**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 3. This failure resulted in (R2) sustaining multiple bruises to her face requiring to be evaluated in the emergency room at the local hospital. This past non-compliance occurred on 10/31/2024 through 11/19/2024. R3's Face Sheet dated 11/4/2024, documents she was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, anxiety, schizophrenia, depression and dementia. R3's Minimum Data Set (MDS) dated [DATE], documents she is cognitively impaired with inattention and disorganized thinking. No indicators of psychosis. Behavioral symptoms not directed toward others. R3's Care Plan, dated 10/31/2024 documents focus: resident at risk for abuse, abusing others demonstrates behaviors that have potential to disturb others. 10/31/2024 altercation with another resident in which (R3) was the perpetrator. Goal: resident will be free from abuse and without abuse behavior. Interventions: 10/31/2024 enhanced supervision 1:1, address resident concerns as they arise, observe for changes in customary routines. Resident moved to sitting room, 1;1 with nurse until EMS (emergency medical services) and police responding to transport resident to local hospital for psych evaluation. R3's Progress Note, dated 10/31/2024 at 11:30 PM, documents there was screaming and yelling down the hall and the CNA (Certified Nurses Assistant) went down and noted it was coming out of res (resident) rm (room) and she was getting back in bed after attacking another res. Res stated that the other res was getting on her nerves. She stated that everything was building up so she got out of bed and started hitting res. R3's Progress Note, dated 10/31/2024 at 11:38 PM, documents res stated that the other res was getting on her nerves and also stated that it kept building up then she got out of bed and started hitting her then went back to get in bed. Res was asked to come out of her rm to go sit in the tv rm and res refuse until this nurse went down to res rm and told her to come up to the tv rm. Res sat in the tv rm until EMS arrived. MD (physician), DON (Director of Nurses) and res family notified of incident. R3's Petition for Involuntary/Judicial Admission, dated 10/31/2024 at 9:30 PM, documents res attacked another res. She has bruising on her hand and bruising to the other pt (patient) neck and face. (R3) stated she was getting on my nerves everything was building up and she got up and went over to the bed and started hitting the other res. R3's Hospital Progress Note, dated 11/1/2024 documents a [AGE] year-old female with history of major neurocognitive disorder admitted [DATE] through the local hospital emergency room after assaulting roommate at the nursing home. The patient has no memory of that. R3 was readmitted to the facility per facility progress note, dated 11/6/2024. On 11/20/2024 at 2:15 PM, R3 was observed laying in bed. (R3) smiled upon approach and when asked about the physical altercation between her and (R2) she stated she never hit anyone in her life and she would never ever do that because that's not the right thing to do. R2's Face Sheet, dated 11/4/2024 documents hemiplegia and hemiparesis following cerebral infarction affecting right dominate side, facial weakness, cognitive communication deficit, dysphagia, expressive language disorder, frontal lobe and executive function deficit following other cerebrovascular disease, mixed receptive-expressive language disorder, pain and osteoarthritis. R2's MDS, dated [DATE], documents resident rarely/never understood, severely cognitively impaired with inattention and disorganized thinking, other behavioral symptoms not directed toward others occurred daily. Dependent with chair/bed-to-chair transfer, sit to lying, roll left and right, sit to stand. Incontinent of bowel and bladder. R2's Late Entry Progress Note, dated 10/31/2024 at 10:00 PM, documents resident is alert and disorientated per usual baseline. Resident denies/exhibits no mental anguish or emotional upset. No new injuries noted on assessment. No pain. Reddish-purple bruising noted. Physician notified of change in condition and responsible party notified. R2's Progress Note, dated 10/31/2024 at 11:54 PM, documents this res was assisted to bed and was not left in rm for about 15 to 20 min (minutes) before hearing screaming and yelling coming up the hall. CNA went down to see what was happening and she notice the other res was getting back in bed and she turned the light on and saw this res leg hanging to the side of the bed like she tried to get up and her face was scratched and bruised up then the CNA called for this nurse to come down to the rm. MD, DON and state representative for this res notified. Res was sent to local hospital to be assessed. R2's Alleged Abuse Report, dated 10/31/2024 at 9:37 PM, documents incident description: there were screaming and yelling coming down the hall and a CNA went down to see what was going on and she noted that this residents legs was hanging out the bed like she wanted to get up and the other res was getting back in bed. This res face was scratched up and a black area under l (left) eye. Resident has aphasia but can explain what's going on and she showed that she hitting her in the face. Immediate action taken: staff stayed in rm for awhile and then the other res was sent to the tv rm until EMS came to take her to psych for evaluation. Level of pain: 4/10, breathing: normal, negative vocalization: none, facial expression: facial grimacing, body language: tensed, consolability: distracted. Injuries observed at time of incident: bruise on face. R2's Hospital Paperwork, dated 10/31/2024, documents she was seen for injury due to physical assault: traumatic periorbital ecchymosis (bruising) of left eye and nose. R2's Progress Note, dated 11/1/2024 at 4:35 AM, documents resident returns to facility via EMS, MD notified. R2's New Identified Skin Condition Form, dated 11/4/2024, documents face - bruising to left eye, nose, left chin, right forehead and right bottom eyelid. On 11/20/2024 at 1:52 PM R2 sat up in a wheelchair in the dining room. Upon approach R2 smiled but didn't respond to IDPH (Illinois Department of Public Health) surveyor's questions regarding the physical altercation between her and R3. R2 had light purple/pink bruising under her left eye at the time of the interview. On 11/20/2024 at 3:07 PM V9, LPN (Licensed Practical Nurse) stated she worked the night of 10/31/2024 and responded to the physical altercation between R2 and R3. R2 doesn't communicate verbally due to post stroke. Prior to the incident R2 was up in the dining room. R3 communicates verbally and is ambulatory and was in bed when staff assisted R2 to bed. A few minutes later I heard screaming and told staff to go down the hall and see what was occurring. R3 was getting back into bed and noted R2's legs were off the side of the bed as if she was trying to get up. Staff turned the light on and saw R2's face was bruised up. Staff called for V9 to come to the room. She observed R2's face bruised and had a sad face and R2 is always happy so she knew R2 was affected by what occurred. R3 was asked why she hit R2 and R3 responded, She was getting on my nerves. R3 didn't respond to V9's additional questions. V9 assessed R2 at that time. Staff stayed in the resident's room. V10 (former DON) and V1 (administrator) were contacted. R3 was moved to the sitting area across the nurse's station and R2 was sent to the hospital for further evaluation and treatment due to the facial bruising. R3 was sent to the hospital for a psychiatric evaluation. On 11/21/2024 at 10:30 AM V11, CNA stated she worked 10/31/2024 2:00 PM - 6:00 AM but was not assigned to R2 and R3, she was assigned to another hall but she heard yelling so she went to the room and when she entered the room she turned the light on and noted R3 was getting back in bed and (R2) was in bed with her legs off the side of the bed which was odd because (R2) is a total lift, she doesn't get out of bed by herself or walk and she immediately noted bruising to (R2's) left eye. (R2) can't verbally communicate but V11 asked her if her roommate, (R3) hit her and (R2) pointed to (R3) yelled and shook her head yes. On 11/21/2024 at 10:50 AM V12, LPN stated she worked night shift on 10/31/2024 and arrived at the facility at around 10:00 PM. The resident to resident altercation occurred between (R2) and (R3) right before she got there. She assisted nursing staff and assessed (R2) when she got to the facility and assessed (R2). R2 was crying and when she asked her if she was in pain (R2) nodded her head, yes. (R2) Sustained bruising to her face from her roommate, (R3) hitting her. V12 also assessed (R3) who was in another room and assessed her to have red and swollen hands at that time. V12 asked (R3) why she hit (R2) and she stated, She deserved it. (R3) was also very agitated and called (R3) a w**** and stated she stole her stuff. On 11/21/2024 at 11:05 AM V13, CNA stated she worked day shift 2:00 PM - 10:00 PM on 10/31/2024. Toward the end of (V13) shift her and V11 were sitting at the nurse's station charting and they heard screaming from the 100 hall. They went to see what was going on and observed (R3) getting back into bed and saw (R2's) legs were off the side of the bed which is abnormal for her because she is a one staff assist lift to get out of bed and she doesn't communicate verbally. V11 asked (R2) if (R3) hit her and (R2) pointed at (R3) and shook her head yes. V13 stated she wasn't assigned to (R2) or (R3) and she didn't assist (R2) to bed that night. V13 stated the nurse came to assess both residents and she left the facility shortly after. On 11/21/2024 at 12:30 PM V14, CNA stated she was assigned to (R2) and (R3) on 10/31/2024 she worked evening shift from 2:00 PM - 10:00 PM. V14 stated (R3) ambulates throughout the facility and has no aggressive behaviors toward other residents, (R3) participated in Halloween activities that day and she was her usual chipper self. (R2) is a total care resident and a sit to stand lift to transfer from wheelchair to bed. V14 stated she worked with V15, CNA and they swapped residents to lay down so V15 assisted (R2) to bed that night. V14 observed the nurse running down 100 hall so she responded to (R2) and (R3's) room and noted (R2) had a bruised face and looked beat up. At that time (R3) was calling (R2) a w****. On 11/20/2024 at 1:45 PM V7, CNA stated roommate (R3) hit R2 on the face a few weeks ago and (R2's) face was all bruised up. R2 is total care resident and requires a sit to stand lift to transfer to and from bed. R2 can't defend herself because she is post stroke and she is unable to communicate verbally. V7 stated she wasn't here when the physical altercation took place but she observed R2 the next day and she looked all black and blue on her face like R3 must have jumped her or something. On 11/20/2024 at 2:00 PM A V8, Social Services Director (SSD) stated she received a call from facility staff on 10/31/2024 at 10:18 PM and staff reported that R3 hit R2 on the face and they were both being sent to the hospital. R3 for a psychiatric evaluation and R2 due to the extent of the injuries she sustained from R3 hitting her on the face multiple times. R3 was admitted to the facility 1/2024, she is pleasant and ambulates throughout the facility and had no behaviors at all until that day. V8 recalled observing R3 up in the dining room participating in Halloween activities that day and there were no signs of upcoming behaviors at that time. On 11/20/2024 at 2:30 PM V1, Administrator stated R3 has a psychiatric diagnosis and has had no bad behaviors since being admitted to the facility. V1 observed R3 participate in Halloween activities in the dining room the day of the incident and there were no signs that anything was off about her that day. V1 stated no other abuse allegation within the last 90 days. Prior to the survey date, the Facility took the following actions to correct the noncompliance on 11/19/2024. Immediate Actions: 1-R1 was assessed, plan of care reviewed and updated. R2 was sent to the hospital for evaluation and treatment of acute psychotic state. 2-Admistrator, Director of Nursing, Assistant Director of Nursing, Staffing Coordinator, Evening Receptionist and a unit manager in-serviced nursing and therapy staff regarding the facility's abuse policy with emphasis on how to prevent abuse. 3-Administrator immediately initiated ongoing audits of abuse immediately addressed upon identification and/or re-education conducted weekly for 4 weeks. After 4 weeks, the audits will be completed monthly for a minimum of 3 months. 4-Any concerns identified from the audits will be addressed immediately and will be reviewed by QAPI team monthly, to determine if current interventions are adequate or additional actions need to be completed to ensure compliance. Ongoing Actions: 1-Education will be provided to new employees prior to being allowed to work in the Facility and all employees at the monthly inservice. 2-Concerns will be addressed immediately and discussed during the monthly QAPI Committee for resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide timely and complete incontinence care for 1 of 3 (R4) residents reviewed for improper nursing care. This failure resulted in R4 feeling sad, and unsafe in the facility and experiencing pain to buttocks during incontinent care and obtaining open areas. Findings include: R4's Care Plan, dated 4/30/21, documents (R4) has bowel incontinence cognitive status. It continues, Provide pericare after each incontinent episode, Check resident Q (every) 2-3 hrs (hours) and PRN (as needed) for incontinent episodes. It also documents 4/27/24 (R4) has urinary incontinence. It continues, Provide incontinent/peri-care PRN, Check every 2-3 hours and/or as required for incontinence. Provide incontinent care as needed. R4's Minimum Data Set, dated [DATE], documents that R4 is cognitively intact, occasionally incontinent of urine and always incontinent of bowel. It also documents that R4 is dependent on staff for toileting. R4's Progress note, dated 7/2/2024 at 3:27 PM, documents Health Status Note, Note Text: Noted open sheared areas to right gluteal fold and to back of left thigh. incontinent care provided and skin protected cream applied. (V10) notified and guest requested to notify son because unable to contact daughter. On 7/20/2024 at approximately 11:24 AM, observed R4 lying in bed on her back, in her room. A strong foul-smelling odor in room. R4's top sheet was wet and soiled with a brown stain. Observed brown liquid dripping onto the floor. R4 stated that she needed to be changed and had been waiting since 7pm last night. R4 then pressed the call light button. V11, Certified Nurses Assistant (CNA), answered the call light. V11 pulled back the top sheet and covered R4 up and left the room. At 11:29 AM, V11 and V13, CNA, returned to R4's room with supplies. V11 pulled back the urine and stool-soaked top sheet revealing a heavily soiled and soaked incontinent brief. R4 was lying on top of a fitted sheet, a draw sheet and an incontinent pad. R4 was soaked through each layer of linen. R4's fitted sheet was soaked and had a large brown ring ranging from the back of R4's knees up to the back of R4's neck. V11 then opened R4's incontinent brief and a large amount of soft stool observed covering R4's peri area and lower abdominal fold. V11 then cleansed R4's peri area and abdominal fold. R4 had facial grimacing and yelled out it hurt when being cleaned. V11 and V13 then turned R4 onto her left side that revealed a heavily soaked and saturated incontinent brief stuck to R4's back and buttocks. The incontinent pad, draw sheet and fitted sheet were heavily soaked through with urine and stool. V11 removed the incontinent brief and revealed a large amount of soft foul-smelling stool ranging from R4's buttocks up to the middle of R4's back. V11 then cleansed the stool from R4's buttocks. R4 yelling in pain with each wipe. V11 attempted to calm R4 and paused between wipes. V11 cleansed R4's buttocks and revealed multiple deep red and brown creases in R4 skin that did not fade during incontinent care, and multiple open areas were observed to R4's buttocks and thighs. R4 stated that it was painful when being cleaned. On 7/2/2024 at 11:24 AM, R4 stated that she does not feel safe at the facility and would feel better at home. When asked why does she say that? R4 responded that they leave you alone here. R4 stated that They don't take care of me here. I have been dirty since 7pm last night. I have asked for help and no one helps. They say they will be back and don't come. R4 continued I am alone here, my son works and is not able to take care of me at home. They think its better here but its not. It makes me sad, no one wants to help me. On 7/2/2024 at 11:29 AM, V11 stated that this is unacceptable. V11 stated that (R4) should have been cleaned before now. V11 stated that she was not aware of (R4) having any open areas. V11 stated that (R4) is alert and able to verbalize her needs. V11 stated that she came in the room prior to this and (R4) was sleeping. V11 stated that they got (R4's) roommate up and then proceeded to the other residents. V11 stated that she was not aware that (R4) was in this condition. V11 stated that she prides herself on the care she gives and that this looks like (R4) had been like this for a long time. On 7/3/2024 at approximately 8:28 AM, V12, Licensed Practical Nurse (LPN) stated that she was made aware of (R4's) condition on yesterday. V12 stated that it was unacceptable the condition (R4) was in. V12 stated that she expects the staff to perform incontinent care after each episode of incontinence. V12 stated that the (R4) should have been checked on and if (R4) notified someone that she was incontinent then she expects them to change her. V12 stated that (R4) is alert and tells the staff when she has become incontinent. V12 stated that after the incontinent care was completed she assessed (R4's) skin and applied some cream to it. V12 stated that the areas to (R4's) body are new. V12 stated that the physician and family were notified. V12 stated that (R4) has been changed and repositioned and cream has been applied to (R4's) skin. The facility's Perineal/Incontinent Care Standards and Guidelines, dated 10/24/22, documents Standard: It will be the standard of this facility to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition and provide appropriate care and services required to maintain functional levels while providing perineal/incontinence care. It continues Guidelines: 4. Provide perineal/incontinence care In accordance with physician orders or resident's plan of care, while ensuring to maintain resident preferences as indicated and resident privacy/dignity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure safe transfers for 1 of 3 residents (R2) reviewed for transfers, in the sample of 12. This failure resulted in R2 being transferred incorrectly and resulted in severe bruising on her body covering her right shoulder from the back and underneath side and her entire chest which resulted in her being hospitalized . Findings include: R2's Physician Order Sheet (POS), dated January 2024, documented diagnoses of Atherosclerotic heart disease, hyperlipidemia, hypertension, abnormal finding of lung field, osteoarthritis, diverticulosis, disorder of thyroid, dysphagia, abnormal levels of serum enzymes, complete intestinal obstruction, acute kidney failure, and personal history of (healed) traumatic fracture. R2's POS also documented that she was taking 81 milligrams (mg) of aspirin once a day. R2's Minimum Data Set (MDS), dated [DATE], documented that R2 was severely impaired for cognition. It also documented that they needed assist for sit to stand, transfer chair to bed, toilet transfer, tub/shower transfer. It also documented, Dependent: Helper does all the effort, Resident does none of the effort to complete the activity or the assistance of two plus helpers (staff) are required for the resident to complete the activity. The MDS also documented that R2 uses a wheelchair and has no impairment on the upper or lower extremities. R2's Care Plan, dated 1/18/2024, documented, (R2) has an ADL self-care performance deficit related to confusion. (R2) is a minimum assist of 1 staff for bed mobility and assist of two staff with sit to stand. (R2) has an ADL (activities of daily living) self-care performance related confusion. R2's Progress Notes, dated 1/29/2024 at 7:53 AM, documented, hospitalized /bruising. R2's Initial Report, dated 1/27/2024 documented, (R2) has bruising of unknown origin in the abdominal region possibly caused by a gait belt. (R2) takes blood thinners. (R2) has not exhibited any loss of range of motion. MD (Medical Doctor) and family notified. Resident sent to hospital for further evaluation. Abuse not suspected at this time. Full evaluation and investigation to follow. On 1/30/2024 at 2:12 PM, R2's bruising started from over her right shoulder, approximately a foot wide, purple in color and extended underneath her arm (approximately five inches in width) on her right arm. The bruising was present from R2's right arm both behind and extended to the front of the shoulder, approximately 5 inches in width. From the front the area went from the top of the right shoulder area and extended to the entire chest area all the way across the chest to the left side. On the right side just above the breast area there was large baseball size swelling underneath the skin (hematoma). R2 grimaced when she was transferred and grabbed her left side and stated she did not know what she did, but the area hurt. Resident was asked what had happened and stated, How the he** would I know. There was no bleeding present. V6's, Certified Nursing Assistant (CNA), witness statement, dated 1/30/2024, documented, This writer (V2, Director of Nursing) spoke with (V6) on Saturday 1/27/2024. She stated that she transferred resident from bed to wheelchair after breakfast using gait belt. She then transferred resident again after lunch to toilet using a gait belt. Staff members commented that resident appears to be requiring more assistance, support with transfers as of recently. This writer asked CNA if she noted any grimacing or flinching when providing care or during transfers. (V6) stated that she feels the sit to stand would not be safe and feels that a mechanical lift would be more appropriate. On 1/30/2024 at 1:03 PM, V6, CNA, stated, Saturday morning I came in to work and when I came in (V10, Licensed Practical Nurse (LPN) and (V11, LPN) were working from the night shift and I asked them if they needed any help and they told me (R2) and her roommate (R6) still needed checked on. So, I went to help and change (R2) and (R6). I changed (R6) first because she is a (mechanical lift) and I got help with her. Then afterwards I went to change (R2). (R2) can roll and help out a little during a transfer. I put a gait belt on her and did a stand pivot with the gait belt. I did not have another staff member in the room with me. I did not use the sit to stand for the transfer. If you look on the computer (R2) it says (R2) is a sit to stand with 2 staff. (R2) is not able to hold on with her hands and I felt that it was safer to do the pivot with the gait belt versus the sit to stand. I do not believe it was me that gave her the bruises. I can only say I did not have assistance with (R2's) transfer and I do not feel that I gave her the bruises, but I did not transfer her with another staff member. On 2/1/2024 at 1:23 PM, V8, Registered Nurse (RN) stated, I was called into the room by a CNA (V6) and the CNA was changing (R2) and getting her ready for bed and she called me in because there was some bruising on her. I assessed her and she had extensive bruising, and I called the physician and had her sent out. I did not measure the bruising. The bruising was down her right side, on her ribs, a large hematoma above her chest. I am not aware of any falls prior or why she would have the bruising like she did, so I sent her out. On 2/1/2024 at 4:52 PM, V9, LPN, I was passing meds on 200 hall, (V8, RN) came and got me and said hey, I need you to witness something with me. I followed her to (R2's) room. (R2) was in the bed leaning on left side in bed and she had a lot of bruising from her mid shoulder area and the bruising went all the way across her entire chest. I did not see any visible bleeding, it was not dark in color and some small darker areas it was faint, it looked like a new bruise as there were no yellow or green colors in the bruise. It covered a very large area, and it surprised me because there was so much bruising from her shoulder to across her entire chest. I was not aware of her having any fall or injuries previously and (V8) sent her out. No measurements were taken but it was extensive bruising and covered her entire chest area. V7's, CNA, witness statement, undated, documented, I went to change (R2) into a gown and put her to bed at around 7:45 AM or 7:30 AM and I noticed she was all bruised up and when I took her shirt off while she was laying in the bed I told the nurse to come and look at her and asked if she knew she had bruises on her. On 1/30/2024 at 11:52 AM, V2, Director of Nursing stated, I reviewed (R2's) chart and (R2) was a sit to stand with two staff assist for transfers. I am not sure why (V6) was the only staff member that transferred (R2) and I am not sure why (V6) did not have another staff member assisting when transferring (R2). I would have expected (V6) to get another staff member when transferring (R2). I am not sure why she did not know (R2) required two staff members or why she transferred her by herself. R2's Hospital Records, dated 1/28/2024 at 12:43 PM, documented, Patient was brought from nursing home for evaluation of bruising noticed today. Nursing home facility is unable to give details about this bruising, it was between yesterday and today that she developed bruising on the anterior chest and the right upper extremity, denied fall or trauma, patient is not on blood thinner, does not have recurrent bruising in the past. She was evaluated in the ER (emergency room) and there was no finding of fracture or dislocation, she has leukocytosis and urine sample has not been obtained in the ED (emergency department). Due to the findings of bruising with no explanation, patient is considered not safe to discharge back to same facility at this time and she will be admitted for observation. Hematoma present right anterior shoulder and bruising down left underarm. Exam: Chest wall: Bruising and ecchymosis on the entire anterior chest wall, hematoma on the right anterior chest, tender, no crepitus. Extremities: Bruising and ecchymosis on the right upper extremity involving the right axilla as well, lower extremity contacted. On 2/1/2024 at 4:48 PM, V1, Administrator stated we expect staff to follow the Care Plan for patient care. I do not have a policy for transfers. The Facility Fall Policy with a revision date of 3/27/2021 documents, It will be the standard of this facility to complete an initial assessment, on- going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify, develop and implement effective fall precaution interventions to prevent falls for 2 of 3 residents (R1, R2) reviewed for fall precautions in the sample of 6. This failure resulted in R1 with a un-witnessed fall, with injury's to the face, receiving 7 stitches to the chin, an maxillary sinus, (front of face), fracture, bruising to face and right radius, (thumb side), fracture and R2 Physician Order was for the use of a Full Mechanical Lift for transfers. Findings include: 1. R1's admission Record, documented, vascular dementia, psychotic disturbance, mood disturbance and anxiety, other abnormalities of gait and mobility, frontal lobe and executive function deficit, signs of cognitive functions and awareness, anxiety, repeated falls and major depressive disorder, recurrent. R1's, Initial Report, dated 11/8/22, documents, had fall at facility on 11/8/22. Sent to ER, (Emergency Room), for further evaluation. admitted for abnormal imaging. R1's, Hospital Records, dated 11/8/22, history and physical emergency room report, documented, right radius, (hand), fracture and left maxillary, (face), fracture. Treatment of 7 stitches to chin, and a Velcro wrist splint for immobilize, continue fracture precautions is expected for healing for the next 5-6 weeks and documented, discharge instructions, as, Please Don't Leave Patient Unattended. R1's, typed letter, undated, signed by a Registered Nurse, documents, resident was remitted from (hospital) to facility on 11/9/22 fall with injuries as follows: facial fracture, right wrist fracture, and sutures to chin. R1's, entitled, #816, Fall, dated 11/24/22, documented, fell to floor in her room, no witnesses found. R1's, entitled, #887, Fall, dated 2/3/23, documented, resident in sitting position next to bed, R1 states, I got up and took a fall and tumbled out for bed headfirst into the door. Further documented, injury of abrasion, to right hip. Mental status as confused, impaired memory. Fall un-witnessed. R1's, Care Plan Intervention, dates, 2/3/23 Keep BED IN LOWEST POSITION acceptable by the resident when the resident is in bed. R1's, entitled, #902, Fall, dated 02/16/23, documented, on floor, between bed and wall, discoloration observed to the right shoulder and right hand, sent out to hospital for evaluation and treatment, documented, no witnesses' found. R1's, Care Plan Intervention, does not document a new fall intervention for fall incident of 2/16/23. R1's, entitled, #915, Fall, dated 2/24/23, documented, found laying on her right side with her back against the bed, sent to hospital for evaluation and treatment, injury of bruise to face at time of incident. R1's mental status as confused, orientated to person and impaired memory. R1's, Care Plan Intervention, dates, 02/24/23 SCOOP or PERIMETER MATTRESS to bed. R1's, entitled, #916, Fall, dated 2/25/23, documents, CNA, (Certified Nurse Aide), walked in and found the resident ambulating without assist. CNA stated, she told the resident that she needs to press her call light when she needs help. Mental status documented oriented to person, impaired memory, confused. R1's, Care Plan Intervention, dates, 02/25/23 Refer to THERAPY for screen/evaluation and treatment as indicated. Not an individualized effective intervention for fall. R1's, entitled, #946, Fall, dated 3/24/23, documented, observed sitting on buttocks on floor, between bed and wheelchair. R1's mental status, impaired memory. On 3/24/23, a second fall, same day, documented, CNA found R1 sitting on the floor beside her bed. R1's, Care Plan Intervention, dates, 03/24/23 Anti-roll backs to wheelchair. R1's, entitled, Maintenance Work Order, dated 3/27/23, documents, Work to be done: Install anti-Roll back on guest wheelchair. R1's, entitled, #967, Fall, dated 4/7/23, documented the CNA approaches floor nurse and states resident is on floor laying on left side lying next to bed and between rollator, (a walker with a seat). R1's mental status documented as confused. R1's, Physical Therapy Discharge summary, dated [DATE] through 2/10/23, 3/16/23 through 4/14/23 and 4/13/23 through 4/27/23, documented progress as baseline as requiring; supervision or touch assistance with gait and stand pivot transfers and transfers. On 5/2/23 at 1:00PM, R1 was in her room, sitting in a wheelchair that was identified to not have anti-roll backs to the wheelchair she was sitting in. On 5/2/23 at 1:14PM, V5, Licensed Practical Nurse, stated, R1 should have Anti-roll backs on her wheelchair, and she struggles day to day with memory. On 5/2/23 at 1:30PM, V4 titled as a Corporate Regional Nurse and V1, Administrator both stated, that R1 is to have anti-rollbacks to her wheelchair as that a work order was submitted to have them placed on her wheelchair. V1 stated, she went to R1's room and states, R1 is currently sitting in someone else's wheelchair, must have been taken from the hall by staff, by mistake and R1 was given her correct wheelchair. On 5/3/23 at 9:19AM, V9, Director of Therapy, states, R1 had Covid, as this changed her mobility instability which resulted in R1 having a medical decline. R1 currently is undergoing Therapy, which she is only able to walk 3-4 steps, she has a lot of progressive fatigue and can only sustain 30 seconds with ambulation as V9, had reviewed back to therapy records from 8/2022 through 4/13/23. On 5/3/23 at 10:50AM, V10, CNA stated, R1 is able to activate her call light, but will not, will get up when she wants too, cannot tell you the day of week or month, she only is aware of herself and surroundings. On 5/3/23 at 11:20AM, V1 and V4 both stated, that R1's falls are reviewed with the Interdisciplinary team, (IDT), with each fall, interventions are discussed, evaluated, documented in the Care Plan and implemented. 2. R2's, admission Record, dated 5/1/23, documented, admission date of 4/3/23 and medical diagnosis; hemiplegia and hemiparesis affecting left side of body, muscle weakness, lack of coordination. R2's, Order Summary Report, dated 5/1/23, documented Hoyer (Full Mechanical Transfer Lift of two assist), ordered recommendation from V8 (Physical Therapist) R2's, Nurse Risk Screen, dated 4/5/23, documents, In progress, no Fall Risk Screen Documented. R2's, Nurse Risk Screen, dated 4/14/23, documented, at High Risk for Falls. On 5/2/23 at 1:28PM, surveyor entered R2's, room, V6 and V7 both CNA's, placed a gait belt around R2's waist, transferred R2 from his high back chair into the bed. R2's high back Chair was observed to have a Full Mechanical Lift sling in the chair that R2 was sitting on. R2's, entitled #976 Fall, dated 4/13/23, documented, R2 found lying on floor by fall mat, was lifted back to bed using a Mechanical lift. Notes: Alert to person, place and time, non-ambulatory, transfer dependent with Mechanical lift. On 5/4/23 at 9:15AM, V1 stated, R2 is ordered for a Full Mechanical Lift, and will assure this is addressed with V6 and V7. The facility's policy and procedure, entitled, Falls, dated 3/27/21, documents, It will be the standard of this facility to complete an on-going monitoring/evaluation of resident condition and subsequent intervention development in an attempt to prevent falls and injuries related to falls. After a fall, the interdisciplinary team should review the circumstances surrounding the fall and develop an appropriate intervention (s) and plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a resident was treated with dignity, and had needs met timely for 4 of 4 residents (R35, R51, R54, R77) observed for dignity in a sample of 43. This failure resulted in R77 feeling dirty, nasty and embarrassed. Findings include: 1. R77's Minimum Data Set (MDS), dated [DATE], documents that R77 is cognitively intact. On 2/22/2023 at 9:10 AM, R77's wheelchair was heavily soiled with visible caked on food on the foot pedals, cushion, and both sides of the wheelchair. On 2/22/2023 at 8:59 AM, R77 stated that his wheelchair is dirty. R77 stated that he has not had his wheelchair cleaned since being here. R77 stated that he was pissed off and felt embarrassed. R77 stated that he doesn't have any legs and his wheelchair is how he moves round. R77 stated that he feels dirty and nasty. This is what you see when you see me. They don't do nothing. Who wants to be seen like this? This is embarrassing. On 2/22/23 at 9:05 AM, V13, Certified Nurse Assistant (CNA), stated that the day shift does not clean the wheelchairs. V13 stated that the wheelchairs are supposed to be cleaned on the midnight shift. V13 stated that caked on food looks like has been there for some time and does not look like the wheelchair has been cleaned. On 2/22/23 at 9:30 AM, V7, CNA, stated that the day shift does not clean the wheelchairs. V7 stated midnight shift does the wheelchairs. V7 stated that she is not sure about a cleaning schedule because this is not something that she does. On 2/23/2023 at 2:15 PM, V1, Administrator, provided the wheelchair cleaning schedule, date 12/15/22, that documents R77's wheelchair is scheduled to be cleaned on Tuesday. As of 2/24/2023 at 3:00 PM the facility had not provided any documentation of R77's wheelchair being cleaned. 2. R35's MDS, dated [DATE] documents that R35 has moderately impaired cognitively. On 02/22/23 at 03:12 PM, R35 stated the agency staff act as if they don't care, and they are not always respectful. 3. R51's MDS, dated [DATE], documents that R51 is cognitively intact. On 02/22/23 at 03:12 PM, R51 stated the agency staff act as if they don't care, and they are not always respectful. 4. R54's MDS, dated [DATE], documents that R54 is cognitively intact. On 02/22/23 at 03:12 PM, R54, stated the agency staff act as if they don't care, and they are not always respectful. The Residents' Rights for People in Long-Term Care Facilities, not dated, documents Your rights to dignity and respect. Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the physician of critical lab results for one of 14 residents (R7) reviewed for quality of care in the sample of 14. This failure resulted in R7 continuing to receive the same treatment for his diabetes despite multiple episodes of hypoglycemia, and R7 being admitted to the intensive care unit of local hospital with diagnosis of hypoglycemia. Findings include: R7's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses of Rhabdomyolysis, Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Unspecified Vertebral Artery, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Depression, Gastro-Esophageal Reflux Disease Without Esophagitis, Primary Hypertension, Metabolic Encephalopathy, Acute Kidney Failure, Dysphagia Following Cerebral Infarction, and Cognitive, Social, or Emotional Deficit Following Cerebral Infarction. R7's Physician Order Summary includes an order dated 12/16/22 for lab testing including a CMP (Complete Metabolic Profile) and HgbA1C (a test that measures your average blood sugar levels over the past 3 months). Another order dated 12/21/22 documents an order for another CMP to be done. An order dated 12/16/22 documents, Perform accucheck one time a day related to Diabetes Mellitus with Hyperglycemia. R7's medication orders dated 12/15/22 document orders for Glimepermide 2 milligrams (mg) once a day and Metformin 500 mg twice a day for diabetes mellitus. R7's results of his CMP dated 12/19/22 document his blood glucose level as 33 (normal limits are 65-99). There is a stop sign symbol on the lab indicating this is a critical level. R7's results of his CMP dated 12/22/22 document his blood glucose level as < 31 (less than 31). There is a stop sign symbol on the lab indicating this is a critical level. Review of R7's Progress Notes from 12/15/22 when he was admitted to the facility, through 12/23/22 when he was discharged to the hospital, do not include any documentation of R7's medical doctor being notified of R7's critical lab results. On 1/6/23 at 10:58 AM, V9, staff with the facility's contracted lab, stated the lab staff call any critical labs to the facility, and if there is no answer, they continue to call the facility until someone confirms they received the critical lab results. V9 stated R7's critical glucose level of <31 was called to V2, Director of Nursing on 12/22/22 at 4:24 PM, and R7's critical glucose level of 33 was called to V17, Licensed Practical Nurse (LPN) on 12/19/22 at 5:32 PM. On 1/10/23 at 9:55 AM, V2, Director of Nursing (DON) stated she does not know why there is no documentation of R7's critical lab values being called to the doctor. She stated she took one of the calls from the lab about his low glucose level but by then the nurse had already taken action and corrected his blood sugar after his accucheck was low that morning. V2 stated the critical lab results should still have been called to the medical doctor. She stated on the day that R7 was sent to the hospital, V15, Nurse Practitioner, was on the phone with the nurse and was aware of R7's accucheck of 21 and V15 ordered Glucagon to be given and 911 to be called when R7's blood sugar was still 21 after Glucagon was administered. V2 stated again that all critical lab results should be called to the Medical Doctor (MD). V2 stated she thinks the MD also has access to the electronic medical record but should still be notified by the nurse to be sure it is not missed. V2 stated she was not aware until it was brought to her attention during the survey that R7 had two different critically low blood glucose results. On 1/10/23 at 11:15 AM, V15, Nurse Practitioner (NP), stated she saw R7 once while he was a resident in the facility. She stated she was not notified of R7 having any critical labs, and stated she would definitely have remembered a blood glucose of 33 or less than 31 being reported to her. V15 stated there was no documentation of V16, Medical Doctor (MD), being notified of the critical lab results in their file on R7, which she stated is where V16 would have documented any communication with the facility regarding critical labs. V15 stated V16 did say the facility did report that R7 had a low accucheck result in the morning on the day V16 made rounds (Wednesday, 12/21/22) and that they had taken action to bring it back up, but they did not report R7's critical low glucose of 33 on 12/19/22 on his CMP to V16 or herself. V15 stated she was also not aware of R7's glucose of less than 31 on his CMP lab report on 12/22/22 when she was talking to the nurse about R7's accucheck result of 21 on 12/23/22 that ended up with him being sent to the hospital. V15 stated if she was aware of R7's critical lab results of low glucose levels, she would have held or discontinued his diabetic medications. V15 stated when R7's accuchecks were low on those other mornings, his diabetic medication should not have been given. V15 stated she would have held R7's Glimepermide (diabetic medication) after his first critically low blood glucose on 12/19/22, but because he continued to receive the same medications, he continued to have low blood glucose and ended up in the hospital with hypoglycemia (low blood glucose). On 1/11/23 at 3:55 PM, V1, Administrator, stated the facility does not have a policy regarding reporting critical labs. The facility's policy, Standards and Guidelines: SG Change in Condition revised 3/27/21 documents, Standard: It will be the standard of this facility to notify the physician, family, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. It continues, Guidelines: 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The facility's undated policy, When to Call/Notify the Doctor documents, 2. Change in Resident Condition: h. results of labs/xrays/diagnostic tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide adequate diabetic management for one of 14 residents (R7) reviewed for quality of care in the sample of 14. This failure resulted in R7 continuing to receive the same treatment for his diabetes despite multiple episodes of hypoglycemia, and R7 being admitted to the intensive care unit of local hospital with diagnosis of hypoglycemia. Findings include: R7's Face Sheet documents he was admitted to the facility on [DATE] with the diagnoses of Rhabdomyolysis, Cerebral Infarction Due to Unspecified Occlusion or Stenosis of Unspecified Vertebral Artery, Type 2 Diabetes Mellitus, Generalized Anxiety Disorder, Depression, Gastro-Esophageal Reflux Disease Without Esophagitis, Primary Hypertension, Metabolic Encephalopathy, Acute Kidney Failure, Dysphagia Following Cerebral Infarction, and Cognitive, Social, or Emotional Deficit Following Cerebral Infarction. R7's Physician Order Summary includes an order dated 12/16/22 for lab testing including a CMP (Complete Metabolic Profile) and HgbA1C (a test that measures your average blood sugar levels over the past 3 months). Another order dated 12/21/22 documents an order for another CMP to be done. An order dated 12/16/22 documents, Perform accucheck one time a day related to Diabetes Mellitus with Hyperglycemia. R7's medication orders dated 12/15/22 document orders for Glimepermide 2 milligrams (mg) once a day and Metformin 500 mg twice a day for diabetes mellitus. R7's Minimum Data Set (MDS) dated [DATE] documents he is severely cognitively impaired, and requires limited assist with bed mobility, transfers, walking in his room, dressing, toileting and eating. The MDS documents he is occasionally incontinent of urine and always incontinent of bowel. R7's Care Plan dated 12/15/22 documents the focus of: Resident has Diabetes and is at risk for high or low blood sugar. The goal for this care plan is: Resident will not experience serious complications related to high or low blood sugar. Interventions for this care plan include: Monitor for and report as needed signs or symptoms of low blood sugar (hyperglycemia) such as irregular heart beat, shakiness, anxiety, sweating, confusion, change in level of consciousnessm or low fingerstick readings. Report consistent unstable blood sugars to physician as needed. (This care plan incorrectly identifies low blood sugar which is hypoglycemia). R7's Medication Administration Record (MAR) dated 12/2022 documents he received his diabetic medications, Glimeperide 2 mg once a day and Metformin 500 mg twice a day despite his accucheck results being below normal on 12/22/22 and his lab reports documenting a critically low glucose level on 12/19/22 and 12/22/22. R7's results of his CMP dated 12/19/22 document his blood glucose level as 33 (normal limits are 65-99). There is a stop sign symbol on the lab indicating this is a critical level. R7's results of his CMP dated 12/22/22 document his blood glucose level as < 31 (less than 31). There is a stop sign symbol on the lab indicating this is a critical level. Review of R7's Progress Notes from 12/15/22 when he was admitted to the facility, through 12/23/22 when he was discharged to the hospital, do not include any documentation of R7's medical doctor being notified of R7's critical lab results. R7's Progress Note dated 12/22/22 at 6:44 AM documents, Perform accucheck one time a day related to Type 2 Diabetes Mellitus with hyperglycemia. Resident BS (blood sugar) was 44 at 5:45 AM. Boost given, he was alert and talking to me saying he did not know if he has had hypoglycemia episodes. Resident consumed the the whole container of Boost and rechecked BS 56 at 6:45 AM. Resident was also given an oatmeal cream cookie. Reported to day nurse. R7's Progress Note dated 12/23/22 at 1:27 PM documents, Resident daughter informed this nurse her dad facial has changed, went to resident room, resident was lying in bed, left hand to his mouth, called resident name, he looked but did not respond . Resident left hand was twitching. Took resident V/S (vital signs) BP (blood pressure) WNL (within normal limits) but HR (heart rate) is irregular. around 9:30 AM, when administer resident medication, resident seem A&O (alert and oriented) 1-2. Now resident is 1-2, AM (morning) medication was administered, but resident medication should crushed due to swallowing precaution, due to alter mental changes. EMS (Emergency Medical Services) was called. Around 1:03 PM BS (blood sugar) was checked, result 21. Glucagon 1 ml (milliliter) given, in the left thigh at 1:11 PM, 1:12 PM EMS was here, gave to EMS. EMS retook BS, BS result 21. IV (intravenous access) was started by EMS, around 1:28 PM resident was on stretcher. Daughter is here. PCP (Primary Care Physician) was called. R7's Hospital Records dated 12/24/22 documented his admitting diagnosis as: Hypoglycemia, likely secondary to oral hypoglycemic adn poor p.o. (by mouth) intake. The hospital summary documents, Patient is a [AGE] year old gentleman came in with hypoglycemia. Likely related to poor p.o. intake and also patient on soft oral diabetic medication. Stopping this medication resolved his blood sugar issues. The hospital History and Physical dated 12/23/22 at 5:45 PM documents, Despite receiving several amps of dextrose and food in the ED (Emergency Department) he remains hypoglycemic and he is being admitted to the ICU (Intensive Care Unit) in this setting on a D10 (dextrose) drip. On 1/6/23 at 10:58 AM, V9, staff with the facility's contracted lab, stated the lab staff call any critical labs to the facility, and if there is no answer, they continue to call the facility until someone confirms they received the critical lab results. V9 stated R7's critical glucose level of <31 was called to V2 on 12/22/22 at 4:24 PM , and R7's critical glucose level of 33 was called to V17, Licensed Practical Nurse (LPN) on 12/19/22 at 5:32 PM. On 1/10/23 at 9:55 AM, V2, Director of Nursing (DON) stated she does not know why there is no documentation of R7's critical lab values being called to the doctor. She stated she took one of the calls from the lab about his low glucose level but by then the nurse had already taken action and corrected his blood sugar after his accucheck was low that morning. V2 stated the critical lab results should still have been called to the medical doctor. She stated on the day that R7 was sent to the hospital, V15, Nurse Practitioner, was on the phone with the nurse and was aware of R7's accucheck of 21 and V15 ordered Glucagon to be given and 911 to be called when R7's blood sugar was still 21 after Glucagon was administered. V2 stated again that all critical lab results should be called to the Medical Doctor (MD). V2 stated she thinks the MD also has access to the electronic medical record but should still be notified by the nurse to be sure it is not missed. V2 stated she was not aware until it was brought to her attention during the survey that R7 had two different critically low blood glucose results. V2 stated she did rounds on 12/23/22 and saw R7 and his roommate and they both stated they were doing alright. She stated about an hour later, R7's daughter notified the nurse that R7 didn't look right and that is when his blood sugar was checked and found to be 21. She stated he was fine just an hour before. V2 stated she told the nurse on duty to check his BS because he had been running low in the mornings. On 1/10/23 at 11:15 AM, V15, Nurse Practitioner (NP) stated she saw R7 once while he was a resident in the facility. She stated she was not notified of R7 having any critical labs, and stated she would definitely have remembered a blood glucose of 33 or less than 31 being reported to her. V15 stated there was no documentation of V16, Medical Doctor (MD) being notified of the critical lab results in their file on R7, which she stated is where V16 would have documented any communication with the facility regarding critical labs. V15 stated V16 did say the facility did report that R7 had a low accucheck result in the morning on the day V16 made rounds ( Wednesday, 12/21/22) and that they had taken action to bring it back up, but they did not report R7's critical low glucose of 33 on 12/19/22 on his CMP to V16 or herself. V15 stated she was also not aware of R7's glucose of less than 31 on his CMP lab report on 12/22/22 when she was talking to the nurse about R7's accucheck result of 21 on 12/23/22 that ended up with him being sent to the hospital. V15 stated if she was aware of R7's critical lab results of low glucose levels, she would have held or discontinued his diabetic medications. V15 stated when R7's accuchecks were low on those other mornings, his diabetic medication should not have been given. V15 stated she would have held R7's Glimepermide (diabetic medication) after his first critically low blood glucose on 12/19/22, but because he continued to receive the same medications, he continued to have low blood glucose and ended up in the hospital with hypoglycemia (low blood glucose). The facility's policy, Standards and Guidelines: SG Diabetes Hypo/Hyperglycemia revised 3/27/21 documents, Standard: It will be the standard of this facility to provide appropriate care to residents with diabetes mellitus. Nursing measures and physician orders will be implemented to minimize the risk of hypo/hyperglycemia. It continues, Guidelines: 4. The physician will order appropriate lab tests (for example, periodic fingersticks or A1C) and adjust treatments based on these results and other parameters such as glycosuria, weight gain or loss, hypoglycemic episodes, etc. It further documents, 14. Document pertinent information regarding medication administration, changes in condition, education, or interventions in clinical record. The facility's policy, Standards and Guidelines: SG Change in Condition revised 3/27/21 documents, Standard: It will be the standard of this facility to notify the physician, family, and/or responsible party/resident representative (as is applicable) of significant changes in condition and providing treatment(s) according to the resident's wishes and physician's orders. It continues, Guidelines: 7. Contact the primary physician to update him/her to the change in condition. In the event the primary physician cannot be notified, attempt to contact the facility's medical director. The facility's undated policy, When to Call/Notify the Doctor documents, 2. Change in Resident Condition: h. results of labs/xrays/diagnostic tests.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide treatment in accordance with professional standards of care for a fall resulting in injury for 1 of 3 residents (R2) reviewed for quality of care in the sample of 3. This failure resulted in a delay in treatment of almost 12 hours for R2 after a fall in which she hit her head and sustained a nondisplaced periprosthetic right femoral fracture which required hospital admission for pain control. Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognitive skills for daily decision making. R2's MDS dated [DATE] documents R2 requires limited assist for transfers, bed mobility and is occasionally incontinent of urine. R2's face sheet documents diagnoses include, ANXIETY, MAJOR DEPRESSIVE DISORDER, MUSCLE WEAKNESS, UNSTEADINESS ON FEET, OTHER ABNORMALITIES OF GAIT AND MOBILITY and COGNITIVE COMMUNICATION DEFICIT. R2's Care Plan, dated 8/23/22, documents R2 is at risk for abnormal bleeding related to use of anticoagulant. Interventions include report to the physician any signs/symptoms abnormal bleeding or hemorrhage. R2's 10/2022 Medication Administration Record (MAR), documents R2 takes Eliquis and Aspirin for anticoagulation. R2's Chart Note dated 10/19/2022 02:44 AM, documents: guest fell, no injury noted, daughter called waiting for call back, message left for gen med (general medicine) in folder. R2's Chart Note, dated 10/19/2022 10:07 AM, documents: Resident continues to complain of pain Tylenol not effective. Dr. notified. Vital sign monitoring continues from being observed on the floor. Neuro checks continue and remain WNL (within normal limits). Afebrile Resident has loss of appetite due to increased pain. Small hematoma noted behind right ear. Unable to move without yelling out. New order received to send to the hospital for evaluation and treatment. POA (Power of Attorney) notified and gave verbal consent to send to hospital. (local) EMS (emergency medical services) notified of order for Resident pick up. R2's Chart Note dated 10/19/2022 3:00 PM, documents: EMS arrived for Resident pick up and transport to (local hospital) ED (emergency department). EMS arrived to facility. Resident left facility accompanied by x2 EMTs (emergency medical technicians) via stretcher. POA in NH (nursing home) sitting with Resident prior to arrival of EMS transport. On 10/27/2022 at 12:00 PM, V4, Licensed Practical Nurse (LPN), stated he received report from night shift nurse on 10/19/22 that R2 had a fall around 2-3am with no injuries and that the doctor and POA were aware. V4 stated he did walking rounds at the beginning of his shift and R2 was in bed. V4 stated around breakfast time the CNA (Certified Nursing Assistant) staff asked him to go to R2's room because they tried to raise the head of R2's bed to eat and she was in pain. V4 stated he entered R2's room and asked R2 what was going on. V4 stated R2 said she had fallen last night and she hurt all over. That her knee, head and shoulder hurt. V4 stated he gave R2 some acetaminophen for her pain and asked her to try and eat. V4 stated he did not do a physical assessment on her at that time. V4 stated around 10:00 am, he called V5, Nurse Practitioner (NP). V4 stated he told V5 that R2 had fallen last night and that she hit her head and was on blood thinners, that R2 was in pain unrelieved by acetaminophen and that her leg was turned outwards. V4 stated he received orders from V5 to send R2 to the hospital. V4 stated he called (local ambulance) transportation and they stated they were running behind. V4 said (local ambulance) transport asked him if this was an emergency and he stated no. V4 stated the (local ambulance) transport stated that they would be at the facility at 12:30-1:00pm for transport. V4 stated R2 did not transport to hospital until 3pm. V4 stated he did not make any additional calls to get R2 to the hospital earlier. V4 stated he felt as if R2 should have been transported to ER (Emergency Room) on night shift. V4 stated he did not notify NP of delay in transfer and he did not request any additional pain medication for R2 due to the acetaminophen not controlling the pain. On 10/27/2022 at 1:00 PM, V5, NP, stated she would expect the facility to transfer R2 immediately to the hospital due to her being on blood thinner and hitting her head during the fall. V5 stated she would have ordered something more for pain if she was aware of R2 not being transferred to ER until 3pm due to her pain not being relieved with acetaminophen. V5 stated she was not a made aware that R2 wasn't transferred to ER until 3pm. R2's hospital records for emergency room visit note dated 10/19/2022 documents per EMS that R2 received 4 milligram (mg) of morphine for pain and that R2's right lower extremity noted to be externally rotated and shortened. This document also documents R2 as having a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control. The Facility standards and guidelines document includes the following: contact the primary physician to update him/her to the change of condition, if the residents condition is considered to be life threatening and the resident requires immediate medical care notify the emergency medical system (911).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided for one of three residents (R2) reviewed for pain in the sample of three. This failure resulted in R2 lying in pain for an excess of 5 hours crying out in pain with any movement without transfer to the hospital or receiving pain medication. R2 sustained a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control. Findings include: R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognitive skills for daily decision making. R2's MDS dated [DATE] documents R2 requires limited assist for transfers, bed mobility and is occasionally incontinent of urine. R2's face sheet documents diagnoses include, ANXIETY, MAJOR DEPRESSIVE DISORDER, MUSCLE WEAKNESS, UNSTEADINESS ON FEET, OTHER ABNORMALITIES OF GAIT AND MOBILITY and COGNITIVE COMMUNICATION DEFICIT. R2's care plan dated 8/23/22 documents R2 has the potential for pain, interventions include notify the resident's physician if they do not state/demonstrate relief or reduction of pain with current pain management regimen. R2's physician order sheet (POS) dated 10/2022 documents the following: monitor for and document pain level and non-pharmacological interventions every shift. Acetaminophen tab 650mg (milligram) by mouth every 6 hours as needed for pain. R2's electronic Medication Administration Record (EMAR) for the date of 10/19/2022 dayshift documents a zero for pain and documents no acetaminophen administration on the dayshift. R2's Chart Note dated 10/19/2022 2:44 AM, documents: guest fell, no injury noted, daughter called waiting for call back, message left for gen med (general medicine) in folder. R2's Chart Note dated 10/19/2022 10:07AM documents: Resident continues to complain of pain Tylenol not effective. Dr. notified. Vital sign monitoring continues from being observed on the floor. Neuro checks continue and remain WNL (within normal limits). Afebrile Resident has loss of appetite due to increased pain. Small hematoma noted behind right ear. Unable to move without yelling out. New order received to send to the hospital for evaluation and treatment. POA (Power of attorney) notified and gave verbal consent to send to hospital. (local) EMS (emergency medical services) notified of order for Resident pick up. R2's Chart Note dated 10/19/2022 3:00 PM, documents: EMS arrived for Resident pick up and transport to (local hospital) ED (emergency department). EMS arrived to facility. Resident left facility accompanied by x2 EMTs via stretcher. POA in NH (nursing home) sitting with Resident prior to arrival of EMS transport. On 10/27/2022 at 12:00 PM, V4, Licensed Practical Nurse (LPN), stated he received report from night shift nurse on 10/19/22 that R2 had a fall around 2-3am with no injuries and that the doctor and POA were aware. V4 stated he did walking rounds at the beginning of his shift and R2 was in bed. V4 stated around breakfast time the CNA (Certified Nursing Assistant) staff asked him to go to R2s room because they tried to raise the head of R2's bed to eat and she was in pain. V4 stated he entered R2's room and asked R2 what was going on. V4 stated R2 said she had fallen last night and she hurt all over. That her knee, head and shoulder hurt. V4 stated he gave R2 some acetaminophen for her pain and asked her to try and eat. V4 stated he did not do a physical assessment on her at that time. V4 stated around 10:00 am, he called V5, Nurse Practitioner (NP). V4 stated he told V5 that R2 had fallen last night and that she hit her head and was on blood thinners, that R2 was in pain unrelieved by acetaminophen and that her leg was turned outwards. V4 stated he received orders from V5 to send R2 to the hospital. V4 stated he called (local ambulance) transportation and they stated they were running behind. V4 said (local ambulance) transport asked him if this was an emergency and he stated no. V4 stated the (local ambulance) transport stated that they would be at the facility at 12:30-1:00pm for transport. V4 stated R2 did not transport to hospital until 3pm. V4 stated he did not make any additional calls to get R2 to the hospital earlier. V4 stated he felt as if R2 should have been transported to ER (Emergency Room) on night shift. V4 stated he did not notify NP of delay in transfer and he did not request any additional pain medication for R2 due to the acetaminophen not controlling the pain. On 10/27/2022 at 1:00 PM, V5, NP, stated she would expect the facility to transfer R2 immediately to the hospital due to her being on blood thinner and hitting her head during the fall. V5 stated she would have ordered something more for pain if she was aware of R2 not being transferred to ER until 3pm due to her pain not being relieved with acetaminophen. V5 stated she was not a made aware that R2 wasn't transferred to ER until 3pm. R2's hospital records for emergency room visit note dated 10/19/2022 documents per EMS that R2 received 4mg of morphine for pain and that R2's right lower extremity noted to be externally rotated and shortened. This document also documents R2 as having a nondisplaced periprosthetic right femoral fracture and was admitted to hospital for pain control.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure fall interventions were in place for 1 of 2 residents (R11) reviewed for falls in the sample of 49. This failure resulted in R11 falling and sustaining a subdural hematoma requiring hospitalization. Findings include: R11's Face Sheet, undated, documents R11 has a diagnosis of Muscle Weakness and a History of Falls. R11's Minimum Data Set (MDS), dated [DATE], documents R11 has moderate cognitive impairment, requires an extensive assist of one staff with transfers and has impaired balance. R11's Care Plan, dated 5/18/21, documents R11 is at risk for falls due to impaired cognition and impaired safety awareness with the following interventions implemented on the following dates: 6/30/21, Will provide with sitter while awake; and 7/21/21, self-releasing seat belt. On 3/22/22 at 1:43PM, V8, R11's Family, stated R11 had a fall about 3 to 4 weeks ago, went to the emergency room, had a brain bleed and urinary tract infection. V8 stated R11 is supposed to have a sitter at bedside and alarms. V8 stated when R11 has to go to the bathroom, she will get up and go and doesn't know to ask for help. On 3/22/22 at 1:55PM and 3/23/22 at 9:35AM, R11 was observed sitting up in the wheelchair in hallway. R11 had no seat belt in place and staff not providing one on one care. R11's Fall Report, dated 2/14/22, documents R11 was observed on the floor in her room on her left side. R11 leaned too far over to the left and fell out of the wheelchair. R11 was assessed, a hematoma to R11's face was noted, and she was sent to the emergency room for further evaluation. R11's Hospital History & Physical, dated 2/14/22 documents R11 had an unwitnessed fall and was diagnosed with a Subdural Hemorrhage and Traumatic Cephalohematoma. R11's CT scan, dated 2/14/22, documents a posterior cephalohematoma and suggestion of a small underlying acute subdural hematoma. R11's Therapy Post Fall Assessment, dated 2/18/22, documents Patient had an unwitnessed fall from the wheelchair. Patient has a self-releasing wheelchair belt, however, was not in place at the time of fall. The facility Initial Federal Report, dated 2/21/22, documents R11 had a fall on 2/14/22, which resulted in a subdural hemorrhage. Description of events: R11 was observed on her left side on the floor of her room. Corrective actions: Resident placed on one on one when up in wheelchair. On 3/24/22 at 9:55AM V2, Director of Nurses, stated she would expect fall interventions to be in place but she thinks they stopped providing one on one care for R11 about a week ago. On 3/23/22 at 2:15PM V35, Regional Director of Clinical Operations, acknowledged that R11's care plan was reviewed on 3/23/22 and the intervention initiated on 6/30/21 of providing R11 with a sitter while awake was removed on 3/23/22. The Falls policy, dated 3/27/21, documents pertinent interventions will be implemented by staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On 3/23/22 at 9:00 AM, R29 stated she gets urinary infections all the time. On 3/23/22 at 9:20 AM, V16, CNA and V17, CNA performed incontinent/catheter care on R29. V17 opened the front of R29's incontinence brief and R29 had a bowel movement. V17 took a washcloth, wiped upwards towards R29's urethra, feces was noted on the washcloth, then took the washcloth and threw it on the floor. V16 then took a package of wipes, getting feces on the outside of the package and turned R29 onto her left side, then changed gloves with no hand hygiene performed. V16 then wiped feces off of R29's right buttock and around a dressing in place to R29's left buttock. The dressing was loose and soiled with feces. V16 and V17 turned R29 onto her back and wiped down the catheter. With dirty gloves on V16 and V17 proceeded to place a clean incontinence brief and clean sheet under R29. V16 removed her gloves, picked up the package of wipes with feces still on the outside of the package and placed them in the hallway. V17, with dirty gloves on, then picked up a clean dry towel, wiped R29's left front perineal crease and closed R29's incontinence brief. V17 then picked up the dirty washcloth, turn sheet and towel up off of the floor, proceeded to the door, touched the doorknob and disposed of the dirty linen. R29's Face Sheet, undated, documents R29 has a diagnosis of UTI, Neuromuscular Dysfunction of the Bladder and Retention of Urine. R29's MDS, dated [DATE], documents R29 is cognitively intact, requires an extensive assistance of 2 staff with toileting, has an indwelling urinary catheter and is incontinent of bowel R29's Care Plan, dated 1/28/21, documents R29 has a UTI related to use of a urinary catheter with an intervention to provide catheter care as ordered. R29's Urine Culture, dated 3/7/22, documents R29 has Escherichia Coli, Enterococcus Faecalis, Vancomycin Resistant Enterococcus (VRE) and Group D Enterococcus. R29's Physician's Order Sheet (POS), documents the following orders: 3/19/22 - catheter care every shift; 3/14/22 - ceftriaxone sodium 1 gram intravenously daily for UTI for 3 days; linezolid 600 milligrams twice daily for UTI/VRE for 14 days. 4. On 3/22/22, R71 was observed in bed with the indwelling urinary catheter bag touching the floor. On 3/24/22 at 2:05 PM, incontinent care/catheter care was observed with V16, CNA and V17 CNA. V16 pulled back R71's incontinence brief and R71 had a bowel movement. V17 wiped down the right inner thigh area removing a large amount of feces. V16 and V17 then rolled R71 onto her right side, cleaned R71's right buttocks, then rolled R71 onto the left side but neither V16 nor V17 cleaned R71's left buttock. V16 and V17, with dirty gloves on, then placed a clean incontinence brief and clean bed pad under R71. V16 and V17 then rolled R71 onto her back and still with dirty gloves cleaned R71's anterior perineal area and down the catheter tubing leaving feces on the upper pubic area and right inner thigh area. V16 and V17 then, still with dirty gloves on pulled the clean incontinent brief up and covered the resident up with a blanket. R71's Face Sheet, undated, documents R71 has a diagnosis of Urinary Tract Infection and Urinary Retention. R71's MDS, dated [DATE], documents R71 is dependent with toileting, has an indwelling urinary catheter and is always incontinent of bowel. R71's Care Plan, dated 11/5/21, documents R71 has a Urinary Tract Infection related to the use of an indwelling urinary catheter and to provide catheter care as ordered. R71's Urine Culture, dated 1/11/22, document R71 has Escherichia Coli in the urine. R71's Urine Culture dated 1/24/22, documents R71 has Proteus Mirabilis in the urine. R71's Urine Culture, dated 2/28/22, documents R71 has Proteus Mirabilis with Extended Spectrum Beta Lactamases (ESBL) and Enterococcus Faecalis in the urine. R71's Treatment Administration Records for January 2022, document catheter care was not completed 8 times during that month. R71's Hospital History & Physical, dated 1/28/22, document R71 was admitted to the hospital with a diagnosis of Acute Urinary Tract Infection. On 3/23/22 at 9:55AM V2, Director of Nurses stated she would expect the CNAs to perform catheter/incontinent care completely and appropriately and to change gloves and perform hand hygiene when going from a clean area to a dirty area. The Standards and Guidelines: SG Indwelling Catheters policy, dated 3/27/21 documents, Standards: It will be the standard of this facility to provide appropriate documentation for use and care for indwelling catheters of the resident's that have the indication for use beyond 14 days. Under Guidelines it further documents, 8. Staff will provide daily catheter care or as ordered by the physician and/or needed. Catheter care should be provided in a manner that promotes infection control and maintenance of the insertion site. Based on observation, interview and record review the facility failed to provide incontinent and catheter care in a manner to prevent Urinary Tract Infections (UTI) and discomfort for 5 of 6 residents (R18, R25, R29, R41 and R71) reviewed for Urinary Tract Infections in the sample of 49. This failure resulted in R18, R25, and R71 requiring hospitalizations for treatment of their Urinary Tract Infections. Findings include: 1. On 3/22/22 at 9:36 AM, V7 Certified Nursing Assistant (CNA) came in to provide incontinent care after R18 was incontinent of stool. R18 has an indwelling urinary catheter and when V7 pulled R18's jeans off she pulled on R18's catheter which was not secured with a leg strap. R18 cried out when V7 pulled on her catheter when removing jeans. The urine in R18's catheter bag was murky brown. V7 donned gloves without performing hand hygiene, and using disposable wipes, wiped visible fecal material from R18's buttocks and rectum. V7's gloves were visibly soiled, and she changed gloves without performing hand hygiene. V7 then turned R18 onto her back and wiped fecal material from R18's thighs and groin but did not spread R18's labia to cleanse her meatus or the catheter tubing. V7 then wiped R18's catheter from about an inch from insertion site out, still wearing the same gloves that were soiled with fecal material. V7 stated, I wash my hands out there and she left R18's room without washing her hands and walked to the soiled utility room and pressed several buttons to unlock the door, dumped her trash in a container, then walked to the nurse's station to wash her hands. On 3/23/22 at 10:38 AM, V27 and V28, CNAs, were providing incontinent care for R18 who had been incontinent of bowel movement (BM). R18 was placed on her side. R18's catheter was pulled from her front, stretched between her legs and sitting between her buttocks, soiled with BM. There was a bottle of body shampoo sitting on R18's bedside table, but no basin of water. V28 turned around and wet a washcloth under the faucet, then turned back to wipe the fecal material from R18's buttocks, still with the catheter tubing between her buttocks. When V28 was wiping the fecal material from R18's buttocks, he was pulling on R18's catheter tubing and she yelled out ouch two different times, but he continued to leave the catheter between her buttocks. R18 did not have a leg strap to secure her catheter to her leg. After wiping the feces from R18's buttocks, the CNAs put a clean diaper on R18, and were getting ready to tape it closed, and writer asked to see the catheter. V27 and V28 opened the clean diaper and R18's catheter was still soiled with feces. V28 wet a washcloth with just water from the sink, no soap, and wiped R18's catheter with one swipe then fastened her diaper. V28 did not spread R18's labia to cleanse around the catheter or her meatus. After V27 and V28 left the room, R18 stated, They did not clean me in front, they just wiped the poop off my butt. There was a package of disposable cleansing wipes under R18's bed. On 3/23/22 at 12:04 PM, V28 approached the surveyor and asked why he had been asked questions while he was providing care to R18, and the survey process was explained to him. V28 asked, So how did we do? Explained to him there were concerns with care, including a concern with catheter tubing positioned between her legs and laying between her buttocks in feces, and he stated, Where should it have been? R18's Face Sheet documents she was admitted to the facility on [DATE] and documents her diagnoses to include urinary tract infection. R18's Lab Results Report dated 10/18/21 documents she had a UTI and identified the causative agent as Klebsiella Pneumoniae. R18's Lab Results Report dated 12/3/21 documents she had a UTI and identified the causative organism as Pseudomonas Aeruginosa. R18's Progress Notes dated 12/15/21 document R18 was readmitted from the hospital on IV antibiotics to treat her diagnosis of UTI. She was hospitalized from [DATE] to 12/15/ 21 for treatment of UTI. R18's Progress Notes dated 1/6/22 document she was readmitted from the hospital after being treated for a UTI. She was hospitalized from [DATE] to 1/6/22 for treatment of the UTI. R18's Physician Order dated 3/9/22 documents, Attach leg strap to secure catheter tubing. R18's Lab Results Report dated 3/12/22 documents she had a UTI and identified the causative organism as Escherichia Coli. R18's Progress Notes dated 3/24/22 at 5:47 AM documents she is currently being treated for a UTI. R18's Minimum Data Set (MDS) dated [DATE] documents she has moderate cognitive impairment, requires extensive assist with toileting, has an indwelling catheter and is always incontinent of bowel. R18's Care Plan dated 9/3/21 documents, (R18) has indwelling catheter. Interventions for this care plan include: Retention strap in place to assist in maintaining catheter alignment as tolerated. Another Care Plan focus for R18 dated 3/15/22 documents, (R18) has a urinary tract infection. Interventions for this care plan include, Provide education as needed to resident in good clean hygiene techniques to avoid cross contamination, wash hands frequently and especially after bowel movements. 2. On 3/23/22 at 9:54 AM R25 stated they do not clean him up timely and do not always clean around his catheter. He stated he has had UTIs the last couple of times he went to the hospital. On 3/24/22 at 12:25 PM V5, CNA and V37, CNA positioned R25 onto his back to perform catheter care. R25's indwelling urinary catheter was not secured to his leg with a leg strap and the catheter was pulled taut several times during care when R25 was rolled back and forth for care. R25 stated sometimes the catheter rubs his skin and irritates it. V37 filled a wash basin with water and squirted some body wash into the water. V37 stated she had just finished providing R25 incontinent care to clean him after he was incontinent of bowel just before writer entered the room. V37 stated the nurse had told her to clean him up before she changed his dressing. V37 soaked a washcloth in soapy water and dabbed the sides of R25's penile shaft, then removed gloves and applied new gloves with no hand hygiene and dabbed around the insertion site of R25's catheter. V37 did not retract R25's foreskin from the head of his penis to thoroughly wash the area, or to completely cleanse his catheter tubing. Several of the washcloths V37 used to clean R25's scrotum were soiled with fecal material after she swiped his scrotum. V37 removed her soiled gloves but did not perform hand hygiene before donning a new pair of gloves. When cleansing the underside of R25's scrotum, there was a moderate amount of fecal material noted on the washcloth but V37 did not go back and wipe R25's scrotum a second time to ensure he was completely clean. V37 did not rinse any of the soap from R25's skin, but just patted him dry. V37 put a new diaper under R25, and applied barrier cream to his groin and scrotum, and pulled him up in bed with the same gloves she had used to wipe fecal material from his scrotum. V37 presented the bottle of soap she used to clean R25. The label on the bottle of soap documented the directions: Skin and Hair Cleanser. Pour a small amount onto a wet washcloth or directly onto hands. Rinse thoroughly. R25's MDS dated [DATE] documents he is alert and oriented and has an indwelling catheter. The MDS also documents R25 is always incontinent of bowel, and he has a Stage 4 pressure ulcer. It documents he is dependent on staff for toileting. R25's Care Plan dated 2/12/22 documents the focus, (R25) has a potential for recurrent urinary tract infections related to: history of UTIs. The interventions include, Provide education as needed to resident in good clean hygiene techniques to avoid cross contamination, wash hands frequently and especially after bowel movements. Another focus in R25's care plan, dated 1/22/22, documents, (R25) has an ADL (Activities of Daily Living) self-care performance deficit related to limited mobility, shortness of breath, weakness. The interventions for this care plan include, Toileting, Maximum assist. Another focus of R25's Care Plan dated 1/22/22 documents, (R25) has Indwelling Catheter related to BPH (Benign Prostatic Hyperplasia). Interventions for this care plan include, Retention strap in place to assist in maintaining catheter tubing alignment as tolerated. R25's Physician Orders document the order dated 12/27/21, Attach leg strap to secure catheter tubing, catheter care as needed for soiling or leakage, catheter care every day shift. R25's Lab Result Report dated 1/3/22 documents his urinalysis results as amber colored cloudy urine with greater than 50 red blood cells (normal is less than 6) and greater than 50 white blood cells (normal is less than 6). The report documented that a culture was indicated and completed but did not identify the causative organism. R25's Hospital Discharge Note dated 1/12/22 documents he was admitted on [DATE] with the diagnoses of Sepsis with acute renal failure without septic shock, due to unspecified organism, unspecified acute renal failure type, Chronic congestive heart failure, unspecified heart failure type, Acute urinary tract infection, and Acute renal insufficiency. Discharge instructions included, Routine Foley care-remove foley with patient able to get to a bedside commode. Monitor for urine retention and check bladder scanner if patient has poor urine output. R25's Hospital Discharge Note dated 2/19/22 documents he was admitted to the hospital on [DATE] with CHF (Congestive Heart Failure), Chronic urinary infection-catheter related. His discharge medications included an antibiotic (Cipro) to treat his UTI. 3. On 03/22/22 at 10:06 AM R41 was lying in bed and her catheter is hanging under her wheelchair, not on her bed close to R41. The tubing of R41's urinary drainage bag was stretched between the wheelchair and R41 in bed. On 3/24/22 at 11:20 AM V5 and V7 CNAs provided catheter care for R41. V7 filled a wash basin with water and squirted some body shampoo into the basin. Before V5 and V7 removed R41's pants, her catheter was under her left leg. While they were removing her pants, R41 cried out when her catheter got caught on her pants and was pulled on. R41 did not have a leg strap to secure her catheter to her leg to keep it from getting pulled on during care. V7 washed her hands, then left the room to get a new diaper for R41. Upon returning to R41's room, V7 did not perform hand hygiene again before donning gloves. R41's groin was slightly red, and she verbalized discomfort when V7 cleansed that area. V7 did not rinse the soap from R41's skin after cleansing her. V7 cleansed R41's catheter starting about an inch out from the insertion site. V7 did not spread R41's labia and cleanse around the catheter or urethra. V5 and V7 turned R41 onto her left side and V7 used disposable wipes to remove dried fecal material from R41's buttocks, then resumed using wash cloths to cleanse her buttocks with soapy water but did not rinse the soap off R41's skin. V7 then placed the new diaper under R41 and fastened it, pulled her up in bed, fixed her pillow and covered her with a blanket without changing her gloves or performing hand hygiene. R41's Electronic Medical Record (EMR) documents her diagnoses to include Urinary Tract Infection (UTI) on 2/1/22. R41's Lab Results Report of Urinalysis and Culture and Sensitivity dated 2/28/22 documents she had a UTI with the causative organisms being Escherichia Coli and Enterococcus Faecalis. R41's Physician Orders (PO) dated 3/1/22 document, Insert/maintain indwelling catheter (16 French) No directions specified for order. Attach leg strap to secure catheter tubing. R41's Physician Order dated 3/3/22 documents R41 was treated for a UTI from 3/3/22 to 3/8/22 with Cipro 500 milligrams (mg) BID (twice daily). R41's Physician Order dated 3/24/22 documents the order: UA and C&S (Culture and Sensitivity) one time only for previous UTI and altered mental status.