Every finding on record at Pruitthealth - Augusta Hills

Based on observations, staff interviews, record review, and review of the facility policy titled, MDS Assessment Accuracy, the facility failed to complete an accurate Minimum Data Set (MDS) assessment that indicated the use of Continuous Positive Airway Pressure (CPAP) machine for one of 15 residents (R) with orders for respiratory therapy. The deficient practice had the potential to place R2 at risk for respiratory complications, unmet needs, and a diminished quality of life.Findings include:Review of the facility policy titled MDS Assessment Accuracy last revised 01/19/2026, revealed on page 1 under the Policy Statement section, It is the policy of this healthcare center that each Minimum Data Set (MDS) reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. The assessment will be scheduled to accurately account for the acuity and complexity of the patient/resident. Each Assessment Reference Date (ARD) will be chosen to capture services rendered and reflect an accurate clinical profile of each patient/resident.Review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to end stage renal disease, asthma, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, dependence on renal dialysis, obstructive sleep apnea (adult), asthma, congestive heart failure (CHF), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dyspnea, wheezing, Type 2 diabetes mellitus with hyperglycemia, anxiety disorder.Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 14 indicating the R2 had intact cognition. Further review of Section O revealed no indicators for R2s respiratory treatment to include continuous positive airway pressure (CPAP) machine use.Review of the Physician's Orders for R2 included but was not limited to an order dated 8/22/2025- CPAP: Mode: CPAP Settings: 5 During sleep with Oxygen at 2L/min Mask Size: large Mask Type: full face To be worn: hours of sleep at bedtime, CPAP: Empty reservoir QAM and allow to air dry.Observation and interview with R2 on 03/22/2026 at 2:49 PM revealed R2 to be sitting up in bed receiving supplemental continuous oxygen at 1.5 LPM via NC. R2 verbalized that he uses continuous oxygen every day and attempts to wear the CPAP at night. CPAP empty reservoir observed on bedside table. Interview and review of R2s most recent MDS with Registered Nurse (RN) Case Mix Director (CMD) on 03/24/2026 at 12:00 PM revealed that there were no respiratory indicators coded in Section O (identifies any special treatments, procedures, and programs received or performed during the assessment period) and stated she would make the corrections to accurately reflect the current orders.During an interview with the Administrator on 3/24/2026 at 12:25 PM she confirmed that R2s respiratory treatments had not been coded on the MDS.

Based on observations, staff interviews, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to meet professional standards of quality during medication administration for one resident (R) R14. This deficient practice had the potential to place residents at risk of receiving the wrong medications. The census was 85.Findings include:Review of the facility policy titled Medication Administration: General Guidelines, reviewed 07/28/2025, revealed the Policy Statement stated, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The Procedure section included, . 9. Only the licensed or legally authorized personnel that prepare a medication may administer it.Observation on 03/23/2026 at 1:47 PM revealed Licensed Practical Nurse (LPN) SS prepared medications for R14, gave the medications to LPN TT, and instructed LPN TT to administer the medication to R14. Further observation revealed that LPN TT administered the medications to R14. Continued observation revealed LPN SS prepared medication for another resident and give to LPN TT to administer. The surveyor stopped LPN TT from administering the medication. In an interview, LPN SS stated she did not see anything wrong with her preparing the medication and LPN TT administering it. In an interview on 03/23/2026 at 5:01 PM, the Director of Nursing (DON) stated that the nurse who prepares the medication should administer it. The DON further stated that at no time should a nurse place opened medications in a cup and pass the cup to another nurse to give the medication. The DON stated LPN TT was in training. In an interview on 03/23/2026 at 5:08 PM, the Clinical Competency Coordinator (CCC) stated that she completed a check-off with the nurses before they worked on the floor. She stated that the new nurse will observe her mentor giving medications until the new nurse feels comfortable. The CCC also stated that the mentoring nurse should not set up medications and hand them to the orientation nurse to give to the resident. She stated that the nurse who prepared the medications should give the medications to the resident. In an interview on 03/25/2026 at 1:51 PM, the DON stated that he expected the mentoring nurse to observe the nurse-in-training. The DON further stated that the trainee should prepare and administer the medications while the mentor observes.

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen Administration, the facility failed to follow the physician's order for continuous oxygen administration for one of 15 resident (R) with orders for respiratory therapy. The deficient practice had the potential to place R2 at risk for respiratory complications, unmet needs, and a diminished quality of life.Findings include:Review of the facility policy titled Oxygen Administration last reviewed 11/17/2025, revealed on page 1 under the Policy Statement section, It is the policy of PruittHealth Hospice and Healthcare Centers/Veteran Homes to provide oxygen safely and accurately to appropriate patients/residents. The Scope section revealed, This policy applies to Nurses and Respiratory Therapists. The Procedure section revealed, Oxygen will be administered by licensed personnel only when ordered by the physician, PA or NP. The physician order may be written PRN for comfort/dyspnea or may specify the number of liters, method of administration and length of time the oxygen is to be administered.Review of the electronic medical record (EMR) revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to end stage renal disease, asthma, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypercapnia, dependence on renal dialysis, obstructive sleep apnea (adult), asthma, congestive heart failure (CHF), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dyspnea, wheezing, Type 2 diabetes mellitus with hyperglycemia, anxiety disorder. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R2 had a Brief Interview for Mental Status (BIMS) score of 14 that indicated little to no cognitive impairment. Review of the Physician's Orders for R2 included but was not limited to, an order dated 03/09/2026 for oxygen at 2L/min (liters per minute) via (by way of) nasal cannula (NC)every shift.Observation and interview with R2 on 03/22/2026 at 2:49 PM revealed R2 sitting up in bed receiving supplemental continuous oxygen at 1.5 LPM via NC. Resident verbalized that he uses continuous oxygen every day. Observation and interview with R2 on 03/23/2026 at 9:00 AM revealed R2 sitting up in bed receiving supplemental continuous oxygen at 2 LPM via NC. Resident states he is going to dialysis today and that he does not transport with supplemental oxygen when he leaves but that he feels like he needs it and states he often becomes short of breath before he arrives at the dialysis center.Observation and interview with R2 on 03/23/2026 11:45 AM revealed R2 lying on a stretcher with supplemental continuous oxygen at 2 LPM via NC be administered via an oxygen cylinder secured at his feet for transport to dialysis. R2 states that this is the first time he has been sent to dialysis with oxygen. The accompanying transport staff confirmed this is the first time he has had continuous oxygen during transport. Review of the Resident Progress Notes for January 2016 through March 2026 reveal R2 had no documentation of supplemental oxygen being sent with the resident to or from the dialysis center.Telephone interview with R2s primary dialysis center nurse on 03/23/2026 at 1:38PM revealed that she cares for R2 while he is receiving dialysis and that while he uses supplemental oxygen as needed at the dialysis center, he does not arrive to the center with an oxygen cylinder or on any type of supplemental oxygen in place.Telephone interview with the transportation company for R2 on 03/23/2026 at 12:18 PM revealed the transportation company is non-emergent and they do not permit transporting patients with oxygen. The representative indicated today was the first day they accommodated this need for R2 so they could get the transport the resident to his dialysis appointment on time.Concurrent interview with the Director of Health Services (DHS), R2s Nurse Practitioner (NP) NN, and LPN 100 Hall Unit Manager (OO) on 03/24/2026 at 12:00 PM revealed R2 refuses to transport to dialysis by a transportation company that will permit oxygen cylinders on their transport. LPN OO stated R2 is able to sit in a wheelchair and transport with a company that will accommodate the oxygen order, however, he will only permit transport by stretcher. Physician's active oxygen order of 2L/min via NC verified. The DHS, NP NN, and LPN OO acknowledged that R2 should be transported with oxygen based on his respiratory diagnoses.Interview with the Administrator on 3/24/2026 at 12:25pm confirmed that the oxygen order had not been followed and it is her expectation that nurses' follow active physician's order.

Based on observations, record review, staff interviews, and review of the policy titled, Self-Administration of Medications by Patients/Residents, the facility failed to assess and determine if one of 34 sampled residents (R) R732 was assessed to safely self-administer medications. Findings include: A review of the facility policy titled, Self-Administration of Medications by Patients/Residents, revised 1/28/2020, revealed the Policy Statement is that each patient/resident who desires self-administered medication is permitted to do so if the healthcare center's Licensed Nurse and Physician have determined that the practice would be safe for the patient/resident and other patients/residents of the healthcare center. Mediation self-administration also applies to family members who wish to administer medication. Review of the electronic medical record (EMR) revealed R732 was admitted to the facility on [DATE] with diagnoses including irritant contact dermatitis due to friction or contact with body fluids, and other complications of gastrostomy - leaking around PEG (Percutaneous Endoscopic Gastrostomy). Review of the February 2025 Physician Orders revealed an order to apply barrier cream to g-tube stoma daily. There is no order to apply Triad hydrophilic dressing to g-tube stoma site. Further review of the EMR revealed no evidence that R732 was assessed to self-administer wound care medications/treatments; and there was no physicians Order to self-administer the treatment. Review of R732's care plan initiated 2/24/2024 revealed no evidence that resident was assessed to self-administer wound care treatments/medications to g-tube site. Observation on 2/26/2025 at 9:40 am revealed in room [ROOM NUMBER], boxes with sterile Accu-sorb Gauze Sponge wound dressing supplies and barrier cream at bedside. R732 was in the bed, applying wound dressing around g-tube stoma site. During an observation and interview on 2/26/2025 at 3:35 pm, in room [ROOM NUMBER], revealed Triad (hydrophilic wound dressing) and several boxes of sterile Accu-sorb Gauze Sponges on the resident's bedside table. R732 stated she takes care of the skin around her gastrostomy tube (g-tube) opening 5-6 times per day because it takes the nurses a while to come and do her skin treatment. During further interview, she stated that the nurses did the treatments the first few days, and then they brought these supplies for her to apply to the g-tube area daily. Observation on 2/27/2025 at 9:05 am revealed in room [ROOM NUMBER], the Triad wound dressing and Accu-sorb Gauze Sponges remain on R732 bedside table. Interview on 2/27/2025 at 2:45 pm, the Administrator and DHS (Director of Health Services) revealed that skin treatment around g-tub stoma should be done by facility nurses. During further interview, they confirmed that R732 should not have wound dressing and sterile Accu-sorb Gauze Sponges at her bedside. The DHS confirmed that R732 was not assessed for using wound cream and Accu-sorb Gauze Sponges by herself, and stated these supplies will be confiscated immediately.

Based on observations, staff interviews, record review, review of the facility policy titled, Daily Occupied Resident Room Cleaning, and review of the facility document Clean Air Filters, the facility failed to maintain clean 'Packaged Terminal Air Conditioner' (PTAC) units filters, and the facility also failed to ensure a clean home-like environment on one of three halls (100 Hall) for Rooms (Rm) (Rm115, Rm116, and Rm117). Findings Include: A review of the facility's document titled, Clean Air Filters, revealed the Instructions Number 2. Remove air filter and inspect for cleanliness. If filter is dirty either wash or replace depending on type of filter. If clean, reinstall filter. Number 4. Clean Grill on cover. Number 6. At minimum, air filters are to be replaced or thoroughly cleaned depending on type of filter every three months. Number 7. Clean evaporator coils if lint build-up is present. A review of the facility's policy titled, Daily Occupied Resident Room Cleaning, dated 10/2020, revealed under the Procedure: Number 7. Spray vertical surfaces (door handles, light switches, spot walls, etc.) with [product name] Peroxide Multi-Surface Disinfectant and let dwell (3-minute dwell time). Number 8. Spray restroom (door handle, light switch, sink, toilet, mirror, dispensers, shower/tub, etc.) with [product name] Multi-Surface Disinfectant and let dwell (3-minute dwell time). Number 9. In the same order that you sprayed each surface, and after the [product name] Multi-Surface Disinfectant has dwelled for at least three minutes, wipe down each surface in the same order that you sprayed Number 13. Inspect your work to make sure that the room has been properly cleaned.WEEKLY DETAIL CLEANING: Each of the following items should be completed during detailed cleaning one time per week in each resident room. Number 4. Wall Washing & Windows. An observation conducted on 2/25/2025 at 10:33 am and 2/26/2025 at 3:33 pm revealed in room [ROOM NUMBER], brown stains on both the bathroom door and the adjacent wall. An observation on 2/25/2025 at 10:20 am and 2/26/2025 at 3:35 pm revealed in room [ROOM NUMBER], a black discolored substance on the PTAC unit grill. An observation on 2/25/2025 at 10:27 am and 2/26/2025 at 3:32 pm revealed in room [ROOM NUMBER], a PTAC filter with grey, fuzzy debris. In interviews conducted on 2/27/2025 at 9:05 am, 2/27/2025 at 9:09 am and 2/27/2025 at 9:13 am, Maintenance Director (MD) stated that the filters are cleaned monthly, with each filter being removed and thoroughly cleaned. Additionally, the entire unit is cleaned annually, with the unit being taken outside for a detailed cleaning. The MD noted that if they encounter any debris while cleaning the filters, they address it immediately. During further interview, the MD confirmed that he needs to clean the black substance from the PTAC unit in room [ROOM NUMBER] that had accumulated dirt, and stated over time, it might blow debris into the resident's room. The MD stated that he had not yet attended to the filter in room [ROOM NUMBER], but confirmed the presence of grey, fuzzy debris. He stated that he plans to clean the filter at the end of the month. The MD also noted a potential negative outcome of dirty PTAC filters is if filters are not cleaned regularly, it could cause respiratory issues for the residents. In an interview on 2/27/2025 at 9:02 am, the Housekeeping Director explained the responsibilities of housekeeping, include the daily cleaning of resident rooms, bathrooms, and ensuring that handrails and surfaces are properly cleaned and disinfected to maintain a safe environment for both residents and staff. After being shown a photo of the bathroom door and wall in room [ROOM NUMBER], the staff member stated that she had been delayed in attending to this room and emphasized that her expectation is for aides to take responsibility for the cleanliness of the rooms, treating them as if they were their own or for their loved ones. In an interview on 2/27/2025 at 9:39 am, the Administrator stated the filters should be cleaned monthly as part of routine housekeeping duties. The Administrator stated during extreme temperatures (either hot or cold); filters should be cleaned twice a month. During further interview, the Administrator revealed a negative outcome from failure to maintain cleanliness of the environment that is not only unappealing, but there could also be issues with air quality, which may put residents at risk for respiratory issues.

Based on observations, staff and resident interviews, and record review, the facility failed to ensure activities of daily living (ADL) care was provided for one of 4 residents (R) (R44) related to showers and facial hair. This deficient practice had the potential to create skin care issues and lack of self-confidence. Findings include: Review of the EMR revealed R44 was admitted to the facility on [DATE] with diagnoses including but not limited to unsteadiness on feet, muscle weakness, abnormal posture, dysphagia, heart disease, abnormalities of gait and mobility, and chronic atrial fibrillation. Review of annual MDS assessment dated [DATE] revealed R44's had a BIMS of 10, which indicated moderate cognitive impairment. Section GG, functional status, revealed R44 required moderate to partial assistance with ADL care. Review of the care plan dated 2/10/2022 indicated that the resident prefers showers during the day and the goal listed as residence preferences will be honored through the next three months. Review of facility's document titled Shower Schedule, undated, revealed that R44 was scheduled every Wednesday and Saturday to obtain a shower. The facility's document titled Shower/Body Audit revealed there was no documentation R44 received a bath or shower for 15 days from 1/28/2025 thru 2/13/2025 and 13 days from 2/13/2025 thru 2/26/2025. Initial screening observation on 2/25/2025 at 10:15 am revealed R44 sitting on the side of the bed with unkept head of hair and large amount of unshaven facial hair on his cheeks and chin. Interview on 2/25/2025 at 10:57 am with R44 stated he had not been given a shower in over 11 days and asked, Can you do something about that? R44's family member requested Please speak to someone as I had been to the administration and complained. I have visited my father and at times he smelled bad and had not been given a bath for many days. Interview on 2/26/2025 at 11:53 am with Licensed Practical Nurse (LPN) UU verified the missing documentation and stated, I will look for more documentation. Interview on 2/27/2025 at 1:36 pm with the Administrator and Director of Nursing (DON) stated they have weekly schedule documentation of how showers are performed for each resident and a notebook with shower audits filed weekly and signed by a nurse. Administrator stated, facility did not follow through with any documentation audits, and stated we will be working on audit follow ups.

Based on observations, staff and resident interviews, record review, and review of the facility policy titled, Weight Monitoring Program, the facility failed to conduct weekly weights as recommended by the Registered Dietician for one of four residents (R) R74. Specifically, R74 experienced a 13.4 % weight loss in a 30-day period. This deficient practice had the potential to cause significant decline in the physical and nutritional health for R74. Findings include: Review of the facility policy titled Weight Monitoring Program, revised 6/2/2023, documented the Procedure: Overview revealed patients/residents placed on the weight monitoring program will be weighed weekly. Procedure: Weight Frequency, number 2. New admissions will be weighed weekly times four weeks and/or until weight is stable. Procedure: Weight Frequency, number 4. patients/residents with a Significant Weight Loss (SWL) will be weighed weekly and reviewed for a minimum of four weeks until weight is stable or increasing. Procedure: Significant Weight Changes, number 1. A significant weight change is defined as 5% weight loss or gain in one month, 7.5% weight loss or gain in three months, and 10% weight loss or gain in six months. Procedure: Communication revealed all disciplines should be aware of all patients/residents who are on the Weight Monitoring Program. Review of the electronic medical record (EMR) revealed R74 was admitted to the facility on [DATE] with pertinent diagnoses including but not limited to dysphagia and gastro-esophageal reflux disease (GERD) without esophagitis. A diagnosis of moderate protein-calorie malnutrition was added on 2/25/2025. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of five, which indicated R74 had severe cognitive impairment. Section GG, Functional Abilities and Goals, documented resident was dependent on eating and oral hygiene. Section K, Swallowing and Nutritional Status, revealed she was on a mechanically altered diet and had not experienced any weight loss in the last month or six months. Review of the care plan dated 12/30/2024 documented resident is at nutrition and/or hydration risk as evidenced by consuming less than 75% of food and/or fluids at most meals. Interventions to care include provide diet as ordered and weigh and monitor results on admission weekly. Review of Progress Note dated 1/3/2025 written at 8:19 am documented Weight PAR Note: R74 is a new admit to facility. She's alert and oriented with some confusion. Currently tolerating a puree diet with no noted concerns. Preferences noted. Meal intake varies. Receives ensure 237 milliliters (ml) two times per day (bid). Accepts well with no noted concerns. Admission weight 98.4 pounds (lbs). Will continue to monitor on weekly weights x 3 weeks and fu poc {sic}. Review of Progress Note dated 1/10/2025 written at 8:19 am documented WEIGHT PAR NOTE: R74 is currently tolerating a puree diet with no noted concerns. Preferences noted. Meal intake varies. Receives Ensure 237 ml bid. Accepts well with no noted concerns. Admission weight 100.0 lbs. Will continue to monitor on weekly weights x 3 weeks and fu poc {sic}. Review of Progress Note dated 2/20/2025 at 10:07 am documented reviewed weight 86.6# on 2/6/2025 BMI 15.34=underweight IBW range 105-134# Lost 13.4% past 30 days. Receives pureed meal plan with ensure bid (adds 250 cal and 9 gm protein per serving). Intake 0-75%. Pt does take the ensure so RCmd {sic} increasing to three times daily (tid). Continue fu {sic} and plan of care. Review of R74's EMR revealed the following documented weights: 12/30/2024 = 98 pounds 1/2/2025 = 98.4 pounds 1/7/2025 = 100 pounds 2/6/2025 = 86.6 pounds 2/26/2025 = 85.8 pounds There are no other recorded weight entries for R74. The significant weight loss of occurred between 1/7/2025 and 2/6/2025. Observation on 2/26/2025 at 12:40 pm, Certified Nursing Assistant (CNA) RR delivered R74's food tray with a puree diet, raised the head of the bed, set up with a lid and straw, and spoon. CNA RR then left the room to deliver other meal trays. Observation on 2/26/2025 at 12:53 pm, Licensed Practical Nurse (LPN) SS assisted R74's roommate with eating. LPN SS then walked over to R74 and spoke to her saying Wake up and eat. She did not attempt to assist R74 with eating her meal. Observation on 2/26/2025 at 12:59 pm, LPN SS entered room [ROOM NUMBER] and removed the meal tray from R74's roommate. She returned to the room to encourage R74 to eat. LPN SS did not assist R74 with eating her meal. Observation on 2/26/2025 at 1:06 pm, LPN SS removed R74's food tray from her room and placed it back on the cart. LPN SS stated that R74 ate approximately 25% of the lunch meal. Interview on 2/26/2025 at 1:09 pm, LPN TT stated that R74 did not flag as a resident requiring weekly weights. Interview on 2/26/2025 at 1:34 pm, CNA PP revealed that she is on the restorative team and stated that the restorative team is responsible for obtaining weights for the residents. She stated that she was not aware that R74 was to have weekly weights taken. Interview on 2/27/2025 at 9:31 am, LPN SS confirmed that R74 is on the weight monitoring program, which entails the nutritionist review, suggest supplements, and weekly weights. She further stated that R74 requires setup assistance with eating. She stated that R74 ate less than 10% of her breakfast in the morning and about 25% of her lunch on 2/26/2025. Interview on 2/27/2025 at 10:04 am, CNA RR stated she doesn't assist R74 with her meals unless she notices that she has not started eating. CNA RR further stated that she was not aware of any weight loss for R74. Phone interview on 2/27/2025 at 10:49 am, the Registered Dietician (RD) stated that she communicates recommendations to the nursing department in writing via email, including the Director of Health Services (DHS), Assistant Director of Health Services (ADHS), and Minimum Data Set (MDS) staff. During further interview, she confirmed that R74 had a significant weight loss of 13.4% in 30 days and recommended increased oral supplements from two to three times per day and weekly weights. She stated that she relies on nursing staff to implement her written recommendations. Interview on 2/27/2025 at 2:20 pm, the DHS confirmed that R74 had triggered significant weight loss and that her weight continues to trend downwards with weight of 85.5 obtained on 2/26/2025. He stated that resident is on the patients at risk (PAR) list for weight loss. The DHS confirmed that all the weights for R74 were listed in the EMR and not located anywhere else, revealing there is a gap in weight measurements between 1/7/2025 and 2/6/2025. He stated that R74 is not currently being weighed weekly, as recommended by the RD. He revealed the reason the weights were not obtained was due to RA CNA PP being pulled off the floor. He stated CNA PP is responsible for obtaining the weekly weights.

Based on observations, staff interviews, and review of the facility policy titled, Cleaning Procedures: Kitchen Area, the facility failed to ensure the main kitchen was kept clean and sanitary. Specifically, the facility failed to ensure routine cleaning of the ceiling, stainless steel surfaces, and refrigerators were conducted consistently in the main kitchen. The deficient practice had the potential to affect 73 of 81 residents receiving an oral diet. Findings include: Review of the facility policy titled, Cleaning Procedures: Kitchen area, dated September 2001, under Policy revealed: The policy applies to all dietary staff, housekeeping, and maintenance partners scheduled to assist in cleaning /sanitizing procedures. Walls, Ceilings, Floors, and Vents: Ceramic tile, stainless steel, and other surfaces-clean according to the manufacturer's instructions. Monthly: Wash the walls, ceilings, doors, and vents with hot water and detergent. Walk-in Refrigerator and Walk-in Freezer: Daily: Wash and sanitize as needed. Weekly: Sweep and mop floors of walk-in refrigerators and more frequently, if needed. Monthly: 1. Clean fans and fan guards in all refrigerator and freezer units. Fans and fan guards must be free of dust and dirt at all times. 2. Remove all items from shelves of reach-in refrigerators and freezers. Wash and sanitize all shelving units. Replace items. Quarterly: 1. Contact the Maintenance Department to clean drainpipes in the walk-in refrigerators and freezers and to clean motors mounted on top of reach-in refrigerators and freezers. Initial walk through on 6/12/2023 at 11:35 a.m. of the kitchen with the Dietary Manager revealed the ceiling was rusty and had a small build up of dust hanging over the puree and oven areas. The dietary manager revealed the Maintenance Department was responsible for cleaning the ceiling. A follow up walk through on 6/13/2023 at 9:00 a.m. of the main kitchen revealed a refrigerator and storage racks in the refrigerator were rusted. Fruit juices, nectar, fruit cups and hot dog/or sausage meat were stored in this refrigerator. [NAME] and white stains were observed on a stainless-steel prep table/cabinet close to the puree area and the oven. [NAME] and brown stains were also observed behind the ovens. Interview on 6/13/2023 at 9:30 a.m. with Dietary Manager she acknowledged that the refrigerator racks were rusty, the ceiling was rusty, and had a small amount of dust hanging over the puree and oven areas. Interview on 6/14/2023 at 9:30 a.m. with Dietary Manager she acknowledged that the stainless-steel prep table/cabinet and the back of the oven had white and brown stains and revealed it was the responsibility of the kitchen staff to clean the refrigerator and the stainless-steel prep table. Interview on 6/14/2023 at 10:40 a.m. with the Administrator he acknowledged that the ceiling had a small amount of dust hanging over the puree and oven areas. He also acknowledged the stainless-steel prep table/cabinet and the back of the oven had white and brown stains. He revealed the dietary staff was responsible for keeping the kitchen environment clean and sanitary.

Based on observations, staff interviews, record review, and review of the facility's procedure titled, Eye Drops, the facility failed to ensure the medication error rate was 5% or less. A total of two errors with 31 opportunities were observed for one of three Residents (R) (R#28), for a total error rate of 6.45%. Findings include: Review of the undated facility's procedure titled, Eye Drops revealed that step six is to gently pull the lower lid down and away from the nose. A critical objective when administering eye drops is that the eye drop, but not the dropper, must make full contact when the resident closes the eyelid. Resident R#28 was admitted with diagnoses that included but were not limited to peripheral vascular disease, essential (primary) hypertension, unspecified glaucoma, type 2 diabetes mellitus with diabetic nephropathy, and visual hallucinations. Review of the quarterly Minimum Data Set (MDS) assessment for R#28 dated 3/23/2023 revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating R#28 had moderate cognitive impairment. Review of medications ordered for R#28 revealed that he is to receive two eye drops during the morning medication administration. Orders: administer dorzol/timol 22.3-6.8 %, 1 drop in each eye, and after ten minutes, administer brimonidine solution 0.15%, 1 drop in each eye. Observation of medication administration 6/14/2023 at 9:07 a.m. with Licensed Practical Nurse (LPN) DD, she was observed administering scheduled eye drops for R#28. LPN DD washed her hands, applied gloves, and administered brimonidine eye drops by pulling up the top eye lid and instilled one drop in each eye. After administration, R#28 stated, You didn't even get any in my eye. R#28 was administered the rest of his scheduled medications by mouth. LPN DD, after washing hands and applying clean gloves, administered dorzol/timol eye drops, one drop in each eye by pulling up the top eye lid. The administration time was 9:17 a.m. Interview on 6/14/2023 at 9:35 a.m. with LPN DD, she indicated the proper way to administer eye drops was to pull the top eye lid up to expose the eye. Interview on 6/14/2023 at 9:50 a.m. with the Director of Health Services revealed the proper way to administer eye drops was to instill one drop in the conjunctival space by pulling down on the lower eye lid. It was his expectation that nurses administer the eye drops the correct way and per pharmacy recommendations between eye drops.

Based on record review and staff interview, the facility failed to implement the care plans to provide treatments as ordered and/or to perform weekly skin audits in order to identify skin breakdown timely for three residents (R) (R#6, R#8, R#9) from five residents reviewed for pressure ulcers. Findings include: 1. Record review for R#6 revealed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had COVID 19 infection in 1/2021. Review of the resident's care plan dated 8/22/2020 revealed that he was at risk for skin breakdown related to immobility with an intervention for treatments as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . He was initially assessed and treated by the Wound Company (name) Nurse Practitioner on 2/3/2021 and almost weekly until 7/6/2021. Review of the Wound Company Nurse Practitioner Notes revealed that she recommended treatments at each visit. Review of the Treatment Administration Records (TARs) revealed that staff failed to provide treatments to the resident's sacral pressure ulcer as recommended by the Wound Company Nurse Practitioner for 20 of 25 days in 2/2021; for 6 of 31 days in 3/2021; for 16 of 30 days in 4/2021; for 4 of 31 days in 5/2021; for 22 of 30 days in 6/2021; for 18 of 31 days in 7/2021; and for 8 of 8 days in 8/2021. The facility failed to ensure that staff provided treatments as recommended by the Wound Company Nurse Practitioner as care planned. 2. Record review revealed that R#8 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plan dated 3/29/21 revealed that she was admitted with old surgical scars (left distal foot and right distal foot) where all her toes had been amputated that had eschar with an intervention for staff to provide wound care as ordered. Continued review revealed that the resident was identified with an arterial/pressure ulcer on her left heel on 4/28/21. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Wound Company Nurse Practitioner notes revealed that she recommended treatments at each visit. Review of the TARs revealed that staff treated the surgical sites on the bilateral feet as ordered by the attending physician in 3/2021. However, staff failed to provide treatment as ordered for 2 of 30 days in 4/2021. Review of the TARS revealed that staff failed to provide treatments as recommended by the Wound Company Nurse Practitioner for 3 of 31 days in 3/3021; for 5 of 30 days in 6/2021; for 27 of 30 days in 7/2021; and for 5 of 12 days in 8/2021. The facility failed to ensure that treatments were provided as ordered by the attending Physician or as recommended by the Wound Company Nurse Practitioner as care planned. 3. Record review revealed that R#9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan dated 6/12/2019 revealed that the resident was at risk for pressure ulcers related to incontinence and decreased mobility with an intervention for the licensed nurse to conduct a systemic skin inspection weekly and by the Certified Nursing Assistant (CNA) during care. The care plan was revised on 5/8/21 when she developed a pressure ulcer on her left heel with an intervention for nursing staff to apply dressings as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . The attending Physician was notified, and treatment obtained. Review of the TAR revealed that staff failed to provide treatment on 5/10/21 and 5/12/21. The resident was assessed and treated by the Wound Company Nurse Practitioner on 6/1/21 and weekly thereafter. Review of the Wound Company Nurse Practitioner notes revealed that she recommended treatments at each visit. Review of the TARs revealed that staff failed to provide treatments as recommended by the Wound Company Nurse Practitioner for 26 of 29 days in 6/2021; for 18 of 31 days in 7/2021; and for 1 of 11 days in 8/2021. Interview with the Licensed Practical Nurse (LPN) Treatment Nurse on 8/18/21 at 10:30 a.m. revealed that the Wound Company Nurse Practitioner emailed her Weekly Wound Assessments to the facility, usually the next day. Continued interview revealed that Medical Records staff or the DHS would print the assessments and give to her or the Registered Nurse (RN) Wound Nurse to review. She stated that the DHS, herself, or the RN Wound Nurse would enter the treatment orders into the computer. Further interview revealed that the facility RN Wound Nurse only worked occasionally now so the DHS had been recently entering treatment orders into the computer. The facility failed to ensure that weekly skin audits were performed in order to identify skin breakdown timely and failed to provide treatments as ordered by the attending Physician or recommended by the Wound Company Nurse Practitioner as care planned. Cross refer to F686.

Based on observation, record review, review of the facility policy Wound Observation and Assessment Documentation (Lippincott's: 2015) and staff interview, the facility failed to provide pressure ulcer treatments as recommended by the Quality Surgical Management (QSM) Nurse Practitioner and failed to perform weekly skin audits to identify skin breakdown timely for three residents (R) (R#6, R#8 and R#9) of five residents reviewed for pressure ulcers. Findings include: Review of the policy Wound Observation and Assessment Documentation (Lippincott's 2015) provided by the Director of Health Services (DHS) as the facility's pressure sore management policy revealed directions on how staff should stage, measure, describe and document the status of a pressure ulcer. Continued review revealed that a comprehensive assessment of the pressure ulcer was to be completed by a Registered Nurse (RN) at least every 7 days. However, the policy was not comprehensive and did not address the importance of providing treatments as ordered to promote wound healing and the prevention of infection or the necessity of weekly skin audits in order to identify skin breakdown timely for residents at risk for the development of pressure ulcers. 1. Record review revealed that R#6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He had COVID 19 infection in 1/2021. Review of his Quarterly Minimum Data Set (MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status Score (BIMS) of 15 indicating that he was cognitively intact; had no behaviors in the last seven days; was non-ambulatory; was totally dependent of one staff person for bed mobility and toilet use; had limitations of his bilateral lower extremities; had an indwelling urinary catheter; was always incontinent of bowel; and had one Stage III pressure ulcer. Review of the resident's care plan dated 8/22/2020 revealed that he was at risk for skin breakdown related to immobility with an intervention for treatments as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review revealed that R#6 was identified with a Deep Tissue Injury (DTI) that measured 4 centimeters (cms.) x 2 cms. on his sacrum on 2/1/2021 and staff referred him to be seen by the Wound Company (name) Wound Care Nurse Practitioner (NP) the next day. Staff initiated Vitamin C, multi-vitamin, [MEDICATION(S)], Prostat (a protein supplement) and Juven (a nutritional powder with vitamin C, E and B12) to promote wound healing. Review of the Wound Company, Wound Care NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 3.5 cms. x 2.5 cms. x 0.7 cms. and had 40% granulation tissue, 40% necrotic (dead) tissue, 20% intact tissue, mild serous drainage and no odors. The NP debrided the pressure ulcer at that time. Continued review revealed that her recommended treatment was for staff to apply [MEDICATION(S)] (a honey-based product used in the removal of necrotic tissue in acute, chronic and stalled wounds) to the wound daily. Review of the Treatment Administration Record (TAR) revealed that staff applied [MEDICATION(S)] to the resident's sacral pressure ulcer every other day on 2/4/21, 2/6/21, 2/8/21, 2/10/21, 2/12/21 and 2/14/21 only. Staff failed to provide treatment daily. Record review revealed that R#6 refused to be assessed by the Wound Company NP on 2/9/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 3.5 cms. x 2.5 cms. x 0.6 cms. and had 40% granulation tissue, 30% necrotic tissue, 30% intact tissue, mild serous drainage and no odor. The NP documented that the resident's pressure ulcer had improved. Continued review revealed that her recommended treatment was for staff to apply [MEDICATION(S)] to the wound daily. Review of the TAR revealed that staff applied [MEDICATION(S)] to the resident's sacral pressure ulcer every other day on 2/16/21, 2/18/21, 2/20/21 and 2/22/21 only. Staff failed to provide treatment every day. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 2.5 cms. x 2.4 cms. x 0.5 cms. and had 60% granulation tissue, 20% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The NP documented that the resident's pressure ulcer had improved. Continued review revealed that her recommended treatment was for staff to apply [MEDICATION(S)] to the wound daily. Review of the TAR revealed that there was no indication that staff applied [MEDICATION(S)] to the resident's sacral pressure ulcer on 2/25/21, 2/26/21 or 2/27/21. Staff provided treatment on 2/24/21 and 2/28/21 only. Record review revealed that R#6 was hospitalized from 3/2/21-3/5/21 for acute [MEDICATION(S)] and was not assessed by Wound Company NP during her scheduled visit 3/2/21. Review of the TAR revealed that staff failed to provide treatment to the resident's sacral pressure ulcer on 3/7/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 5 cms. x 2.5 cms. x 1.0 cms. and had 30% granulation tissue, 20% necrotic tissue, 20% intact tissue and 30% other tissue, mild serous drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer had deteriorated after his hospitalization . Continued review revealed that her recommended treatment was for staff to apply [MEDICATION(S)] to the wound three times per week. However, review of her summary list of residents assessed that day revealed that she recommended daily treatment. Review of the Treatment Administration Record (TAR) revealed that there was no indication that staff applied [MEDICATION(S)] to the resident's sacral pressure ulcer daily on 3/11/21, 3/13/21 and 3/15/21. There was no indication that staff clarified the treatment recommendations with the Wound Company NP. Review of the Facility Wound Management record dated 3/16/21 revealed that R#6's Stage III pressure ulcer measured 6 cms. x 5.5 cms. x 1.0 cms. and had 30% granulation tissue, 20% necrotic tissue, 20% intact tissue in the wound bed and a red rashy appearance to the periwound. The wound had light serous drainage and no odor. Continued review revealed that there was no change in treatment. Review of the TAR revealed that staff applied [MEDICATION(S)] every other day on 3/18/21 and 3/20/21. There was no indication that any treatment was provided on 3/22/21. Review of the Facility Wound Management record dated 3/24/21 revealed that R#6's Stage III pressure ulcer measured 6 cms. x 5 cms. x 1.0 cms. and had 50% granulation tissue, 30% necrotic tissue and 20% intact tissue in the wound bed. The wound had light serous drainage and no odor. Continued review revealed that there was no change in treatment. Review of the TAR revealed that staff applied [MEDICATION(S)] every other day on 3/24/21, 3/26/21 and 3/28/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 5 cms. x 3 cms. x 1.0 cms. and had 60%granulation tissue, 20% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The NP documented that the resident's pressure ulcer was improving. Continued review revealed that her recommended treatment was for staff to apply Santyl (an enzyme that helped break up and remove dead skin and tissue) to the wound daily. Review of the TAR revealed that there was no indication that staff applied the Santyl every day and continued to apply [MEDICATION(S)] to the resident's sacral pressure ulcer every other day on 4/1/21 and 4/5/21. There was no indication that any treatment was provided on 4/3/21. Record review revealed that R#6 was hospitalized from 4/6/21 to 4/14/21. Review of the TAR revealed that there was no indication that staff provided any treatment to the resident's pressure ulcer from 4/15/21-4/17/21. On 4/18/21, staff applied [MEDICATION(S)], instead of Santyl to the resident's pressure ulcer. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 3 cms. x 5 cms. x 0.8 cms. and had 60% granulation tissue, 20% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer was improving. Continued review revealed that her recommended treatment was for staff to cleanse the wound with normal saline/wound cleanser or soap and water, apply Santyl to the wound, and cover with a dry protective dressing daily. Review of the TAR revealed that there was no indication that staff applied the Santyl every day and continued to apply [MEDICATION(S)] to the resident's sacral pressure ulcer every other day on 4/22/21, 4/24/21 and 4/26/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 4 cms. x 5 cms. x 0.8 cms. and 40% granulation tissue, 30% necrotic tissue, 30% intact tissue, mild serous drainage and no odor. The NP documented that the resident's pressure ulcer had deteriorated due to its increase in wound volume. Continued review revealed that her recommended treatment was for staff to continue Santyl to the wound daily. Review of the TAR revealed that staff initiated the Santyl daily on 4/27/21-5/3/21. However, there was no indication that any treatment was provided on 4/29/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 4 cms. x 5 cms. x 1.2 cms. and had 50% granulation tissue, 30% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer was unchanged. Continued review revealed that her recommended treatment was for staff to apply Santyl and foam dressing to the wound daily. Review of the TAR revealed that there was no indication that staff applied the Santyl every day on 5/6/21 and 5/10/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 4 cms. x 4.5 cms. x 1.4 cms. and had 50% granulation tissue, 30% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer was unchanged. Continued review revealed that her recommended treatment was for staff to apply Santyl and foam dressing to the wound daily. Review of the TAR revealed that staff provided treatment as ordered from 5/12/21-5/17/21. Record review revealed that R#6 was not assessed by the Wound Company NP on 5/18/21 due to an outside physician's appointment. Review of the TAR revealed that there was no indication that staff provided treatment on 5/20/21 and 5/23/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage III sacral pressure ulcer measured 5 cms. x 3 cms. x 1.5 cms. and had 60% granulation tissue, 20% necrotic tissue, 20% intact tissue, mild serous drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer did have an increase in granulation tissue. Continued review revealed that her recommended treatment was for staff to apply Santyl and foam dressing to the wound daily. Review of the TAR revealed that staff provided treatment as recommended from 5/26/21-5/31/21 and from 6/1/21-6/5/21. However, there was no indication that staff provided treatment on 6/6/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's sacral pressure ulcer measured 5.5 cms. x 4.2 cms. x 5.1 cms. and had 40% granulation tissue, 40% necrotic tissue, 20% intact tissue, large sero-purulent drainage and no odor. The Nurse Practitioner documented that the resident's pressure ulcer had significantly declined and was now a Stage IV pressure ulcer with muscle tissue visible in the wound bed. Continued review revealed that a tissue culture was obtained to determine infection type. Further review revealed that staff were to irrigate the sacral wound with 0.5 % (full strength) Dakins solution (an antimicrobial cleanser used to prevent and treat skin and tissue infections), pack the wound with 0.25% (half strength) wet to dry dressing and cover with a dry dressing twice a day. Review of the TAR revealed that staff continued to apply Santyl daily to the wound on 6/9/21, 6/12/21 and 6/13/21. There was no indication that staff provided any treatment on 6/10/21, 6/11/21 or 6/14/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage IV sacral pressure ulcer measured 5.8 cms. x 4.5 cms. x 5.3 cms. and had 40% granulation tissue, 30% yellow/black necrotic tissue, 20% intact tissue and 10% other tissue, large sero-purulent drainage and mild odor. The Nurse Practitioner documented that the resident's pressure ulcer had deteriorated and that spiculating bone was visible in the wound bed. A bone biopsy and culture were obtained. Continued review revealed that the resident's wound culture from last visit was reviewed. Further review revealed that the NP's plan was to withhold antibiotic treatment until the bone culture results were obtained. Treatment with 0.25% Dakins Solution and a foam dressing was to continue twice a day. The NP did not specify in her note that staff should irrigate the wound with 0.5% Dakins Solution. Review of the TAR revealed that staff initiated new treatment on 6/16/21 to clean the wound bed with normal saline/wound cleanser, apply 0.25% Dakin's moistened wet gauze to wound bed, cover with a ABD pad and secure with tape every day. Continued review of the TAR revealed that staff provided applied the Dakin's Solution daily, instead of twice a day, on 6/16/21, 6/19/21 and 6/21/21. There was no indication that staff provided any treatment to the resident's sacral pressure ulcer on 6/17/21, 6/18/21, 6/20/21, 6/22/21. Review of the Wound Culture Report dated 6/9/21, reported 6/11/21 and faxed to the facility on [DATE] revealed that the resident's sacral pressure ulcer showed moderate growth Morganella morganii. [MEDICATION(S)] (an antibiotic) 500 mgs BID (twice a day) x 7 days was written on the report but, there was no date or staff person's initial to indicate who wrote the order. There was no indication that [MEDICATION(S)] was ordered and initiated until 7/12/21. The resident completed the seven-day therapy. Interview with the Director of Health Services (DHS) on 8/11/21 at 1:52 p.m. revealed that she had reviewed the wound culture results on 7/12/21 and notified the NP for the attending Physician who ordered the [MEDICATION(S)]. The DHS stated that when the Wound Company NP obtained the wound culture on 6/9/21, she told the Treatment Nurse that she may order [MEDICATION(S)] for the resident; however, the Wound Company NP did not write an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further interview revealed that the Wound Company NP had assessed the resident later (6/22/21) and never mentioned the [MEDICATION(S)]. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage IV sacral pressure ulcer measured 5.5 cms. x 4.5 cms. x 6.4 cms. and had 65% granulation tissue, 5% necrotic tissue, 20% intact tissue, 10% other tissue, large sero-purulent drainage and no odor. The wound had undermining and tunneling. The NP documented that the resident's pressure ulcer was unchanged. Continued review revealed that the resident's bone culture and biopsy results were obtained and that she recommended a consult with an Infectious Disease Physician. Treatment with 0.25% Dakins Solution and a foam dressing was to continue twice a day. Review of the TAR revealed that staff initiated the twice a day treatment order for 0.25% Dakin's Solution on 6/23/21. However, there was no indication that any treatments were provided on 6/23/21, 6/28/21-6/30/21. Treatment was provided with the Dakins Solution once per day only on 6/24/21, 6/25/21, 6/26/21, 7/2/21 and 7/5/21. Review of the Wound Company NP assessment dated [DATE] revealed that R#6's Stage IV sacral pressure ulcer measured 5.5 cms. x 4.5 cms. x 6 cms. and had 70% granulation tissue, 5% yellow/black necrotic tissue, 20% intact tissue, 5% other tissue, large sero-purulent drainage and no odor. The wound had undermining and tunneling. The NP documented that the resident's pressure ulcer was unchanged. Continued review revealed that the resident's bone culture showed [CONDITION(S)] and that he required an Infectious Disease (ID) Physician consult and intravenous antibiotics. Staff were unable to obtain an early appointment with the ID Physician, so the resident's attending Physician opted to send R#6 to the local hospital Wound Care Center to begin treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that staff were to continue the Dakins Solution treatments twice a day. Review of the TAR revealed that there was no indication that any treatments were provided 7/7/21, 7/9/21, 7/12/21, 7/18/21 and 7/24/21. Treatment was provided only once a day on 7/8/21, 7/15/21, 7/17/21, 7/19/21 and 7/20/21. Record review revealed that R#6 was not assessed by the Wound Company NP after 7/6/21. Review of the Facility Wound Management record dated 7/22/21 revealed that the resident's sacral pressure ulcer was unstageable and measured 5 cms. x 4.5 cms. x 5.4 cms. with undermining and tunneling. R#6 was assessed by a local hospital Wound Care Clinic on 7/23/21. Review of the Wound Clinic noted dated 7/23/21 revealed that R#6's Stage IV sacral pressure ulcer measured 7 cms. x 8 cms. x 1.4 cms. with tunneling of 8 cms. in the 7 o'clock position. There was necrotic tissue and palpable bone, no purulent discharge and minimal surrounding [CONDITION(S)]. Excisional debridement was performed to promote healing and reduce infection. Continued review revealed that the debridement, dressing changes with [MEDICATION(S)] and Dakins, and antibiotic therapy should improve the pressure ulcer. Further review revealed that if the pressure ulcer did not improve, the resident would need hospitalization and evaluation for surgical debridement and possible diverting [CONDITION(S)]. The Wound Care Clinic Physician wrote a prescription for [MEDICATION(S)] 300 milligrams (mgs.) three times per day for 10 days and a Wound Care order for [MEDICATION(S)]/Dakins to sacral ulcer QD (every day). R#6 was to follow-up with the Wound Care Clinic in two weeks. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] #6 until 7/26/21 at 10:00 p.m., three days after his appointment with the Wound Care Clinic. Further review revealed that R#6 completed the antibiotic therapy on 8/5/21. Review of the TAR revealed that staff continued to apply the Dakin's solution moistened soaked gauze to the sacral pressure ulcer twice a day (original order date 6/23/21) except on 7/24/21 and 8/7/21 when there was no indication that any treatment was provided. Treatment with the Dakin's solution was provided once per day on 7/29/21, 7/30/21, 8/5/21 and 8/8/21. There was no indication that staff applied [MEDICATION(S)] to the sacral pressure ulcer. Interview with the Director of Health Services (DHS) on 8/12/21 at 10:40 a.m. revealed that staff should have written the 7/23/21 Wound Care Clinic Physician's treatment order for once per day. Continued interview revealed that [MEDICATION(S)] and Dakin's solution were not used together in a treatment and that the Physician meant that staff could use either the Dakin's solution or the [MEDICATION(S)]. However, there was no indication that staff clarified with the Wound Care Clinic Physician regarding his treatment order. Review of the Facility Wound Management record dated 7/29/21 revealed that the sacral pressure ulcer measured 9.5 cms. x 10.5 cms. x 4.5 cms. with undermining and tunneling. Record review on 8/4/21 revealed that R#6 had an appointment with the Wound Care Clinic for follow-up but, was not seen because transportation was late for his appointment. Review of the Nurses Noted dated 8/9/21 at 3:57 p.m. revealed that the nurse was notified the R#6's sacral dressing was soiled and coming off. Upon assessment by the nurse, the resident was not talkative as he usually was. He had not eaten his breakfast or lunch. His oxygen (O2) saturation level on room air was within normal limits. His blood pressure was low at 98/58 and his pulse was high at 108 breaths per minute. His temperature and respirations were within normal limits. The Physician was notified of the resident's status and ordered staff to send the resident to the Emergency Department (ED). Review of the Hospital History and Physical dated 8/9/21 revealed that the resident had an elevated White Blood Count of 21.34 (normal was 3.5-10.5). His lab results showed leukocytosis, [CONDITION(S)], [CONDITION(S)] and hypochloremia. Continued review revealed that his sacral pressure ulcer had diffuse [CONDITION(S)] and active purulent drainage with foul odor. Review of the Hospital Progress Note dated 8/10/21 revealed that that the sacral pressure ulcer measured 7 cms. x 8 cms. with classic and necrotic tissues in the wound base, undermining and tunneling at the 7 o'clock and 5 o'clock positions and mild malodor. There was minimal surrounding [CONDITION(S)] and no gross drainage noted. There was some brownish drainage expressed from an open abscess that tracked along the left leg and left buttock area. Further review revealed that the assessment showed a Stage IV sacral pressure ulcer, possible [CONDITION(S)] of the coccyx and left leg/buttock abscess. Review of the weekly skin audits revealed that staff failed to provide a head-to-toe skin assessment for R#6 in order to identify skin breakdown timely on 1/21/21, 2/12/21, 2/26/21, 3/12/21, 4/5/21, 4/19/21, 4/26/21, 5/3/21, 5/17/21, 5/24/21, 5/31/21, 6/7/21, 6/14/21, 6/21/21, 6/28/21, 7/5/21, 7/12/21, 7/26/21 and 8/2/21. Follow-up telephone interview with the Wound Company NP on 8/11/21 at 12:05 p.m. revealed that she was not aware that staff had not provided treatments as documented on her weekly wound assessments but, she expected staff to follow her treatment recommendations. Continued interview revealed that she could not say with 100% certainty that staff's failure to provide treatments per her recommendations resulted in the deterioration of the resident's pressure ulcer and infection. Further interview revealed that she did not believe the resident's pressure ulcer would improve without surgical intervention and intravenous (IV) antibiotics. During an interview with the resident's Attending Physician on 8/18/21 at 12:09 p.m., he was asked if he was aware of the decline in the resident's sacral pressure ulcer. He stated at that time that he let the Wound Company staff take care of the wounds. Continued interview revealed that if it appeared that Wound Company staff were not providing appropriate treatment then he would call them for clarification. Further interview revealed that he was aware of the resident's non-compliance with repositioning and refusal of treatments at times. He stated that he could not remember the timeline of the wound culture results but, that he may have been aware at the time the [MEDICATION(S)] was initiated. Continued interview revealed that he could not determine that staff's failure to provide treatments per the Wound Company NP's recommendations caused the decline in the resident's pressure ulcer because the resident was non-compliant with care. The facility failed to ensure that pressure ulcer treatments were provided for R#6 as recommended by the Wound Company NP from 2/2/21-7/22/21 and as ordered by the Wound Care Clinic Physician from 7/23/21-8/8/21 and the pressure ulcer deteriorated from a DTI to a Stage IV with visible bone, undermining and tunneling, and [CONDITION(S)]. The facility failed to ensure that weekly skin audits were performed for R#6 who was admitted with pressure ulcers and at risk for developing additional pressure ulcers in order to identify breakdown timely. 2. Record review revealed that R#8 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 9, indicating she had some cognitive impairment; had no behaviors; was non-ambulatory; required extensive assistance from one staff person for bed mobility and toilet use; was always incontinent of bladder and bowel; weighed 220#; had 2 Unstageable pressure ulcers and one arterial/venous ulcer. Review of the resident's care plan dated 3/29/21 revealed that she was admitted with old surgical scars where all her toes had been amputated that had eschar with an intervention for staff to provide wound care as ordered. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nurses Note dated 4/28/21 at 1:06 p.m. revealed that the areas on the resident's amputation sites were wet to touch and that a blister was observed on her left heel. The Physician was notified and ordered staff to clean the amputation sites with normal saline/wound cleanser, apply [MEDICATION(S)], cover with ABD pad and Kerlix every other day and as needed. There was also an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 4/2021 TAR revealed that staff failed to provide treatment to the surgical sites on 4/2/21 and the left heel on 4/29/21. Review of the Facility Wound Management Report dated 5/4/21 revealed that the left heel blister measured 3.5 cms. x 1.8 cms. and was intact. On 5/11/2021, the Wound Company NP assessed R#8. Review of the Wound Company NP's assessment dated [DATE] revealed that the resident had an Unstageable pressure ulcer on her left distal foot (at the site of transmetatarsal amputation) that measured 1 cms. x 2 cms. x 0.5 cms., had excessive yellow necrotic tissue, mild serous drainage and no odor. The resident also had an Unstageable pressure ulcer on her right distal foot (at the site of transmetatarsal amputation) that measured 0.9 cms. x 0.6 cms. x 0.4 cms., had excessive yellow necrotic tissue, mild serous drainage and no odor. Continued review revealed that staff were supposed to cleanse the wounds with normal saline or soap and water, apply [MEDICATION(S)] and cover with dry dressing three times a week. There was no indication that the NP addressed the left heel blister at that time. Review of the TAR revealed that staff treated the pressure ulcers as ordered. Staff continued to apply skin prep to the left heel daily. Review of the Wound Company NP assessment dated [DATE] revealed that the Unstageable pressure ulcer on her left distal foot measured 1 cms. x 0.9 cms. x 0.6 cms., had 80% granulation tissue and 20% intact tissue, mild serous drainage and no odor. The Unstageable pressure ulcer on her right distal foot measured 0.5 cms. x 0.3 cms. x 0.3 cms., had 80% granulation tissue and 20% intact tissue, mild serous drainage and no odor. Continued review revealed that the pressure ulcers were improving. There was no indication that the NP addressed the left heel ulcer. The Wound Company NP reviewed the resident's arterial studies and recommended a vascular consult regarding revision of her transmetatarsal amputation. Continued review revealed that staff were supposed to continue the [MEDICATION(S)] three times a week. Review of the TAR revealed that staff failed to provide treatment to the left distal foot and the right distal foot on 5/20/21 and 5/24/21. Staff failed to apply skin prep to the left heel daily on 5/20/21, 5/21/21 and 5/24/21. Review of the Wound Company NP assessment dated [DATE] revealed that the Unstageable pressure ulcer on the resident's left distal foot measured 1 cms. x 1.2 cms. x 0.5 cms., had 80% granulation tissue and 20% intact tissue, mild serous drainage and no odor. The Unstageable pressure ulcer on her right distal foot measured 0.5 cms. x 0.3 cms. x 0.3 cms., had 80% granulation tissue and 20% intact tissue, mild serous drainage and no odor. Both pressure ulcers were improving. There was no indication that the Nurse Practitioner addressed the left heel pressure ulcer. Continued review revealed that staff were supposed to continue the [MEDICATION(S)] three times a week. Review of the TAR revealed that staff provided treatment as ordered from 5/25/21-5/31/21. Staff applied skin prep to the left heel daily 5/25/21-5/31/21. Review of the Wound Company NP assessment dated [DATE] revealed that the Unstageable pressure ulcer on the resident's left distal foot measured 1 cms. x 1.2 cms. x 0.5 cms., had 80% granulation tissue and 20% intact tissue, mild serous drainage, no odor and was unchanged. The Unstageable pressure ulcer on her right distal foot measured 1.5 cms. x 1.2 cms. x 0.3 cms., had 80% necrotic tissue tissue and 20% intact tissue, mild serous drainage, no odor and had deteriorated. There was no indication that the Nurse Practitioner addressed the left heel pressure ulcer. Continued review revealed that staff were supposed to continue the [MEDICATION(S)] three times a week. Review of the TAR revealed that staff provided treatment as ordered from 6/1/21-6/7/21. Staff applied skin prep to the left heel daily 6/1/21-6/7/21. Review of the Wound Company NP assessment dated [DATE] revealed that the Unstageable pressure ulcer on the resident's left distal foot measured 1 cms. x 1.2 cms. x 0.5 cms., had 80% granulation tissue and 20% intact tissue, moderate serous drainage, no odor and was unchanged. The Unstageable pressure ulcer on her right distal foot measured 2.5 cms. x 2.5 cms. x 0.3 cms., had 80% black necrotic tissue and 20% intact tissue, no drainage, no odor and had deteriorated. The Nurse Practitioner assessed the left heel wound as arterial/pressure that measured 4 cms. x 3.5 cms. x 0.5 cms., with dark purple discoloration, no drainage and no odor. Continued review revealed that treatment to the left distal foot was changed to apply Maxsorb Ag (used on moderately to heavily draining partial and full thickness wounds) and dry dressing three times a week. Treatment to the right distal foot changed to apply Skin prep and dry dressing three times a week. Staff were supposed to apply skin prep and dry dressing to the left heel daily. Review of the TAR revealed that staff provided treatments as ordered to the right distal foot and left distal foot. Continued review revealed that staff failed to provide skin prep to the left heel on 6/14/21. Review of the Wound Company NP assessment dated [DATE] revealed that the Unstageable pressure ulcer on the resident's left distal foot measured 1 cms. x 1.2 cms. x 0.5 cms., had 80% granulation tissue and 20% intact tissue, moderate serous drainage, no odor and was unchanged. The Unstageable pressure ulcer on her right distal foot measured 2.5 cms. x 2.5 cms. x 0.3 cms., had 80% black necrotic tissue and 20% intact tissue, no drainage, no odor and was unchanged. The left heel arterial/pressure ulcer measured 4 cms. x 3.5 cms. x 0.5 cms., had 30% dermis, 30% intact tissue, 40% other tissue, mild serous drainage and no odor. The wound was unchanged. Treatment to the left distal foot was to continue with the Maxsorb AG three times per week. Treatment to the right distal foot was to continue with the Skin prep and dr

Based on observation, interview, record review, and review of facility policy, it was determined for two of 20 sampled residents (Residents (R) # 36 and R# 109)) the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical needs and included the resident's goals and desired outcomes. Record review revealed R#36 was admitted to the facility on [DATE] with a supra-pubic catheter for [MEDICAL CONDITION]. A Physician order [REDACTED]. Review of R#36's care plan dated 4/30/15 documented the resident had a Foley catheter, but did not reflect the catheter was to be changed monthly and as needed. Record review revealed R#109 readmitted to the facility 1/3/18 with a Foley catheter for [MEDICAL CONDITION]. The use of a Foley catheter was added to the plan of care however, there were no goals or timeframes established to evaluate fulfillment of goals. Although interventions were identified, in the absence of established goals, their effectiveness could not be measured. Findings include: Review of a facility policy entitled Care Plan Preparation, Long Term Care, (revised 5/12/17), revealed the care plan for each resident must include goals, interventions, and evaluation. According to the policy, goals should be expressed in measurable objectives with timetables to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Interventions should describe the services to be employed to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Evaluation should then occur of the fulfillment of goals as planned. The policy directs staff to state goals clearly as they should be used to evaluate the effectiveness of the care plan. Additionally, interventions should be specific to allow staff to carry out the intervention with assurance of accuracy. 1. Resident (R) # 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additional review of the resident's medical record revealed [REDACTED]. Review of the resident's medical records revealed a Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the resident's care plan revealed a problems/needs with an onset of 4/30/15 that stated (1) the resident has a suprapubic catheter related to a vesico vaginal fistula and (2) the resident has a history of urinary tract infections (UTIS) and the potential for UTIs. Interventions included: o Providing perineal care daily and as needed, o Report redness, swelling, discharge or urinary related odor to supervisor. o Observe and report changes in urine color, cloudiness, or sedimentation to the charge nurse. o Report complaints of pain or discomfort from the catheter to the charge nurse. o Check catheter every shift for patency, proper position of tubing, and bag. o Report catheter leakage to charge nurse. o Administer medications as ordered to decrease UTIs. o Observe for signs and symptoms of UTI and notify the Physician. o Ensure resident does not lay on the tubing. o Change stat lock as ordered. o Notify the Physician as indicated. o An updated intervention dated 11/1/17 documented the resident was to have a urology consult as ordered. There was no documentation indicating the physician's orders [REDACTED]. 2. Review of the medical record revealed R #109 was readmitted to the facility 1/3/18 with a [DIAGNOSES REDACTED]. Review of the care plan (with unspecified date) revealed placement of a Foley catheter related to a [DIAGNOSES REDACTED]. The added care plan problem did not include established goals or measurable objectives and timeframes for meeting goals. Interventions planned to address the resident's use of a Foley catheter included to report any signs/symptoms of infection to the Physician and replace the catheter as needed. The planned interventions were to be carried out by the charge nurse. The care plan contained no further directives for staff related to the resident's Foley catheter use and positioning of catheter and drainage bag. Observation of R #109 on 01/23/18 at the following times 9:19 a.m., 12:26 p.m. and 2:49 p.m. revealed the resident was lying in bed. The resident's urine collection bag was positioned with the bottom lying completely on the floor. Also, the catheter drainage tubing was noted to be resting completely on the floor. Additional observation of the resident on 1/25/18, at 4:04 p.m., revealed the resident was in the bed with the urinary catheter tubing and/or collection bag positioned directly on the floor. Interview was conducted at the nurses' station on 1/25/18 at 4:06 p.m. with the facility's Registered Nurse (RN), Infection Control Coordinator. The Coordinator indicated staff are trained to ensure catheter tubing and bags are kept off the floor. In addition, staff should monitor to make certain proper infection control procedures are maintained. The care plan lacked these interventions when addressing the Foley catheter use for R #109. Interview was conducted in the hallway on 1/25/18 at 5:30 p.m. with the Licensed Practical Nurse (LPN) assigned to care for R #109. The LPN denied having ever seeing the urine collection bag or catheter tubing lying on the floor. The LPN did go on to state the resident's bed was low and it was difficult to keep the catheter tubing and collection bag off the floor. There was no evidence in the plan of care for consideration of the resident's use of a low bed when evaluating person-centered care to address Foley catheter use. Interview was conducted in the hallway on 1/25/18 at 5:32 PM with the Certified Nurse's Assistant (CNA) assigned to care for R #109. The CNA indicated part of an aide's duties included emptying the urine collection bag at the end of shift and documenting output. The CNA stated due to Resident #109 being in a low bed keeping the tubing and collection bag off the floor was a problem. Review of the plan of care revealed no evidence the information obtained from the CNA had been considered when the facility reviewed the use of a Foley catheter for Resident #109. The facility failed to develop care interventions that included care and positioning of the resident's Foley catheter while resident's bed was in a low position Cross refer to F690

Based on observation, interview, record review, and review of facility policy it was determined for two of four sampled residents (Residents (R) #36 and#109) who required the use of a urinary drainage catheters, the facility failed to provide appropriate treatment and care based on current standards of practice and/or in accordance with Physician's orders. Record review revealed R #36 was admitted to the facility with a suprapubic catheter for a [MEDICAL CONDITION] bladder and vesico-vaginal fistula and Physician orders for the catheter to be changed monthly. The facility was unable to provide documentation of the catheter being changed monthly. Record review revealed R #109 was admitted to the facility with a Foley catheter. Multiple observations during the survey revealed the resident lying in bed with the catheter tubing and draining bag laying on the floor. Findings Include: 1. Resident (R) # 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. record revealed [REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R#36 had a Brief Interview for Mental Status (BIMs) score of 15, indicating the resident was cognitively intact. The MDS noted the resident had an indwelling catheter and ostomy. The resident was insulin dependent and received insulin for seven of seven days during the look back period. Review of Physician orders dated 9/1/17 revealed an order to change the suprapubic catheter monthly and as needed. Review of the resident's care plan dated 4/30/15 revealed a problem that stated the resident has a suprapubic catheter related to a vesico vaginal fistula, and the resident has a history of urinary tract infections (UTIs) and the potential for UTIs. Interventions included providing perineal care daily and as needed;, report redness, swelling, discharge or urinary related odor to supervisor; observe and report changes in urine color, cloudiness, or sedimentation to the charge nurse; report complaints of pain or discomfort from the catheter to the charge nurse; check catheter every shift for patency, proper position of tubing, and bag; report catheter leakage to charge nurse; administer medications as ordered to decrease UTIs observe for signs and symptoms of UTI and notify the Physician; change stat lock as ordered, and notify the Physician as indicated. An updated intervention dated 11/1/17 documented the resident was to have a urology consult as ordered. However, there was no intervention indicating the catheter was to be changed monthly and as needed. Review of the Medication Administration Record [REDACTED]. Reviews of the care plan dated 6/21/17, 8/28/17, and 11/6/17 documented the plan of care was to be continued with no changes. Review of nurse's notes from 11/27/17 through 1/24/18 revealed no documentation that the catheter had been changed. During an interview conducted on C hall with Licensed Practical Nurse (LPN) BB on 1/25/18 at 8:31 a.m., BB revealed that she did not know when R#36's catheter had been changed and which shift was responsible for changing it. She stated she had not changed the resident's catheter. During an interview conducted on C Hall with CNA AA on 1/25/18 at 8:33 a.m., the CNA stated she makes sure the catheter is secured and the bag is off the floor and below the level of the bladder. She also makes certain the catheter is not leaking. During a review of the November, December, and January MARs with the Director of Nursing (DON) on 1/25/18 at 12:30 p.m., the DON confirmed there was no documentation that the catheter had been changed and could not state when the catheter had last been changed. On 01/25/18 at 1:20 p.m., the Administrator advised that the facility was checking with the resident's urologist to see if the catheter had been changed during an office visit to the location. The facility was unable to provide documentation indicating the catheter had been changed. During an interview in the conference room with LPN CC, Unit Manager on 01/25/18 at 4:22 p.m., LPN CC stated the resident had told him the catheter had been changed the previous week. LPN CC also stated that there was no documentation to confirm the catheter had been changed the preceding week or in previous months. The Unit Manager stated that the urologist had provided vital signs for the resident, but no documentation the catheter had been changed. The facility failed to ensure R #36's suprapubic catheter was changed according to Physician's orders. 2. Review of the facility policy entitled, Indwelling urinary catheter (Foley) care and management (Revised on 11/11/16) revealed a resident's drainage bag should be kept below the level of the bladder and hips to prevent backflow of urine into the bladder. The policy cautioned against placing the drainage bag on the floor to reduce the risk of contamination. Review of the medical record revealed R #109 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review of the medical record revealed R#109 was admitted to acute care (hospital) from 12/30/17 to 1/03/18. The 1/03/18 readmission [DIAGNOSES REDACTED]. coli), [MEDICAL CONDITION]. The resident returned with a Foley catheter in place and was placed on isolation precautions. Review of an Admission Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/11/17 revealed a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment. The MDS assessment identified R #109 to require the extensive assistance of one to two staff persons with all activities of daily living (ADLs). The MDS assessment further identified the resident to be always incontinent of bowel and bladder. The resident triggered for further review of incontinent status and a Care Area Assessment (CAA) summary was documented and a care plan developed to address the incontinent status. Review of the care plan revealed placement of a Foley catheter related to a [DIAGNOSES REDACTED]. The care plan did not include a date to specify when the problem/need had been identified for the resident. Additionally, the care plan's added problem/need of placement of a Foley catheter contained no established goals or measurable objectives and timeframes for meeting goals. Although there were no goals with timeframes established to address the Foley catheter use, interventions were planned. The interventions included to report any signs/symptoms of infection to the Physician and replace the catheter as needed. The care plan contained no further directives for staff related to the resident's Foley catheter use. Review of the medical record revealed a Physician's order was given on 1/19/18 that stated, Resident Foley cath 18 Fr. 10cc clarification order and to be placed on MAR. Further review of the medical record revealed no evidence of a Physician's order for when the Foley catheter was to be changed or care to be provided regarding the catheter use. Observation of R#109 on 1/23/18 at 9:19 a.m., 12:26 p.m., and 2:49 p.m., revealed the resident was lying in bed. The bed was noted to be in a low position. Attempts to interview the resident were not successful as the resident did not respond to verbal stimuli. The resident's urine collection bag was noted to be inside a cloth dignity bag. However, the bag was positioned with the bottom of the drainage bag lying on the floor. Additionally, the catheter drainage tube was noted to be lying on the floor, with approximately four to six inches of the tubing resting completely on the floor. Continued observation on 1/25/18, at 4:04 p.m. of R#109 revealed the resident was lying in bed, with the bed in a low position. The resident's urinary catheter tubing and/or collection bag were positioned directly on the floor. Staff were observed throughout the observations to walk past the resident's room with no intervention initiated to secure the catheter tubing and/or urine collection bag off the floor. An interview was conducted at the nurses' station on 1/25/18 at 4:06 p.m. with the facility's Registered Nurse (RN), Infection Control Coordinator. The Infection Control Coordinator indicated it was not acceptable for any resident with a catheter to have the tubing and/or collection bag lying on the floor. Staff are trained to not allow this to occur. In addition, staff should monitor to make certain proper infection control procedures are maintained. Upon completion of the interview the Infection Control Coordinator accompanied the surveyor to the room of R#109 where the bottom of the urine collection bag was noted to be resting on the floor. The Infection Control Coordinator proceeded to instruct staff to anchor the collection bag in a manner to prevent contact with the floor. Interview was conducted in the hallway on 1/25/18 at 5:30 p.m. with the Licensed Practical Nurse (LPN) assigned to care for R #109. The LPN denied having ever seeing the urine collection bag or catheter tubing lying on the floor. The LPN also stated the resident's bed was low and it was difficult to keep the catheter tubing and collection bag off the floor. The LPN stated everyone (staff) should be monitoring for Infection Control issues and if a resident's catheter tubing and/or urine collection bag were seen touching the floor it should be secured off the floor. Interview was conducted in the hallway on 1/25/18 at 5:32 p.m. with the Certified Nurse's Assistant (CNA) assigned to care for R#109. The CNA indicated part of an aide's duties included emptying the urine collection bag at the end of shift and documenting output. The CNA stated due to Resident #109 being in a low bed, keeping the tubing and collection bag off the floor was a problem. However, the CNA denied having ever seen the resident's tubing and bag on the floor. According to the CNA the facility had provided training that included ensuring a resident with a Foley catheter always had the catheter tubing and urine collection bag off the floor. The facility failed to ensure R #109's Foley catheter was properly position to promote adequate drainage and proper infection control procedures were maintained.

Based on observation, interview, record review and facility policy review, the facility failed to maintain a medication error rate of less than 5% when two of two nurses failed to administer medication as ordered for two of the three residents (R#2 and R#4) observed during medication pass. R#2 was given the incorrect dosage of an inhaler and was given another resident's medication. R#4 was given the incorrect medication during medication pass. There were 25 medication opportunities, with 3 errors, which resulted in a 12% medication error rate. Findings include: 1.) During medication pass on 6/4/17 at 8:29 a.m. with Licensed Practical Nurse (LPN) AA R#2's medications were being drawn up into a cup, including [MEDICATION NAME] Disku 250/50. Continued observation revealed that there was a sticker on the outside of the [MEDICATION NAME] box that had an open date of 4/20/17 and an expired date of 5/20/17, and the instructions said to give one puff. Also, the LPN placed 17 grams (gm) of [MEDICATION NAME] in 120 milliliters (ml) of water; however, when she handed the surveyor the bottle, the [MEDICATION NAME] belonged to another resident. The LPN agreed after placing her other medication in the cup, that this was all this resident was to get at that time. During observation of administering the medication to the resident, she drank the [MEDICATION NAME] and was given two puffs of the [MEDICATION NAME], but did not swish and spit afterwards. Review of the June 2017 Physician Orders and Medication Record revealed [MEDICATION NAME] Disku 250/50 one puff every 12 hours and swish and spit after use. Continued review revealed [MEDICATION NAME] 17 gm three times a week. Interview with the LPN AA on 6/4/17 at 11:05 a.m., confirmed that the [MEDICATION NAME] was expired according to the sticker, which she pulled from the medication cart, and confirmed that there was no [MEDICATION NAME] on the medication cart for this resident. 2.) During a medication pass on 6/4/17 at 9:11 a.m. with Registered Nurse (RN) BB R#4 was given given [MEDICATION NAME] 100 mg along with her other medications, totaling eight. Review of the June 2017 Physician Orders and Medication Record revealed no evidence of [MEDICATION NAME]; however, Senna-Plus 17.2-100 mg two tablets were to be given daily. Interview with RN BB on 6/4/17 at 11:00 a.m., confirmed that she did give the [MEDICATION NAME], but Senna-Plus was on the medication cart. Interview with the Director of Nursing (DON) on 6/4/17 at 12:40 p.m., revealed that there should not be any expired medications on the medication carts, when medications are opened they are labeled with an opened date and expired date and that the pharmacy comes in to complete medication pass, last inservice was in April 2017. Review of the facility policy Medication Administration: General Guidelines with revised date 1/23/15 revealed that medications are administered in accordance with written orders of the attending physician; Signal stickers that denote important information regarding the medications are used to assist in accurate medication administration; and Medications supplied for one patient/resident are never administered to another patient/resident.

Based on observation, and staff interview, the facility failed to ensure that one of two nurses during medication pass locked and/or stored medication out of harms way of residents and/or visitors. The census was 85 with 7 wandering residents. Findings include: During medication pass with Registered Nurse (RN) BB on 6/4/17 at 8:53 a.m., she gathered all of R#3's medications, then went into the resident's room and stayed approximately two minutes, without locking her medication cart, which was out in the hallway. Continued observation revealed that upon return to the medication cart she opened it up and started with another resident. During medication pass with RN BB on 6/4/17 at 9:11 a.m. revealed that she gathered R#4's medications, including over the counter (OTC) medication of Colace and Tylenol, and left these two bottles sitting on the corner of the right side of the medication cart along with the cart being unlocked as she went to give R#4 her medication. Continued observation revealed that the RN was gone for three minutes and when she returned to her medication cart, she obtained a pain medication for the resident; however, did not move the two bottles nor did she lock her cart. She returned to R#4's room and gave the resident her pain medication, which she was out of sight of her cart for approximately two to three minutes. Upon returning to medication cart, she did not remove the bottles. Interview with the Director of Nursing (DON) on 6/4/17 at 12:40 p.m., revealed that all medications should be locked on the cart away from other residents and/or visitors. Continued interview revealed that all staff have been inserviced on this.

Based on observations, record review and staff interview, it was determined that the facility failed to turn and reposition and float the left foot as care planned for one resident (R) (R#52) of three residents reviewed for pressure sores. Refer F314 Findings include: R#52 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility, was at risk for pressure sore development and had one (1) Stage III pressure sore that was not present on the last MDS assessment dated [DATE]. Review of the care plan dated 4/10/15 revealed that the resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, nutritional risks, a history of pressure sores, dependence on staff for repositioning and multiple contractures with interventions for nursing staff to turn and reposition the resident during rounds and PRN (as needed) and to use pillows and other supportive devices to assist with positioning as needed. The care plan was revised on 7/7/16 due to impaired skin integrity of the left ankle and difficulty in positioning the contracted left foot without the ankle touching the bed with an intervention for nursing staff to float the left foot with pillows. On 1/23/2017 at 2:05 p.m., R#52 was lying on her back on a pressure relieving mattress. Observation of the resident at that time with Licensed Practical Nurse (LPN) DD revealed that the resident's bilateral arms and hands were severely contracted in a flexed position. Her left leg was in a flexed contracture at the knee and her feet were internally rotated. Her left ankle bone was resting on some gauze on the bed. LPN DD stated at that time that staff had identified a pressure sore on the resident's ankle bone that morning and she was in the room to provide treatment. The area appeared as a Stage II pressure sore with moderate serous drainage and measured approximately 2 centimeters (cms.) by 1 cms. review of the resident's medical record revealed [REDACTED]. Observation of R#52 on 1/25/17 at 10:05 a.m., 11:21 a.m., 2:00 p.m. and 3:30 p.m. revealed that staff failed to float the resident's left foot on a pillow and the resident's left ankle was resting directly on the bed. Furthermore, although staff had placed a pillow under the resident's right hip, staff failed to turn and reposition the resident and appropriately apply positioning devices so that constant pressure on the resident's sacrum and buttocks was alleviated. Observation of R#52 on 1/26/17 at 12:15 p.m., 2:35 p.m. and 4:10 p.m., revealed that she was lying on her back in the bed. Staff had placed a pillow under her left knee but, her left ankle was resting directly on the bed. Staff failed to float the resident's left foot. Interview with Registered Nurse/Treatment Nurse FF on I/27/17 at 11:35 a.m. revealed that all nursing staff were responsible for ensuring that residents at risk for skin breakdown were turned and repositioned every two hours and that pressure relieving devices were in place. Continued interview revealed that the CNAs checked the residents on even hours and the nurses checked them on odd hours. Further interview revealed that she would check those residents at risk at the beginning of her shift, around lunch and then at 2:00 p.m. to ensure that they were turned and repositioned and that devices were in place.

Based on record review and staff interview, it was determined that the facility failed to follow physician's orders for medication administration for one resident (R) (R#142) from a sample of 32 residents. Findings include: R#142 (closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Nursing Home Visit Report dated 3/22/16 revealed that the Nurse Practitioner (NP) assessed the resident with [MEDICAL CONDITION] (blood pressure was 113/61) and decreased the dosage of the Losartan, an antihypertensive medication. Continued review of the medical record revealed a physician's order dated 3/22/16 for staff to decrease the Losartan from 50 milligrams (mgs.) every day to 25 mgs. However, review of the March 2016 Medication Administration Record (MAR) revealed that nursing staff failed to transcribe the order to the MAR and continued to administer the 50 mgs. of Losartan to the resident every day from 3/22/16 to 3/29/16 when the Nurse Practitioner (NP) discontinued the medication. Review of the Skilled Daily Nurses Notes from the resident's admission on 2/23/16 to 3/29/16 when the Losartan was discontinued revealed that the resident's blood pressures fluctuated between 86/54 and 186/105. Interview with Licensed Practical Nurse (LPN) GG on 1/26/17 at 4:10 p.m. revealed that the nurse who cared for a resident was responsible for transcribing any medication orders to the MAR and that the Assistant Director of Health Services (ADHS), whose last day working was the previous Friday, was responsible for ensuring that the orders were transcribed daily. Interview with Registered Nurse (RN) HH on 1/26/17 at 4:30 p.m., revealed that the night shift nurse was responsible for reconciling the physician orders with the MAR to ensure that medication orders were transcribed.

Based on observation, record review and staff interview, it was determined that the facility failed to ensure that pressure relieving measures were implemented to promote healing of an existing pressure sore for one resident (R) (R#52) of three residents reviewed for pressure sores. Findings include: R#52 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility, was at risk for pressure sore development and had one (1) Stage III pressure sore that was not present on the last MDS assessment dated [DATE]. Review of the care plan dated 4/10/15 revealed that the resident was at risk for alteration in skin integrity related to impaired mobility, incontinence, nutritional risks, a history of pressure sores, dependence on staff for repositioning and multiple contractures with interventions for nursing staff to turn and reposition the resident during rounds and PRN (as needed) and to use pillows and other supportive devices to assist with positioning as needed. The care plan was revised on 7/7/16 due to impaired skin integrity of the left ankle and difficulty in positioning the contracted left foot without the ankle touching the bed with an intervention for nursing staff to float the left foot with pillows. On 1/23/2017 at 2:05 p.m., R#52 was lying on her back on a pressure relieving mattress. Observation of the resident at that time with Licensed Practical Nurse (LPN) DD revealed that the resident's bilateral arms and hands were severely contracted in a flexed position. Her left leg was in a flexed contracture at the knee and her feet were internally rotated. Her left ankle bone was resting on some gauze on the bed. LPN DD stated at that time that staff had identified a pressure sore on the resident's ankle bone that morning and that she was in the room to provide treatment. The area appeared as a Stage II pressure sore with moderate serous drainage and measured approximately 2 centimeters (cms.) by 1 cms. review of the resident's medical record revealed [REDACTED]. Observation of R#52 on 1/25/17 at 10:05 a.m., 11:21 a.m., 2:00 p.m. and 3:30 p.m. revealed that staff failed to float the resident's left foot on a pillow and the resident's left ankle was resting directly on the bed. Furthermore, although staff had placed a pillow under the resident's right hip, staff failed to turn and reposition the resident and appropriately apply positioning devices so that constant pressure on the resident's sacrum and buttocks was eleviated. Interview with Certified Nursing Assistant (CNA) EE on 1/25/17 at 12:15 p.m., revealed that for residents at risk for skin breakdown, staff were supposed to ensure that pressure relieving devices were applied and residents turned and repositioned every two hours. Observation of R#52 on 1/26/17 at 12:15 p.m., 2:35 p.m. and 4:10 p.m., revealed that she was lying on her back in the bed. Staff had placed a pillow under her left knee but, her left ankle was resting directly on the bed at those times. Staff failed to float the resident's left foot. Interview with Registered Nurse/Treatment Nurse FF on I/27/17 at 11:35 a.m. revealed that all nursing staff were responsible for ensuring that residents at risk for skin breakdown were turned and repositioned every two hours and that pressure relieving devices were in place. Continued interview revealed that the CNAs checked the residents on even hours and the nurses checked them on odd hours. Further interview revealed that she would check those residents at risk at the beginning of her shift, around lunch and then at 2:00 p.m. to ensure that they were turned and repositioned and that devices were in place. Interview with the Director of Health Services (DHS) on 1/27/17 at 11:45 a.m. revealed that he expected staff to follow the resident's care plan to prevent/promote healing of pressure sores and that supervisory nursing staff should monitor that those interventions were in place.

Based on observation and staff interview the facility failed to ensure that opened food items in the kitchen refrigerators and freezer were securely wrapped, labeled and dated. Additionally, the facility failed to remove a food slicer that had food particles and other dried substance on it, and had been nonoperational for six months, from the food preparation table. This deficient practice increased the likelihood of foodborne illness and had the potential to affect 72 residents receiving an oral diet. Findings include: Review of the facility policy (revised 6/14/16) titled Labeling, Dating, Storage documented: It is the policy of PruittHealth for all partners who assist in handling, preparing, serving, and storing food and beverage items to follow the proper procedures for labeling, dating and storage to ensure proper food safety. This applies to all Dietary partners employed by Pruitthealth. PROCEDURE: 1. Food and/or beverage items will be properly labeled with the name of the item, an open date, and a discard date. 2. Foods will be stored in their original containers or in an approved or wrapped tightly in film, foil etc. and clearly labeled with the name of the item and discard date. 3. Prepared food and/or beverage items will be discarded within 48 hours of preparation. 4. Those items that require refrigeration and/or require refrigeration once they have been opened, will be labeled with an open date and discarded based on chart below. Review of the facility policy (Issued September, 2001) titled Cleaning Procedures: Small Equipment revealed cleaning and sanitizing procedures A tour of the kitchen on 1/23/17 with the Dietary Aide (DA) CC, revealed the following observations: At 10:15 a.m. in the walk-in cooler revealed a half package of open, unwrapped American slice cheese that was not labeled or dated in the walk in cooler. During an interview with DA CC at this time, she stated that she is just a cook and manages the kitchen in the absent of Dietary Manager. At 10:20 a.m. in the walk-in freezer revealed open dinner rolls that were not labeled or dated. At 10:24 a.m. in the reach-in refrigerator revealed an open jar of ham base that was not labeled and dated 10/18/16. Further observation revealed the jar had a hole in the bottom and dark crusty substance around the lid. During an interview with the DA CC, she confirmed these findings. At 10:30 a.m. of the preparation counter revealed a food slicer covered with plastic next to an uncovered mixer. The food slicer was observed with food debris particles, orange colored dried substances, and dark brown rust color substances on the blade of the slicer and also on the attached slicer board. During an interview with DA CC at the time of observation, she stated that she did not believe that the food slicer worked. DA CC further stated that the blade is non reusable and maintenance is to replace the blade. She stated that the food slicer was just being stored on the preparation counter. DA CC stated that mixer was uncovered because staff was getting ready to make pudding using the mixer. Interview on 1/26/17 at 1:25 p.m. with the Dietary Manager (DM) revealed that her expectations are for all food preparation equipment to be clean and properly stored after each use. She stated that the food slicer was not being used by staff due to blades being dulled. The DM further stated that staff had not used the food slicer in six months and that it should had been removed from the counter and cleaned. An Interview on 1/27/17 at 8:40 a.m. with the Dietary Manager revealed that her expectations are that refrigerator required foods are to be stored, dated, and labeled by staff after being open.

Based on observation and staff interview the facility failed to ensure that the power strip was mounted to the wall for one (1) resident (#24) and failed to ensure that medical equipment was plugged into the wall outlet to provide a hazard free environment. The sample size was twenty-seven (27) residents. Findings include: Observation on 05/04/15 at 12:55 p.m. revealed that resident #24 had an electrical power strip that was located on the floor at the head of the bed, not mounted to the wall. Continued observation of the power strip revealed that the resident had two (2) pieces of medical care equipment, a tube feeing pump and an oxygen concentrator that were plugged into the power strip and not in a wall outlet. Observation on 05/05/15 at 11:00 a.m., and again on 05/06/15 at 11:15 a.m. revealed that the power strip for resident #24 remained on the floor at the head of the bed unmounted to the wall. The resident's medical care equipment was still plugged into the power strip. Interview on 05/06/15 at 11:15 a.m. in the room with the Director of Maintenance he confirmed that the power strip in room for resident #24 was on the floor and not mounted to the wall. He further revealed that all power strips should be mounted to the wall and the power strip for resident #24 was over looked. The Maintenance Director further acknowledged that the resident's tube feeding pump and oxygen concentrator were plugged into the power strip and not into the wall. He revealed that medical care equipment should be plugged into a wall outlet and not a power strip. Continued interview revealed that he or his associate conduct quarterly room inspections on all rooms in the facility, and that the room inspections include observing resident outlets and any use of power strips.

Based on record review, staff interview, hospital ED Provider Notes review, and hospital Critical Care Admission Note review, the facility failed to provide ongoing indwelling urinary catheter monitoring and assessment in conformance with resident Care Plans for six (6) residents (#1, #2, #3, #4, #5, and #6), of six (6) residents having indwelling urinary catheters, from a total survey sample of twenty-one (21) residents. This failure to monitor, per the Care Plan, resulted the delay in identifying that the indwelling urinary catheter of one resident, Resident #1, had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to adequately monitor resident indwelling urinary catheters causing the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter occlusion was identified), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator and Director of Nursing acknowledged the expectation of care involved twice-daily monitoring of indwelling urinary catheters, but further acknowledged that there was no evidence to indicate that this monitoring was being consistently done, per this protocol. The facility's failure to ensure urinary catheter monitoring per facility protocol, and in accordance with the Care Plan, resulted in a delay in staff identifying that Resident #1 had sustained an occluded urinary catheter, allowing the resident to become septic, resulting in the resident being transferred and admitted to the hospital in critical condition. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility implemented, and completed, a process which involved the re-training, via staff in-service, of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to the necessary care for residents having urinary catheters. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: During an interview with the Administrator and Director of Nursing (DON) conducted on 09/11/2013 at at 12:20 p.m., the Administrator and DON stated that the facility's expectation of care and protocol for care to be provided to residents having indwelling urinary catheters was for nursing staff to observe urinary catheters at least twice per day. 1. Record review for Resident #1 revealed 07/24/2013 admission physician's orders [REDACTED].#1 specified the insertion of a 16 French indwelling urinary catheter to straight drainage. Review of the Care Plan for Resident #1 revealed that while the Care Plan did not reference the resident's use of an indwelling urinary catheter, the Care Plan did identify, with an 08/13/2013 entry, that the resident was incontinent of both bowel and bladder, and specified as Approaches to monitor for signs and symptoms of urinary tract infections (UTIs), to include foul-smelling urine and elevated temperature, and to notify the physician as indicated. A Nurse's Notes entry for Resident #1 of 08/09/2013 at 9:00 a.m. documented that at that time, the resident's urinary catheter was patent and draining, that the resident's temperature was 98.4 degrees Fahrenheit (F), and that the resident was resting quietly. A Nurse's Notes entry for Resident #1 later in the evening of 08/09/2013, timed at 9:00 p.m., also documented that the resident was resting quietly in bed and had a temperature of 98.4 degrees F. However, despite the fact that Resident #1, who had an indwelling urinary catheter, had Care Plan Approaches specifying for nursing staff to monitor the resident for signs and symptoms of urinary tract infections (to include foul-smelling urine and elevated temperature), and despite the fact that facility protocol specified twice-daily monitoring for residents having urinary catheters, there was no evidence, after the 08/09/2013 Nurse's Notes entry referenced above, of any further monitoring of Resident #1, regarding the status of the resident's catheter, urine, or temperature, until a Nurse's Notes entry of 08/25/201 (sixteen days later). This untimed, 08/25/2013 Nurse's Notes entry documented that Resident #1 was complaining of pain in the abdomen, that the abdomen was tender to touch, that the urine output had been less than 100 milliliters (mls), and that the resident had been sent to the hospital and admitted . Review of the hospital ED Provider Notes (EDPN) of 08/25/2013 for Resident #1 revealed that the resident had lower abdominal distension, that the urinary catheter was occluded by mold, and that once the catheter was replaced, the catheter drained a copious amount of cloudy urine. The EDPN documented an order for [REDACTED]. Review of Resident #1's Critical Care Admission Note (CCAN) of 08/25/2013 documented that when resident's catheter was replaced in the emergency room , the resident produced approximately 1600 mls. of purulent urine. The CCAN further documented that Resident #1 was being admitted to ICU with [MEDICAL CONDITION], acute kidney injury and lactic acidosis. During an interview with the Administrator and DON conducted on 09/11/2013 at 12:20 p.m., these staff members acknowledged that there was no evidence to indicate indwelling urinary catheter monitoring had been done per facility protocol. Based on the above, there is no evidence to indicate that staff monitored Resident #1 for signs and symptoms of infection and foul-smelling urine as specified by the Care Plan after 08/09/2013, even after the insertion of a urinary catheter on 07/25/2013. Rather, the next documented monitoring and assessment of the urinary status of Resident #1 after 08/09/2013 was not until 08/25/2013 (sixteen days later), when the resident was noted to complain of abdominal pain and tenderness, and to have decreased urine output and cloudy urine. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit having a urinary tract infection, [MEDICAL CONDITION], acute kidney injury, and severe metabolic acidosis. Cross refer to F315, example 1, for more information regarding Resident #1. 2. Record review for Resident #2 revealed a Quarterly Minimum Data Set (MDS) of 06/03/2013 in which Section H - Bladder and Bowel documented that the resident had an indwelling catheter, and Section I - Active [DIAGNOSES REDACTED]. Review of Resident #2's Care Plan revealed an identified Problem indicating that the resident had a suprapubic indwelling urinary catheter, and Approaches included for staff to monitor for signs and symptoms of UTIs, to monitor the catheter tubing for kinks or twists, to keep the drainage bag below bladder level, and to notify the physician as indicated. As indicated in the 09/11/2013, 12:20 p.m. interview referenced above, the Administrator and DON stated the facility's protocol for monitoring residents having urinary catheters was for nursing staff to observe urinary catheters at least twice per day. However, record review for Resident #2 revealed Nurse's Notes dated 06/30/2013 at 2:30 a.m., 07/25/2013 at 11:00 p.m., 07/29/2013 at 2:30 a.m., 07/30/2013 at 11:00 p.m., 08/01/2013 at 11:00 p.m., 08/11/2013 at 4:00 a.m. and 08/13/2013 at 3:50 p.m. which documented only once-daily catheter observation, with no evidence of second observations of the status of the urinary catheter on these dates, even though the Care Plan specified monitoring and the facility's procedure specified that monitoring be done twice daily. Additionally, there was no evidence to indicate that nursing staff observed the resident's urinary catheter at all on 06/28/2013, 06/29/2013, 07/19/2013, 07/20/2013, 07/21/2013, 07/22/2013, 07/23/2013 and 07/24/2013. There was also no evidence to indicate that staff conducted any observations to monitor Resident #2's indwelling urinary catheter, or to monitor the resident for any signs and symptoms of infection, as specified by the Care Plan, from 07/01/2013 through 07/16/2013 (16 sequential days), or from 08/13/2013 through until 08/29/2013. During interview with the DON on 9/06/2013 at 3:20 p.m.., she acknowledged the lack of evidence to indicate that the resident had received care in accordance with the Care Plan. Based on the above, the facility failed to monitor the status of the indwelling urinary catheter for Resident #2, and failed to monitor the resident for signs and symptoms of urinary tract infection, in accordance with the Care Plan and with facility protocol. Cross refer to F315, example #2, for more information regarding Resident #2. 3. Record review for Resident #3 revealed an annual MDS assessment with an Assessment Reference Date of 04/30/2013 which documented, in Section H - Bladder and Bowel, that the resident had an indwelling urinary catheter. Section I - Active [DIAGNOSES REDACTED]. A Care Plan entry of 05/13/2013 for Resident #3 indicated that the resident had an indwelling urinary catheter, and Approaches included for nursing staff to monitor the resident for signs and symptoms of UTI, such as elevated temperature and foul smelling urine, and to notify the physician as indicated. However, further record review for Resident #3, to include review of the Nurse's Notes, revealed no evidence to indicate that nursing staff observed the resident to monitor the status of the indwelling urinary catheter, or to monitor for signs and symptoms of UTI, as specified by the Care Plan, from 06/28/2013 through 07/07/2013 (ten sequential days), and from 07/09/2013 through 08/29/2013 (fifty-two sequential days). During interview with the DON on 9/06/2013 at 3:20 p.m.., she acknowledged the lack of evidence to indicate that the resident had received care in accordance with the Care Plan. Based on the above, the facility failed to monitor Resident #3 for signs and symptoms of urinary tract infection, in relation to the resident's indwelling urinary catheter, in accordance with the Care Plan. Cross refer to F315, example 3, for more information regarding Resident #3. 4. Record review for Resident #5 revealed a quarterly MDS assessment of 06/11/2013 which documented, in Section H - Bladder and Bowel, that the resident had an indwelling urinary catheter. Section I - Active [DIAGNOSES REDACTED]. A Care Plan entry for Resident #5 identified that the resident utilized a suprapubic urinary catheter, and specified as Approaches to change the suprapubic urinary catheter every 30 days and as-needed for excess leakage or occlusions, as well as to monitor the resident for decreased urinary output and to notify the physician as indicated. As noted in the 09/11/2013, 12:20 p.m. interview referenced above, the Administrator and DON stated the facility's protocol for monitoring residents having urinary catheters was for nursing staff to observe urinary catheters at least twice per day. However, record review for Resident #5, including Nurse's Notes entries, revealed evidence of only once-daily indwelling urinary catheter observation on the dates of 07/02/2013 at 9:00 p.m. and 07/04/2013 at 3:15 p.m. Also, there was no evidence of any monitoring of the suprapubic urinary catheter at all on the dates from 06/28/2013 through 06/30/2013, 07/01/2013, 07/03/2013, and from 07/05/2013 through 08/29/2013. During interview with the DON on 9/06/2013 at 3:20 p.m., she acknowledged the lack of evidence to indicate that the resident had received care in accordance with the Care Plan. Based on the above, the facility failed to monitor the status of Resident #5's indwelling urinary catheter, including monitoring for the need to change the catheter for leakage or occlusion and monitoring for decreased output to ensure prompt physician consultation when necessary, as specified by the Care Plan and in accordance with facility protocol. Cross refer to F315, example 4, for more information regarding Resident #5. 5. Record review for Resident #6 revealed a Quarterly MDS of 07/19/2013 which documented, in Section H - Bladder and Bowel, that the resident utilized an indwelling urinary catheter, and in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. A Care Plan entry for Resident #6 identified that the resident utilized an indwelling urinary catheter, and specified as Approaches for nursing staff to check the catheter each shift for patency as well as for proper positioning of the tubing and bag, and to notify the physician as indicated. In addition to the Care Plan Approach for Resident #6 specifying catheter checks each shift, during the 09/11/2013, 12:20 p.m. interview with the Administrator and DON referenced above, these staff members stated the facility's protocol for monitoring residents having urinary catheters was for nursing staff to observe urinary catheters at least twice per day. However, record review for Resident #6, including review of Nurse's Notes, revealed evidence of only once-per-day monitoring, rather than per-shift monitoring, as specified by the Care Plan and facility protocol, on 07/17/2013 at 4:20 p.m., 08/04/2013 at 3:10 a.m., 08/13/2013 at 3:30 p.m., 08/21/2013 at 11:00 p.m., 08/23/2013 at 11:00 p.m., 08/24/2013 at 9:40 a.m., 08/26/2013 at 11:00 p.m., and 08/29/2013 at 11:00 p.m. Additional record review for Resident #6 revealed no evidence to indicate that nursing staff observed and monitored the resident's indwelling urinary catheter at all on the dates of 07/14/2013, 07/15/2013, 07/16/2013, from 07/18/2013 through 08/03/2013, from 08/09/2013 through 08/12/2013, from 08/14/2013 through 08/19/2013, on 08/22/2013, and on 08/25/2013. During interview with the DON on 9/06/2013 at 3:20 p.m., she acknowledged the lack of evidence to indicate that the resident had received care for the indwelling urinary catheter in accordance with the Care Plan. Based on the above, the facility failed to monitor the status of Resident #6's indwelling urinary catheter every shift for patency and proper positioning of the tube and bag, in accordance with the Care Plan and with facility protocol, to ensure prompt physician consultation when necessary. Cross refer to F315, example 5, for more information regarding Resident #6. 6. Record review for Resident #4 revealed an admission MDS of 06/25/2013 which documented, in Section H - Bladder and Bowel, that the resident utilized an indwelling urinary catheter, and in Section I - Active Diagnoses, that [DIAGNOSES REDACTED]. The Care Plan for Resident #4 identified that the resident utilized an indwelling urinary catheter, and specified as Approaches that nursing staff were to check the catheter tubing for kinks and to position the catheter tubing below the level of the bladder. As indicated in the 09/11/2013, 12:20 p.m. interview referenced above, the Administrator and DON stated the facility's protocol for monitoring residents having urinary catheters was for nursing staff to observe urinary catheters at least twice per day. However, further record review for Resident #4 revealed evidence of only once-per-day observations of the resident's catheter, those being in the Skilled Daily Nursing Notes, on the dates and times of 07/06/2013 at 12:00 p.m., 07/07/2013 at 2:00 p.m., 07/10/2013 at 11:00 p.m., 07/12/2013 at 2:00 p.m., 07/14/2013 at 2:00 p.m., 07/18/2013 at 11:00 p.m., 07/20/2013 at 3:00 p.m., 07/27/2013 at 1:00 p.m., and 07/28/2013 at 2:30 a.m. Additionally, there was no evidence of observation and monitored of the catheter at all on the dates of 07/19/2013, 07/21/2013, 07/22/2013, 07/23/2013, 07/24/2013, 07/25/2013, 07/26/2013 07/29/2013, 07/30/2013, 07/31/2013, and from 08/01/2013 through 08/29/2013 (twenty-nine sequential days). During interview with the DON on 9/06/2013 at 3:20 p.m., she acknowledged the lack of evidence to indicate that the resident had received care in accordance with the Care Plan, related to the indwelling urinary catheter. Based on the above, the facility failed to monitor the status of Resident #4's indwelling urinary catheter, to include monitoring the condition and placement of the tubing, as specified by the Care Plan and in accordance with facility protocol. Cross refer to F315, example 6, for more information regarding Resident #4. The Immediate Jeopardy was determined to be removed on 09/12/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/30/2013, the Minimum Data Set (MDS) assessment of Resident #1 was re-opened and corrected to include urinary catheter usage. B. On 08/30/2013, the care plan for Resident #1 was updated to reflect that a urinary catheter was present, and to reflect care approaches. C. On 08/30/2013, all residents with urinary catheters were audited to ensure proper MDS assessment coding per regulation. D. On 08/30/2013, the care plans of all residents having urinary catheters were audited to ensure that resident care plans reflected catheter-usage and care approaches. E. On 09/10/2013, facility MDS Coordinators were educated on resident assessment and care planning to ensure thorough assessment, correct MDS coding, and plan-of-care completion. F. On 09/11/2013, education was provided to nursing staff related to catheter monitoring, assessment, and documentation. One-hundred (100) percent of all nursing staff had received training as of that date. All new nursing staff will be oriented to catheter care, monitoring, assessing and documentation upon hire. G. On 09/11/2013, in-service education, which was initiated on 09/03/2013, was completed for certified nursing assistants (CNAs) related to urinary catheters and monitoring techniques. One-hundred (100) percent of all CNAs had received this education by 09/11/2013. H. On 09/11/2013, a new form, the CNA Sheets Form, was implemented by which CNAs would document daily regarding care provided to residents, including those having urinary catheters. The Form will allow for the documentation of resident vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. The Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms. One-hundred (100) percent of all CNAs had received education related to the usage and completion of this form by 09/11/2013. I. On 09/11/2013, the facility instituted a new policy requiring that all newly-hired CNAs will be trained on facility policies and procedures related to urinary catheters, catheter care, and reporting to nursing staff. J. On 09/11/2013, the facility required that ongoing education related to urinary catheters, catheter care, catheter monitoring, and catheter assessment will be provided to all nursing staff and all CNA staff via quarterly and annual in-service training sessions. Additionally, as-needed training will be provided, as determined by the facility's Quality Assessment and Performance Improvement (QAPI) Committee. K. On 09/11/2013, the facility put into place a procedure by which the Director of Health Services (DHS) or the Assistant Director of Health Services (ADHS) will complete a Catheter Patient Care Management Checklist weekly for the first month, then bi-weekly for the next two months, then monthly thereafter. This Form includes assessing the necessity of the catheter, the proper anchoring of the catheter, the correct inclusion of the catheter on the resident care plan, and if staff are monitoring and assessing the catheter each shift. L. On 09/11/2013, the facility put into place a procedure by which the DHS would report issues identified during monitoring accomplished by the Catheter Patient Care Management Checklist to the facility's QAPI Committee. The QAPI Committee monitoring and consideration would include the correct and accurate completion of the Patient Care Management Checklist, the presence of a system review to determine the root cause of identified problems, and the presence of the implementation of an action plan for identified issues once the root cause of a problem was determined. The QAPI Committee will also determine the need for additional staff training, based on the ongoing results of staff performance monitoring, per facility procedures referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on September 12, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Education had been provided to all current nursing staff related to catheter monitoring, assessment, and documentation, but new nursing staff will need to be oriented to catheter care, monitoring, assessing and documentation upon employment. The facility had provided in-service education for all currently employed CNAs related to urinary catheters and monitoring techniques, and on the newly implemented CNA Sheets Form utilized by CNAs to document daily resident care, including catheter care and monitoring vital signs, urinary catheter output, and additional concerns to be relayed to the nurse. However, all CNAs hired after the completion of this complaint survey will need to receive training on facility policies and procedures related to urinary catheters. This process will need to be reassessed once newly hired staff have been employed. Additionally, the Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms, but this procedure was only instituted on 09/11/2013, one day prior to the exit date of this complaint survey. Additionally, On 09/11/2013, the facility put into place the Catheter Patient Care Management Checklist to be monitored by the DHS, who will then report findings to the facility's QAPI Committee. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September 2013, and monthly thereafter, to continue the analysis process related to resident assessment and the facility's provision of indwelling catheter care to residents. Therefore, the non-compliance continues, with the scope and severity reduced to an "E" level.

Based on record review and staff interview, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) Committee evaluated the implementation and effectiveness of the newly-developed Urinary Tract Infection/catheter protocol related to facility urinary tract infections (UTIs), and evaluated the adherence to the facility's indwelling urinary catheter protocol for the ongoing monitoring of urinary catheter status and function. This failure affected Resident #1, who had an indwelling urinary catheter which became occluded with mold after staff failed to monitor twice daily, per facility protocol, and five (5) additional residents, who also had indwelling urinary catheters for which staff failed to provide twice-daily monitoring, from a total survey sample of twenty-one (21) residents. This failure of staff to observe and monitor per facility protocol resulted in the delay of staff in identifying that the indwelling urinary catheter of Resident #1 had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to adequately monitor residents having indwelling urinary catheters which caused the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter was discovered to have become occluded), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator and Director of Nursing acknowledged that facility protocol specified twice-daily monitoring of indwelling urinary catheters. The Administrator revealed that a new UTI/catheter protocol had been discussed with the QAPI Committee, as had the previous, but now discontinued, facility method of documenting urinary catheter checks on resident Medication Administration Records (MARs). However, the Administrator provided no evidence of QAPI Committee evaluation of the implementation and effectiveness of the new UTI/catheter protocol, or of an alternate method of urinary catheter check documentation. The failure of the QAPI Committee to ensure the evaluation of the implementation and effectiveness of existing protocols, and the resulting failure of facility staff to provide the necessary monitoring of indwelling urinary catheters, placed residents having urinary catheters at risk of a delay in the detection of, and the treatment for, complications related to these catheters. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility implemented, and completed, a process which involved the re-training of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to this process. Additionally, new processes involving staffs' completion of CNA Sheets Forms and the Catheter Patient Care Management Checklist will require continued monitoring by nursing management staff to ensure adherence. Also, the DON will be reporting to the QAPI Committee the status of nursing staff compliance with these new processes. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: Cross refer to F315. Based on observation, record review, and staff interview, the facility failed to ensure the necessary indwelling urinary catheter observation and monitoring, per facility protocol, for six (6) residents (#1, #2, #3, #4, #5, and #6), all of whom had indwelling urinary catheters. This failure of the facility to ensure the ongoing observation and monitoring of the status and function of resident urinary catheters resulted in a failure of the facility to ensure the timely identification of both problems/complications regarding catheters and of the necessity of as-needed catheter replacement. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. During an interview with the Administrator conducted on 09/12/2013 at 9:30 a.m., the Administrator was questioned regarding the facility's QAPI Committee process. During this interview, the Administrator stated that, upon review of the monthly QAPI Committee notes, it was noted that the Committee had discussed the need to be more aggressive with resident urinary tract infections (UTIs). The Committee had discussed a new protocol related to UTIs, and had talked about the use of a broad-spectrum antibiotic for the initial seventy-two (72) hours. In a previous interview conducted on 08/30/2013 at 3:50 p.m., the Director of Nursing had presented a new facility UTI/catheter protocol, which was noted to specify the administration of a Cranberry 200 milligram capsules daily, Vitamin C 500 milligrams twice daily, and Mandelamine 500 milligrams twice daily (for residents having no kidney problems). During the 09/12/2013, 9:30 a.m. interview with the Administrator referenced above, it was stated that, in addition to discussing the new UTI/catheter protocol, the QAPI Committee had also discussed modifying the indwelling urinary catheter policy related to the frequency of replacement for indwelling urinary catheters. The Committee had discussed modifying the policy to require the changing of urinary catheters every twenty-nine days, instead of changing catheters as-needed. When questioned if the QAPI Committee had evaluated other issues related to urinary catheters, she stated that the Committee had discussed removing the reference to monitoring resident urinary catheter care each shift from resident MARs, which had been the procedure utilized by the facility to document catheter-monitoring. In a 09/23/2013, 10:46 a.m. telephone interview, the Administrator indicated that this method of documenting urinary catheter checks had been discontinued by the facility as of 06/27/2013. However, during this survey, the Administrator could provide no evidence of QAPI Committee evaluation, regarding the implementation or effectiveness of the newly established UTI/catheter protocol for the use of Cranberry, Vitamin C, and Mandelamine in residents having urinary catheters, and no evidence of further action related to the Committee's prior discussion of modifying the frequency of urinary catheter change. There was no evidence presented to indicate any consideration by the Committee of the need for modifying these interventions or developing alternative interventions. Additionally, no evidence was presented of the QAPI Committee's evaluation of alternative methods or plans of action regarding nursing staff documentation of resident indwelling urinary catheter monitoring, even though the facility had discontinued the MAR indicated [REDACTED]. For Resident #1, evidence indicated that facility staff observed the indwelling urinary catheter only once daily on six (6) days, and failed to observe the catheter at all on a total of thirty-five (35) days. After facility staff failed to monitor the resident for a period of sixteen sequential days, the resident was found, after transfer to the hospital emergency department, to have a urinary catheter which was occluded by mold. The resident was subsequently admitted to the Intensive Care Unit with [MEDICAL CONDITION] and acute kidney injury. For Resident #2, from 06/20/2013 through 08/30/2013, evidence indicated that nursing staff observed the catheter only once per day on nine (9) days, and failed to observe the catheter at all on forty-five (44) days. For Resident #3, from 06/28/2013 through 08/29/2013, evidence indicated that nursing staff failed to observe the catheter at all on sixty-two (62) days. For Resident #4, from 07/06/2013 through 08/30/2013, evidence indicated that nursing staff observed the indwelling urinary catheter only once per day on nine (9) days, and failed to observe the catheter at all on thirty-nine (39) days. For Resident #5, from 06/05/2013 until 08/30/2013, evidence indicated that nursing staff observed the indwelling urinary catheter only once per day on two (2) days, and failed to observe the urinary catheter at all on sixty (60) days. For Resident #6, from 07/14/2013 until 08/30/2013, evidence indicated that nursing staff observed the indwelling urinary catheter only once per day on eight (8) days, and failed to observe and monitor the urinary catheter at all on thirty-two (32) days. For Resident #1, #2, #3, #4, #5, and #6, the facility failed to ensure ongoing, twice-daily monitoring of the status and function of this resident's indwelling urinary catheter in accordance with the established facility protocol for catheter monitoring, to ensure the timely identification of both problems/complications regarding the catheter and/or the necessity of as-needed replacement of the catheter, as specified by physicians' order. The Immediate Jeopardy was determined to be removed on 09/12/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/30/2013, the Minimum Data Set (MDS) assessment of Resident #1 was re-opened and corrected to include urinary catheter usage. B. On 08/30/2013, the care plans for Resident #1 was updated to reflect that a urinary catheter was present, and to reflect care approaches. C. On 08/30/2013, all residents with urinary catheters were audited to ensure proper MDS assessment coding per regulation. D. On 08/30/2013, the care plans of all residents having urinary catheters were audited to ensure that resident care plans reflected catheter-usage and care approaches. E. On 09/10/2013, facility MDS Coordinators were educated on resident assessment and care planning to ensure thorough assessment, correct MDS coding, and plan-of-care completion. F. On 09/11/2013, education was provided to nursing staff related to catheter monitoring, assessment, and documentation. One-hundred percent of all nursing staff had received training as of that date. All new nursing staff will be oriented to catheter care, monitoring, assessing and documentation upon hire. G. On 09/11/2013, in-service education, which was initiated on 09/03/2013, was completed for certified nursing assistants (CNAs) related to urinary catheters and monitoring techniques. One-hundred (100) percent of all CNAs had received this education by 09/11/2013. H. On 09/11/2013, a new form, the CNA Sheets Form, was implemented by which CNAs will document daily regarding care provided to residents, including those having urinary catheters. The Form will allow for the documentation of resident vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. The Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms. One-hundred (100) percent of all CNAs had received education related to the usage and completion of this form by 09/11/2013. I. On 09/11/2013, the facility instituted a new policy requiring that all newly-hired CNAs will be trained on facility policies and procedures related to urinary catheters, catheter care, and reporting to nursing staff. J. On 09/11/2013, the facility required that ongoing education related to urinary catheters, catheter care, catheter monitoring, and catheter assessment will be provided to all nursing staff and all CNA staff via quarterly and annual in-service training sessions. Additionally, as-needed training will be provided, as determined by the facility's Quality Assessment and Performance Improvement (QAPI) Committee. K. On 09/11/2013, the facility put into place a procedure by which the Director of Health Services (DHS) or the Assistant Director of Health Services (ADHS) will complete a Catheter Patient Care Management Checklist weekly for the first month, then bi-weekly for the next two months, then monthly thereafter. This Form includes assessing the necessity of the catheter, the proper anchoring of the catheter, the correct inclusion of the catheter on the resident care plan, and if staff are monitoring and assessing the catheter each shift. The QAPI Committee will also determine the need for additional staff training, based on the ongoing results of staff performance monitoring, per facility procedures referenced above. L. On 09/11/2013, the facility put into place a procedure by which the DHS would report issues identified during monitoring accomplished by the Catheter Patient Care Management Checklist to the facility's QAPI Committee. The QAPI Committee monitoring and consideration would include the correct and accurate completion of the Patient Care Management Checklist, the presence of a system review to determine the root cause of identified problems, and the presence of the implementation of an action plan for identified issues once the root cause of a problem was determined. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on September 12, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Education had been provided to all current nursing staff related to catheter monitoring, assessment, and documentation, but new nursing staff will need to be oriented to catheter care, monitoring, assessing and documentation upon employment. The facility had provided in-service education for all currently employed CNAs related to urinary catheters and monitoring techniques, and on the newly implemented CNA Sheets Form utilized by CNAs to document daily resident care, including catheter care and monitoring vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. However, all CNAs hired post the completion of this complaint survey will need to receive training on facility policies and procedures related to urinary catheters. This will need to be reassessed once newly hired staff have been employed. Additionally, the Charge Nurse is to will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms, but this procedure was only instituted on 09/11/2013, one day prior to the exit date of this complaint survey. Additionally, on 09/11/2013, the facility put into place the Catheter Patient Care Management Checklist to be monitored by the DHS, who will then report findings to the facility's QAPI Committee. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September 2013, and monthly thereafter, to continue the analysis process related to resident assessment, the facility's provision of indwelling catheter care to residents, and the need for additional staff training. Therefore, the non-compliance continues, with the scope and severity level reduced to an "E" level.

Based on record review and staff interview, the facility administration failed to ensure the ongoing monitoring of residents having indwelling urinary catheters to ensure the prompt identification of complications and/or the need for catheter replacement. This failure affected Resident #1, who had an indwelling urinary catheter which became occluded with mold after staff failed to monitor twice daily, per facility protocol, and five (5) additional residents, who also had indwelling urinary catheters for which staff failed to provide twice-daily monitoring, from a total survey sample of twenty-one (21) residents. This failure of staff to observe and monitor per facility protocol resulted in the delay of staff identifying that the indwelling urinary catheter of Resident #1 had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to adequately monitor residents having indwelling urinary catheters which caused the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter was discovered to have become occluded), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator acknowledged awareness of an issue regarding Resident #1 involving the resident's indwelling urinary catheter and hospital admission, but could provide no evidence of any corrective actions, as of the 08/30/2013 entrance date of this complaint survey. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility implemented, and completed, a process which involved the re-training of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to this process. Additionally, new processes involving staffs' completion of CNA Sheets Forms and the Catheter Patient Care Management Checklist will require continued monitoring by nursing management staff to ensure adherence. Also, the DON will be reporting to the QAPI Committee the status of nursing staff compliance with these new processes. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: Cross refer to F315. Based on observation, record review, and staff interview, the facility failed to ensure the necessary indwelling urinary catheter observation and monitoring, per facility protocol, for six (6) residents (#1, #2, #3, #4, #5, and #6), all of whom had indwelling urinary catheters. This failure of the facility to ensure the ongoing observation and monitoring of urinary catheter function resulted in the urinary catheter of Resident #1 becoming occluded with mold, with the resident developing [MEDICAL CONDITION] and requiring admission to the hospital Intensive Care Unit. During an interview with the Administrator conducted on 08/30/2013 at 2:00 p.m., the Administrator was questioned about an awareness of issues involving facility indwelling urinary catheter care. The Administrator stated that she was aware of the facility's Admissions Coordinator receiving a telephone call from a hospital staff member expressing concerns regarding the urinary catheter of Resident #1. The Administrator stated that a facility nurse had gone to the hospital to begin an investigation and to speak with the family of Resident #1. However, the Administrator could provide no evidence of further investigation of the expressed concerns regarding the care of Resident #1's urinary catheter, or of any corrective actions taken as of the 08/30/2013 entrance date of this complaint survey. Additionally, during an interview conducted on 09/11/2013 at 12:20 p.m., the Administrator expressed no awareness of the facility's failure to provide ongoing monitoring of resident indwelling urinary catheters prior to this complaint survey, and provided no evidence of corrective actions undertaken by the facility related to this problem prior to the survey. For Resident #1, evidence indicated that facility staff observed the indwelling urinary catheter only once daily on six (6) days, and failed to observe the catheter at all on a total of thirty-five (35) days. After facility staff failed to monitor the resident for a period of sixteen sequential days, the resident was found, after transfer to the hospital emergency department, to have a urinary catheter which was occluded by mold. The resident was subsequently admitted to the Intensive Care Unit with [MEDICAL CONDITION] and acute kidney injury. For Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6, evidence indicated that facility nursing staff failed to conduct observation and monitoring of the indwelling urinary catheters at all on forty-five (44) days, sixty-two (62) days, thirty-nine (39) days, sixty (60) days, and thirty-two (32) days, respectively. For these residents, the facility failed to ensure ongoing, twice-daily monitoring of the status and function of indwelling urinary catheters, per established facility protocol. The Immediate Jeopardy was determined to be removed on 09/12/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/30/2013, the Minimum Data Set (MDS) assessment of Resident #1 was re-opened and corrected to include urinary catheter usage. B. On 08/30/2013, the care plans for Resident #1 was updated to reflect that a urinary catheter was present, and to reflect care approaches. C. On 08/30/2013, all residents with urinary catheters were audited to ensure proper MDS assessment coding per regulation. D. On 08/30/2013, the care plans of all residents having urinary catheters were audited to ensure that resident care plans reflected catheter-usage and care approaches. E. On 09/10/2013, facility MDS Coordinators were educated on resident assessment and care planning to ensure thorough assessment, correct MDS coding, and plan-of-care completion. F. On 09/11/2013, education was provided to nursing staff related to catheter monitoring, assessment, and documentation. One-hundred percent of all nursing staff had received training as of that date. All new nursing staff will be oriented to catheter care, monitoring, assessing and documentation upon hire. G. On 09/11/2013, in-service education, which was initiated on 09/03/2013, was completed for certified nursing assistants (CNAs) related to urinary catheters and monitoring techniques. One-hundred (100) percent of all CNAs had received this education by 09/11/2013. H. On 09/11/2013, a new form, the CNA Sheets Form, was implemented by which CNAs will document daily regarding care provided to residents, including those having urinary catheters. The Form will allow for the documentation of resident vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. The Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms. One-hundred (100) percent of all CNAs had received education related to the usage and completion of this form by 09/11/2013. I. On 09/11/2013, the facility instituted a new policy requiring that all newly-hired CNAs will be trained on facility policies and procedures related to urinary catheters, catheter care, and reporting to nursing staff. J. On 09/11/2013, the facility required that ongoing education related to urinary catheters, catheter care, catheter monitoring, and catheter assessment will be provided to all nursing staff and all CNA staff via quarterly and annual in-service training sessions. Additionally, as-needed training will be provided, as determined by the facility's Quality Assessment and Performance Improvement (QAPI) Committee. K. On 09/11/2013, the facility put into place a procedure by which the Director of Health Services (DHS) or the Assistant Director of Health Services (ADHS) will complete a Catheter Patient Care Management Checklist weekly for the first month, then bi-weekly for the next two months, then monthly thereafter. This Form includes assessing the necessity of the catheter, the proper anchoring of the catheter, the correct inclusion of the catheter on the resident care plan, and if staff are monitoring and assessing the catheter each shift. The QAPI Committee will also determine the need for additional staff training, based on the ongoing results of staff performance monitoring, per facility procedures referenced above. L. On 09/11/2013, the facility put into place a procedure by which the DHS would report issues identified during monitoring accomplished by the Catheter Patient Care Management Checklist to the facility's QAPI Committee. The QAPI Committee monitoring and consideration would include the correct and accurate completion of the Patient Care Management Checklist, the presence of a system review to determine the root cause of identified problems, and the presence of the implementation of an action plan for identified issues once the root cause of a problem was determined. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on September 12, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Education had been provided to all current nursing staff related to catheter monitoring, assessment, and documentation, but new nursing staff will need to be oriented to catheter care, monitoring, assessing and documentation upon employment. The facility had provided in-service education for all currently employed CNAs related to urinary catheters and monitoring techniques, and on the newly implemented CNA Sheets Form utilized by CNAs to document daily resident care, including catheter care and monitoring vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. However, all CNAs hired post the completion of this complaint survey will need to receive training on facility policies and procedures related to urinary catheters. This will need to be reassessed once newly hired staff have been employed. Additionally, the Charge Nurse is to will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms, but this procedure was only instituted on 09/11/2013, one day prior to the exit date of this complaint survey. Additionally, on 09/11/2013, the facility put into place the Catheter Patient Care Management Checklist to be monitored by the DHS, who will then report findings to the facility's QAPI Committee. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September 2013, and monthly thereafter, to continue the analysis process related to resident assessment, the facility's provision of indwelling catheter care to residents, and the need for additional staff training. Therefore, the non-compliance continues, with the scope and severity level reduced to an "E" level.

Based on record review, staff interview, facility Changing of Catheters: Care and Anchoring policy review, hospital D/C Summaries form review, facility Physician Communication Tool review, hospital ED Provider Notes review, and hospital Critical Care Admission Note review, the facility failed to provide ongoing indwelling urinary catheter monitoring and assessment, per facility protocol, for six (6) residents (#1, #2, #3, #4, #5, and #6) having indwelling urinary catheters, from a total survey sample of twenty-one (21) residents. This failure to monitor and assess resulted in the delay of staff identifying that the indwelling urinary catheter of one resident, Resident #1, had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to adequately monitor resident indwelling urinary catheters causing the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter occlusion was identified), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator and Director of Nursing acknowledged the expectations of care involved twice-daily monitoring of indwelling urinary catheters, but further acknowledged that there was no evidence to indicate that this monitoring was being consistently done, per facility protocol. The facility's failure to ensure urinary catheter monitoring per facility protocol resulted in a delay in staff identifying that Resident #1 had sustained an occluded urinary catheter, allowing the resident to become septic, resulting in the resident being transferred and admitted to the hospital in critical condition. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "E" while the facility implemented, and completed, a process which involved the re-training, via staff in-service, of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to the necessary care for residents having urinary catheters. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: Review of the facility's policy entitled Changing of Catheters: Care and Anchoring, dated November 2012, revealed the policy to require that each resident who was incontinent of bladder and had an indwelling catheter would receive the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The policy indicated that catheters would be changed as needed for reasons which included occlusion, or per physician's orders [REDACTED]. The policy further specified that licensed nurses were responsible for implementation of this policy, and the Director of Health Services was responsible for monitoring compliance to the policy. Further review of this urinary catheter care policy revealed that, even though the policy did list indications for changing a catheter which included any signs or symptoms of infection, the policy did not reference the specific frequency of resident monitoring to be used by staff to identify such signs/symptoms of infection, or the need for catheter change, for residents having urinary catheters. During an interview with the Administrator and Director of Nursing (DON) conducted on 09/11/2013 at 12:20 p.m., both staff members were questioned about the urinary catheter policy referenced above. Both the Administrator and DON stated that the facility's expectation of care/protocol specifying the care to be provided to residents having urinary catheters was, and had been, for nursing staff to observe resident urinary catheters at least twice per day. The Administrator and DON stated that this twice-per-day monitoring had been the expected procedure to be utilized by staff for urinary catheter monitoring, and that this procedure specifying the twice-per-day monitoring of resident urinary catheters had been included in past nursing staff training programs to instruct staff on the provision of urinary catheter care. These staff members presented staff in-service training material which, when reviewed, revealed instruction to staff stressing the importance of inspecting resident catheter equipment twice a day. During an interview with the Administrator conducted on 09/12/2013 at 9:30 a.m., the Administrator had stated that in the past, the facility had utilized an entry on resident Medication Administration Records (MARs) to monitor and document per-shift urinary catheter checks. In a 09/23/2013, 10:46 a.m. telephone interview with the Administrator conducted post the survey exit and during the survey quality assurance review, the administrator further revealed that facility's use of MARs for urinary catheter check documentation had been discontinued as of 06/27/2013. 1. Record review for Resident #1 revealed admission physician's orders [REDACTED]. A Nurse's Notes entry of 07/24/2013 at 1:00 p.m. for Resident #1 also documented the resident's admission to the facility, further documenting that the resident was being admitted to the nursing home from the hospital. This Nurse's Notes entry documented that the resident had a urinary catheter while in the hospital, but that this urinary catheter had been discontinued during the hospital stay. This Notes entry also documented that the resident had received the antibiotic [MEDICATION NAME] ([MEDICATION NAME]) while in the hospital, and that the resident would be monitored for signs and symptoms of infection. Review of a hospital D/C Summaries form dated 07/24/2013 from Resident #1's hospital stay prior to nursing facility admission revealed a hospital admission date of [DATE] and a discharge date of [DATE]. This D/C Summaries form documented that the resident had presented to the hospital with an abnormal urinalysis and that he/she had been admitted to the hospital for a urinary tract infection. This Summaries form further documented that during the resident's hospital stay, he/she had received the antibiotic [MEDICATION NAME], and that at the time of hospital discharge and nursing home transfer, the resident was stable. Review of a Laboratory Services form for Resident #1 revealed a Comprehensive Metabolic Panel (CMP) which had a collection date of 07/25/2013, the day after the resident's 07/24/2013 nursing home admission. This CMP documented that at that time, Resident #1 had a normal blood Urea Nitrogen result of 7 milligrams/deciliter (mg/dL) (Reference Range, 7 - 25 mg/dL), and a normal Creatinine result of 0.7 mg/dL (Reference Range, 0.5 - 1.6 mg/dL). Record review revealed a Nurse's Notes entry of 07/25/2013 at 9:30 a.m. which documented that Resident #1 had complained of pelvic pressure, and that an in/out urinary catheterization procedure had been done, yielding 1200 cubic centimeters (ccs) of clear, yellow urine. A subsequent Nurse's Notes entry for later in the evening of 07/25/2013, timed at 11:00 p.m., documented that Resident #1 had not voided since the in/out catheterization that morning, thus a #16 French urinary catheter was placed, which yielded greater than 1500 ccs of clear, yellow urine. A 07/25/2013, 8:00 p.m. Physician's Interim Orders form for Resident #1 was noted to specify the insertion of a 16 French urinary catheter to straight drainage. A Nurse's Notes entry of 07/26/2013 at 11:00 p.m. documented that Resident #1's urinary catheter was patent, with no complaints verbalized, and a Nurse's Notes entry of 07/27/2012 at 1:00 p.m. documented that the urinary catheter was intact to bedside drainage, with straw-colored urine noted. A Nurse's Notes entry of 07/28/2013 at 2:00 a.m. documented that Resident #1's urinary catheter was intact at that time, and documented that the resident had amber-colored urine which was flowing freely. This Notes entry further documented that the resident was resting quietly and was in no distress, having voiced no complaints of pain or discomfort at that time. A Nurse's Notes entry later in the morning of 07/28/2013 at 9:00 a.m. documented that the urinary catheter was patent with clear, amber urine to bedside drainage. Subsequent Nurse's Notes of 07/29/2013 at 9:00 a.m. and 11:00 p.m., 08/01/2013 at 2:00 p.m. and at 9:00 p.m., 08/07/2013 at 9:00 a.m. and 9:00 p.m., and 08/09/2013 at 6:15 a.m. and 9:00 a.m. documented that staff had observed and assessed Resident #1's urinary catheter twice daily, as specified by facility procedure, and documented that the catheter was intact, draining, and/or patent. However, further record review for Resident #1, to include review of the Nurse's Notes, revealed evidence to indicate that the resident's urinary catheter was observed and monitored by facility staff only once daily, instead of twice daily per facility protocol, on the dates and times of 07/26/2013 at 11:00 p.m., 07/27/2013 at 1:00 p.m., 07/30/2013 at 11:00 p.m., 07/31/2013 at 11:00 p.m., 08/06/2013 at 9:00 p.m., and 08/08/2013 at 9:00 a.m. There was no evidence to indicate that staff had assessed and monitored the resident's urinary catheter at all on the dates of 08/02/2013, 08/03/2013, 08/04/2013 and 08/05/2013. Additionally, Resident #1's Nurse's Notes entry of 08/09/2013 at 9:00 a.m. referenced above documented that Resident #1's urinary catheter was patent and draining, and documented that the resident had no complaints of pain or noted distress at that time. However, further record review revealed no evidence to indicate that nursing staff observed and monitored Resident #1, related to the condition or status of the indwelling urinary catheter, after this 08/09/2013, 9:00 a.m. Nurse's Notes entry, until an untimed Nurse's Notes entry of 08/25/2013 (sixteen days later) documented that Resident #1 was complaining of pain in the abdomen and that the resident's abdomen was tender to touch. This 08/25/2013 Nurse's Notes entry documented that the resident was crying out with increased pain and was holding the abdomen. This Nurse's Notes entry also documented that the resident's urine output had been less than 100 milliliters (mls), and that the resident had been transferred to the hospital. A Physician Communication Tool (PCT) dated 08/25/2013 also documented Resident #1's abdominal tenderness. This PCT also documented that Resident #1's urine output had been less than 100 mls, and documented that cloudy urine was noted to the urinary catheter. This PCT also documented that the resident had been transferred to the hospital. The 08/25/2013 Nurse's Notes entry referenced above also documented that Resident #1 had been sent to the hospital emergency room , and documented that the resident was then admitted to the hospital. Review of the hospital ED Provider Notes (EDPN) of 08/25/2013, timed at 2:06 p.m., for Resident #1 revealed in the Chief Complaint section that Resident #1 had Altered Mental Status upon arrival to the emergency room . The EDPN documented that Resident #1 was moaning and had lower abdominal distension, with suprapubic tenderness. This EDPN also documented that Resident #1's urinary catheter was occluded by mold. The ED Course section of the EDPN documented that Resident #1 had a urinary tract infection, and that the urinary catheter had been replaced in the emergency room . The ED Course section also documented that once replaced, the urinary catheter was draining a copious amount of cloudy urine, documented as approximately 1300 mls. at that time. This section also documented that Resident #1 stopped moaning once the urinary catheter was replaced. Review of the Lab Results section of the 08/25/2013 hospital EDPN of Resident #1 referenced above revealed a Urinalysis section, with a Result Time of 3:19 p.m., which documented abnormal results, including urine that was described as turbid and white with a large amount of blood, 3-plus urine bacteria, a large amount of leukocytes, and white blood cell clumps. The Complete Blood Count section, having a Result Time of 3:56 p.m., documented abnormal results which included a high white blood cell count of 27.1. The CMP section, having a Result Time of 3:57 p.m., also documented abnormal results which included a high Serum Blood Urea Nitrogen (BUN) level of 65, and a high Creatinine level of 7.1. The ED Medication Orders section of the 08/25/2013 hospital EDPN of Resident #1 documented an order for [REDACTED]. Review of Resident #1's Critical Care Admission Note (CCAN) of 08/25/2013, timed at 4:08 p.m., revealed that the CCAN documented, as had the hospital EDPN referenced above, that upon the resident's arrival in the emergency room , the resident's catheter was noted to have mold and was replaced. The CCAN documented that once the urinary catheter was removed, the resident produced a total of approximately 1600 mls. of purulent urine. The CCAN further documented that Resident #1 was extremely acidemic in the emergency room , and was being admitted to ICU with [MEDICAL CONDITION], acute kidney injury and lactic acidosis. The Assessment and Plan section of this CCAN documented that the resident had [MEDICAL CONDITION], had a urinary tract infection which was present on hospital admission, acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis due to profound lactic acidosis. During an interview with the Administrator conducted on 09/11/2013 at 10:40 a.m., the Administrator acknowledged that there was no evidence to indicate that Resident #1 had been monitored, in relation to the resident's indwelling urinary catheter, for a period of approximately two (2) weeks, and that the resident was then diagnosed as having [MEDICAL CONDITION] requiring admission to the hospital ICU. During a subsequent interview with the Administrator and DON conducted on 09/11/2013 at 12:20 p.m., these staff members acknowledged that there was no evidence to indicate indwelling urinary catheter monitoring had been done twice daily, per facility protocol. Based on the above, facility staff failed to adequately monitor Resident #1, for whom an indwelling urinary catheter had been placed on 07/25/2013. There was no evidence to indicate that staff routinely observed and monitored the urinary catheter of Resident #1 twice daily, per facility protocol, to determine the status of the catheter or the need for catheter change. Rather, evidence indicated that facility nursing staff observed Resident #1's urinary catheter only once daily on six (6) days from the 07/25/2013 date of catheter placement through 08/25/2013, and failed to observe the resident's catheter at all on nineteen (19) days during this same period. After 08/09/2013, the next documented monitoring and assessment of the urinary catheter status of Resident #1 was not until 08/25/2013 (sixteen days later), when the resident was noted to complain of abdominal pain and was noted to have decreased urine output and cloudy urine. The resident was subsequently transferred to the hospital, where he/she was found to have a urinary catheter that was occluded by mold, an elevated urine bacterial count, an elevated leukocyte count, an elevated white blood cell count, an elevated BUN level, and white blood cell clumps in the urine. The resident was later admitted to the Intensive Care Unit having a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. In addition to Resident #1, the following residents were noted to have indwelling urinary catheters which required twice-daily monitoring, per facility protocol, to assess the status of the catheter: 2. Record review for Resident #2 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 06/03/2013 which documented, in Section H - Bladder and Bowel, that the resident had an indwelling catheter. Section I - Active [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. During an observation conducted on 08/30/2013 at 2:00 p.m., Resident #2 was observed in a wheelchair. The resident was observed to have an indwelling urinary catheter draining to a bag, with white sediment noted in the catheter tubing. A Nurse's Notes entry for Resident #2 dated 06/30/2013 at 2:30 a.m. documented that the resident's indwelling urinary catheter had been observed once that day, noting the urinary catheter was draining. However, there was no evidence to indicate that nursing staff had conducted a second observation of the resident's urinary catheter on that date, as specified by facility protocol. Further record review revealed no evidence to indicate that nursing staff staff observed the resident's indwelling urinary catheter at all on the dates of 06/28/2013 and 06/29/2013. Subsequent to the 06/30/2013, 2:30 a.m. Nurse's Notes entry referenced above, which noted Resident #2's suprapubic catheter was intact and draining to bedside drainage, there was no evidence to indicate that nursing staff observed, monitored or assessed the resident's indwelling urinary catheter from 07/01/2013 through 07/16/2013, representing sixteen (16) sequential days with no evidence of monitoring or assessment of the status of the resident's urinary catheter. An untimed Nurse's Notes entry of 07/17/2013 then documented that Resident #2's urine in the bedside drainage bag had a blood-tint and a foul smell, thus requiring physician consultation at that time. A Nurse's Notes entry of 07/18/2013 at 10:00 p.m. documented that Resident #2's urinary catheter was intact, and draining blood-tinged urine, but record review revealed no evidence of any further observation or monitoring of the resident's indwelling urinary catheter for the dates of 07/19/2013, 07/20/2013, 07/21/2013, 07/22/2013, 07/23/2013 or 07/24/2013. A Nurse's Notes entry of 07/25/2013 at 11:00 p.m. documented a single observation of the catheter on that date. Subsequent Nurse's Notes entries for Resident #2 documented two-to-three per day observations of the indwelling urinary catheter on the dates and times of 07/28/2013 at 2:55 a.m. and 6:30 p.m., 07/31/2013 at 3:40 p.m. and 11:00 p.m., 08/02/2013 at 7:00 a.m. and 11:00 p.m., 08/03/2013 at 7:15 a.m. (and a second notation for the 7:00 a.m.-7:00 p.m. shift), 08/04/2013 at 2:55 a.m. and 6:15 p.m., 08/05/2013 at 3:00 a.m. and 11:00 p.m., 08/06/2013 at 7:45 a.m., 2:50 p.m., and 11:00 p.m., 08/07/2013 at 6:30 a.m., 2:15 p.m., and 11:00 p.m., 08/08/2013 at 3:20 p.m. and 11:00 p.m., and 08/09/2013 at 6:00 a.m. and 3:35 p.m., all documenting that the resident's indwelling urinary catheter was in place, patent, and/or draining. However, further record review for Resident #2, to include review of the Nurse's Notes, revealed evidence to indicate that the resident's urinary catheter was observed and assessed by facility staff only once daily, instead of twice daily per facility protocol, on the dates and times of 07/29/2013 at 2:30 a.m., 07/30/2013 at 11:00 p.m., 08/01/2013 at 11:00 p.m., 08/11/2013 at 4:00 a.m. and 08/13/2013 at 3:50 p.m. After the 08/13/2013, 3:50 p.m. Nurse's Notes entry for Resident #2 referenced above, which documented that the resident's suprapubic catheter was intact with drainage of amber-clear urine, there was no evidence of any further observation or monitoring of the status of the catheter, or for signs and symptoms of infection, from that date through 08/29/2013 (sixteen sequential days). During an interview conducted on 09/12/2013 at 11:30 a.m., the DON acknowledged that there was a lack of evidence to indicate that the indwelling urinary catheter condition and status had been monitored and assessed, per facility protocol. Based on the above, for the period of time from 06/28/2013 through 08/29/2013, evidence indicated that facility nursing staff observed and monitored the status of Resident #2's indwelling urinary catheter only once per day, instead of twice daily per established facility protocol, on a total of nine (9) days, and failed to observe and monitor the catheter at all on a total of forty-four (44) days. Specifically, there was no evidence of any observation or monitoring of the urinary catheter from 06/30/2013 until 07/17/2013, when the resident was then noted to have blood-tinged, foul-smelling urine, for which the physician was consulted. Additionally, after a documented observation of the catheter on 08/13/2013, there was no evidence of any additional observation or monitoring of the resident's urinary catheter through 08/29/2013. The facility had thus failed to ensure ongoing, twice-daily monitoring of the status and function of this resident's indwelling urinary catheter in accordance with the established facility protocol for catheter monitoring, to ensure the timely identification of both problems/complications regarding the catheter and the necessity of as-needed replacement of the catheter, as specified by the physician's orders [REDACTED]. 3. Record review for Resident #3 revealed an annual MDS assessment with an Assessment Reference Date of 04/30/2013 which documented, in Section H - Bladder and Bowel, that the resident had an indwelling urinary catheter. Section I - Active [DIAGNOSES REDACTED]. A quarterly MDS assessment with an Assessment Reference Date of 07/22/2013 documented, in Section H - Bladder and Bowel, that the resident continued to utilize an indwelling urinary catheter. The current physician's orders [REDACTED]. During an observation of Resident #3 conducted on 09/06/2013 at 3:30 p.m., the resident was observed while in bed to have an indwelling urinary catheter draining to bedside drainage. Record review for Resident #3, to include review of Nurse's Notes entries, revealed no evidence, in the Nurse's Notes or elsewhere, to indicate that nursing staff observed and monitored the resident's urinary catheter at all on the dates of 06/28/2013, 06/29/2013 and 06/30/2013. Nurse's Notes entries of 07/08/2013 at 9:00 a.m. and 11:00 p.m. documented that nursing staff had assessed Resident #3's indwelling urinary catheter twice that day to be patent. However, further record review, to include review of the Nurse's Notes, revealed no evidence of any observation and monitoring of the resident's indwelling urinary catheter from 07/01/2013 through 07/07/2013 (seven sequential days), and from 07/09/2013 through 08/29/2013 (a total of fifty-two sequential days). During an interview conducted on 09/12/2013 at 11:30 a.m., the DON acknowledged that there was a lack of evidence to indicate that the resident's indwelling urinary catheter condition and status had been monitored and assessed, per facility protocol. Based on the above, for the period of time from 06/28/2013 through 08/29/2013, evidence indicated that facility nursing staff failed to observe and monitor Resident #3's urinary catheter at all on a total of sixty-two (62) days. The facility had thus failed to ensure ongoing, twice-daily observation and monitoring of the status and function of this resident's indwelling urinary catheter in accordance with the established facility protocol for catheter monitoring, to ensure the timely identification of both problems/complications regarding the catheter and the necessity of as-needed replacement of the catheter, as specified by the physician's orders [REDACTED]. 4. Record review for Resident #5 revealed a quarterly MDS assessment with an Assessment Reference Date of 06/11/2013 which documented, in Section H - Bladder and Bowel, that the resident had an indwelling urinary catheter. Section I - Active [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. During an observation of Resident #5 conducted on 09/06/2013 at 3:00 p.m., the resident was observed while in bed to have a suprapubic urinary catheter draining to bedside drainage. Record review for Resident #5, to include review of Nurse's Notes entries, revealed evidence indicating that the resident's indwelling urinary catheter was observed by staff only once per day, instead of twice daily per facility protocol, on the dates and times of 07/02/2013 at 9:00 p.m. and 07/04/2013 at 3:15 p.m. Additional record review for Resident #5 revealed no evidence to indicate that nursing staff observed and monitored the resident's suprapubic urinary catheter at all on the dates of 06/28/2013, 06/29/2013, 06/30/2013, 07/01/2013, and 07/03/2013, for the period of time from 07/05/2013 through 07/31/2013 (a total of twenty-six days, with the resident being out of the facility on leave-of-absence on 07/22/2013), and for the subsequent period of time from 08/01/2013 through 08/29/2013 (a total of twenty-nine days). During an interview conducted on 09/12/2013 at 11:30 a.m., the DON acknowledged that there was a lack of evidence to indicate that the resident's indwelling urinary catheter condition and status had been monitored and assessed, per facility protocol. Based on the above, for the period of time from 06/28/2013 until 08/29/2013, evidence indicated that facility nursing staff observed and monitored the status of Resident #5's indwelling urinary catheter only once per day, instead of twice daily per established facility protocol, on a total of two (2) days, and failed to observe and monitor the urinary catheter at all on a total of sixty (60) days. The facility had thus failed to ensure ongoing, twice-daily monitoring of the status and function of this resident's indwelling urinary catheter in accordance with the established facility protocol for catheter monitoring, to ensure the timely identification of both problems/complications regarding the catheter and the necessity of as-needed replacement of the catheter, as specified by the physician's orders [REDACTED]. 5. Record review for Resident #6 revealed a quarterly MDS with an Assessment Reference date of 07/19/2013 which documented, in Section H - Bladder and Bowel, that the resident utilized an indwelling urinary catheter. Section I - Active [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. During an observation conducted on 08/30/2013 at 4:16 p.m., Resident #6 was observed while bed and having an indwelling urinary catheter draining to bedside drainage. Record review for Resident #6 for the period of 07/14/2013 through 08/30/2013 revealed Nurse's Notes entries for the dates and times of 08/05/2013 at 3:00 a.m. and 4:20 p.m., 08/06/2013 at 3:00 p.m. and 11:20 p.m., 08/07/2013 at 3:00 p.m. and 11:00 p.m., 08/08/2013 at 3:50 p.m. and 11:00 p.m., 08/20/2013 at 3:50 p.m. and 11:00 p.m., 08/27/2013 at 6:15 a.m., 1:40 p.m., and 11:00 p.m., and 08/28/2013 at 6:45 a.m. and 11:00 p.m. which documented two-to-three daily nursing staff observations of the resident's indwelling urinary catheter. However, further record review for Resident #6, to include review of the resident's Nurse's Notes, revealed evidence indicating that nursing staff observed and monitored the resident's indwelling urinary catheter only once per day, rather than twice per day per facility protocol, on the dates and times of 07/17/2013 at 4:20 p.m., 08/04/2013 at 3:10 a.m., 08/13/2013 at 3:30 p.m., 08/21/2013 at 11:00 p.m., 08/23/2013 at 11:00 p.m., 08/24/2013 at 9:40 a.m., 08/26/2013 at 11:00 p.m., and 08/29/2013 at 11:00 p.m. Additional record review for Resident #6 revealed no evidence to indicate that nursing staff observed and monitored the resident's indwelling urinary catheter at all on the dates of 07/14/2013, 07/15/2013, 07/16/2013, 07/18/2013, 07/19/2013, 07/20/2013, 07/21/2013, 07/22/2013, 07/23/2013, 07/24/2013, 07/25/2013, 07/26/2013, 07/27/2013, 07/28/2013, 07/29/2013, 07/30/2013, 07/31/2013, 08/01/2013, 08/02/2013, 08/03/2013, 08/09/2013, 08/10/2013, 08/11/2013, 08/12/2013, 08/14/2013, 08/15/2013, 08/16/2013, 08/17/2013, 08/18/2013, 08/19/2013, 08/22/2013, and 08/25/2013. During an interview conducted on 09/12/2013 at 11:30 a.m., the DON acknowledged that there was a lack of evidence to indicate that the indwelling urinary catheter condition and status had been monitored and assessed, per facility protocol. Based on the above, for the period of time from 07/14/2013 through 08/29/2013, evidence indicated that facility nursing staff observed and monitored the status of Resident #6's indwelling urinary catheter only once per day, instead of twice daily per established facility protocol, on a total of eight (8) days, and failed to observe and monitor the urinary catheter at all on a total of thirty-two (32) days. The facility had thus failed to ensure ongoing, twice-daily monitoring of the status and function of this resident's indwelling urinary catheter in accordance with the established facility protocol for catheter monitoring, to ensure the timely identification of both problems/complications regarding the catheter and the necessity of as-needed replacement of the catheter, as specified by the physician's orders [REDACTED]. 6. Record review for Resident #4 revealed an admission MDS with an Assessment Referenced Date of 06/25/2013. Section H - Bladder and Bowel of this MDS documented that the resident utilized an indwelling urinary catheter, and Section I - Active [DIAGNOSES REDACTED]. During an observation of Resident #4 conducted on 08/30/2013 at 3:00 p.m., the resident was in bed with an indwelling urinary catheter draining to bedside drainage. Record review for Resident #4 revealed Skilled Daily Nurse's Notes of 07/08/2013 at 9:00 a.m., 10:30 a.m. and 11:00 p.m., 07/09/2013 at 7:00 a.m. and an untimed entry, 07/11/2013 at 1:00 p.m. and an untimed entry, 07/13/2013 at 3:00 p.m. and 1100: p.m., 07/15/2013

Based on record review, staff interview, facility Physician Communication Tool review, hospital ED Provider Notes review, and hospital Critical Care Admission Note review, the facility failed to ensure an accurate comprehensive assessment regarding indwelling urinary catheter use for one (1) resident (#1), of six (6) residents having indwelling urinary catheters, from a total survey sample of twenty-one (21) residents. The facility failed to accurately assess Resident #1, related to indwelling urinary catheter use, by failing to identify on the Admission Minimum Data Set (MDS) assessment that indwelling urinary catheter use had been initiated for this resident the day after facility admission, and continued throughout the MDS assessment look-back period. Facility staff also failed to monitor Resident #1's catheter, per established facility protocol, thus causing a delay in identifying that the catheter had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to ultimately ensure adequate assessment and the provision of care to residents having indwelling urinary catheters which had caused the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter occlusion was identified), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator and Director of Nursing acknowledged the facility's failure to ensure that Resident #1's urinary catheter use was included in the resident's comprehensive assessment. The facility's failure to ensure an accurate comprehensive assessment and adequate urinary catheter monitoring resulted in a delay in staff identifying that Resident #1 had sustained an occluded urinary catheter, allowing the resident to become septic, and resulting in the resident being transferred and admitted to the hospital in critical condition. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the facility implemented, and completed, a process which involved the re-training, via staff in-service, of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to the necessary care for residents having urinary catheters. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: Cross refer to F315, example 1, for more information regarding Resident #1. Record review for Resident #1 revealed admission physician's orders [REDACTED]. The day following Resident #1's facility admission, a 07/25/2013, 8:00 p.m. Physician's Interim Orders form specified the insertion of a number 16 French urinary catheter to straight drainage for this resident. A Nurse's Notes entry of 07/25/2013 at 11:00 p.m. documented that the indwelling urinary catheter had been placed for Resident #1 due to the resident's failure to void. However, the Minimum Data Set (MDS) assessment for Resident #1 dated 07/31/2013 inaccurately documented, in Section H-Bladder and Bowel, that Resident #1 did not utilize an appliance, including an indwelling catheter. This was despite the 07/25/2013, 8:00 p.m. Physician's Interim Orders form and the 07/25/2013, 11:00 p.m. Nurse's Notes entry referenced above which documented that the urinary catheter had been ordered and inserted prior to the date of completion of this MDS. During an interview with the Administrator and Director of Nursing (DON) conducted on 09/11/2013 at at 12:20 p.m., the Administrator and DON stated that the facility's expectation of care and protocol for care to be provided to residents having urinary catheters included for nursing staff to observe and monitor resident urinary catheters at least twice per day. However, subsequent to the omission of Resident #1's urinary catheter from the resident's 07/31/2013 MDS, and despite facility protocol specifying twice-daily staff monitoring of resident urinary catheters, further record review for Resident #1 revealed no evidence to indicate that staff monitored the resident's urinary catheter at all on 08/02/2013, 08/03/2013, 08/04/2013 and 08/05/2013. A Nurse's Notes entry of 08/09/2013 at 9:00 a.m. did document an observation of Resident #1's urinary catheter, indicating that the catheter was patent and draining. However, further record review revealed no evidence to indicate that facility nursing staff observed and monitored Resident #1's urinary catheter after 08/09/2013 until 08/25/2013, when a Nurse's Notes entry of 08/25/2013 documented that Resident #1 was complaining of pain in the abdomen and crying out with increased pain. Documentation in a Physician Communication Tool dated 08/25/2013 for Resident #1 included that the resident's urine was cloudy and that the resident had been transferred to the hospital. The hospital ED Provider Notes (EDPN) of 08/25/2013 for Resident #1 documented that the resident's urinary catheter was occluded by mold, and that once the catheter was replaced in the emergency room , the urinary catheter drained approximately 1300 mls. of cloudy urine. The ED Medication Orders section of this EDPN documented an order for [REDACTED]. Resident #1's hospital Critical Care Admission Note (CCAN) of 08/25/2013 documented that the resident was admitted to the Intensive Care Unit with [MEDICAL CONDITION], a urinary tract infection which was present on hospital admission, acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. Based on the above, facility staff failed to ensure that the comprehensive assessment initially identified the indwelling urinary catheter use of Resident #1, and subsequently failed to routinely monitor the resident for signs and symptoms of infection and the status of the urinary catheter, per facility protocol. The resident was subsequently transferred to the hospital on [DATE] and was admitted to the Intensive Care Unit having a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. The Immediate Jeopardy was determined to be removed on 09/12/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/30/2013, the Minimum Data Set (MDS) assessment of Resident #1 was re-opened and corrected to include urinary catheter usage. B. On 08/30/2013, the care plan for Resident #1 was updated to reflect that a urinary catheter was present, and to reflect care approaches. C. On 08/30/2013, all residents with urinary catheters were audited to ensure proper MDS assessment coding per regulation. D. On 08/30/2013, the care plans of all residents having urinary catheters were audited to ensure that resident care plans reflected catheter-usage and care approaches. E. On 09/10/2013, facility MDS Coordinators were educated on resident assessment and care planning to ensure thorough assessment, correct MDS coding, and plan-of-care completion. F. On 09/11/2013, education was provided to nursing staff related to catheter monitoring, assessment, and documentation. One-hundred (100) percent of all nursing staff had received training as of that date. All new nursing staff will be oriented to catheter care, monitoring, assessing and documentation upon hire. G. On 09/11/2013, in-service education, which was initiated on 09/03/2013, was completed for certified nursing assistants (CNAs) related to urinary catheters and monitoring techniques. One-hundred (100) percent of all CNAs had received this education by 09/11/2013. H. On 09/11/2013, a new form, the CNA Sheets Form, was implemented by which CNAs will document daily regarding care provided to residents, including those having urinary catheters. The Form will allow for the documentation of resident vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. The Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms. One-hundred (100) percent of all CNAs had received education related to the usage and completion of this form by 09/11/2013. I. On 09/11/2013, the facility instituted a policy requiring that all newly-hired CNAs will be trained on facility policies and procedures related to urinary catheters, catheter care, and reporting to nursing staff. J. On 09/11/2013, the facility required that ongoing education related to urinary catheters, catheter care, catheter monitoring, and catheter assessment will be provided to all nursing staff and all CNA staff via quarterly and annual in-service training sessions. Additionally, as-needed training will be provided, as determined by the facility's Quality Assessment and Performance Improvement (QAPI) Committee. K. On 09/11/2013, the facility put into place a procedure by which the Director of Health Services (DHS) or the Assistant Director of Health Services (ADHS) will complete a Catheter Patient Care Management Checklist weekly for the first month, then bi-weekly for the next two months, then monthly thereafter. This Form includes assessing the necessity of the catheter, the proper anchoring of the catheter, the correct inclusion of the catheter on the resident care plan, and if staff are monitoring and assessing the catheter each shift. L. On 09/11/2013, the facility put into place a procedure by which the DHS would report issues identified during monitoring accomplished by the Catheter Patient Care Management Checklist to the facility's QAPI Committee. The QAPI Committee monitoring and consideration would include the correct and accurate completion of the Patient Care Management Checklist, the presence of a system review to determine the root cause of identified problems, and the presence of the implementation of an action plan for identified issues once the root cause of a problem was determined. The QAPI Committee will also determine the need for additional staff training, based on the ongoing results of staff performance monitoring, per facility procedures referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on September 12, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Education had been provided to all current nursing staff related to catheter monitoring, assessment, and documentation, but new nursing staff will need to be oriented to catheter care, monitoring, assessing and documentation upon employment. The facility had provided in-service education for all currently employed CNAs related to urinary catheters and monitoring techniques, and on the newly implemented CNA Sheets Form utilized by CNAs to document daily resident care, including catheter care and monitoring vital signs, urinary catheter output, and additional concerns to be relayed to the nurse. However, all CNAs hired after the completion of this complaint survey will need to receive training on facility policies and procedures related to urinary catheters. This process will need to be reassessed once newly hired staff have been employed. Additionally, the Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms, but this procedure was only instituted on 09/11/2013, one day prior to the exit date of this complaint survey. Additionally, on 09/11/2013, the facility put into place the Catheter Patient Care Management Checklist to be monitored by the DHS, who will then report findings to the facility's QAPI Committee. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September 2013, and monthly thereafter, to continue the analysis process related to resident assessment, the facility's provision of indwelling catheter care to residents, and the need for additional staff training. Therefore, the non-compliance continues, with the scope and severity level reduced to a "D" level.

Based on record review, staff interview, facility Changing of Catheters: Care and Anchoring policy review, hospital ED Provider Notes review, and hospital Critical Care Admission Note review, the facility failed to prevent the neglect of one (1) resident (#1) who had an indwelling urinary catheter, from a survey sample of six (6) residents having indwelling urinary catheters, from a total survey sample of twenty-one (21) residents. The facility neglected Resident #1 by failing to provide ongoing indwelling urinary catheter observation and monitoring, per facility protocol. This failure of facility staff to observe and monitor, per protocol, resulted in the delay of staff identifying that the indwelling urinary catheter of Resident #1 had become occluded with mold. The resident was subsequently transferred to the hospital and admitted to the Intensive Care Unit in critical condition with a urinary tract infection, [MEDICAL CONDITION], acute kidney injury related [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This resulted in a situation in which the facility's non-compliance with the requirements of participation caused, or had the likelihood to cause, serious harm, injury or death to residents. The facility's Administrator and Director of Nursing were informed of the Immediate Jeopardy on September 10, 2013, at 2:30 p.m. The situation involving facility staffs' failure to adequately monitor resident indwelling urinary catheters causing the Immediate Jeopardy was identified to have existed as of August 25, 2013 (the date Resident #1's urinary catheter occlusion was identified), continued through September 11, 2013, and was removed on September 12, 2013. The Administrator and Director of Nursing acknowledged the expectation of care involved twice-daily monitoring of indwelling urinary catheters, but further acknowledged that there was no evidence to indicate that this monitoring was being consistently done, per protocol. The facility's failure to ensure urinary catheter monitoring per facility protocol resulted in a delay in staff identifying that Resident #1 had sustained an occluded urinary catheter, allowing the resident to become septic, and resulting in the resident being transferred and admitted to the hospital in critical condition. An allegation of jeopardy removal was received on September 10, 2013. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on September 12, 2013, and the facility remained out of compliance at a lower scope and severity of "D" while the facility implemented, and completed, a process which involved the re-training, via staff in-service, of all nursing staff related to the assessing and monitoring of residents having indwelling urinary catheters, and the documentation required related to this process, but continued to implement the process of ensuring that all newly hired nursing staff would be oriented to the necessary care for residents having urinary catheters. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the assessment, monitoring, and provision of care to residents having urinary catheters. Observations were made to assess staff performance related to urinary catheter care. Findings include: The facility's policy entitled Changing of Catheters: Care and Anchoring, dated November 2012, required that each resident having an indwelling catheter would receive the appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible. The policy indicated that catheters would be changed as needed for reasons which included occlusion, or per physician's orders [REDACTED]. The policy did not reference the frequency of monitoring to be used by staff to identify such signs or symptoms of infection, or the need for catheter change, for residents having urinary catheters. During an interview with the Administrator and Director of Nursing (DON) conducted on 09/11/2013 at 12:20 p.m., when questioned about the urinary catheter policy, both the Administrator and DON stated that the facility's expectation of care/protocol specifying the care to be provided to residents having urinary catheters was, and had been, for nursing staff to observe resident urinary catheters at least twice per day. The Administrator and DON stated that this twice-per-day monitoring was the expected procedure to be utilized by staff for urinary catheter monitoring, and that nursing staff had been trained related to twice-per-day monitoring of resident urinary catheters in nursing staff training programs. These staff members presented in-service training material which, when reviewed, revealed instruction to staff stressing the importance of inspecting resident catheter equipment twice a day. Record review for Resident #1 revealed admission physician's orders [REDACTED]. A 07/24/2013, 1:00 p.m. Nurse's Notes entry documented Resident #1's admission to the facility and the resident's history of urinary tract infections, and indicated that staff would monitor the resident for signs and symptoms of infection. A 07/25/2013, 8:00 p.m. Physician's Interim Orders form for Resident #1 specified the insertion of a number 16 French urinary catheter, and a Nurse's Notes entry of 07/25/2013 at 11:00 p.m. documented that a number 16 French urinary catheter had been placed. However, despite the facility's protocol, per the 09/11/2013, 12:20 p.m. interview with the Administrator and DON referenced above, specifying twice-daily observation and monitoring of resident indwelling urinary catheters, further record review, to include review of Nurse's Notes entries, revealed evidence indicating that Resident #1's urinary catheter was observed and monitored only once daily on the dates and times of 07/26/2013 at 11:00 p.m., 07/27/2012 at 1:00 p.m., 07/30/2013 at 11:00 p.m., 07/31/2013 at 11:00 p.m., 08/06/2013 at 9:00 p.m., and 08/08/2013 at 9:00 a.m. There was no evidence of any observation and monitoring of the urinary catheter on 08/02/2013, 08/03/2013, 08/04/2013 and 08/05/2013. An 08/09/2013, 9:00 a.m. Nurse's Notes entry for Resident #1 documented that, at that time, the resident 's catheter was patent and draining, and that the resident had no noted distress. However, further record review revealed no evidence to indicate that facility staff observed or monitored Resident #1's indwelling urinary catheter at all after this 08/09/2013, 9:00 a.m. Nurse's Notes entry until 08/25/2013 (fifteen sequential days). An untimed Nurse's Notes entry of 08/25/2013 documented that Resident #1 was complaining of abdominal pain, that the resident was crying out with increased pain, that the resident's urine output had been less than 100 milliliters, and that the resident had been transferred to the hospital. Resident #1's hospital ED Provider Notes (EDPN) of 08/25/2013 p.m. documented that, upon arrival at the emergency room , Resident #1's urinary catheter was occluded by mold, and that the resident was moaning and had lower abdominal distension. The EDPN also documented that when replaced, the urinary catheter drained cloudy urine, and that Resident #1 stopped moaning. The EDPN also documented that Resident #1 was referred to Critical Care and admitted to the Intensive Care Unit (ICU) in critical condition. Resident #1's Critical Care Admission Note (CCAN) of 08/25/2013 revealed that the resident was admitted to ICU having [MEDICAL CONDITION], a urinary tract infection present on hospital admission, acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. This CCAN also documented the administration of intravenous antibiotic [MEDICATION NAME]-tazobactam. During the interview with the Administrator and DON conducted on 09/11/2013 at 12:20 p.m., these staff members acknowledged that there was no evidence to indicate indwelling urinary catheter monitoring had been done twice daily, per facility procedure. Based on the above, the facility neglected Resident #1 by failing to observe and monitor the status of the resident's indwelling urinary catheter twice daily, per facility protocol, after the 07/25/2013 insertion of the indwelling urinary catheter. Evidence indicated that facility staff observed and monitored the resident's urinary catheter only once daily on six (6) days, and failed to observe and monitor the catheter at all on nineteen (19) days from the 07/25/2013 placement of the urinary catheter through the 08/25/2013 hospital transfer, with the last day of observation and monitoring being 08/09/2013. Additionally, facility nursing staff failed to monitor the resident for signs and symptoms of infection from 08/09/2013 until 08/25/2013 (sixteen sequential days), even though the 07/24/2013, 1:00 p.m. Nurse's Notes entry referenced above noted the need for monitoring for signs of infection, and even though the facility's Changing of Catheters Policy referenced above indicated that a reason for catheter change would be signs and symptoms of infection. On 08/25/2013, after fifteen sequential days with no evidence of monitoring, Resident #1 complained of abdominal pain and had decreased urine output. The resident was transferred to the hospital and admitted to ICU having [MEDICAL CONDITION], acute kidney injury related to [MEDICAL CONDITION]/urinary tract infection, and severe metabolic acidosis. Cross refer to F315, example 1, for more information regarding Resident #1. The Immediate Jeopardy was determined to be removed on 09/12/2013, at which time the facility had presented and implemented an allegation of jeopardy removal with the following interventions: A. On 08/30/2013, the Minimum Data Set (MDS) assessment of Resident #1 was re-opened and corrected to include urinary catheter usage. B. On 08/30/2013, the care plan for Resident #1 was updated to reflect that a urinary catheter was present, and to reflect care approaches. C. On 08/30/2013, all residents with urinary catheters were audited to ensure proper MDS assessment coding per regulation. D. On 08/30/2013, the care plans of all residents having urinary catheters were audited to ensure that resident care plans reflected catheter-usage and care approaches. E. On 09/10/2013, facility MDS Coordinators were educated on resident assessment and care planning to ensure thorough assessment, correct MDS coding, and plan-of-care completion. F. On 09/11/2013, education was provided to nursing staff related to catheter monitoring, assessment, and documentation. One-hundred (100) percent of all nursing staff had received training as of that date. All new nursing staff will be oriented to catheter care, monitoring, assessing and documentation upon hire. G. On 09/11/2013, in-service education, which was initiated on 09/03/2013, was completed for certified nursing assistants (CNAs) related to urinary catheters and monitoring techniques. One-hundred (100) percent of all CNAs had received this education by 09/11/2013. H. On 09/11/2013, a new form, the CNA Sheets Form, was implemented by which CNAs would document daily regarding care provided to residents, including those having urinary catheters. The Form will allow for the documentation of resident vital signs, urinary catheter output, and additional concerns regarding resident status to be relayed to the nurse. The Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms. One-hundred (100) percent of all CNAs had received education related to the usage and completion of this form by 09/11/2013. I. On 09/11/2013, the facility instituted a policy requiring that all newly-hired CNAs will be trained on facility policies and procedures related to urinary catheters, catheter care, and reporting to nursing staff. J. On 09/11/2013, the facility required that ongoing education related to urinary catheters, catheter care, catheter monitoring, and catheter assessment will be provided to all nursing staff and all CNA staff via quarterly and annual in-service training sessions. Additionally, as-needed training will be provided, as determined by the facility's Quality Assessment and Performance Improvement (QAPI) Committee. K. On 09/11/2013, the facility put into place a procedure by which the Director of Health Services (DHS) or the Assistant Director of Health Services (ADHS) will complete a Catheter Patient Care Management Checklist weekly for the first month, then bi-weekly for the next two months, then monthly thereafter. This Form included assessing the necessity of the catheter, the proper anchoring of the catheter, the correct inclusion of the catheter on the resident care plan, and that staff are monitoring and assessing the catheter each shift. L. On 09/11/2013, the facility put into place a procedure by which the DHS would report issues identified during monitoring accomplished by the Catheter Patient Care Management Checklist to the facility's QAPI Committee. The QAPI Committee monitoring and consideration would include the correct and accurate completion of the Patient Care Management Checklist, the presence of a system review to determine the root cause of identified problems, and the presence of the implementation of an action plan for identified issues once the root cause of a problem was determined. The QAPI Committee will also determine the need for additional staff training, based on the ongoing results of staff performance monitoring, per facility procedures referenced above. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on September 12, 2013. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. Education had been provided to all current nursing staff related to catheter monitoring, assessment, and documentation, but new nursing staff will need to be oriented to catheter care, monitoring, assessing and documentation upon employment. The facility had provided in-service education for all currently employed CNAs related to urinary catheters and monitoring techniques, and on the newly implemented CNA Sheets Form utilized by CNAs to document daily resident care, including catheter care and monitoring, vital signs, and urinary catheter output to be relayed to the nurse. However, all CNAs hired after the completion of this complaint survey will need to receive training on facility policies and procedures related to urinary catheters. This will need to be reassessed once newly hired staff have been employed. Additionally, the Charge Nurse will monitor, on a daily basis, to ensure completion of these CNA Sheets Forms, but this procedure was only instituted on 09/11/2013, one day prior to the exit date of this complaint survey. Additionally, On 09/11/2013, the facility put into place the Catheter Patient Care Management Checklist to be monitored by the DHS, who will then report findings to the facility's QAPI Committee. The QAPI Committee had met on 08/30/2013 to begin consideration of corrective actions related to urinary catheter care. However, the next QAPI Committee meeting was not scheduled to take place until the third week of September 2013, and monthly thereafter, to continue the analysis process related to resident assessment, the facility's provision of indwelling catheter care to residents, and the need for additional staff training. Therefore, the non-compliance continues, with the scope and severity level reduced to a "D" level.