Based on observation, interview, and record review, the facility failed to ensure a resident's bed was fully assembled which resulted in the resident having a fall from the bed and sustaining a hip fracture for 1 of 3 residents reviewed for accidents. (Resident B) The isolated actual harm deficient practice began on January 10, 2023 when the facility failed to ensure a resident's bed was fully assembled. The deficient practice was corrected on January 12, 2023, prior to the start of the survey, and was therefore Past Noncompliance. Findings include: Resident B's clinical records were reviewed on January 19, 2023 at 9:55 a.m. Diagnoses included, but were not limited to cancer, coronary artery disease, heart failure, hypertension, diabetes mellitus, thyroid disorder, and seizure disorder. The admission Minimum Data Set (MDS) assessment, dated January 04, 2023, indicated Resident B was cognitively intact. When communicating she was able to understand others with clear comprehension. She could independently walk, with a walker, in her room with staff's supervision. She had fallen at home prior to her admission. A Fall Risk Review (non-dated, identified by the Director of Nursing as completed upon admission) indicated identified fall risks that included, but were not limited to a history of falls prior to admission within the past month, falls within the past two to six months and had an unsteady gait (unsteady when walking). The review indicated the resident was a moderate risk for falls. A Care plan, with start date January 09, 2023, indicated Resident B was at risk for falling related to history of falls prior to admission. The care plan goal, dated through April 09, 2023, indicated Resident B would remain free of falls with major injury. Care approaches staff would implement to achieve the established goal indicated: January 09, 2023 start date: -Therapy would evaluate and treat as needed. -Staff to assist with transfers as needed. -Provide non-skid footwear. -Keep personal items and frequently used items within reach. -Keep call light within reach. -Ensure the floor was free of liquids and foreign objects. -Encourage resident to assume standing position slowly. January 10, 2023 start date: -Bed frame changed. Resident B's progress notes indicated: January 02, 2023 at 5:33 p.m., Resident was able to walk with a walker and stand by assistance. Resident would use a wheelchair for long distance. January 03, 2023 at 9:45 a.m., Physician Admit Note. Patient admitted for rehab following seizure and subdural hematoma [brain injury with bleeding]. Patient unsteady . January 06, 2023 at 2:51 a.m., Resident ambulated with a walker and unsteady gait. January 10, 2023 at 8:45 a.m., Writer called to room and notified that resident had a fall. Resident had complaints of left hip pain. N.O. [new order] received for left hip/pelvis x-ray January 11, 2023 at 5:27 p.m., IDT Review [review committee] - Resident noted with fall in her room. Resident stated she was standing up with walker and went to sit down on the end of the bed and slid off on to the floor Resident B's left hip X-ray, dated January 10, 2023, indicated an intertrochanteric left femoral fracture (type of hip fracture). Resident B's discharge hospital notes, dated January 15, 2023, indicated, .she sustained a fall in her room at [nursing home] Her fall appeared to be mechanical in nature [attribute fall to extrinsic factors in the environment]. She was found to have a left hip fracture and was admitted to Orthopedic surgery service for management During the interview, on January 19, 2023 at 10:45 a.m., Employee 13 indicated on the morning of January 10, 2023 she entered Resident B's room and observed her to be on the floor at the foot end of her bed. The mattress had slid off the bed and was hanging off the foot end of the bed. No foot board was on the bed and the two bottom corner mattress guards, that would secure the mattress in place, were gone. Employee 13 then alerted Employee 7 of the fall. During the interview, on January 19, 2023 at 10:25 a.m., Employee 7 indicated on the morning of January 10, 2023 Employee 13 reported Resident B had fallen in her room. Employee 7 went to Resident B's room and observed the resident to be on the floor at the foot end of the bed. No foot board was on the bed and the two bottom corner mattress guards, that would secure the mattress in place, were gone. The mattress was observed to have slid down from the top of the bed and hung over the foot end of the bed drooping towards the floor. Resident B had reported she went to sit down and the bed moved on me. Employee 7 checked the bed frame wheels and the wheels had been in the locked position and the bed had not moved, only the mattress had. On January 19, 2023 at 1:10 p.m., Resident B's roommate (identified from resident room census dated January 10, 2023) was interviewed. During the interview, the roommate indicated Resident B's bed foot board had been removed prior to her being admitted . The roommate pointed out two resident closets and a chest of drawers on the right side of the room when walking into the room. The roommate had not been able to freely maneuver her wheelchair between the chest and closets and previous roommates (prior to Resident B) bed on the left side of the room. Staff had come to the room and removed the foot board to allow her independent mobility. The roommate's clinical records were reviewed on January 19, 2023 at 1:00 p.m. The quarterly Minimum Data Set Assessment indicated the roommate was cognitively intact. On January 19, 2023 at 9:35 a.m., Resident B's family was interviewed. During the interview, the family indicated since Resident B's first day of admission through January 10, 2023, the foot board of her bed had been missing. The mattress had slide down and would need to be pulled up to be correctly positioned on the bed frame. Staff were aware of this issue, as staff had been observed to slide the mattress up from the bottom of the bed to correctly center it on the frame. During the interview, on January 19, 2023 at 11:15 a.m., the Administrator indicated Resident B's bed from January 10, 2023 had been removed and was no longer in use. A bed similar to the Resident B's bed was observed. During the observation, the Administrator pointed at the foot board of the bed and indicated the foot board had not been on the bed at the time of the fall. On the bed frame, at the corner foot ends were plastic cups that fit around the bottom corners of the mattress. The cups may have been missing, and not on the bed, at the time of the fall. On January 19, 2023 at 1:25 p.m. the Administrator provided a copy of Trilogy Service Standards (non-dated). The Administrator indicated the standards are utilized as a check list to ensure room readiness for each new resident. A review of the check list indicated a .Plant Operations . Furniture in good repair; Bed functions properly. The Past Noncompliance isolated actual harm deficient practice began on January 10, 2023. The deficient practice was removed corrected by January 12, 2023 after the facility implemented a systemic plan that included the following actions: -Resident B's bed was removed from service. -A facility wide bed audit was completed. -Staff were in-serviced on correct implementation of Trilogy Service Standards that included ensuring all furniture was in good repair and beds function properly. -Staff were in-serviced on correct implementation of immediately reporting and to whom of resident equipment in need of repair. -Administrative staff auditing resident beds weekly and monitoring of systemic plan. This Federal tag relates to Complaint IN00399133. 3.1-45(a)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure catheters (a tube inserted into the bladder to drain urine) were not inserted without a clinical justification resulting in actual harm when a resident had multiple urinary tract infections (UTI) and 2 hospital transfers for UTI's (Resident 22) and catheter tubing and bags were not in direct contact with the floor (Residents 22 and 19) for 2 of 3 residents reviewed for catheters and UTI's. Findings include: 1. During an interview, on 9/27/22 at 10:51 a.m., Resident 22 indicated she was not sure why she had a catheter, and wished she did not have it. She had severe bladder pain, and was not sure if she had been checked for a UTI. At the same time, the resident was observed up in her wheelchair in the lounge area, with the catheter bag partially inside a dignity bag (bag to cover up the urine drainage system to provide privacy). The dignity bag was dragging the floor. On 9/27/22 at 12:46 p.m., Resident 22 was observed up in her wheelchair, on the patio, with the Foley (a flexible tube inserted through the urethra into the bladder to drain urine) catheter bag dragging the floor. On 9/27/22 at 3:14 p.m., Resident 22 was observed up in her wheelchair, propelling herself down the hallway, and the Foley catheter tubing was touching the floor. The Foley catheter bag was partially inside the dignity bag, and the dignity bag was dragging the floor. Resident 22's record was reviewed on 9/28/22 at 11:37 a.m. An annual Minimum Data Set (MDS) assessment, dated 8/16/22, indicated the resident had a moderate cognitive impairment, an indwelling catheter, and required extensive assistance of 1 staff member for toilet use. Census information indicated the resident was admitted to the facility on [DATE]. An admission assessment, dated 10/8/19, indicated was continent of the bladder and did not have an indwelling catheter. A physician's order, dated 1/19/21, and discontinued 10/15/21, indicated Foley catheter 16 French (F) (size of catheter tubing) and 5 milliliter (ml) balloon. A progress note, dated 1/20/21, indicated the resident's hospice (specialized care for the terminally ill) nurse placed a Foley catheter the day before, 16 F and 5 ml balloon. The note lacked documentation of a clinical indication for the catheter or any indication the resident had urinary retention. A progress note, dated 1/21/21, indicated an Interdisciplinary Team (IDT) review of the Foley catheter placement for urinary retention. The note lacked documentation of the urinary retention or any other clinical indication for the catheter. A diagnosis, dated 1/21/21, indicated neuromuscular dysfunction of the bladder (lacking bladder control due to brain,, spinal cord, or nerve problems). The diagnosis lacked documentation of any supporting documentation. A physician's order, dated 10/23/21 and discontinued 9/13/22, indicated furosemide (a diuretic medication) 40 milligrams (mg) by mouth daily. A progress note, dated 10/24/22, indicated the resident no longer received hospice services. A physician's progress note, dated 12/21/21, indicated the resident urinated too much and wanted a catheter. The physician's assessment indicated incontinence and the plan was to discontinue torsemide (a diuretic) to see if it helped with urination and to possibly increase the oxybutynin at the next visit if no improvement. A re-admission nursing assessment, dated 3/5/22, indicated the resident did not have an indwelling catheter. A physician's progress note, dated 4/7/22, indicated the resident complained frequently of urination and leaking, and wanted to try something. The resident was on furosemide for chronic swelling of legs, still some edema (swelling), planned to try oxybutynin 10 mg every day. A physician's progress note, dated 5/5/22, indicated the resident was seen related to sore right upper quadrant of abdomen, complained of bloating, and gas. Physician's orders included, but were not limited to, discontinue oxybutynin to see if it helped gas. A progress note, dated 5/16/22, indicated the resident had a non-healing wound to the right inner groin, history of urinary incontinence, usual inability to know when incontinent, and increased moisture when up in wheelchair due to sweating and briefs (adult diaper). Physician ordered a Foley catheter be inserted through 5/30/22, and removed on 5/31/22, if improvements were noted. If none noted, the physician was to be updated for further direction. The note lacked documentation the resident had urinary retention or another diagnosis to support the insertion of a Foley catheter. A progress note, dated 5/16/22, indicated an 18 F, 30 ml balloon Foley catheter was inserted with sterile technique. The notes lacked documentation the resident had urinary retention or another diagnosis to support the insertion of a Foley catheter. A progress note, dated 5/16/22, indicated IDT review of Foley catheter, placement was to promote healing to inner groin from urine excoriation. The note lacked documentation the resident had urinary retention. A care plan, date initiated 5/19/22, indicated the resident had a Foley catheter for neurogenic bladder. Interventions included, but were not limited to, observe for signs or symptoms of UTI. A progress note, dated 5/21/22, indicated the Foley catheter, 18 F, 30 ml, was replaced using sterile technique due to occlusion. Cloudy urine with sediment was immediately returned. The note lacked documentation the resident had urinary retention or another diagnosis to support the insertion of a Foley catheter. Progress notes lacked documentation the Foley catheter was followed up on 5/30/22, as ordered by the physician. A progress note, dated 6/13/22, indicated the nurse attempted to flush the Foley catheter but was unsuccessful. The Foley catheter was repositioned, and flush attempted again, but was unsuccessful. The catheter was removed, and re-anchored with an 18 F and 30 ml balloon. Cloudy yellow urine was immediately returned. The note lacked documentation the resident had urinary retention or another diagnosis to support the insertion of a Foley catheter. A progress note, dated 6/18/22, indicated the resident had a yeast like odor to the vaginal area, and white discharge was noted. The physician was notified. A physician's order, dated 6/19/22, indicated Diflucan (a medication for fungal infections) 150 mg by mouth one time only for vaginal yeast infection. A progress note, dated 6/19/22, indicated the resident remained with a yeast like odor to the peri (groin) area. A Diflucan was administered that morning. A progress note, dated 7/6/22, indicated the physician was notified a urine chemical strip (detects changes in a person's urine such as potential infections) was performed with positive results. The resident complained of burning and discomfort. The resident's urine was noted with a strong, foul odor, and visible sediment. A sample was sent to the lab. A progress note, dated 7/7/22, indicated the resident was tearful the last evening and complained of urinary and back pain related to UTI. As needed pain medications were administered as ordered and a new order for pyridium (a urinary pain relief medication) was obtained. A progress note, dated 7/8/22, indicated the lab was unable to do a culture on the urine sample sent related to multiple organisms were present A recollection was indicated. The physician ordered the urine to be re-collected and sent to the lab for further work up. A progress note, dated 7/8/22, indicated a new urine sample was collected for lab pick up. A physician's order, dated 7/8/22, indicated Azo urinary pain relief (a medication to ease bladder pain) 99.5 mg by mouth 4 times a day as needed for urinary burning. A progress note, dated 7/10/22, indicated the resident had a fever earlier in the shift and had positive urinalysis results after recollection due to contamination. The physician was notified of the results and ordered Cipro (an antibiotic) 500 mg by mouth twice daily for 7 days. A physician's progress note, dated 7/11/22, indicated the resident was seen for multiple problems including, but not limited to, upset stomach and back pain. The resident was previously on hospice services, but was discharged when she had a fecal impaction. The assessment indicated the resident had a UTI, and the plan was to change the Cipro to Levaquin (an antibiotic) 500 mg by mouth for 10 days. A physician's order, dated 7/10/22 and discontinued on 7/11/22, indicated Cipro 500 mg by mouth twice daily for UTI. A physician's order, dated 7/12/22 and completed 7/22/22, indicated levofloxacin 500 mg daily. A progress note, dated 7/25/22, indicated the resident complained of bladder pain, and the catheter had a moderate amount of cloudy yellow urine. Water intake was encouraged and the resident was given an as needed Azo tablet. A progress note, dated 7/27/22, indicated the resident complained of generalized pain throughout the abdomen. The resident was not able to say exactly where the pain was, but responded when the area near the bladder was palpated. The resident had a functional Foley catheter. The physician was notified. A physician's progress note, dated 7/27/22, indicated the resident was seen related to complaints of right upper quadrant and epigastric (upper abdomen) pain and cried during the exam. The resident was not sure if she wanted to go to the emergency room, but eventually agreed to go. The resident had a Foley catheter for urinary retention. The note lacked documentation of when or how the urinary retention was diagnosed. A diagnosis, dated 7/27/22, indicated acute cystitis (infection of the bladder or lower urinary tract) without hematuria (blood in urine). Hospital records, dated 7/27/22, indicated the resident was treated for an acute UTI with cystitis, no hematuria. The resident was prescribed Macrobid (an antibiotic) 100 mg by mouth every 12 hours for 7 days. The resident present to the hospital with a Foley catheter, which was changed while she was there. A computed tomography (CT) scan (medical imaging technique used to obtain detailed internal images of the body) of the abdomen and pelvis was performed at the hospital and indicated the left ureter (thin tube between kidney and bladder) was dilated and no urethral calculus (stone) was noted. The dilation was possibly due to a recently passed stone. A progress note, dated 7/27/22, indicated the resident returned from the hospital, and Macrobid 100 mg twice daily for 7 days was ordered. A physician's order, dated 7/28/22 and completed 8/3/22, indicated Macrobid 100 mg by mouth twice daily for UTI. A physician's order, dated 7/30/22, indicated Foley catheter, indwelling urinary catheter size 18 F with 10 ml balloon for neuromuscular dysfunction of the bladder. A physician's progress note, dated 8/31/22, indicated the resident was seen related to complaints of bladder spasms, and had chronic Foley for neurogenic bladder and urine retention. The progress note lacked documentation the Foley catheter was actually inserted related to urine excoriation and any support for how the neurogenic bladder or urinary retention were diagnosed. The physician ordered oxybutynin 5 mg twice daily. A physician's order, dated 9/13/22, indicated oxybutynin 10 mg by mouth twice daily for bladder spasms. A physician's order, dated 9/13/22, indicated furosemide 40 mg by mouth twice daily for edema. A physician's progress note, dated 9/13/22, indicated the resident was seen related to complaints of bladder spasms and pain. The resident had a standard Foley catheter in place and increased swelling to the left leg. The physician ordered to increase the oxybutynin to 10 mg twice daily and increase Lasix to 40 mg twice daily. A progress note, dated 9/18/22, indicated the resident complained of abdominal pain at a 10 out of 10 on the pain scale despite medication being administered. The resident had watery stool, nausea and vomiting, and abdominal distention with a history of bowel obstructions. The resident was sent to the emergency room for evaluation and treatment. Hospital records, dated 9/18/22, indicated the resident was treated for an acute UTI with cystitis and hematuria. The resident complained of abdominal pain and was not sure when it started. The resident was prescribed Macrobid 100 mg by mouth every 12 hours for 7 days. A CT scan of the abdomen and pelvis was performed at the hospital and indicated the bladder was decompressed with a Foley catheter in place, and there were nonobstructing stones in the left kidney. Impressions of the CT scan included, but were not limited to, inflamed appearing urinary bladder with Foley catheter in place with possible cystitis, correlate with urinalysis (urine test to check for infection). A progress note, dated 9/19/22, indicated an IDT review of the hospitalization. The resident was sent to the hospital for abdominal pain and the resident returned from the emergency room with a diagnosis of UTI, to be treated with an antibiotic. The clinical record lacked documentation the resident was referred to a urologist (a physician who specializes in the urinary system) or any supporting documentation the resident had urinary retention. During an interview, on 9/29/22 at 9:39 a.m., the Director of Health Services (DHS) indicated the resident had a diagnosis of neuromuscular dysfunction of the bladder prior to the catheter insertion in May 2022. She was not sure why the catheter was inserted in May or what testing or clinical justification was found for the diagnosis. During an interview, on 9/29/22 at 10:48 a.m., the DHS indicated the Foley catheter was inserted in May 2022 for moisture associated skin breakdown, and this was not a normal reason a catheter would have been placed. She was not able to find any follow up was done for the catheter as per the physician's order, and the catheter was left in place. She reviewed the documentation from when the resident had a Foley catheter from January to October 2021, and was unable to find any supportive documentation for the diagnosis of urinary retention or neuromuscular dysfunction of the bladder. The resident was on hospice services at the time, but was not any longer. Foley catheter tubing and bags should not have been in contact with the floor. The resident was not referred to a urologist. On 9/29/22 at 11:31 a.m., the DHS provided a document titled, Guidelines for the Use of Indwelling Catheter, and indicated it was the policy currently being used by the facility. The policy indicated, .OVERVIEW: The purpose of urinary catheterization is to provide urinary drainage when medically necessary and to evaluate its continued use. A resident who enters the campus with an indwelling urinary catheter, or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary .An indwelling catheter is not used unless there is a valid medical justification; An indwelling catheter for which continuing use is not medically justified is discontinued as soon as clinically warranted by the attending physician and/or urologist .A resident with or without a catheter, receives the appropriate care and services to prevent infections to the extent possible .SOP DETAILS: 1. Urinary catheters are deemed medically necessary for the following reasons and must have supporting diagnosis for its use (per the interpretive guidelines): a. Resident has acute urinary retention or bladder outlet obstruction .f. Other conditions as deemed valid by the attending physician and/or urologists with supporting documentation. Examples of Inappropriate Uses of Indwelling Catheters: g. As a substitute for nursing care of the resident with incontinence 2. On 9/28/22 at 9:36 a.m., Resident 19 was observed sitting in a wheelchair by the nurses' station. Resident 19's catheter (a tube inserted into the bladder to drain urine) tubing was observed touching the floor underneath his wheelchair. On 9/28/22 at 2:34 p.m., Resident 19 was observed lying in bed with his eyes closed, the catheter bag was observed hanging from bed frame with the catheter tubing on the floor. On 9/29/22 at 10:51 a.m., the Director of Health Services (DHS) indicated catheter tubing should not be on the floor. On 9/30/22 at 12:19 p.m., Resident 19 was observed sitting in a wheelchair in the main dining room eating lunch with the catheter tubing touching the floor. On 9/30/22 at 12:28 p.m., Resident 19 was observed sitting in a wheelchair propelling himself from the dining room with the catheter tubing dragging onto the floor. At that time, the Clinical Support observed the resident propelling himself with the catheter tubing touching the floor and indicated Resident 19's catheter tubing should not be touching the floor. The Clinical Support indicated she would go and assist Resident 19 with his catheter tubing to get the tubing off the floor. On 10/5/22 at 12:42 p.m., Resident 19 was observing sitting in a wheelchair propelling himself from the dining room with the catheter tubing dragging the floor. Resident 19's record was reviewed on 9/29/22 at 10:26 a.m. Diagnoses included but were not limited to, benign prostatic hyperplasia (prostate gland [a gland surrounding the neck of the bladder] enlargement that can cause urination difficulty), retention of urine, and obstructive and reflux uropathy (occurs when urine cannot drain through the urinary tract). A quarterly Minimum Data Set (MDS) assessment, dated 9/22/22, indicated the resident was cognitively intact, had an indwelling catheter, required extensive assistance of one person for toilet use, required extensive assistance of two persons for dressing and personal hygiene, and had impairments of the lower extremities (hip, knee, ankle, foot) on both sides. A bowel and bladder care plan, initiated on 12/6/19, indicated Resident 19 required a suprapubic (S/P) (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow) catheter. Interventions included but were not limited to leg strap in place to prevent resident's catheter from being pulling out, provide assistance with catheter care and change catheter per physician orders with the goal, target dated 12/29/22, of the resident will be free from adverse effects from catheter use. A physician's order, dated 4/10/22, indicated Resident 19 required a S/P catheter with daily and as needed care to cleanse area around S/P site and the catheter to be changed every four weeks. On 9/29/22 at 11:31 a.m., the DHS provided a document titled, Urinary Catheter Care, and indicated it was the policy currently being used by the facility. The policy indicated, .OVERVIEW: To prevent infection of the resident's urinary tract. SOP DETAILS: .11. Be sure the catheter tubing and drainage bag are kept off the floor 3.1-41(a)(1) 3.1-41(a)(2)