Based on observation, interview, and record review, the facility failed to effectively monitor and treat pain for a resident with severe cognitive impairment with a healing dislocated and fractured left shoulder for 1 of 1 resident reviewed for pain. (Resident F) This resulted in Resident F having impaired mobility and poor quality of life as evidenced by not leaving his bed per his usual routine. Finding includes: During an observation on 12/27/23 at 12:59 p.m., Resident F was lying in bed with the head of the bed elevated, positioned on his back, unclothed. His eyes were open and he was picking at his incontinent brief with his right hand. His legs were making small movements against the sheets of the bed. During an observation on 12/27/23 at 4:00 p.m., the resident was lying flat in bed, positioned on his back with a hospital gown draped over his right arm. His head was back, his mouth was open, and he was grimacing. He was making small movements with his right arm. During an observation on 12/28/23 at 11:50 a.m., accompanied by QMA 2, Resident F was observed lying flat in bed, positioned on his back with a positioning wedge lying next to his left side. His eyes and mouth were open. The resident lacked verbal response when spoken to, but made eye contact. QMA 2 moved the resident to his right side to place the wedge beneath his left side. The resident began moving his right arm and bilateral legs and grimacing. QMA 2 indicated he had declined in the past week and a half. He previously was walking about the hallways, eating in the dining room, and talking. He indicated it was difficult to dress and turn the resident for incontinent care because of the pain in his left shoulder and arm. He had reported the resident's pain to the nurses. Resident F's clinical record was reviewed on 12/27/23 at 10:07 a.m. Diagnoses included Alzheimer's disease, Parkinson's disease, psychotic disorder with hallucinations, anxiety disorder, and depression. An admission Minimum Data Set (MDS) assessment, dated 9/25/23, indicated the resident had severe cognitive impairment, clear speech, and was usually understood and could understand others. He required limited assistance of one staff member for bed mobility, transfer, toileting and hygiene. He required supervision for walking, dressing and eating, and was steady when moving from a seated position to standing, walking and turning his body. Resident F's comprehensive care plan, revised on 10/2/23, indicated he had chronic conditions with risk for discomfort, complications, or decline. Interventions included assess for verbal and non-verbal signs and symptoms relating to pain: grimacing, guarding, crying, moaning, increased anxiety. Medications were to be given per physician order, and staff were to monitor for increased weakness or unsteadiness. A nursing progress note, dated 12/16/23 at 10:50 a.m., indicated the resident had been complaining of pain in his left shoulder and left hip. The physician ordered X-rays of both locations on 12/16/23. An Interdisciplinary Team (IDT) note, dated 12/16/23 at 11:00 a.m., indicated the resident had fallen on 12/13/23 and placed himself on the floor on 12/15/23. He had complained of pain to his left shoulder and left hip on 12/16/23. A nursing progress note, dated 12/16/23 at 5:06 p.m., indicated the X-ray obtained of the resident's left shoulder showed a dislocation and a displaced, comminuted fracture of the humeral head. The resident was sent to the hospital emergency room for treatment. The resident's current physician's orders included acetaminophen (to treat pain) 650 mg (milligram), one tablet every four hours as needed for general discomfort (12/20/23) and perform a pain assessment every shift for pain management (9/21/23). Resident F's electronic Medication Administration Record (eMAR) for December 2023, indicated the following: Acetaminophen was administered on 12/20/23 at 10:34 p.m., 12/21/23 at 7:59 p.m., 12/22/23 at 6:09 a.m., and 12/25/23 at 8:16 a.m. The outcome for each administration was indicated as effective. Review of the December 2023 eMAR pain level assessment orders indicated the following: There was no morning pain assessment completed for 12/5/23, 12/11/23, 12/12/23, 12/17/23, 12/19/23, 12/21/23, 12/26/23 and 12/27/23. There was no evening pain assessment completed for 12/8/23, 12/12/23, 12/13/23, 12/17/23, and 12/25/23. The clinical record indicated pain levels for the resident were documented under the vitals section and included the following: a pain rating of seven on 12/27/23 at 7:00 a.m., a rating of five on 12/26/23 at 7:17 a.m., a rating of seven on 12/21/23 at 10:07 a.m., and a rating of four on 12/15/23, 12/16/23, and 12/17/23. The record lacked indication of interventions being offered for pain relief. During an interview on 12/28/23 at 10:27 a.m., the DON indicated the resident was in pain. They had attempted to weigh him this morning, but he was moaning. She felt his pain may be why he had not gotten out of bed and was recently spitting out his medications. He did have acetaminophen ordered for pain, but the staff had not been providing doses. The documentation of pain ratings should be completed with a numerical value and should be completed each shift. During a phone interview on 12/28/23 at 10:42 a.m., CNA 3 indicated the resident had a drastic change in the last couple weeks. He had previously been walking around and talking. The resident had not been the type to lay around in bed all the time and she felt he was having pain. A current facility policy, revised 11/22, titled, Pain Management Program, provided by the DON on 12/28/23 at 1:35 p.m., indicated the following: .Purpose: To establish a program which can effectively manage pain to remove adverse physiologic and physiological effects of unrelieved pain and to develop an optimal pain management plan to enhance healing and promote physiological and psychological wellness Definition: .When the resident is unable to describe pain, physical signs such as grimacing, body posturing/protecting, vital sign changes, and changes in behavior and mood will be used to determine the present {SIC} of pain The pain management components: Documentation of pain assessment and monitoring .Assessment of non-verbal residents for signs and symptoms of pain .Standard: 1. Pain assessment protocol will be initiated under any of the following situations: a. Any indication of pain based on the pain assessment performed for each resident at the time of admission and with any condition change and/or incident associated with the potential of pain d. A change in resident condition occurs to require pain control This citation relates to complaint IN00424249. 3.1-37(a)

B1. During an observation on 3/14/22 at 11:06 a.m., Resident D was seated in her wheelchair and positioned in the doorway of her room on the 400 unit playing bingo. She was noted with excessive edema on her bilateral lower extremities and a dressing noted to her right lower leg. No wraps were in place during the observation. During an observation on 3/15/22 at 9:15 a.m., Resident D sat in her recliner with her bilateral lower extremities wrapped with excessive edema. Her legs were not elevated during the observation. During an observation on 3/17/22 at 12:19 p.m., Resident D sat in her recliner in her room with ace wraps on her edematous bilateral lower extremities. Her oxygen was on via nasal canula and her legs were not elevated during the observation. During an observation on 3/18/22 at 2:30 p.m., the resident sat in her wheelchair in her room. Her bilateral lower extremities were wrapped and remained with excessive edema. The right ace wraps was wet on the lower leg near the ankle and her legs were not elevated. Resident D's clinical record review was completed on 3/22/22 at 10:47 a.m. Diagnoses included, but were not limited to the following: cellulitis of right lower limb, morbid obesity due to excess calories, and lymphedema, not elsewhere classified. The clinical record lacked an order for daily weights. Medications included but were not limited to the following: Metolazone (diuretic) 5 milligram by mouth one time a day every 3 days related to cellulitis of right lower limb. The order started on 3/17/22 and completed on 3/19/22. There was a discrepancy with the frequency when compared to the provider progress note. Review of a Nurse Practitioner's progress note, dated 3/16/22, indicated the resident had returned from the emergency room with complaints of increased edema in her bilateral legs with increased weeping in the right leg. Physical exam indicated 3 + edema in the left ankle and foot and 4+ edema in the right ankle and foot. The documented plan indicated to add metolazone for 5 days due to increased edema and discomfort and daily weights related to fluid overload. Documentation indicated the plan was communicated with facility staff and placed in the charts on 3/16/22. An active order, dated 3/10/22, indicated monthly weights and vitals were ordered. Review of the electronic Medication Administration Record, dated March 2022, indicated the Metolazone order was completed with only one dose administered. Review of documented weights indicated the last weight was obtained on 3/1/22. A care plan for activities of daily living, revised 6/8/21, indicated indicated the resident required assistance with activities of daily living related to physical limitation, weakness, decreased mobility, schizophrenia, and chronic obstructive pulmonary disease. Interventions included, but were not limited to, resident required assistance of 1 staff member for toileting, transfers, bed mobility, and locomotion in the manual wheelchair for long distances. A care plan for cardiac, initiated 3/16/2022, indicated the resident was at risk for cardiac issues related to hypertension, atherosclerosis and peripheral vascular disease. Interventions included, but were not limited to the following: weights per policy and notify provider of significant losses or gains; observe for edema, weight gain, and adventitious lungs sounds and report to provider as needed. A care plan for diuretic, initiated 3/16/22, indicated the resident is at risk for adverse effects related to daily diuretic use. Interventions included, but were not limited to, administer diuretic medications as ordered. A Nurse's Note, dated 3/19/22 at 11:29 p.m., indicated the resident received pain medication as a result of reported leg pain. A Nurse's Noted, dated 3/20/22 at 3:44 a.m., indicated the residents legs continued to drain clear fluid and the resident was administered pain medication due to her screaming and yelling about her leg. A Nurse's Note, dated 3/20/22 at 8:39 p.m., indicated the resident complained of leg pain and received pain medication. A Nurse's Note, dated 3/21/22 at 5:44 a.m., indicated the resident complained of pain and burning to her right lower leg. The resident continued with serous drainage from the right leg. During an observation on 3/22/22 at 2:00 p.m., Resident D sat in her wheelchair in the hallway across from the nursing office with continued excessive edema noted in her bilateral lower extremities. Her oxygen was on via nasal canula. During an interview on 3/22/22 at 2:13 p.m., Licensed Practical Nurse (LPN 15) indicated all residents with daily weights show up in the electronic Medication Administration Record where the Nurse is alerted when the daily weight is required. She indicated the nurse is required to ensure daily weights are obtained and documented. During an interview on 3/22/22 at 2:18 p.m., LPN 12 indicated she was assigned to the 400 unit on this date and none of the resident on this unit required daily weights. She indicated an order would be in the resident's chart if they required daily weights. During an interview on 3/22/22 at 2:33 p.m., LPN 12 indicated Resident D had significant edema noted in her bilateral lower extremities. LPN 12 indicated the electronic clinical record lacked an order for daily weights and still had an active order for monthly weights. She indicated there was a discrepancy in the orders noted on the provider progress noted from 3/16/22 and daily weights had not been obtained according to the providers written order in the progress note. During an interview on 3/22/22 at 2:53 p.m., LPN 4 indicated daily weights were not obtained as ordered by the provider on 3/16/22 and the order was not updated for weights. During an interview on 3/22/22 at 4:15 p.m., LPN 4 indicated there was a discrepancy between the order entered in the the electronic Medication Administration Record for Metolozone (diuretic for edema) and the plan indicated in the Nurse Practitioner's progress note dated 3/16/22. She indicated the discrepancy should have been recognized during the 24 hour report meeting between the unit managers and clarified with the Nurse Practitioner immediately. She was uncertain how this was missed. A current policy, titled Weights, provided by LPN 4 on 3/22/22 at 4:44 p.m., indicated the following: GUIDELINES: Resident should be routinely weighed on the same type of scale . The scale should be tested to ensure it is in calibration as required 2. Resident identified as .risk may be weighed weekly or . per physician order . 7. Weekly weight may be discontinued ., as determined by the . Physician A policy, dated 1/1/14, titled CHANGE IN CONDITION PHYSICIAN NOTIFICATION/PHYSICIAN ORDERS/OVERVIEW GUIDELINES, provided by LPN 4 on 3/22/22 at 4:44 p.m., indicated the following: .All significant changes in resident status are thoroughly assessed and physician notification is based on assessment findings and is to be documented in the medical record. 2. Medical care problems are communicated to the attending physician in a timely, concise, and thorough manner NURSE RESPONSIBILITIES . The nurse should not hesitate to contact the attending physician at any time for a problem which in his or her judgement requires immediate medical intervention NURSING DOCUMENTATION . A. Any calls to or from physician will be documented in the nurse's notes indicating information conveyed and received. B. All orders taken from the physician or his/her office, the Physician's Assistant or Nurse Practitioner. C. The nurse receiving telephone verbal orders should write it on the 24 Hour Report. D. Acute and subacute problems are to be communicated shift-to-shift by verbal report and highlighting or discussing the problems listed on the 24 Hour Shift Report to facilitate communication and Quality Assessment and Improvement follow-up This Federal tag relates to complaint IN00371487. 3.1-37(a) Based on record review and interview, the facility failed to transfer a resident to the hospital for care following resident representative's request and physical decline resulting in resident diagnosis of sepsis for 1 of 4 closed records reviewed. (Resident B) This deficient practice resulted in Resident B being hospitalized for sepsis (blood poisoning). The facility also failed to provide care and treatment for a resident with edema for 1 of 1 residents reviewed for daily weights. (Resident D) Findings include: 1. During a phone interview on 3/15/22 at 1:19 p.m., the resident's family member indicated the resident was admitted to the facility following a hospitalization after a stroke and COVID-19 infection. He had a catheter and in the past was susceptible to urinary tract infections in the past. The family member was concerned when a change in the resident's condition was noticed upon viewing a video taken. After viewing the video, she requested the resident be sent to the hospital on 1/20/22. The facility refused to send him to the hospital. The facility indicated they would obtain a urine sample to be tested. The family member indicated she knew something was wrong and wanted the resident evaluated in the emergency department, but the staff refused. During a phone interview on 3/17/22 at 10:00 a.m., another family member they indicated his mother was the decision maker and resident representative. He knew that the family member from the previous interview had requested the resident be sent to the emergency room because of his worsening condition at the nursing facility. The family was concerned due to his history of frequent urinary tract infections. The family had been having difficulty getting information about his previous medical tests and X-rays. This family member felt the facility was not addressing the families concerns regarding the resident's decline. He had not requestedthe resident be sent to the emergency room, but was aware the family member from the previous interview and another family member had requested this several times. The staff had continually indicated to family that the resident was comfortable and being cared for without providing details regarding his care. The resident's admission Packet, dated 1/8/22, indicated the resident's spouse as resident representative The spouse had signed on behalf of the resident on all admission documentation. The clinical record for Resident B was reviewed on 3/15/22 at 1:31 p.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), acute respiratory failure, COVID-19, Alzheimer's disease, chronic heart failure, and cognitive communication deficit. An admission Minimum Data Set (MDS) assessment, dated 1/14/22, indicated the resident had severe cognitive impairment, required extensive assistance of staff for activities of daily living, required supplemental oxygen, had an indwelling catheter, and required a feeding tube for nourishment. A nursing note, dated 1/9/22 at 8:23 a.m., indicated the resident had arrived to the facility with an order for Macrobid for UTI (urinary tract infection). The note indicated the resident was allergic to Macrobid and the on call physician service was notified and the facility was awaiting clarification from the provider. A provider message system record was provided by the Administrator on 3/18/22 at 10:58 a.m., and included, but was not limited to, an undated message from the facility staff with the following message timed 1:55 p.m.: On (Resident B), please contact wife. The family is concerned that he does not have an antibiotic for UTI and pneumonia. I have asked for an antibiotic for him twice but it gets denied. Please call and explain to this family why he is not getting an antibiotic. Thank you. A reply was received at 3:07 p.m., from the nurse practitioner indicating he had talked to the spouse regarding appropriate use of antibiotics. She understands. A nursing note, dated 1/20/22 at 3:54 p.m., entered by LPN 6, indicated the following: This writer received request from staff to call pt's wife, who wants him sent to the hospital. Pt {patient} examined by this writer and found him to be resting comfortably and in no distress. Vitals are stable as noted: B/P {blood pressure} 121/54, T {temperature} 98.2, P [pulse] 82, R [respirations] 18, O2 [oxygen saturation] 95% on room air. Lungs are clear and equal bilaterally there is a wet cough noted. Abd [abdomen] soft and non-tender w/[with] positive bowel sounds in all quadrants Foley catheter patent and draining clear, yellow fluid with scant amount of mucous thread. Pt's rash on his face is much improved and he has been shaved this shift. Wounds are treated per orders and are improving. Reported all the above to DON [Director of Nursing] and MD [Medical Doctor] on call. Received order from MD to keep pt in facility as there is no medical reason to send him out. Reported all the above to pt's wife. Pt's wife stated 'but I just feel like he's going down, and I watched the video my son took of him, he looks awful, and he sounds like he has a death rattle.' This writer attempted to reassure the wife that he was safe and improving and that he does have a cough, but that it was not a death rattle. This writer also reported to the wife the MD's order that the pt had no medical reason to go to the hospital. The wife then accused this writer of lying about pt's symptoms and wanting to keep him to make the facility money. This writer again tried to reassure the wife that he was stable and improving, that this writer was not lying, and that he did not need to go to the hospital. The wife then said 'this is not over!' and hung up the phone. Reported all the above to DON. A physician's order, dated 1/20/22, indicated a urine sample was to be collected for culture to rule out a urinary tract infection. The clinical record indicated the urine sample was collected on 1/21/22 at 3:45 p.m. A lab result for urinalysis, dated 1/24/22 at 12:02 p.m., indicated a positive result for a urinary tract infection. During an interview on 3/22/22 at 4:35 p.m., LPN 3 indicated the result from 1/24/22 was the only result received from the laboratory and he had no information of a preliminary result being received at the facility. He had checked the lab portal and the electronic health record and was unable to locate a preliminary urinalysis report. A change of condition progress note, dated 1/25/22 at 7:21 p.m., indicated the resident had an altered level of consciousness, shortness of breath, labored breathing, cough, abnormal lung sounds, and decreased urine output. A nursing progress note, dated 1/25/22 at 9:05 p.m., indicated an order was received from the provider to send the resident to the hospital for evaluation and treatment of the urinary tract infection. Review of hospital clinical documentation, dated 1/25/22 at 9:53 p.m., included, but was not limited to: Patient here from extended care facility for urinary tract infection and pneumonia. Family stated patient's condition had been deteriorating and they wanted him to be evaluated at the emergency department. Patient arrived at the emergency department with fever and wet cough. Family just aware of urine results today and he had been started on clindamycin for his pneumonia on 1/20/22. The clinical impression was indicated as sepsis and urinary tract infection. Patient was treated in the emergency room with intravenous (IV) fluids, IV Rocephin (an antibiotic), and IV Azithromycin (an antibiotic). The resident was admitted to the hospital for continued inpatient management for urinary tract infection with sepsis. During an interview on 3/18/22 at 10:35 a.m., the Administrator indicated the resident's spouse got very excited and the staff had worked with the resident's children to help mom. The spouse had seen the video the son had taken and she asked for the resident to be sent out emergency room. The physician felt it would be worse for the resident to go out to the hospital due to COVID-19. He indicated the facility had listed the son as the responsible party with the facility and the spouse the emergency contact. An emergency contact can request resident to be sent to the emergency room, but ultimately, given the circumstances with her difficulty with the transition of her husband's condition, the responsible party would be the decision maker. The facility did not have a physician's order to send the resident to the emergency room and the resident had been evaluated by a provider on 1/19/22, 1/20/22, and again on 1/21/22. A document titled, Resident Rights, revised 2/19/21, provided by the Administrator on 3/17/22 at 12:08 p.m., included, but was not limited to, the following: Residents' Rights .B. Residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Resident's have the right to exercise their rights as a resident of the facility and as a citizen or resident of the United States. 3.1(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure proper indwelling urinary catheter care was provided on each shift, to prevent infection in a resident dependent for activities of daily living, for 1 of 3 residents reviewed for urinary tract infections. (Resident C) This deficiency resulted in a hospitalization of Resident C for a urinary tract infection with sepsis. Findings include: During an interview at the time of observation on 3/14/22 at 3:51 p.m., Resident C indicated he was dependent on staff to provide catheter care and other activities of daily living due to his immobility. He indicated he required a continuous urinary catheter and staff typically cleaned his catheter insertion site a couple of times each week. He indicated staff have never cleaned his urinary catheter insertion site every shift. Resident C indicated he had a recent hospitalization that lasted one week for a urinary tract infection and he remained on intravenous antibiotic therapy for treatment. A double lumen Peripherally Inserted Central Catheter (PICC) line was observed in the resident's upper right arm. Resident C indicated he had a suprapubic catheter prior to his hospitalization and it was removed during his hospitalization and a Foley catheter was anchored prior to readmission to the facility on 3/6/22. During an observation on 3/14/22 at 4:12 p.m., Resident C's urinary catheter drainage bag was hung on his bed frame and contained 500 milliliters of clear yellow urine. During an observation on 3/17/22 at 12:22 p.m., the resident was observed in bed watching television with the urinary catheter collection bag hung on the resident's bed frame. Clear yellow urine was noted in the urinary collection bag and tubing. During an observation on 3/17/22 at 12:41 p.m., a staff member was at the bedside of Resident C and fed him his meal. Resident C's clinical record was reviewed on 3/18/22 at 3:31 p.m. Diagnoses included, but were not limited to the following: quadriplegia unspecified, neuromuscular dysfunction of bladder, unspecified and urinary tract infection, site not specified. The clinical record lacked an active order for Foley catheter care. An order started on 12/28/21 and discontinued on 2/27/22 was as follows: Suprapubic catheter: 22 French, 10 milliliter balloon to gravity drainage. A quarterly Minimum Data Set, dated [DATE], indicated Resident C did not exhibit any rejection of care behaviors and he required total dependence of staff members for transfers, toileting, personal hygiene, and bathing. He required extensive physical assistance of 2 staff members for bed mobility, had an indwelling catheter and always had bowel incontinence. A care plan for activities of daily living, revised on 2/17/21, indicated the resident required assistance with activities of daily living related to quadriplegia. Interventions included, but were not limited to, dependence on 2 staff members for toileting, bathing and bed mobility. A care plan for antibiotic therapy, initiated 3/7/22, indicated the resident required antibiotic therapy related to infection. Interventions included, but were not limited to, administer antibiotic medication as ordered by the physician. A care plan for incontinence, revised on 3/11/21, indicated the resident was incontinent of bowel, had an indwelling catheter, and at risk for complications due to incontinence, need for assistance, urinary retention and frequent urinary tract infections. Interventions included, but were not limited to the following: observe, document and notify the Medical Doctor as needed for signs and symptoms of urinary tract infections such as fever, dysuria, hematuria or foul smelling urine. A care plan for indwelling catheter, revised 3/14/222, indicated the resident required an indwelling catheter related to neurogenic bladder. Interventions included, but were not limited to the following: provide catheter care and empty catheter every shift and as needed and keep Foley catheter anchored to thigh for security and to prevent trauma. Medications included, but were not limited to the following: Invanz Solution reconstituted 1 gram (antibiotic) daily intravenously for 9 days for sepsis and was dated 3/7/22. Orders included, but were not limited to the following: a. Cleanse suprapubic catheter with soap and water, dry, apply barrier cream and then apply a split gauze two times a day and as needed. This order originated on 12/28/21 and discontinued on 1/27/22. Review of the electronic Medication Administration Record and Treatment Administration Record from 1/1/22 to 1/31/22 lacked documentation of the suprapubic catheter care as ordered on the following dates: 1/3/22, 1/9/22, 1/14/22, 1/16/22, 1/19/22 and 1/24/22. b. Cleanse suprapubic catheter with normal saline, apply calcium alginate, split gauze and change daily and as needed for wound to suprapubic site. This order originated on 1/27/22 and discontinued on 2/27/22. Review of the electronic Medication Administration Record and Treatment Administration Record from 1/1/22 to 2/28/22 lacked documentation of the suprapubic catheter care as ordered on the following dates: 1/30/22, 2/22/22 and 2/24/22. c. Foley catheter: 16 French, 10 milliliter balloon to gravity drainage. This order originated on 3/14/22. A Nurse's Note, dated 2/27/22 at 9:19 a.m., indicated the resident was sent to the emergency room for evaluation and treatment due to the resident's request and a change in condition. The resident had an elevated temperature, hematuria noted in indwelling urinary drainage bag, output noted in brief, shaking, and bilateral upper and lower extremity edema. A Nurse's Note, dated 2/27/22 at 12:58 p.m., indicated Resident C was admitted to the hospital with a urinary tract infection and sepsis. Review of Resident C's hospitalization Patient Summary Report and Discharge Instructions, indicated Resident C admitted to the hospital on [DATE] with a diagnosis of urinary tract infection and sepsis. His temperature was initially 103 degrees, pulse was 122, lactic acid 5.2 and a white blood cell count of 25.2 . His suprapubic urinary catheter was removed and a Foley catheter was placed. The urine culture was positive for Escherichia coli. Resident C was discharge back to the skilled nursing facility on 3/6/22 with a PICC line and intravenous antibiotic orders for sepsis. A Nurse's Note, dated 3/6/22 at 4:21 p.m., indicated the resident returned to the facility at this time after an acute hospitalization related to a urinary tract infection with sepsis. A PICC line was noted in the right upper extremity for continued intravenous antibiotic therapy. An anchored Foley catheter was placed at the hospital. Review of a Nurse Practitioner's note, dated 3/8/22 indicated the resident recently returned from the hospital with treatment for urinary tract infection with sepsis. Review of a Nurse's Note, dated 3/8/22 at 2:43 p.m., indicated the resident continued with a Foley catheter and intravenous antibiotic therapy. Review of a Nurse's Note, dated 3/13/22 at 5:22 a.m., indicated Resident C continued with a Foley catheter and intravenous antibiotic therapy. Review of the electronic Medication Administration Record and Treatment Administration Record for the month of March 2022 lacked an order or documentation of Foley catheter care. Review of the point of care catheter documentation, completed by the Certified Nurse's Aides for the month of March 2022 and provided by Licensed Practical Nurse on 3/21/22 at 4:46 p.m., lacked catheter care documentation for every shift on the following dates: 3/7/22, 3/8/22, 3/10/22, 3/11/22, 3/12/22, 3/14/22, 3/15/22, 3/16/22, 3/17/22, 3/19/22 and 3/20/22. During an interview at the time of observation on 3/21/22 at 1:23 p.m., Resident C indicated no one had performed urinary catheter care on this date and he consented to a urinary catheter care observation. The resident was in his bed slightly turned to his left side. The indwelling catheter drainage bag was not attached to the bed frame or visible during the observation. During an interview on 3/21/22 at 1:32 p.m., Certified Nurse's Aide (CNA) 13 indicated the CNA's documented all of their urinary catheter care in the electronic point of care charting. During an interview and observation on 3/21/22 at 1:42 p.m., Licensed Practical Nurse (LPN) 14 indicated catheter care orders were in the electronic medical record for residents that had urinary catheters. She indicated residents with urinary catheters were expected to have an order for catheter care and the Nurses had to sign off to ensure that catheter care had been completed as ordered. She was unable to find an active order for catheter care in Resident C's clinical record and indicated as a result, the electronic Medication Administration Record lacked an area to sign them off. She indicated Resident C had a recent hospitalization for a urinary tract infection with sepsis so she was unsure why his electronic medical record lacked an order for urinary catheter care. LPN 14 indicated CNA's were able to complete the Foley catheter care and Nurses were required to oversee urinary catheter care had been done and was charted in the electronic medical record . She indicated the suprapubic urinary catheter care was completed and documented only by the nurses since CNA's were not qualified for suprapubic catheter care. During an observation on 3/21/22 at 1:55 p.m., upon entry to Resident C's room an unknown staff member emptied the resident's urinary catheter drainage bag and then hung it on the frame of the bed once it was emptied. During an interview at the time of observation on 3/21/22 at 1:59 p.m., urinary catheter care was completed for Resident C in his bed by CNA 13 and LPN 14. During the observation, CNA 13 performed hand hygiene, donned gloves, asked the resident for consent to perform urinary catheter care, pulled the resident's linens and unsoiled brief away from the resident's body, then used a disposable personal cleansing cloth and wiped the catheter tubing from the catheter insertion site and moved in a motion away from the body. She immediately repeated the same motion with the same soiled cloth 2 more times with the same disposable personal cleansing cloth. During an interview with CNA 13 at the time of the catheter care observation, she indicated she always used the disposable personal cleansing cloths on the residents' urinary catheter tubing in this manner before she continued the urinary catheter care with soap and water. CNA 13 used a clean cloth with soap and water and cleaned at the insertion site and moved outward from the insertion site then followed with the same motion using a clean rinse cloth and dried in the same motion with a towel. A catheter securement device was not secured to the resident's leg nor applied during the observation. The resident's previously worn unsoiled brief was placed back on the resident prior to leaving the resident's bedside. During the catheter care observation, Resident C held a conversation with LPN 14 who stood at the bedside during catheter care and indicated he had some questions he would like answered by LPN 4 and requested LPN 14 to communicate that information with LPN 4 when the urinary catheter observation was completed. During an interview on 3/21/22 at 2:07 p.m., following catheter care, Resident C indicated, That was the first time catheter care was perform like that since I returned to the facility from my recent hospitalization. He indicated he wanted to speak with LPN 4 about the frequency in which the staff should have provided the urinary catheter care like he received during the observation because staff have not been doing it like that. During an interview at the time of observation on 3/21/22 at 2:15 p.m., LPN 4 indicated indwelling urinary catheter care should have been performed each shift. She indicated an order for indwelling urinary catheter care should have been in Resident C's chart and must have been missed when he returned from his recent hospital stay. She indicated Resident C had a recent diagnosis of urinary tract infection with sepsis with his recent hospitalization. She indicated urinary catheter care was an important component of infection prevention in residents with an indwelling urinary catheter. LPN 4 indicated the resident had a suprapubic catheter prior to his discharged to the hospital on 2/27/22. He returned to the facility on 3/6/22 with a Foley catheter from his hospitalization. Upon review of the electronic Medication Administration Record and Treatment Administration Record along with LPN 4, she indicated suprapubic catheter care was not documented as ordered prior to the resident's hospitalization and she did not have a way to ensure the tasks were completed without the documentation. LPN 4 indicated Nurses and Unit Managers were responsible to ensure indwelling catheter care was completed and documented in the residents electronic medical record. During an interview on 3/21/22 at 2:35 p.m., LPN 4 indicated the resident's physician orders for urinary catheter care should have been followed. During an interview on 3/21/22 at 4:00 p.m., LPN 4 indicated Resident C was dependent on staff for activities of daily living. During an interview at the time of observation of the electronic Medication Administration Record and the Treatment Administration Record along with LPN 4 on 3/21/22 at 4:20 p.m., she indicated she could not see documentation of indwelling urinary catheter care completed for Resident C on all shifts since he returned to the facility on 3/6/22. During an interview on 3/22/22 at 9:44 a.m., Resident C indicated the difference in catheter care during the observation on 3/21/22 was that they actually cleaned the catheter at the insertion site. He indicated. The staff usually do not touch my penis and scrub the catheter where it goes into my body. Instead, they usually clean around my penis and avoid where it enters my body. He indicated when he spoke with LPN 4 on 3/21/22, she indicated staff were supposed to provide urinary catheter care every shift. He indicated he only received urinary catheter care 1 time on 3/21/22 and he felt it was done due to the requested urinary catheter care observation and as a result of the survey process because no additional catheter care was provided on second shift or night shift. An undated policy, titled Policy for Suprapubic Catheter Care, provided by the Executive Director on 3/22/22 at 11:45 a.m., indicated the following: It is the policy of this facility that all resident with suprapubic catheters will receive catheter care at the site of insertion at least daily to prevent irritation and possible infection. Procedure for Suprapubic Catheter Care .Gently cleanse abdominal insertion site and catheter with warm, soapy water in concentric circles working down the tube away from the insertion site. Rinse in the same manner and dry gently. Remove gloves and wash hands or use alcohol-based hand rub. Apply clean gloves. Apply clean dressing as ordered and secure with tape as needed Document care given and observation about the condition of insertion site A current policy, titled Policy for Foley Catheter Care, provided by LPN 4 on 3/21/22 at 4:46 p.m., indicated the following: It is the policy of this facility that residents will be provided with catheter care twice daily and as needed as soiling occurs. It will include a thorough cleansing of the perineal and catheter-meatal areas using soap and water . Procedure for Foley Catheter Care .The catheter-meatal junction is a significant portal of entry for bacteria in to the urinary tract, potentially causing urinary tract infections. Therefore, it is most important that the perineum, catheter-meatal junction, and tubing be kept clean and free from fecal contamination This Federal tag relates to complaint IN00371487 3.4-41(a)(2)