not limited to: Epilepsy (a seizure disorder), Intermittent Explosive Disorder (impulsive anger outbursts), Generalized Anxiety (anxiousness), Heart Failure, Unspecified Sequelae of Cerebral Infarction (long term effects of a stroke), Dysphagia and Gastrostomy. Record review of Resident #24's Optional State Assessment MDS dated [DATE] revealed resident had a BIMS score of 15, which indicated the residents was cognitively intact. Record review of Resident #24's Medication Administration Records and Treatment Administration Records revealed: **December 2024 MAR had no saline flush of implanted medi-port due until 12/31/24; **November 2024 MAR revealed Medi-port accessed via Huber needle on 11/2/24; **November 2024 MAR revealed normal saline flush of implanted medi-port scheduled for 11/20/24, but never signed that it was performed. **October 2024 MAR revealed Huber needle access scheduled for 10/02/24, but never signed that it was performed. **October 2024 MAR revealed normal saline flush of implanted medi-port scheduled and signed as completed for 10/31/24. **September 2024 MAR revealed Huber needle access scheduled for 9/2/24, but never signed that it was performed. **September 2024 MAR revealed normal saline flush of implanted medi-port scheduled and signed as completed 9/30/24. Record review of Resident #24's physician orders revealed the Huber needle order showed a revised date of 11/30/2024 with a new start date of 12/1/2024, and the normal saline flush was originally ordered on 8/31/2024, revised 8/22/2024, and put on hold on 9/12/2024. There were no new or revised orders after this to resume or restart the medi-port flush. Physician's orders also revealed there was never an order to flush the medi-port with heparin. Record review of Resident #24's progress note, dated 11/30/2024, revealed the physician had given orders to discontinue implanted medi-port flush due to high risk of infection due to Resident #24's lack of hygiene. Record review of Attendance/In-Service Records revealed a Medication Administration in-service was done with the nursing staff on 10/15/2024. Record review of Resident #24's care plan, initiated 8/27/24, revealed Resident #24 has an implanted port that could be used with physician's orders and access of a Huber needle. Observation 12/1/24 at 1:58 PM revealed an almost empty bottle of water at Resident #24's bedside. Resident #24's Foley Catheter hung on the bedside. The urine was yellow but clear. Observation also revealed the medi-port to the upper chest wall was not accessed at this time. Observation on 12/2/24 at 2:30 PM revealed almost empty Pepsi bottle and an almost empty large bag of candy and cookies in Resident #24's room, which reveals that resident is getting some form of nutrition and hydration. Interview with Resident #24 on 12/01/24 at 1:58 PM, she stated she was still not eating, except cream of wheat and tomato soup because no one was watching her eat. Resident #24 stated she thought she was dehydrated and had a urinary tract infection but could not drink water because it made her sick to her stomach unless it had Kool-Aid in it. She stated her urine has been dark. She stated she had some low back pain, but mostly her chronic lower extremity pain. She had a 3/4 eaten fruit cup as well as a large package of cookies at bedside that was approximately 3/4 empty, as well as a very large bag of candy that was probably 3/4 gone. Interview with Resident #24 on 12/02/24 at 02:30 PM, Resident #24 stated she told at least three nurses that her urine looked bad and she didn't want her kidneys to go out again. She was unsure of which three nurses she told. She stated she bought her own sodas to drink and sell, and she also keeps some in her fridge. Resident #24 stated she asked about IV fluids through her medi-port because she felt dehydrated, but they wouldn't do it for her. She stated they (the nurses at this facility) were supposed to be flushing her medi-port, but that the administrator told her they were not going to pay $500 for kits to flush her port if she was not going to let them do it correctly. Interview with CNA-E on 12/4/24 at 12:00 PM, she stated she has worked here approximately 1.5 years, so she knows this resident, and Resident #24 refused hygiene frequently. She refused 6-2, 2-10 and 10-6 shift. There was a specific CNA on 2-10 that she preferred to have perform her hygiene, and Resident #24 would only accept bed baths from that CNA. She was still scheduled for 10- 6 shift for shower or bed bath, but the other 2-10 CNA would give them if she was working. CNA-E stated Resident #24 had not complained about urinary tract infections or dehydration to her or anyone else she knew of. She stated the CNAs were the ones who emptied the foley, and if the urine was dark, the nurse was notified, but stated Resident #24's urine had not been dark or had an odor to it. Interview with LVN-F on 12/02/24 at 02:45 PM, she stated the Resident had not complained of low back pain, urinary tract infection or feeling dehydrated. She stated Resident #24 never requests specific snacks, Gatorade or Pedialyte and has never requested IV fluids from her or anyone else that she knows of. LVN-F also stated Resident #24 had not complained of urgency, burning or low back pain, and she bought her own Kool-Aid and sodas to drink, but she has never buys Gatorade or Pedialyte. LVN-F stated Resident #24 had no recent infections, to include urinary tract infections. LVN-F also stated no medications or treatments were withheld, and the Medi-port had only been accessed and flushed by RNs. Interview with RN-H on 12/2/24 1:58 PM, she stated Resident #24 had not voiced any concerns to the nurses about her foley or urine, as well as had not complained of any low back pain, urgency or frequency. She usually complained about lower extremity pain, but that was it. RN-H stated she had accessed the medi-port to flush it as ordered monthly. She stated she prepped the area first, held the port, felt for the center, accessed the port, pulled back to check for blood return, then flushed with normal saline and then heparin. She stated she did not know why the MARs showed the port and flush were being done on separate days/times because they are done together. She attempted to pull up the order on her computer but couldn't find the order because it was discontinued. She also stated she was not sure why any of the nurses would continue to access and flush the port if the order was discontinued or held. When asked to show the order for Heparin, she stated she was wrong, there was no order for Heparin, and they did not flush the port with Heparin. RN-H also looked and could not find the order to discontinue the saline flush, even though it was not showing up in her medications anymore. Interview with the DON on 12/02/24 at 03:13 PM, he stated Resident #24 had Medi-port prior to admission to this facility, and nursing had been flushing the port monthly since she had been here at the facility. He stated these should be documented on the Treatment Administration Record, but he would look to see if they were documented somewhere else. DON also stated that he is not sure why the flush is showing that it is being done on a different day than the port is being accessed because they are supposed to be done together. The DON looked at the order for the saline flush, which was put on hold when Resident #24 was admitted to the hospital in September 2024, and never could find an order to resume flushes when the Resident came back to the facility. He stated it was only supposed to be a three day hold, then resumed or renewed. He stated if the order was never resumed or renewed, the nurses would not have been able to sign, so something must be wrong with the order. He also stated he was not sure why there was a progress not to discontinue the flush. Interview with the DON on 12/4/24 at 12:45 PM, he stated the nurses were not trained, in-serviced or had annual skills checkoffs for implanted medi-port access or maintaining the medi-port. Record review of the facility's Intravenous Catheter Policy, updated 10/2022 and reviewed 01/2023, revealed under general guidelines, paragraph 1, facility staff who manage infusion catheters will have training and demonstrated clinical competency in intravenous therapy; 2 - staff may only insert catheter types for which they have adequate training and demonstrated skill. Record review of the facility's Intravenous Therapy Policy, with a revision date of 03/2022, revealed for a port that is not being accessed for infusing or intermittent medication administration, under the Frequency section, 4 - flush implanted venous ports not accessed for infusions with at least 10ml preservative-free 0.9% sodium chloride and 3-5ml heparin 100 units ml every 3 months for maintenance flushing or refer to manufacturer's instruction. Record review of the facility's Charting and Documentation Policy, revised 07/2017, revealed under Policy Interpretation and Implementation: 2 - the following information is to be documented in the resident medical record: objective observations, medications administered, treatment of services performed, changes in resident's condition, events involving the resident, progress or changes in the care plan goals or objectives.

Based on interviews and record review, the facility failed ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #8) reviewed for significant medication errors. The facility failed to ensure that RN A administered Resident #8's Tresiba Flex Touch Solution Pen Injector on 8 of 9 opportunities from 11/1/24 to 11/30/24. This failure could place residents at risk of a decline in condition or hospitalization . The findings included: Record review of Resident #8's admission record reflected a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident #8 ' s diagnoses included type 2 diabetes mellitus with hyperglycemia (persistently high blood sugar), type 2 diabetes mellitus with diabetic polyneuropathy (nerve damage caused by persistently high blood sugar) and cognitive communication deficit. Record review of Resident #8's quarterly MDS dated [DATE] reflected a BIMS of 8 which indicated moderate cognitive impairment. Record review of Resident #8's order summary report reflected the following orders: Check blood sugar levels via accucheck one time a day related to type 2 diabetes mellitus with hyperglycemia ordered on 7/9/24. Tresiba FlexTouch Subcutaneous Solution Pen Injector 100 units/ml (Insulin Degludec) Inject 62 units subcutaneously one time a day for diabetes ordered on 11/1/24. Record review of Resident #8's November 2024 MAR reflected the following: An order for Tresiba FlexTouch Subcutaneous Solution Pen Injector 100 units/ml (Insulin Degludec) Inject 62 units subcutaneously one time a day for diabetes at 6:00am (There were no hold parameters). Ordered on 11/1/24 at 3:51pm. This medication was held by RN A on 11/3/24 (BS 108), 11/10/24 (BS 97), 11/11/24 (BS 84), 11/17/24 (BS 81), 11/18/24 (BS 101), 11/24/24 (BS 83), 11/25/24 (BS 91), and 11/28/24 (BS 106) which was 8 of 9 opportunities that RN A had to administer the medication. Attempts were made to contact RN A for interview on 12/3/24 at 3:33pm, 12/4/24 at 9:15am and 12:39pm by the state surveyor and on 12/04/24 at 09:43am, 12:36pm, and 12:37pm, by the DON with no success. In an interview on 12/4/24 at12:15pm the DON stated he did not know why the Tresiba was held since there were no hold orders. The DON stated it was important to follow physician orders for the Tresiba administration to make sure Resident #8's sugar did not go higher, the medication had the desired effect, and the resident did not have any undesired consequences. The DON stated he and the ADON were responsible for making sure that orders made sense and were followed. The DON stated if a medication was held, the physician should have been notified by telephone at that time, and it was supposed to be documented in the progress notes right away. The DON stated the last in-service on medication administration was in October and nurses were checked off on medication administration during orientation. The DON stated every morning they would pull an orders report that would show all of the new orders and any orders that were placed on hold, but they did not have a report to tell them when medications were not given. The DON stated he did not recall seeing that there was a pattern with Resident #8's Tresiba being held. The DON stated information regarding medications, treatments, etc. were put into the 24-hour report to pass along to the next shift, but he did not recall hearing anything about Resident #8 not getting her Tresiba during morning meetings. In an interview on 12/4/24 at 2:43pm the MD stated he was not aware of Resident #8's Tresiba being held and he would have expected to have been notified when it was held. The MD stated if he had been notified that the medication was not given, he would have asked the nurse why it was held and provided clarification of his order. The MD stated if medications were not given when they were supposed to be, it could cause the resident to have complications. The MD stated that if he was not notified of medication issues, he would not know what was going on with the resident and would not be able to provide effective care and treatment for the residents. The MD stated he would talk with the DON and the nurse to find out why the medication was not given and why he was not notified. Record review of the facility ' s Medication Administration Policy dated 4/1/19 and reviewed 7/8/24 reflected in part: Medications are administered in a safe and timely manner, and as prescribed. 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions. 4. Medications are administered in accordance with prescriber orders, including any required time frame. 8. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident ' s attending physician or the facility ' s medical director to discuss the concerns.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention program to provide a safe and sanitary environment for 1 of 1 laundry room, and 1 of 1 facility reviewed for infection control, in that: The facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread by not testing for Legionella and not implementing a system for doing so. The facility failed to ensure laundry was disinfected properly by failing to sort garments before washing to prevent cross-contamination These failures could place all residents of the facility at risk for airborne infection and cross-contamination. The findings included: Observation of the washing machine in the laundry on 09/14/23 at 3:15 p.m. revealed blankets, sheets, towels, and gowns in the same load. There were two manufacturer posters on the wall in the laundry directly across from the washers. One of the posters was titled, Linen Handling Procedures which addressed sorting soiled linen, loading washers, avoiding overloading, and keeping all equipment clean. The other poster was titled, Laundry System Process Information, which had 3 sections: Linen Types- sheets, towels, blankets, rags/mops, bed pads, personal, reclaim, and isolation. The section, Wash Program, had numbers listed for each linen type,1-8 to enter into the washing machine. Section Machine # was a list of numbers to push on the washers for dispensing the proper amount and type of chemicals for that load. There was another section, Wash Procedures which listed 1. Sort soiled linens 2. Shake out each piece to remove any items or trash 3. Separate stained items for pretreatment 4. Do not overload/underload the washer 5. Check the supply of laundry chemicals 6. Unload washed linens .7.place in dryer as soon as possible .8. Remove from dryer .9. Clean, folded linen should be stored for 24 hours for best overall results. Interviews with LAU (laundry) and HKS (housekeeping supervisor) on 09/14/23 at 3:37 p.m. regarding the sorting of linens, washer operation, and temperatures revealed that LAU stated she sorted the laundry according to the color of the clothing. LAU stated she sorted blankets, sheets, gowns, and towels to be washed separately. The LAU stated she put the load of blankets, sheets, gowns, and towels in the washer because it was the last load of the day, and it was a small load. The LAU could not state why it was important to separate the laundry. The LAU did not know what temperature the washer should be. The HKS stated the laundry staff, including herself, had never had any training or in-services on the washers, only to put the numbers in for the loads and chemicals. The HKS stated she was new at the facility and did not know who was responsible for training on laundry functioning. An interview with ICP on 09/14/23 at 3:40 p.m. stated laundry should be sorted and washed at certain temperatures to kill any germs but could not think of what those temperatures should be. The ICP stated she did not know who was responsible for for training laundry staff. The ICP stated she did not know how laundry staff were monitored to ensure handling of the laundry was within guidelines. An interview with the ADM on 09/14/23 at 3:53 p.m. stated the laundry should be sorted according to the manufacturer list (on the wall). The ADM stated sheets, blankets, and gowns should not be in the same load because there was cross-contamination with linens that may be more heavily soiled with body fluids as opposed to clothing that may not be more heavily soiled with body fluids. The ADM stated every garment should be washed at the proper temperature of 140-160F to kill germs according to the manufacturer. The ADM stated the automatic chemical dispensing was designed to dispense the proper amount of chemicals according to the load selected by the person sorting the laundry. The ADM stated laundry personnel were responsible for sorting and knowing the temperature garments should be washed. The ADM stated the facility tested for Legionella but did not know they had to send it to a lab. The ADM stated the facility used ph chem strips for testing Legionella. The ADM stated the MS was responsible for all water testing, including Legionella. The ADM stated he was not sure if the facility was testing for Legionnaires according to their policy. The ADM stated he was unaware the laundry was not being monitored, or who trained laundry staff. The ADM stated resident's, especially the elderly, could get very sick from cross-contaminated laundry because their immune systems were vulnerable. A record review of the facility Environment of Care Policy and Procedure Manual (2003) indicated that the water temperatures of the laundry and kitchen areas should be maintained at a temperature of 140 degrees F. An interview with the MS on 09/14/23 at 3:10 pm revealed he did not know what Legionnaire's (a serious type of pneumonia (lung infection) caused by Legionella bacteria. People can get sick when they breathe in small droplets of water or accidentally swallow water containing Legionella into the lungs) was, he had never tested for it and was unaware of the repercussions if Legionnaire's was to infect the building. The MS was also unaware of the facility policy, Legionella Water Management Program reviewed 03/28/23. A record review of the facility's Legionella Water Management Program Policy Interpretation and Implementation reviewed 03/28/23 indicated the water management program included the following elements: 5. b. A detailed description and diagram of the water system in the facility, including the following: 1. Receiving 2. Cold water distribution 3. Heating 4. Hot water distribution 5. Waste 5. c. The identification of areas in the water system that could encourage the growth and spread of Legionella or other waterborne bacteria, including storage tanks, water heaters, filters, aerators, showerheads and hoses, misters, atomizers, air washers and humidifiers, hot tubs, fountains and medical devices such as CPAP machines, hydrotherapy equipment etc. 5. d. The identification of situations that can lead to Legionella growth, such as: 1. Construction 2. Water main breaks 3. Changes in municipal water quality 4. The presence of biofilm, scale, or sediments 5. Water temperature fluctuations 6. Water pressure changes 7. Water stagnation 8. Inadequate disinfection 5. e. Specific measures used to control the introduction and/or spread of legionella (e.g., temperature, disinfectants) 5. f. The control limits or parameters that are acceptable and that are monitored 5. g. A diagram of where the control measures are in place 5. h. A system to monitor control limits and the effectiveness of control measures 5. i. A plan for when control limits are not met or not effective 5. j. Documentation of the program

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect for one of seven residents reviewed for falls. The facility did not follow the Physical Therapist's (PT) recommendation not to sit R#1 in a wheelchair. R#1 was placed in a wheelchair and then fell from the wheelchair on 11/29/15. R#1 sustained a broken nose and a cervical fracture (a broken neck) and was admitted to the hospital. This failure could affect the 38 residents at risk for falls that use a wheelchair in the facility. The findings were: The facility's Abuse and Neglect policy, effective date 01/2008 and revised on 05/2014 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. R#1's Admission Record dated 11/03/15 indicated R#1 was initially admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech; was understood and usually understood others. The MDS also indicated R#1 had inattention (easily distracted, out of touch or difficulty following what was said) and altered level of consciousness, both were present but fluctuated. The MDS indicated R#1 required extensive assistance for bed mobility by two plus persons assist; dressing, eating and toilet use by one person physical assist. The MDS also indicated R#1 was not steady and only able to stabilize with staff assistance during surface to surface transfers. Under Functional Limitation in Range of Motion, the MDS indicated R#1 had impairment on both sides of her lower extremities. The MDS also indicated R#1 had previous falls within the last month and the last two-six months. Hospital Record, Date of Procedure: 11/18/15 indicated R#1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The procedure performed was right [MEDICAL CONDITION] (RTBKA.) Admission/Readmission Data Summary dated 11/24/15 at 2:20 p.m. indicated R#1 was readmitted from the hospital with the added [DIAGNOSES REDACTED]. The Readmission Data Summary indicated R#1 was unable to orient to the facility due to the patient being very confused. Under physical restraints the summary indicated R#1 did not have any, but did have a low bed and floor mats. Review of Admission Care Plan dated 11/24/15 indicated R#1 11. Falls/Safety/Elopement Risk Goal: Resident will remain free of injuries and falls. Initials were placed on the following interventions: Keep call bell in reach; Orthostatic [MEDICAL CONDITION] precautions; Encourage use of call light; If unable to use call light, CNA (Certified Nurse Aide) will assess resident q (every) 30-60 minutes; Instruct resident on safety measures and PT (Physical Therapy) referral. Incident/Accident Report dated 11/25/15 at 6:00 p.m. indicated R#1 was observed on the floor mat on R#1's right side and that R#1 had hit the right side of her head on the floor. R#1 stated she was trying to get out of bed. A two centimeter laceration was noted to the right eyebrow with swelling noted to the eyebrow and cheek. physician's orders [REDACTED].#1 to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were Resident educated-reminded to use call light for assistance. Resident in low bed. The Incident/Accident Report also indicated the staff were in serviced on falls, evaluation and prevention. Physical Therapy (PT) Plan of Care: Start of Care 11/26/15 for R#1 indicated R#1's Medical Diagnosis 1 was Complete traumatic amputation at level between the knee and the ankle, right lower leg; Medical Diagnosis 2 was [MEDICAL CONDITION] with early onset; Medical Diagnosis 3 was Age-related physical debility and R#1's Treatment [DIAGNOSES REDACTED]. The reason for referral was this [AGE] year old female underwent a RT BKA onset 11-04-15 due to [MEDICAL CONDITION]. The patient also has prior old left AKA (above knee amputation) . The PT Plan of Care indicated precautions for R#1 were fall and cardiac precautions. The PT Plan of Care did not specify what these precautions were. The PT Plan of Care also indicated underlying impairments were Cognition Orientation was to person (x1) and Cognition, Safety Awareness was severely impaired. The assessment on R#1 for Balance, Static Sitting (Posture without motion) at her current level indicated R#1's grade was a P (poor-unable to maintain balance without moderate/maximum support). For Balance, Dynamic Sitting (Posture during active motion), R#1's grade was also poor. Under Current Level of Function, the PT Plan of Care indicated the patient unable to tolerate upright sitting in chair/wheelchair. Incident/Accident Report dated 11/29/15 at 10:50 a.m. indicated that R#1 was at the nurses station in her wheelchair with Licensed Vocational Nurse (LVN) C. The LVN turned her back and R#1 fell face first to the floor and hit her mid forehead area. The Incident/Accident Report indicated R#1 was was sent to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were continue with low bed and floor mats with constant supervision. Radiology Report, Date of Exam: 11/29/15 at 12:47 p.m. indicated the impression was severe [MEDICAL CONDITION] disease changes in lower cervical spine and irregularity of anterior ring of C1 (vertebrae) compatible with a fracture at that site. Physician's Telephone Order dated 12/01/15 indicated R#1 was readmitted to the nursing facility and to continue with cervical collar at all times; monitor every shift and PT/OT (Occupational Therapy)/ST (Speech Therapy) to evaluate and treat as needed. R#1 was observed on 12/02/15 at 9:17 a.m. Surveyor accompanied by Licensed Vocational Nurse (LVN) A entered R#1's room. R#1 was on a low bed with a mat on the floor. R#1 had a neck brace; her face was swollen and around her eyes was a dark purple color. R#1 stated she was trying to get something from the car when she fell forward. LVN A asked R#1 when she had returned to the facility. R#1 stated she had gotten back today, five days ago. LVN A stated R#1 was mostly not able to respond appropriately, but at times, seemed alert and oriented. LVN A stated R#1 would try to get out of bed and had fallen previously. LVN A also stated R#1 had been in and out of geriatric psychiatric services, and had recently had her right leg amputated due to poor circulation. R#1 was observed on 12/02/15 at 12:55 p.m. R#1 had been moved to a room closer to the nurses station, since 9:17 a.m. At this time, CNA B stated that on 11/29/15, right before lunch, R#1 was in her wheelchair in front of the nurses station and R#1 tried to get up. CNA B stated R#1 was confused and disoriented before the fall. CNA B added R#1 would try to get out of bed also. LVN C stated on 12/02/15 at 1:40 p.m. that she was the charge nurse on Sunday, 11/29/15, the day R#1 fell . LVN C stated R#1 and family member (FM) H were disagreeing in her room. R#1 was telling FM H she wanted to go for a walk, and FM H was telling R#1 she did not have legs, so that made R#1 mad. LVN C stated the CNAs transferred R#1 to her wheelchair and brought her to the nurses station to distract her. LVN C stated she placed R#1's wheelchair against the wall, making sure the brakes were locked. LVN C then stepped forward to the counter to tell the CNAs to take the rest of the residents to the dining room for activities. LVN C stated she heard another resident yell out. When LVN C turned around she saw R#1 go forward. LVN C stated she tried to reach R#1 but was unable to catch her. LVN C stated R#1 had a regular wheelchair, and had thought R#1 could possibly fall, but because the facility was restraint free LVN C did not feel there was anything that could be put in place to hold R#1 in the wheelchair. LVN C stated R#1 had her left leg amputated prior to her admission to the facility and the right leg amputation recently, in November. LVN C stated she had not been involved in any meetings discussing R#1's risk for falls or fall prevention measures after the recent amputation. The Physical Therapist (PT) stated on 12/02/15 at 3:05 p.m. that the resident assessments were given to nursing staff, one to the Director of Nurses and the other was placed in the resident's medical chart. The PT stated each professional was required to become familiar with the resident's condition and the recommendations made. R#1 was observed in her room on 12/02/15 at 3:50 p.m. FM H was visiting the resident. FM H stated it was a terrible accident, but there should have been a way to help keep R#1 in the wheelchair. The Director of Nurses (DON) stated on 12/02/15 at 5:00 p.m. that prior to the recent right leg amputation, R#1 was sitting in a wheelchair. The DON stated there had not been any discussion on interventions to prevent R#1 from falling after her recent leg amputation. The DON said he could see how the recent amputation could have affected R#1's balance. The DON stated he was not sure if the PT meant R#1 could not tolerate sitting due to pain or what he meant. The DON added they already had the resident on a low bed, floor mat and in PT. R#1 was observed on 12/15/15 at 11:55 a.m. in the dining room. R#1 was sitting in a geri chair (a reclining chair) and she was wearing the neck brace and was feeding herself. CNA D stated on 12/15/15 at 2:55 p.m. that R#1 was in a regular wheelchair after her recent amputation, but was now in a geri chair. CNA D stated after R#1 had her leg amputated, she mostly stayed in bed. CNA D stated she had helped place R#1 in her wheelchair the day R#1 fell . CNA D added she had not received an in service concerning R#1 after her leg was amputated. CNA D stated PT did in services, but none had been given on R#1 to date. CNA D stated a nurse, maybe LVN C notified her on using a geri chair with R#1. CNA D added R#1's mattress was now on the floor and she was not attempting to get out of bed, as she did when she was on a low bed. FM H stated on 12/15/15 at 3:30 p.m. that the day R#1 fell was the only day R#1 had been placed on the wheelchair, as far as he could remember. LVN A stated on 12/15/15 at 3:40 p.m., R#1 stayed in bed after her recent amputation during her shift, 7:00 a.m. to 3:00 p.m., until falling on 11/29/15. LVN A stated when a resident was admitted or readmitted , PT would assess the resident and gave instructions on safety precautions. LVN A stated she had not received an in service on R#1 after R#1's recent amputation. LVN A stated the PT would also write a telephone order (TO) with his recommendations. LVN A searched through R#1's medical chart and stated there was no TO from PT to nursing staff stating not to place R#1 in a wheelchair. R#1's Physician (P) L stated on 12/15/15 at 4:30 p.m. that he did not see any problem with R#1 being placed on her wheelchair. P L stated he had seen her sitting on her wheelchair several times after her recent amputation. P L stated that the PT's recommendation was open to interpretation. P L stated he did not know if the PT meant R#1 could not tolerate sitting in a wheelchair due to pain or what. P L added the recommendation was not clear to him. The DON stated on 12/15/15 at 5:40 p.m. that he had not seen the PT's assessment of R#1 prior to her falling. The DON added nursing staff had not received any direct recommendations from the PT department on R#1 after her recent amputation, and before her fall. The DON added PT usually gave nursing services in services on fall or any other precautions he assessed, but no in service was given on R#1. The DON stated R#1 had not been placed in a wheelchair after her leg was amputated until the day she fell . The DON stated the resident and FM H wanted R#1 to be placed on her wheelchair after being in bed for five days. The DON stated on 12/15/15 at 5:40 p.m., there were 38 residents utilizing a wheelchair who were at risk for falls.

Based on observation, interview and record review, the facility failed to implement interventions, including adequate supervision and/or assistive devices for one Resident (R#1) of seven residents reviewed for falls. The facility did not follow the Physical Therapist's (PT) recommendation not to sit R#1 in a wheelchair. R#1 was placed in a wheelchair and then fell from the wheelchair on 11/29/15. R#1 sustained a broken nose and a cervical fracture (a broken neck) and was admitted to the hospital. This failure could affect the 38 residents at risk for falls that use a wheelchair in the facility. The findings were: R#1's Admission Record dated 11/03/15 indicated R#1 was initially admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech; was understood and usually understood others. The MDS also indicated R#1 had inattention (easily distracted, out of touch or difficulty following what was said) and altered level of consciousness, both were present but fluctuated. The MDS indicated R#1 required extensive assistance for bed mobility by two plus persons assist; dressing, eating and toilet use by one person physical assist. The MDS also indicated R#1 was not steady and only able to stabilize with staff assistance during surface to surface transfers. Under Functional Limitation in Range of Motion, the MDS indicated R#1 had impairment on both sides of her lower extremities. The MDS also indicated R#1 had previous falls within the last month and the last two-six months. Hospital Record, Date of Procedure: 11/18/15 indicated R#1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The procedure performed was right below the knee amputation (RTBKA.) Admission/Readmission Data Summary dated 11/24/15 at 2:20 p.m. indicated R#1 was readmitted from the hospital with the added [DIAGNOSES REDACTED]. The Readmission Data Summary indicated R#1 was unable to orient to the facility due to the patient being very confused. Under physical restraints the summary indicated R#1 did not have any, but did have a low bed and floor mats. Review of Admission Care Plan dated 11/24/15 indicated R#1 11. Falls/Safety/Elopement Risk Goal: Resident will remain free of injuries and falls. Initials were placed on the following interventions: Keep call bell in reach; Orthostatic hypotension precautions; Encourage use of call light; If unable to use call light, CNA (Certified Nurse Aide) will assess resident q (every) 30-60 minutes; Instruct resident on safety measures and PT (Physical Therapy) referral. Incident/Accident Report dated 11/25/15 at 6:00 p.m. indicated R#1 was observed on the floor mat on R#1's right side and that R#1 had hit the right side of her head on the floor. R#1 stated she was trying to get out of bed. A two centimeter laceration was noted to the right eyebrow with swelling noted to the eyebrow and cheek. physician's orders [REDACTED].#1 to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were Resident educated-reminded to use call light for assistance. Resident in low bed. The Incident/Accident Report also indicated the staff were in serviced on falls, evaluation and prevention. Physical Therapy (PT) Plan of Care: Start of Care 11/26/15 for R#1 indicated R#1's Medical Diagnosis 1 was Complete traumatic amputation at level between the knee and the ankle, right lower leg; Medical Diagnosis 2 was Alzheimer's Disease with early onset; Medical Diagnosis 3 was Age-related physical debility and R#1's Treatment [DIAGNOSES REDACTED]. The reason for referral was this [AGE] year old female underwent a RT BKA onset 11-04-15 due to PVD. The patient also has prior old left AKA (above knee amputation) . The PT Plan of Care indicated precautions for R#1 were fall and cardiac precautions. The PT Plan of Care did not specify what these precautions were. The PT Plan of Care also indicated underlying impairments were Cognition Orientation was to person (x1) and Cognition, Safety Awareness was severely impaired. The assessment on R#1 for Balance, Static Sitting (Posture without motion) at her current level indicated R#1's grade was a P (poor-unable to maintain balance without moderate/maximum support). For Balance, Dynamic Sitting (Posture during active motion), R#1's grade was also poor. Under Current Level of Function, the PT Plan of Care indicated the patient unable to tolerate upright sitting in chair/wheelchair. Incident/Accident Report dated 11/29/15 at 10:50 a.m. indicated that R#1 was at the nurses station in her wheelchair with Licensed Vocational Nurse (LVN) C. The LVN turned her back and R#1 fell face first to the floor and hit her mid forehead area. The Incident/Accident Report indicated R#1 was was sent to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were continue with low bed and floor mats with constant supervision. Radiology Report, Date of Exam: 11/29/15 at 12:47 p.m. indicated the impression was severe degenerative disease changes in lower cervical spine and irregularity of anterior ring of C1 (vertebrae) compatible with a fracture at that site. Physician's Telephone Order dated 12/01/15 indicated R#1 was readmitted to the nursing facility and to continue with cervical collar at all times; monitor every shift and PT/OT (Occupational Therapy)/ST (Speech Therapy) to evaluate and treat as needed. R#1 was observed on 12/02/15 at 9:17 a.m. Surveyor accompanied by Licensed Vocational Nurse (LVN) A entered R#1's room. R#1 was on a low bed with a mat on the floor. R#1 had a neck brace; her face was swollen and around her eyes was a dark purple color. R#1 stated she was trying to get something from the car when she fell forward. LVN A asked R#1 when she had returned to the facility. R#1 stated she had gotten back today, five days ago. LVN A stated R#1 was mostly not able to respond appropriately, but at times, seemed alert and oriented. LVN A stated R#1 would try to get out of bed and had fallen previously. LVN A also stated R#1 had been in and out of geriatric psychiatric services, and had recently had her right leg amputated due to poor circulation. R#1 was observed on 12/02/15 at 12:55 p.m. R#1 had been moved to a room closer to the nurses station, since 9:17 a.m. At this time, CNA B stated that on 11/29/15, right before lunch, R#1 was in her wheelchair in front of the nurses station and R#1 tried to get up. CNA B stated R#1 was confused and disoriented before the fall. CNA B added R#1 would try to get out of bed also. LVN C stated on 12/02/15 at 1:40 p.m. that she was the charge nurse on Sunday, 11/29/15, the day R#1 fell . LVN C stated R#1 and family member (FM) H were disagreeing in her room. R#1 was telling FM H she wanted to go for a walk, and FM H was telling R#1 she did not have legs, so that made R#1 mad. LVN C stated the CNAs transferred R#1 to her wheelchair and brought her to the nurses station to distract her. LVN C stated she placed R#1's wheelchair against the wall, making sure the brakes were locked. LVN C then stepped forward to the counter to tell the CNAs to take the rest of the residents to the dining room for activities. LVN C stated she heard another resident yell out. When LVN C turned around she saw R#1 go forward. LVN C stated she tried to reach R#1 but was unable to catch her. LVN C stated R#1 had a regular wheelchair, and had thought R#1 could possibly fall, but because the facility was restraint free LVN C did not feel there was anything that could be put in place to hold R#1 in the wheelchair. LVN C stated R#1 had her left leg amputated prior to her admission to the facility and the right leg amputation recently, in November. LVN C stated she had not been involved in any meetings discussing R#1's risk for falls or fall prevention measures after the recent amputation. The Physical Therapist (PT) stated on 12/02/15 at 3:05 p.m. that the resident assessments were given to nursing staff, one to the Director of Nurses and the other was placed in the resident's medical chart. The PT stated each professional was required to become familiar with the resident's condition and the recommendations made. R#1 was observed in her room on 12/02/15 at 3:50 p.m. FM H was visiting the resident. FM H stated it was a terrible accident, but there should have been a way to help keep R#1 in the wheelchair. The Director of Nurses (DON) stated on 12/02/15 at 5:00 p.m. that prior to the recent right leg amputation, R#1 was sitting in a wheelchair. The DON stated there had not been any discussion on interventions to prevent R#1 from falling after her recent leg amputation. The DON said he could see how the recent amputation could have affected R#1's balance. The DON stated he was not sure if the PT meant R#1 could not tolerate sitting due to pain or what he meant. The DON added they already had the resident on a low bed, floor mat and in PT. R#1 was observed on 12/15/15 at 11:55 a.m. in the dining room. R#1 was sitting in a geri chair (a reclining chair) and she was wearing the neck brace and was feeding herself. CNA D stated on 12/15/15 at 2:55 p.m. that R#1 was in a regular wheelchair after her recent amputation, but was now in a geri chair. CNA D stated after R#1 had her leg amputated, she mostly stayed in bed. CNA D stated she had helped place R#1 in her wheelchair the day R#1 fell . CNA D added she had not received an in service concerning R#1 after her leg was amputated. CNA D stated PT did in services, but none had been given on R#1 to date. CNA D stated a nurse, maybe LVN C notified her on using a geri chair with R#1. CNA D added R#1's mattress was now on the floor and she was not attempting to get out of bed, as she did when she was on a low bed. FM H stated on 12/15/15 at 3:30 p.m. that the day R#1 fell was the only day R#1 had been placed on the wheelchair, as far as he could remember. LVN A stated on 12/15/15 at 3:40 p.m., R#1 stayed in bed after her recent amputation during her shift, 7:00 a.m. to 3:00 p.m., until falling on 11/29/15. LVN A stated when a resident was admitted or readmitted , PT would assess the resident and gave instructions on safety precautions. LVN A stated she had not received an in service on R#1 after R#1's recent amputation. LVN A stated the PT would also write a telephone order (TO) with his recommendations. LVN A searched through R#1's medical chart and stated there was no TO from PT to nursing staff stating not to place R#1 in a wheelchair. R#1's Physician (P) L stated on 12/15/15 at 4:30 p.m. that he did not see any problem with R#1 being placed on her wheelchair. P L stated he had seen her sitting on her wheelchair several times after her recent amputation. P L stated that the PT's recommendation was open to interpretation. P L stated he did not know if the PT meant R#1 could not tolerate sitting in a wheelchair due to pain or what. P L added the recommendation was not clear to him. The DON stated on 12/15/15 at 5:40 p.m. that he had not seen the PT's assessment of R#1 prior to her falling. The DON added nursing staff had not received any direct recommendations from the PT department on R#1 after her recent amputation, and before her fall. The DON added PT usually gave nursing services in services on fall or any other precautions he assessed, but no in service was given on R#1. The DON stated R#1 had not been placed in a wheelchair after her leg was amputated until the day she fell . The DON stated the resident and FM H wanted R#1 to be placed on her wheelchair after being in bed for five days. The facility's policy and procedure, Falls-Evaluation and Prevention, effective date 01/2008 and revised date 03/2012 indicated it was the policy of the nursing facility to evaluate residents for their fall risk and develop interventions for prevention. The policy stated residents should be evaluated for their fall risk on admission/readmission to the nursing home; following any change of status that may affect balance, mobility, or safety; following a fall and quarterly. Under Procedure, the policy stated the nursing staff/interdisciplinary care team should determine if a resident was at risk for falls and develop appropriate interventions based on the evaluation. The goal listed was to prevent falls if possible and avoid any injury related to falls. The DON stated on 12/15/15 at 5:40 p.m., there were 38 residents utilizing a wheelchair who were at risk for falls.

Based on observation, interview and record review, the facility failed to implement their policies and procedures that prohibit neglect for one Resident (R#1) of seven residents reviewed for falls. The facility did not follow the Physical Therapist's (PT) recommendation not to sit R#1 in a wheelchair. R#1 was placed in a wheelchair and then fell from the wheelchair on 11/29/15. R#1 sustained a broken nose and a cervical fracture (a broken neck) and was admitted to the hospital. This failure could affect the 38 residents at risk for falls that use a wheelchair in the facility. The findings were: R#1's Admission Record dated 11/03/15 indicated R#1 was initially admitted on [DATE]. R#1's [DIAGNOSES REDACTED]. R#1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R#1 had clear speech; was understood and usually understood others. The MDS also indicated R#1 had inattention (easily distracted, out of touch or difficulty following what was said) and altered level of consciousness, both were present but fluctuated. The MDS indicated R#1 required extensive assistance for bed mobility by two plus persons assist; dressing, eating and toilet use by one person physical assist. The MDS also indicated R#1 was not steady and only able to stabilize with staff assistance during surface to surface transfers. Under Functional Limitation in Range of Motion, the MDS indicated R#1 had impairment on both sides of her lower extremities. The MDS also indicated R#1 had previous falls within the last month and the last two-six months. Hospital Record, Date of Procedure: 11/18/15 indicated R#1 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The procedure performed was right [MEDICAL CONDITION] (RTBKA.) Admission/Readmission Data Summary dated 11/24/15 at 2:20 p.m. indicated R#1 was readmitted from the hospital with the added [DIAGNOSES REDACTED]. The Readmission Data Summary indicated R#1 was unable to orient to the facility due to the patient being very confused. Under physical restraints the summary indicated R#1 did not have any, but did have a low bed and floor mats. Review of Admission Care Plan dated 11/24/15 indicated R#1 11. Falls/Safety/Elopement Risk Goal: Resident will remain free of injuries and falls. Initials were placed on the following interventions: Keep call bell in reach; Orthostatic [MEDICAL CONDITION] precautions; Encourage use of call light; If unable to use call light, CNA (Certified Nurse Aide) will assess resident q (every) 30-60 minutes; Instruct resident on safety measures and PT (Physical Therapy) referral. Incident/Accident Report dated 11/25/15 at 6:00 p.m. indicated R#1 was observed on the floor mat on R#1's right side and that R#1 had hit the right side of her head on the floor. R#1 stated she was trying to get out of bed. A two centimeter laceration was noted to the right eyebrow with swelling noted to the eyebrow and cheek. physician's orders [REDACTED].#1 to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were Resident educated-reminded to use call light for assistance. Resident in low bed. The Incident/Accident Report also indicated the staff were in serviced on falls, evaluation and prevention. Physical Therapy (PT) Plan of Care: Start of Care 11/26/15 for R#1 indicated R#1's Medical Diagnosis 1 was Complete traumatic amputation at level between the knee and the ankle, right lower leg; Medical Diagnosis 2 was [MEDICAL CONDITION] with early onset; Medical Diagnosis 3 was Age-related physical debility and R#1's Treatment [DIAGNOSES REDACTED]. The reason for referral was this [AGE] year old female underwent a RT BKA onset 11-04-15 due to [MEDICAL CONDITION]. The patient also has prior old left AKA (above knee amputation) . The PT Plan of Care indicated precautions for R#1 were fall and cardiac precautions. The PT Plan of Care did not specify what these precautions were. The PT Plan of Care also indicated underlying impairments were Cognition Orientation was to person (x1) and Cognition, Safety Awareness was severely impaired. The assessment on R#1 for Balance, Static Sitting (Posture without motion) at her current level indicated R#1's grade was a P (poor-unable to maintain balance without moderate/maximum support). For Balance, Dynamic Sitting (Posture during active motion), R#1's grade was also poor. Under Current Level of Function, the PT Plan of Care indicated the patient unable to tolerate upright sitting in chair/wheelchair. Incident/Accident Report dated 11/29/15 at 10:50 a.m. indicated that R#1 was at the nurses station in her wheelchair with Licensed Vocational Nurse (LVN) C. The LVN turned her back and R#1 fell face first to the floor and hit her mid forehead area. The Incident/Accident Report indicated R#1 was was sent to the emergency room for evaluation and treatment. Measures put in place or systemic changes made were continue with low bed and floor mats with constant supervision. Radiology Report, Date of Exam: 11/29/15 at 12:47 p.m. indicated the impression was severe [MEDICAL CONDITION] disease changes in lower cervical spine and irregularity of anterior ring of C1 (vertebrae) compatible with a fracture at that site. Physician's Telephone Order dated 12/01/15 indicated R#1 was readmitted to the nursing facility and to continue with cervical collar at all times; monitor every shift and PT/OT (Occupational Therapy)/ST (Speech Therapy) to evaluate and treat as needed. R#1 was observed on 12/02/15 at 9:17 a.m. Surveyor accompanied by Licensed Vocational Nurse (LVN) A entered R#1's room. R#1 was on a low bed with a mat on the floor. R#1 had a neck brace; her face was swollen and around her eyes was a dark purple color. R#1 stated she was trying to get something from the car when she fell forward. LVN A asked R#1 when she had returned to the facility. R#1 stated she had gotten back today, five days ago. LVN A stated R#1 was mostly not able to respond appropriately, but at times, seemed alert and oriented. LVN A stated R#1 would try to get out of bed and had fallen previously. LVN A also stated R#1 had been in and out of geriatric psychiatric services, and had recently had her right leg amputated due to poor circulation. R#1 was observed on 12/02/15 at 12:55 p.m. R#1 had been moved to a room closer to the nurses station, since 9:17 a.m. At this time, CNA B stated that on 11/29/15, right before lunch, R#1 was in her wheelchair in front of the nurses station and R#1 tried to get up. CNA B stated R#1 was confused and disoriented before the fall. CNA B added R#1 would try to get out of bed also. LVN C stated on 12/02/15 at 1:40 p.m. that she was the charge nurse on Sunday, 11/29/15, the day R#1 fell . LVN C stated R#1 and family member (FM) H were disagreeing in her room. R#1 was telling FM H she wanted to go for a walk, and FM H was telling R#1 she did not have legs, so that made R#1 mad. LVN C stated the CNAs transferred R#1 to her wheelchair and brought her to the nurses station to distract her. LVN C stated she placed R#1's wheelchair against the wall, making sure the brakes were locked. LVN C then stepped forward to the counter to tell the CNAs to take the rest of the residents to the dining room for activities. LVN C stated she heard another resident yell out. When LVN C turned around she saw R#1 go forward. LVN C stated she tried to reach R#1 but was unable to catch her. LVN C stated R#1 had a regular wheelchair, and had thought R#1 could possibly fall, but because the facility was restraint free LVN C did not feel there was anything that could be put in place to hold R#1 in the wheelchair. LVN C stated R#1 had her left leg amputated prior to her admission to the facility and the right leg amputation recently, in November. LVN C stated she had not been involved in any meetings discussing R#1's risk for falls or fall prevention measures after the recent amputation. The Physical Therapist (PT) stated on 12/02/15 at 3:05 p.m. that the resident assessments were given to nursing staff, one to the Director of Nurses and the other was placed in the resident's medical chart. The PT stated each professional was required to become familiar with the resident's condition and the recommendations made. R#1 was observed in her room on 12/02/15 at 3:50 p.m. FM H was visiting the resident. FM H stated it was a terrible accident, but there should have been a way to help keep R#1 in the wheelchair. The Director of Nurses (DON) stated on 12/02/15 at 5:00 p.m. that prior to the recent right leg amputation, R#1 was sitting in a wheelchair. The DON stated there had not been any discussion on interventions to prevent R#1 from falling after her recent leg amputation. The DON said he could see how the recent amputation could have affected R#1's balance. The DON stated he was not sure if the PT meant R#1 could not tolerate sitting due to pain or what he meant. The DON added they already had the resident on a low bed, floor mat and in PT. R#1 was observed on 12/15/15 at 11:55 a.m. in the dining room. R#1 was sitting in a geri chair (a reclining chair) and she was wearing the neck brace and was feeding herself. CNA D stated on 12/15/15 at 2:55 p.m. that R#1 was in a regular wheelchair after her recent amputation, but was now in a geri chair. CNA D stated after R#1 had her leg amputated, she mostly stayed in bed. CNA D stated she had helped place R#1 in her wheelchair the day R#1 fell . CNA D added she had not received an in service concerning R#1 after her leg was amputated. CNA D stated PT did in services, but none had been given on R#1 to date. CNA D stated a nurse, maybe LVN C notified her on using a geri chair with R#1. CNA D added R#1's mattress was now on the floor and she was not attempting to get out of bed, as she did when she was on a low bed. FM H stated on 12/15/15 at 3:30 p.m. that the day R#1 fell was the only day R#1 had been placed on the wheelchair, as far as he could remember. LVN A stated on 12/15/15 at 3:40 p.m., R#1 stayed in bed after her recent amputation during her shift, 7:00 a.m. to 3:00 p.m., until falling on 11/29/15. LVN A stated when a resident was admitted or readmitted , PT would assess the resident and gave instructions on safety precautions. LVN A stated she had not received an in service on R#1 after R#1's recent amputation. LVN A stated the PT would also write a telephone order (TO) with his recommendations. LVN A searched through R#1's medical chart and stated there was no TO from PT to nursing staff stating not to place R#1 in a wheelchair. R#1's Physician (P) L stated on 12/15/15 at 4:30 p.m. that he did not see any problem with R#1 being placed on her wheelchair. P L stated he had seen her sitting on her wheelchair several times after her recent amputation. P L stated that the PT's recommendation was open to interpretation. P L stated he did not know if the PT meant R#1 could not tolerate sitting in a wheelchair due to pain or what. P L added the recommendation was not clear to him. The DON stated on 12/15/15 at 5:40 p.m. that he had not seen the PT's assessment of R#1 prior to her falling. The DON added nursing staff had not received any direct recommendations from the PT department on R#1 after her recent amputation, and before her fall. The DON added PT usually gave nursing services in services on fall or any other precautions he assessed, but no in service was given on R#1. The DON stated R#1 had not been placed in a wheelchair after her leg was amputated until the day she fell . The DON stated the resident and FM H wanted R#1 to be placed on her wheelchair after being in bed for five days. The facility's Abuse and Neglect policy, effective date 01/2008 and revised on 05/2014 indicated Neglect was the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The DON stated on 12/15/15 at 5:40 p.m., there were 38 residents utilizing a wheelchair who were at risk for falls.

Based on observation, interview and record review the facility failed to implement their written policy and procedure that prohibits neglect for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nursing assessments of residents with indwelling catheters and [MEDICAL CONDITION]. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to implement their policy and procedure that prohibits neglect for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nursing assessments of residents with indwelling catheters and [MEDICAL CONDITION]. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. The Administrator failed to: 1) Develop and implement policies and procedures for [MEDICAL CONDITION] and urinary residual. 2) Supervise the Director Of Nurses (DON) to ensure she followed the facility's neglect policy. The DON was aware that R #1 was at risk of [MEDICAL CONDITION] and urinary tract infection but failed to ensure effective interventions were in place to protect R #1. The DON failed to: 1) Develop and implement policies and procedures for [MEDICAL CONDITION] and urinary residual. 2) Put effective measures into place to ensure staff followed physician orders. 3) Supervise the nursing staff to ensure that the nursing staff were accurately assessing R #1, consistently documenting those assessments, and following R #1's physician orders. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the DON stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." The facility's Administrator Job Description dated ,[DATE] revealed: "...The overall purpose of the administrator position is to assure the provision of the best available quality of care for facility residents...Understands and complies with all Corporate, State and Federal mandates in a positive, proactive manner..." The facility's Director of Nursing Job Description dated [DATE] revealed: "...The overall purpose of the director of nursing position is to direct the provision of nursing services to facility residents...Oversees/directs/coordinates nursing staff to provide proper resident care consistent with standard nursing practices...Assures provision of appropriate...nursing services according to care plans and (physician's) instructions...Assures compliance with state/federal regulations..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. On [DATE] at 4:00 p.m., in response to surveyor's question regarding how the IJ came about, the DON stated, "I don't think we had an immediate jeopardy situation because we followed our policies and procedures. There were no problems with (R #1) that night." The DON stated she ensured staff were competent in their skills for caring for residents with indwelling catheters and [MEDICAL CONDITION] by completing a "skills check list." On [DATE] at 4:00 p.m., surveyor requested from the DON the employee's "skills check list." No documents were provided. On [DATE] at 4:15 p.m., in response to surveyor's question regarding how the IJ came about, the Administrator stated, "I am still confused on that one. I think everyone has a difference of opinion. We didn't have a policy and procedure for (indwelling catheters) but did for intake and output." The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to administration. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one Resident one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: The Texas Administrative Code, Title 22, Part 11, Chapter 217, Rule 217.11, Standards of Nursing Practice states: "The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; ...(iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status;...(G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations;...(M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications..." R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to professional standards. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on observation, interview and record review the facility failed to provide services in accordance with each resident's written plan of care for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -Staff did not follow a physician order to check R #1's urine retention. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to the physician's written plan of care. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on observation, interview, and record review, the facility failed to ensure each resident received and was provided the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the plan of care for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to nursing assessments of residents with indwelling catheters and [MEDICAL CONDITION]. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.

Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one Resident (R #1) of seven Residents reviewed for [MEDICAL CONDITION] and indwelling catheters. -The facility was aware that R #1 had a history of [REDACTED]. -Staff did not follow a physician order to check R #1's urine retention. -Staff did not consistently assess R #1 for complications related to [MEDICAL CONDITION]. -R #1 was sent to the hospital with signs and symptoms of [MEDICAL CONDITIONS] and dehydration six days after R #1 pulled out his urinary catheter. -R #1 died six days later after being admitted to the hospital. This failure resulted in identification of an Immediate Jeopardy (IJ) on [DATE] at 4:25 p.m. While the IJ was removed on [DATE] at 9:10 p.m., the facility remained out of compliance for actual harm at a scope of pattern due to the facility was continuing to in-service staff and monitoring the Plan of Removal. This deficient practice placed seven residents with indwelling urinary catheters at risk of neglect due to not receiving proper assessments and care and services required to prevent delay in treatment, complications, hospitalization , or possible death. Findings were: R #1's Face Sheet dated [DATE] revealed a [AGE] year old male admitted on [DATE] with the [DIAGNOSES REDACTED].) R #1's Admission Minimum Data Set ((MDS) dated [DATE] revealed R #1 had an indwelling catheter (a urinary catheter designed to be left in place for a prolonged period); did not have a life expectancy of less than six months; did not have a swallowing disorder; was not dehydrated; had clear speech; made self understood; understood others; had moderately impaired cognition (decisions poor; cues supervision required); had not rejected care; was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene and bathing. R #1's Admission Care Plan dated [DATE] revealed: -"(Indwelling catheter)" was handwritten in section number 6 with "intake and output" documented with a check mark as an approach to R #1's care. R #1's Care Plans dated [DATE] revealed the following: -"(R #1) has a [DIAGNOSES REDACTED]. -"(R #1) has (indwelling) catheter and is at risk for increased urinary (tract) infections ...Monitor urine for odor, color, sediments, and amount of urine and report (signs and symptoms) of (infection to the physician)...Encourage fluid intake within dietary limits..." Review of R #1's current Physician's Orders revealed R #1 did not have a fluid restriction. -"(R #1) is at risk for dehydration...Encourage fluid intake...Monitor skin turgor, dry cracked lips, etc. - report (abnormals) to (the physician)..." According to Lippincott's Nursing Procedures, 6th Edition: Indwelling Urinary Catheter Care: -"Sediment buildup can occur anywhere in a catheterization system, especially in bedridden and dehydrated patients...Acute [MEDICAL CONDITION] may result from a catheter obstructed by sediment. Be alert for sharply reduced urine flow from the catheter..." -"...Documentation (:) ...Note the character of the urine in the drainage bag, any sediment buildup...Also record fluid intake and output..." R #1's Consolidated Physician's Orders dated "[DATE]-[DATE]" revealed the following care and medication orders [REDACTED] -Indwelling catheter care with soap and water twice daily. -[MEDICATION NAME] (aids in reducing the size of the prostate) 0.4 milligrams (mg) every day at bedtime. R #1's Nurses Notes revealed the following entries: -[DATE] at 11:00 a.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 9:00 p.m.: There was no documentation that R #1's urine was assessed. -The Nurses Notes revealed no documentation from [DATE] through [DATE]. -[DATE] at 2:00 p.m.: "...(R #1) stated he felt sick..." There was no documentation that R #1's urine was assessed. -[DATE] at 2:30 p.m.: "(Urinalysis)...to be done on Tuesday..." -[DATE] ",[DATE]" shift: "...(Physician) called...(urinalysis in the morning)...(Indwelling catheter) draining foul odor, concentrated urine (with small amount of blood in urine)..." There was no further documentation of R #1's condition. -The Nurses Notes revealed no other documentation until the following entry. -[DATE] at 1:15 p.m.: "(R #1) sitting (up in wheelchair), no distress noted (at) this time...(indwelling catheter) in place..." There was no documentation that the quality and quantity of R #1's urine was assessed. -The Nurses Notes revealed no other documentation until the following entries. -([DATE]) at 3:00 a.m.: "(R #1) called per call light, (Certified Nurse Aide) went to check (and) noted (R #1's indwelling catheter) out (with) balloon intact (and) bleeding from his penis, went to check resident (and R #1) said, 'I was hurting so I pulled it out.' Asked where was he hurting, (R #1) said he was hurting from his penis. Noted that urinary bag was empty, very scant bleeding from the penis. Tylenol 650 mg given for pain...(R #1) said, 'I do not want (an indwelling catheter) anymore.' No bladder distention noted. MD notified..." -([DATE]) at 6:00 a.m.: "(R #1) able to void per diaper (with) blood tinged urine, good amount, will (continue) to monitor for urine retention (and) if above 300 (milliliters) may reinsert the (indwelling catheter) as ordered by (the physician)." R #1's Telephone Order dated [DATE] revealed: "...Leave the (indwelling catheter) out, observe for [MEDICAL CONDITION] (and) may reinsert (indwelling catheter) if urine retention (is) above 300 (milliliters)." According to the Mayo Clinic, http://www.mayoclinic.com/health/urinary- incontinence/DS /DSECTION=tests-and-diagnosis, a procedure that is used to check for [MEDICAL CONDITION] includes using a catheter or ultrasound test to measure the amount of leftover (residual) urine in the bladder, and is performed after voiding. According to Lippincott's Nursing Procedures, 6th Edition: -"Intermittent (straight) urinary catheter insertion involves inserting a temporary catheter into the bladder to drain urine...an intermittent catheter is removed as soon as the urine is drained...Intermittent urinary catheterization has been used in patients with...bladder outlet obstruction..." -"...Implementation (:) ...Check the patient's intake and output record to see the time and amount of the most recent voiding..." -"...Insert the catheter...and...drain the urine into the urine receptacle..." -"...Perform intermittent catheterization at regular intervals to prevent bladder overdistention..." -"...Documentation (:) ...Record the date, time, and size and type of catheter used. Also describe the amount, color, and other characteristics of urine emptied from the bladder..." On [DATE] at 3:15 p.m., LVN "F" stated if a physician ordered to reinsert an indwelling catheter if urine retention was above 300 milliliters, staff were to use a "straight catheter" to measure the urine retention. LVN "F" stated untreated [MEDICAL CONDITION] could cause "urosepsis and a resident could die." LVN "F" stated she did not know why R #1 was not assessed for urine retention using intermittent catheterization. On [DATE] at 3:55 p.m., surveyor asked the DON why staff had not assessed R #1's urine retention as R #1's physician had ordered, the DON stated, "(R #1) was voiding so we didn't need to do a straight cath." R #1's Nurses Notes dated [DATE] through [DATE] revealed staff did not assess R #1's residual urine. R #1's Treatment Record dated ,[DATE] revealed no documentation of R #1's order dated [DATE] that staff were to assess R #1's urine retention. The Treatment Record dated ,[DATE] revealed staff documented by initialing that R #1 received indwelling urinary catheter care on the 7:00 a.m. to 3:00 p.m. and the 3:00 p.m. to 11:00 pm. shifts from [DATE] through [DATE]. R #1's Telephone Order dated [DATE] revealed an order for [REDACTED]. According to Mosby's 2012 Nursing Drug Reference, 25th Edition, side effects of the antibiotic [MEDICATION NAME] include confusion. Nursing considerations include assessing intake and output ratio, and therapeutic response. R #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. R #1's Nurses Notes revealed: -[DATE] at 10:45 a.m.: "...(R #1) alert..." -[DATE] at 12:30 p.m.: "...(R #1) continues to be having episodes of confusion...(Family) made aware of the orders from the (doctor) to continue the (antibiotic) as ordered..." -[DATE] and signed by Licensed Vocational Nurse (LVN) "E" on the 3:00 p.m. to 11:00 p.m. shift: *3:48 p.m.: "Made rounds, passed by (R #1's) room, saw (R #1) asleep on his right side." *4:00 p.m.: "Made rounds (to check R #1), (R #1) asleep, no distress..." *4:35 p.m.: "(R #1) asleep still (.) I went into (R #1's) room, visually assessed (R #1), (R #1) resting asleep..." *4:50 p.m.: "(R #1's family member) in to see (R #1)..." *5:10 p.m.: "Took vitals, (blood pressure) ,[DATE], (pulse) 72, (respirations) 18, (temperature) 99.3, (oxygen saturation) 95%, (R #1) alert, unoriented due to UTI, (R #1) currently on (an antibiotic) given on [DATE] at (the evening) upon (doctor's) orders. (R #1) had wet brief, (R #1) stated, 'I need to be changed I peed.' (Family member) and I opened brief, saw his wet brief..." *5:15 p.m.: "...(Family member) kept badgering (R #1) and demanding him to wake up and (family members) were pushing (R #1) verbally to identify colors, to wake up, to sit up and to stop acting sick..." *6:00 p.m.: "...(R #1's family member) requesting (R #1) to be sent out to ER. I called (the Director of Nurses) to (R #1's) room to speak with family. (The Director of Nurses) explained medications and treatment to (family). They still insisted for (R #1) to be sent out. (The Director of Nurses) took vitals once again, (blood pressure) ,[DATE], (pulse) 70, (respirations) 18, (temperature) 99.4...Called (R #1's physician) about sending (R #1) out per family request. (R #1's physician) was given report on (R #1) and condition of (R #1). (R #1's physician) stated for us not to send him out since he is already being treated for [REDACTED]. Family voices their concerns, still insisting on (R #1) being sent out." *6:30 p.m.: "...(R #1) stated he peed. Brief was changed as needed. (R #1) continues to be disorientated. (The Director of Nurses) asked me to send out (R #1) per possible stroke and change in mental status...Family...did thank us for seeing (R #1's) new sudden change in mental status..." *7:15 p.m.: "Called (ambulance for transport)...(Doctor) was notified." *8:00 p.m.: "(Ambulance) transferred (R #1) to (Hospital "AA")..." R #1's "Patient Transfer Form" dated [DATE] and signed by LVN "E" revealed the following handwritten entries in the "Additional Pertinent Information" section: -"Possible stroke...per family request...altered mental status...(blood pressure) ,[DATE], (pulse) 86, (respirations) 20, (temperature) 97.2..." On [DATE] at 1:30 p.m., LVN "E" stated that on [DATE] at around 4:50 p.m., R #1's family member requested "to send (R #1) to the hospital. (The family member) said he was hallucinating. My assessment didn't show any problems. I told the DON the (family member's) little complaint." LVN "E" stated that at approximately 8:00 p.m. on [DATE], R #1 was sent to Hospital "AA" because "I noticed he did have a change in cognition." R #1's clinical record from Hospital "AA" revealed the following: -Emergency Department Record dated [DATE] revealed: * R #1 arrived at Hospital "AA" at 9:11 p.m. with "Sepsis" and "Altered Mental Status." *At 9:31 p.m., R #1's urinary assessment revealed R #1 exhibited "dribbling, urgency;" had urine "sediment"; the urine was "orange" with a "strong" odor. Mosby's Medical Dictionary, 9th Edition defines symptoms of "dribbling, urgency" as "Retention with overflow...a complication of bladder outlet obstruction in which the bladder is full but is not emptied completely..." According to the Mayo Clinic, http://www.mayoclinic.com/print/sepsis/DS , ..."Sepsis is a potentially life-threatening complication of an infection..." *At 9:33 p.m., R #1's "Rapid Triage" revealed: "...(Family) reports change in mental status (for) 3 days..." -Laboratory reports from Hospital "AA" dated [DATE] revealed the following: Urinalysis: -Appearance: "cloudy." -Blood: "high." -White blood cells: "too numerous to count, high." -Red blood cells: ",[DATE], high." Blood work: -White blood cells: "11.0, high." -Blood, urea, nitrogen: "90, high." -Creatinine: "2.5, high." -Lactic Acid: "2.1." The laboratory reports dated [DATE] indicated urinary tract infection and dehydration. -History and Physical from Hospital "AA" dated [DATE]: *"...(R #1) developed an acute onset of becoming very confused at the (facility), and apparently (R #1) was transferred to the emergency room ...where he was found to be very hypotensive..." *"...They put a (indwelling catheter) in the ER and he drained more than 1000 (milliliters) of urine in less than 30 minutes, for which (R #1) was having (impaired ability to urinate)..." *"...(R #1's) blood pressure when he came to the ER was ,[DATE]..." *"...Assessment: 1. Acute [MEDICAL CONDITION], probably [MEDICAL CONDITION]...3. Obstructive prostatitis (impaired ability to urinate)...4. Urinary tract infection..." According to American Family Physician, http://www.aafp.org/afp/,[DATE]/p643.html, [MEDICAL CONDITION] complications include infection and [MEDICAL CONDITION]. -[DIAGNOSES REDACTED]. *Acute [MEDICAL CONDITION]. -"Code Blue Record" dated [DATE]: *R #1 went into [MEDICAL CONDITION] at 2:08 p.m., was given CPR for approximately 26 minutes and died at 2:34 p.m. On [DATE] at 11:30 a.m., Family Member (FM) "BB" stated that she visited R #1 "daily" for approximately two hours and during different times of the day. FM "BB" stated that on [DATE] and [DATE], R #1 "hadn't been urinating" because "his brief was not wet when I checked him." FM "BB" stated that R #1 "was lethargic and hallucinating." FM "BB" stated she voiced her concerns to the staff and that the staff "did nothing about it" because of "his condition (on [DATE])." FM "BB" stated that on [DATE] at approximately 5:00 p.m., R #1 "was in bed" and "would not wake up." FM "BB" stated, "(R #1's) skin was grey and his eyes were yellow." FM "BB" stated she had voiced her concerns to staff that "something was wrong with (R #1)" and requested R #1 be transported to the hospital. FM "BB" stated, "I had to keep telling them he needed to go the hospital" and that at approximately 8:00 p.m. on [DATE] after her requests, R #1 was sent to Hospital "AA." On [DATE] at 3:00 p.m., Certified Nurse Aide (CNA) "B" stated it was the facility's policy that fluid intakes and outputs were only reported to the nurses with certain residents. CNA "B" stated that the nurse lets them know verbally which residents are "stress" (if a resident could not urinate.) CNA "B" stated that CNA's empty the urinary drainage bag at the end of the shift and verbally tell the nurse how much urine output each resident had for the shift. When surveyor asked CNA "B" what the rationale was for measuring urine output, CNA "B" stated, "To know what is going into the resident is coming out. If the resident does not urinate they could die." When surveyor asked CNA "B" how she measured incontinent resident's urine, CNA "B" stated she documented how many times the resident's brief was changed and if the resident does not urinate, she reported it to the nurse. On [DATE] at 3:30 p.m., Licensed Vocational Nurse (LVN) "C" stated it was the facility's policy that nurses only document the intake of residents with feeding tubes, the CNA's notify the nurse of the resident's output, but that outputs were not documented and monitored by the nurses. When surveyor asked LVN "C" why would it be important to monitor a resident's fluid intake and output, LVN "C" stated, "If a resident has an infection, concentrated urine, retaining urine and [MEDICAL CONDITION], or not voiding." When surveyor asked LVN "C" what would happen if a resident's bladder was distended, LVN "C" stated, "The resident's bladder could bust, which something very bad could happen." On [DATE] at 3:45 p.m., LVN "D" stated it was the facility's policy to document a resident's fluid intake and output only when it was ordered by the physician. LVN "D" stated that R #1 did not have an order to monitor fluid intake or output, and that residents who were at risk of dehydration and [MEDICAL CONDITION] "should be monitored ... (A resident) could get bladder distention, UTI (or) urosepsis." LVN "D" stated , "I believe we should (monitor fluid intakes and outputs) because it is good practice. Possibly there could be harm and (a resident) could die." On [DATE] at 3:30 p.m., the Director of Nurses (DON) stated, "Unless intakes and outputs are physician ordered, only then do we do intakes and outputs. The physician determines if it is necessary." Surveyor asked how the facility monitored residents at risk for dehydration and [MEDICAL CONDITION]. The DON stated the nurses monitored residents for dehydration and urine retention by "the CNA will let us know if the output is low. The same staff take care of the residents every day. The resident will complain of bladder pain or decreased urine. Staff see the resident's urine. (It) would be compared to what it had been." When surveyor asked how the facility monitored resident's residual urine, the DON stated, "(We would) notify the physician of residual urine." On [DATE] at 4:00 p.m., when asked the facility's policy for monitoring fluid intake and output, Nurse Consultant (NC) "CC" stated, "Your (the state) quality measure says that monitoring is only needed for residents when it is needed." When asked how the facility monitored residents for bladder distention, NC "CC" stated, "Hopefully it would be in the nurses notes." On [DATE] at 4:05 p.m., the DON stated that when R #1 was sent to the hospital on [DATE], "I was here that day. I assessed him and he was fine. The family kept saying he had an electrolyte imbalance." The DON stated that a resident's fluid intake and output would be monitored when a resident had a "fluid restriction" or "clinically necessary for hydration." The facility's "Catheters-Insertion and Care-Indwelling, Straight, Suprapubic and External" Policy and Procedure dated ,[DATE] revealed: * "...It is the policy of this home that the resident with a urinary catheter will be provided services in a safe and appropriate manner in order to minimize the risks of urinary tract complications..." * "...Straight Catheter...Check physician's orders for straight catheter order...Document the date, time, procedure, amount of urine, color, consistency, odor, presence of blood, pus, or anything unusual..." * "...Indwelling Catheter Care...Observe for and report to the charge nurse...urinary complaints...other significant observations..." The facility's "Intake and Output Measurement" Policy and Procedure dated ,[DATE] revealed: "It is the policy of this home to provide accurate measurement of intake and output when ordered by the physician and/or when it is determined to be necessary to meet the resident's needs..." The facility's Abuse Policy and Procedure dated ,[DATE] revealed: * "It is the policy of this home to prevent resident...neglect in any form..." * "...Neglect: The failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness..." On [DATE] at 4:25 p.m., an IJ was identified and the Director of Nurses (DON) and Administrator were informed at 4:25 p.m. of the IJ due to the above failures. On [DATE] at 9:10 p.m., the facility's Plan of Removal was accepted and contained the following: "Systematic Approach (:)" 1. Medical Director...was notified of the Immediate Jeopardy by the Administrator at 4:40 p.m. on [DATE] via telephone. 2. Facility's practice related to recognizing and assessing resident for complication related to (indwelling catheters) (specifically decreased urine output). * A list of all residents with (indwelling catheters) was generated. * All residents with (indwelling catheters) were assessed by the charge nurse for pain, bladder distention, urine color, clarity and consistency, vital signs on [DATE] completed by 5:30 p.m. * All residents with (indwelling catheters) will be placed on intake and output (I & O) beginning [DATE]. I & O will be recorded in the clinical record on the I & O record form. * CNAs will be in-serviced, starting [DATE], to report to the charge nurse if the resident has pain, urine with odor, no output, elevated temperature, cloudy urine. No CNA will be allowed to start their shift without being in-serviced. * The Charge Nurse will be in-serviced starting [DATE] that if the resident's output is less than the intake that they will need to assess the resident for complications related to the (indwelling catheter). No charge nurse will be allowed to start the shift without being in-serviced. * The nursing assessment will include signs and symptoms of dehydration, pain, urine appearance, vital sounds, lung sounds, etc. * Any concerns with the resident assessment will be communicated to the resident's physician. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The DON will monitor during her daily rounds that assessments are being completed as needed and physician's contacted, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility Quality Assurance (QA) committee will monitor the progress of the plan and make changes until such time as it is resolved. 3. Facility's practice related to following physician orders related to [MEDICAL CONDITION]. * A list of all residents with physician orders for monitoring [MEDICAL CONDITION] was generated. * No physician orders to monitor residents with [MEDICAL CONDITION] were identified. * If an order is received to monitor a resident for [MEDICAL CONDITION], then the resident will have post void residual measured using intermittent catheterization. The residual amount will be reported to the physician if outside the parameters given in the order and/or an indwelling catheter will be placed per the order. * Charge Nurses will be in-serviced on this beginning [DATE] and will not be permitted to return to duty until in-serviced. * The facility will monitor the plan. * The facility DON will monitor physician orders and ensure residuals are measured, five times per week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time it is resolved. 4. Facility's practice related to monitoring intake and output. * If a physician order is obtained for monitoring intake and output, the facility will document the I & O on the I & O record form. * The facility will monitor the plan. * The facility DON will monitor during her daily rounds that the I & O forms are being completed, five times a week for two weeks to ensure training was adequate, then during random record reviews thereafter. * The facility QA committee will monitor the progress of the plan and make changes until such time as it is resolved. End of Plan of Removal. On [DATE] at 9:10 p.m., the Administrator and DON were informed the IJ was removed. However, the facility remained out of compliance at a level of severity for actual harm with a scope identified as pattern. The facility was still monitoring the Plan of Removal. Through observations, interviews and record reviews, the survey team determined that inservicing was initiated, indwelling catheter assessments were accurate, and staff followed the indwelling catheter and [MEDICAL CONDITION] monitoring that was documented in the facility's Plan of Removal were implemented. The facility's Indwelling Catheter list dated [DATE] revealed seven residents with indwelling catheters. Throughout the survey and during the exit conference, the facility was given the opportunity to provide additional information related to catheters and [MEDICAL CONDITION]. As of exit on [DATE] at 4:35 p.m., the facility provided no further information.