4a. The clinical record for Resident 99 was reviewed on 3/1/23 at 3:30 p.m. The diagnoses included, but were not limited to, diabetes mellitus (DM), congestive heart failure (CHF), and right above the knee amputee. A care plan, dated 2/27/23, indicated the resident had diabetes mellitus. The interventions included, but were not limited to, diabetes mellitus medications as ordered per the physician, and fasting serum blood sugar as ordered by the physician. A physician's order, dated 2/25/23, indicated to obtain blood sugars twice a day and notify the nurse practitioner or physician if the blood sugar was less than 70 or greater than 350. The following blood glucose levels were out of the physician call orders: a. On 11/11/23 at 5:53 p.m., the blood sugar level was 399. b. On 11/14/23 at 5:00 p.m., the blood sugar level was 385. c. On 2/19/24 at 5:18 p.m., the blood sugar level was 358. There was no documentation the physician was notified of the blood sugar out of the call parameter. 4b. A care plan, dated 2/27/23, indicated the resident had congestive heart failure. The interventions included, but were not limited to, monitoring weights daily as ordered. A physician's order, dated 10/13/23, indicated to notify the nurse practitioner or physician daily if the resident's weight was greater than 3 pounds in 24 hours or greater than 5 pounds in one week. The following daily weights were missing: a. The daily weights were missing on 11/7, 11/8, 11/11, 11/16, 11/17, 11/18, 11/24, 11/25, 11/27, 11/29 and 11/30/2023. b. The daily weights were missing on 12/1, 12/6, 12/7, 12/8, 12/9, 12/13, 12/14, 12/15, 12/17, 12/18, 12/21, 12/22, 12/23, 12/25, 12/28, 12/29 and 12/31/23. c. The daily weights were missing on 1/1, 1/6, 1/7, 1/8, 1/12, 1/13, 1/14, 1/15, 1/17, 1/18, 1/22, 1/23, 1/25, 1/28, 1/29 and 1/31/24. There was no documentation the physician was notified of the missing daily weights. During an interview, on 3/4/24 at 11:18 a.m., the ADNS indicated they did not have a CHF policy and the facility followed the weight policy for residents with CHF. During an interview, on 3/5/24 at 4:30 p.m., the DNS indicated the staff followed the physician's orders and called the physician if the blood glucose was above the call orders. The staff should follow the physician's order and get a daily weight and chart them. A current policy, titled Glucose Testing, dated 1/2023 and received from the ADNS on 3/1/24 at 11:30 a.m., indicated .To provide nursing staff with guidelines for the testing of residents glucose level .Verify the physician's orders for blood glucose testing .The nurse shall notify the physician of the results in accordance with physician's orders and/or facility protocols for hyper/hypoglycemia A current policy, titled Physician Orders, dated as revised 3/2022 and received from the ADNS on 3/4/24 at 1:00 p.m., indicated .All activities (medications, activities, lab orders, x-rays, diet, etc) that effect the resident shall be ordered by the physician/designee. No orders shall be changed or discontinued by anyone other than the physician/designee. Nursing shall follow all orders as written. If there is a question or concern, the physician/designee shall be contacted for clarification A current policy, titled Weights, dated as revised 10/2023 and received from the ADNS on 3/1/24 at 11:30 p.m., indicated .Residents shall be monitored for adequate nutritional status to ensure each one is able to maintain the highest practicable level of well-being .CHF Diagnoses: Weights for these residents are often performed on a daily basis as ordered by the physician. Any weight change of three (3) pounds (gain) in (24) twenty-four or five (5) pounds in a week shall be documented. The physician shall be notified of any weights changes that exceed the ordered parameters This citation relates to Complaints IN00425592. 3.1-37(a) Based on observation, interview, and record review, the facility failed to ensure services were provided to effectively administer back blows for a choking resident in accordance with treatment guidelines established by the facility and failed to ensure the plan of care was effectively revised with accurate care information (Resident S). This deficient practice resulted in Resident S experiencing a choking episode with a change in the level of consciousness which required emergent treatment. The facility also failed to ensure residents maintained upright positioning while sitting in chairs (Resident V and F), to ensure the physician was notified for blood sugars above specified parameters and to ensure weights were completed daily (Resident 99) for 4 of 4 residents reviewed for quality of care. Findings include: 1. A Facility Reported Incident (FRI) report, dated 1/4/24 at 12:40 p.m., indicated Resident S was in the dining room eating lunch when the nursing staff observed the resident choking on her food and her color was changing. The resident was not able to cough or clear her airway. The Heimlich maneuver and suctioning were performed. Food particles were suctioned from the resident's mouth. The resident's code status was confirmed as do not resuscitate (DNR). The Power of Attorney (POA) was called to notify of the situation and authorization was obtained to call 911 to send the resident out of the facility for care. The resident was not responsive after the Heimlich and suctioning were performed. The Registered Nurse (RN) manager attempted the sternal rub, elevated the resident's arms above her head and leaned the resident forward in her dining chair. The resident was observed not breathing and two staff verified the resident's respirations had ceased and there was no pulse. The Emergency Management Services (EMS) arrived and confirmed the DNR code status and lack of pulse. No other actions were performed. The report did not include documentation to indicate the specific steps performed by staff during the provision of the Heimlich Maneuver. Google-Merriam Webster-indicated the definition of the Heimlich maneuver was the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea. The website page https://www.redcross.org/content/dam/redcross/atg/PDFs/Take_a_Class/Adult_Ready_Reference_Card.pdf indicated .Conscious Choking Cannot cough, speak, or breathe .Give 5 [five] back blows .Give 5 abdominal thrusts .Continue care Give sets of 5 back blows and 5 abdominal thrusts until the object is forced out, the person can cough forcefully or breathe, or the person becomes unconscious . The clinical record for Resident S was reviewed on 2/29/24 at 10:56 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, anxiety disorder, and dysphagia (difficulty swallowing). A quarterly Minimum Data Set (MDS) assessment, dated 11/7/2023, indicated the signs and symptoms of a potential swallowing disorder were positive for the resident holding food in her mouth/cheeks or positive for the resident to have residual food in her mouth after meals. A physician's order, dated 8/4/23, indicated the resident was to receive a regular diet, regular texture, and thin consistency. A physician's order, dated 9/14/23, indicated speech therapy to evaluate and treat oral dysphagia. A speech therapy note, dated 9/14/23, indicated the resident's diagnoses included, but were not limited to, dementia and dysphagia. The resident was referred to speech therapy for a swallowing assessment due to an increase in oral pocketing which placed the resident at an increased risk for aspiration and compromised airway protection. The clinical impression indicated the resident was recommended for treatment of dysphagia to facilitate airway protection and to maximize airway protection on the least restrictive diet. The resident's plan of care was not revised to include the swallowing concerns from the speech therapy note. A speech therapy note, dated 10/13/23, indicated the discharge recommendation were supervision for all meals with meal tray set up and to cut whole foods into bite sized pieces. The diet recommendation was for a regular texture and thin liquids. The resident's plan of care was not revised to include the swallowing concerns from the speech therapy note. A nursing progress note, dated 1/31/24 at 12:41 p.m., indicated the resident had to be reminded to chew and swallow the food she had left in her mouth once she made it to the television room. The care plans were reviewed and there was no care plan for dysphagia, food pocketing or the need to cut the resident's food into bite sized pieces. A witness statement obtained by the facility, dated 1/4/24, indicated RN 16 was called by a staff CNA due to Resident S being cyanotic (blue or purplish discoloration due to deficient oxygenation of the blood). The Heimlich maneuver was done by CNA 9 and a chewed piece of meat was dislodged. The resident's color changed to pale although there were still no respirations. The Heimlich was continued, and suction was done. The resident did not have respirations and the code status of DNR was verified. A witness statement obtained by the facility, dated 1/4/24, indicated CNA 17 was assisting the residents with lunch. CNA 17 heard another CNA ask if Resident S was okay. Resident S's face looked pale, and she was holding onto a walker. CNA 17 went to get a nurse. The nurses came into the dining room to assist, and CNA 17 assisted to take other residents out of the dining room to clear the area. A witness statement obtained by the facility, dated 1/4/24, indicated CNA 21 was in the dining room during lunch. A staff indicated Resident S was choking and CNA 21 saw CNA 9 had already started doing the Heimlich maneuver on the resident. A witness statement obtained by the facility, dated 1/5/24, indicated CNA 20 saw Resident S's face turn purplish and yelled for help. Another staff had started doing the Heimlich maneuver. A witness statement obtained by the facility, dated 1/5/24, indicated CNA 9 had been told Resident S was changing colors in her face. CNA 9 thought the resident was choking so CNA 9 started to do the Heimlich on the resident and kept doing the Heimlich. A witness statement obtained by the facility, dated 1/5/24, indicated Unit Manager (UM) 8 had arrived onto the unit and saw staff doing the Heimlich on Resident S. The crash cart was present, and suctioning was completed. The staff had suctioned food particles from the resident's mouth. The resident was nonresponsive, had no respiration, and no pulse. A witness statement obtained by the facility, dated 1/5/24, indicated UM 22 had entered the dining room on 1/4/24 and saw a CNA administering the Heimlich maneuver to Resident S. UM 22 helped the CNA to try to get the resident to cough the food up. CNA 22 was using the suction machine while the CNA continued to do the Heimlich. CNA 22 was able to get pieces of food and phlegm suctioned from the resident's mouth. The resident had no pulse and no respiration. The witness statements from RN 16, CNA 17, CNA 21, CNA 20, CNA 9, UM 8, and UM 22 did not include documentation to determine the staff had completed back blows in accordance with the Red Cross conscious choking protocol. During an interview, on 2/29/24 at 11:48 a.m., CNA 9 indicated, on 1/4/24, he was assisting another resident to eat. Speech Therapist (ST) 10 was in the dining room and indicated Resident S did not look right. Resident S stood up and looked like she was choking. CNA 9 got behind the resident and did the Heimlich. CNA 9 had both hands under the resident's breasts and was pushing up doing the Heimlich. One of the nurses had the tube thing to get the food out of the resident's mouth. ST 10 assisted to do the Heimlich. CNA 9 and ST 10 kept switching back and forth from behind the resident to push up her abdomen. CNA 9 indicated the resident's abdomen continued to be pushed up whether she was sitting or standing. The only time CNA 9 and ST 10 stopped pushing on the abdomen was when the nurse was using the suction machine. CNA 9 indicated the resident was going to eventually choke since she stuffed her mouth so much and was in a rush to eat. CNA 9 indicated he felt since the resident got regular food and stuffed her mouth, she should have received chopped up food. The food she got was too big. During an interview, on 2/29/24 at 12:09 p.m., RN 15 indicated CNA 9 said Resident S was choking and all the staff went into the dining room right away. RN 15 indicated she thought they had got the food out although the resident did not breathe again. CNA 9 did the Heimlich by pressing on the resident's abdomen. Then RN 15 tried to suction. There was food removed from the resident's mouth which looked like beef or bacon and it was one chunk about the size of a 50-cent piece. The resident had trouble chewing in the past. The resident would hold food in her mouth and the staff had to be careful to make sure she swallowed everything. During an interview, on 3/1/24 at 11:31 a.m., UM 8 indicated she was at the facility the day the resident choked. The staff was doing the Heimlich when UM 8 arrived at the unit. CNA 9 and another staff were switching back and forth to do the Heimlich. The resident was a DNR, so cardiopulmonary resuscitation (CPR) was not performed. The resident was sitting in the chair and the staff were leaning over the resident and doing abdominal thrusts. When CNA 9 was tired of doing the abdominal thrusts then the other person would do the abdominal thrusts. UM 8 was not familiar with the diet the resident was prescribed. UM 8 reviewed the electronic health record (EHR) and indicated the resident was on a regular diet, regular texture. The care plan only included setting up the meal tray and providing assistance as needed. The care plan did not have any other instructions for Resident S other than to assist with meals as needed. UM 8 indicated if the resident was at high risk while eating then there should be something on the care guide assignment sheet. During an interview, on 3/1/24 at 1:26 p.m., the ST 10 indicated Resident S had resided on the memory care and was nonverbal. ST 10 indicated she was one of the staff who was alternating doing the Heimlich with CNA 9. The Heimlich standard procedure was to grab the person around the waist and do upward thrusts. The resident's airway was completely obstructed. ST 10 saw a piece of food about the size of a dime. The resident was not able to manipulate a knife or fork to cut up food into bite size pieces. The resident had advanced dementia and had lost awareness of food in her mouth. Resident S ate way too fast and did not chew food adequately to safely swallow. She had the ability to chew although she did not have the cognitive awareness of food being present in her mouth and the need to grind to chew the food. ST 10 indicated she would not change the diet since there was a lot of pleasure with eating. The resident needed supervision since she did not have the cognition to recognize there was food in her mouth. ST 10 educated the charge nurse and the unit manager on the need to cut the food into small bites and to take small sips of fluid. A resident care guide, provided by the Assistant Director of Nursing (ADNS), on 3/1/24 at 2:32 p.m., indicated the resident needed to be toileted every 2 hours and was incontinent of bowel and bladder. The guide indicated Resident S required the total assistance of for ADLs (Activities of Daily Living). The resident was nonverbal although could understand when spoken to. The resident's care guide did not include interventions for supervision with meals or for cutting the resident's food into bite sized pieces. During an interview, on 3/1/24 at 2:39 p.m., UM 22 indicated, on 1/4/24, she saw a CNA doing the Heimlich maneuver on the resident. The CNA kept doing the Heimlich maneuver and the nursing staff grabbed the crash cart. The staff were able to get some of the food particles out of the resident's mouth, but not all of them. The food particles looked like corned beef and were less than half an inch in size. CNA 9 was doing the Heimlich and alternated with ST 10. The Heimlich maneuver was when CNA 9 stood behind the resident with his arms wrapped under her arms and was thrusting up under her breasts and under her sternum. The resident would rush to eat, and we would need to tell her to slow down and chew her food up. The staff had to empty her mouth out and one time she was sleeping and had food in her mouth. The resident had a mechanical soft diet for a while and then went back up to a regular diet. The daughter had requested no turkey sausage or bacon because the resident had trouble with those foods. The staff would only cut up the resident's food if they felt like it needed to be cut up. The staff interviews did not include information to determine CNA 9, ST 10, or RN 10 provided back blows during emergent care for choking for Resident S in accordance with the Red Cross conscious choking protocol. During an interview, on 3/1/24 at 3:18 p.m., RN 24 indicated she was the facility CPR instructor. The facility utilized the American Red Cross for First Aid and CPR training. The training for the adult choking victim included assessing the person for choking, then doing back blows and abdominal thrust and continue until the person could expel what was in their throat. Then call 911 and do CPR if unconscious. The staff were to start with 5 back blows, then 5 abdominal thrusts and continue to do back blows and abdominal thrusts until the person became unconscious and then do CPR if applicable. The American Red Cross did not use the word Heimlich anymore. The sequence was to use back blows then abdominal thrusts. During an interview, on 3/1/24 at 3:38 p.m., the ADNS and Administrator indicated the staff should use the method for a choking victim by using back blows and abdominal thrusts as taught at the facility. The Administrator indicated there was no documentation in the care plan or resident care guide to show the resident needed her food cut into bite sized pieces. A current policy, titled First Aid, dated 10/2023 and received by the DNS on 3/6/24 at 5:05 p.m., indicated .POLICY: See attached procedure from American Red Cross Manual for First Aid CPR and AED An American Red Cross First Aid, CPR and AED Instructor Manual, not dated and received from the ADNS on 2/29/24 at 4:48 p.m., indicated .Caring for a Choking Adult .Tell participants they will now practice giving back blows and abdominal thrusts to an adult A current policy, titled Caring for Choking by the American Red Cross, not dated and received from the DNS on 3/6/24 at 5:05 p.m., indicated .If the person is unable to speak, cry or cough, CALL 9-1-1 and get equipment, or tell someone to do so .Give 5 back blows .Position yourself to the side and slightly behind the choking person. Place one arm diagonally across a person's chest and bend them forward at the waist .Firmly strike the person between the shoulder blades with heel of your hand. Each back blow should be separate from the others .Give 5 abdominal thrusts .Have the person stand up and find their navel with two fingers. Move behind the person and place your front foot in between the person's feet with your knees slightly bent .Make a fist with your other hand and place the thumb side against the person's stomach right above your fingers. Cover your fist with your other hand .Pull inward and upward to give an abdominal thrust. Each abdominal thrust should be forceful and separate from the other .Alternatively, you may give chest thrusts to a person who is too large to wrap your arms around, pregnant or in a wheelchair .Continue giving sets of 5 back blows and 5 abdominal thrusts until .The person can cough forcefully, speak, cry or breathe .The person becomes unresponsive .If the person becomes unresponsive, gently lower them to the floor and begin, CPR, starting with compressions .After each set of compression and before attempting breaths, open the person's mouth, look for the object and, if seen, remove with a finger sweep 2. During an observation, on 2/27/24 at 2:11 p.m., Resident V was sitting up in her Broda chair (chair for positioning) and her body was leaned to the left. She was trying to grasp a cup of water with her right hand and was not able to pick up the cup. During an observation, on 2/28/24 at 3:45 p.m., the resident was sitting up in her Broda chair in the common area at the end of hall 100, she was leaned towards the left side. There were no staff present in the common area. During an observation, on 3/5/24 at 11:10 a.m., the resident was sitting up in a high back wheelchair. Her head was leaning to the left almost touching the hand piece of the chair and there was a small pillow on the left side of the wheelchair which did not support the resident's head. During an observation, on 3/6/24 at 11:27 a.m., the resident was sitting up in a high back wheelchair, her head was leaning towards the left with her head tilted towards her chest. There was a pillow by her left arm tucked into the left side of the wheelchair. The pillow did not support the resident's head. During intermittent observations, the resident did not attempt to reposition herself in the Broda or high back wheelchair. The clinical record for Resident V was reviewed on 3/1/24 at 3:38 p.m. The diagnoses included, but were not limited to, systemic lupus, unspecified fracture of the right pubis (one of three bones which make up the hip bone), displaced fracture of the left femur, and unspecified dementia. A care plan, dated 11/17/23, indicated the resident had severely impaired cognitive function and decision-making skills related to dementia. The interventions included, but were not limited to, cue, reorient, and supervise as needed. A care plan, dated 4/5/23 and last revised on 12/1/23, indicated the resident had an activities of daily living (ADL) self-care performance deficit related to limited mobility, musculoskeletal impairment, pain from a history of a left femur fracture, and lack of coordination. The interventions included, but were not limited to, the resident required extensive staff assistance with turning and repositioning in bed and required extensive staff assistance with personal hygiene and oral care. A care plan, dated 4/5/23 and last revised on 1/17/24, indicated the resident was at a high risk for falls related to balance, unaware of safety needs, and unsteadiness on feet. The interventions included, but were not limited to, anticipating, and meeting the resident's needs and a body pillow when in bed. During an interview, on 3/6/24 at 11:27 a.m., CNA 5 indicated the resident did have a Broda chair, but the facility gave the chair back to the hospice provider. The resident was still able to pivot during a transfer and it was too difficult to get the resident out of the Broda chair. The resident favored the left side and even leaned towards the left while she was in bed. CNA 5 did not try to reposition the resident. 3. During an observation, on 2/28/24 at 3:53 p.m., Resident F was sitting up in her wheelchair, her head was tilted to the right. There was no positioning cushion in her wheelchair. During an observation, on 2/29/24 at 11:44 a.m., the resident was sitting up in her wheelchair in the common area, her head was tilted to the right. There was a cushion on the bottom of her wheelchair and no other type of device in the chair. During an observation, on 3/1/24 at 11:12 a.m., the resident was sitting up in her wheelchair close to the common area. Her head was tilted to the right with her chin tilted towards her chest. There was no positioning cushion in her wheelchair. During an observation, on 3/4/24 at 3:48 p.m., the resident was sitting up in the common area and her head was leaning to the right. There was no positioning cushion in her wheelchair. During an observation, on 3/5/24 at 11:14 a.m., the resident was sitting up in the common area in her wheelchair. Her head was tilted down and there was a positioning cushion on the left side of her wheelchair. The clinical record for Resident F was reviewed on 3/1/24 at 3:04 p.m. The diagnoses included, but were not limited to, unspecified dementia, generalized muscle weakness, and unsteadiness in her feet. A physician's order, dated 4/25/23, indicated the resident was to always have a right lateral support in her chair to ensure an upright sitting position. An Occupational Therapy (OT) progress report, dated 4/12/23, indicated the resident was awaiting a neck brace to encourage proper seated alignment and the resident was given a high back chair with a right lateral support. A care plan, dated 6/27/21 and last updated on 11/29/23, indicated the resident was at risk for altered range of motion to the bilateral lower extremities due to a diagnoses of muscle weakness and dementia which had progressed. The resident required restorative nursing to walk with a front wheeled walker and to perform trunk flexion before standing. The care plans did not include the resident's positioning and the need for a neck brace or a lateral support in her chair. During an interview, on 3/4/24 at 3:55 p.m., QMA 6, indicated she did not know what type of support the resident was supposed to have in her wheelchair. The resident did not have any support in her wheelchair. During an observation, on 3/4/24 at 3:56 p.m., with QMA 6, there was no type of lateral support located in the resident's room. During an interview, on 3/4/24 at 4:17 p.m., the Occupational Therapist (OT) 7 indicated the resident was seen by OT due to the resident leaning to one side. The lateral support was an L shaped cushion. OT 7 did not know what was going on with the cushion. At the time of exit, the facility did not provide a positioning and mobility policy.

Based on observation, interview and record review, the facility failed to protect a resident from injury during a transfer when the CNA did not follow transfer instructions for 1 of 3 residents reviewed for accidents. (Resident 2) Resident 2 sustained a fracture to her femur when she was lowered to the floor. Finding includes: An incident report filed with the Indiana Department of Health indicated Resident 2 sustained a fall, on 06/05/23 at approximately 2:00 p.m., when she became weak during a transfer. The Nurse Practitioner assessed the resident, and a STAT (immediate) x-ray was ordered. The x-ray showed an acute right transverse distal femur fracture (a fracture to the leg bone between the hip and the knee). Per the report, Resident 2 was sent out to the hospital and had to have surgery and rehabilitation therapy before returning to the facility. During an observation, on 07/17/23 at 9:00 a.m., Resident 2 was observed sitting up in bed and leaning slightly to her left. She had a palm protector in her right hand and her right arm was propped up with a pillow. Resident 2 was eating her meal with her left hand. An interview was attempted, but Resident 2 was nonverbal. The record for Resident 2 was reviewed on 07/14/23 at 11:01 a.m. Diagnoses included, but were not limited to, history of falling, difficulty walking, and hemiplegia and hemiparesis affecting the right side (weakness and paralysis on the right side of the body). A nurses' note, dated 06/05/2023 at 3:04 p.m., indicated .Nurse called to residents room due to resident falling on the floor in her bathroom. Writer went into room and observed the resident on the floor with her right leg folded under her. Nurse assessed resident for injuries from fall, stabilized resident's right leg and took vital signs T.97.2, P.89 R.16 B/P 188/83. Resident assisted off the floor by nurse and CNA and into her wheelchair and then into her bed A care plan, undated, indicated Resident 2 was a high risk for falling and to have 2 staff members for weight bearing assist with all transfers using a gait belt. The care plan indicated to use 2 people to assist with toileting. The physician's orders were reviewed and did not include orders on use of a full body mechanical lift or transfers using 2 people and a gait belt. A current CNA assignment sheet, provided by the Assistant Director of Nursing on 07/14/23 at 11:20 a.m., indicated .High fall risk .2 person assist with gait belt/wheelchair .Extensive assist .Rt (right) side hemiparesis During an interview, on 07/14/23 at 11:14 a.m., CNA 1 indicated Resident 2 could be transferred by a full body lift with two (2) staff or by gait belt with two (2) staff. She did transfer Resident 2, in the bathroom, by herself and did not use a gait belt. She indicated the proper way to transfer Resident 2 was documented on the CNA assignment sheet, but she did not have her assignment sheet with her that day, she was in a hurry. She was aware the resident required two (2) people and a gait belt for transfers. It was not the first time she had worked with the resident, prior to the incident. CNA 1 indicated when she was transferring Resident 2 in the bathroom, the resident had her good hand on the assist bar. CNA 1 placed her weak hand on the bar, and when she stood Resident 2 up, the resident went limp, and they both went down. CNA 1 indicated the resident was weak on one side. She did call the nurse and together they assisted the resident to her bed. During an interview, on 07/14/23 at 11:25 a.m., the Assistant Director of Nursing indicated CNA 1 was interviewed to find out why she did not follow the CNA assignment sheet. During an interview, on 07/14/23 at 11:38 a.m., TX 3 (Therapy Staff) indicated Resident 2 was to transfer using two (2) people and a gait belt. She was assessed on 04/24/23 (prior to the event) upon her admit to facility and was totally dependent on staff for transfers, meaning a full body mechanical lift was to be used or two (2) staff members with a gait belt for transfers. How the resident was transferred was determined by the resident's pain level and the resident's weight bearing status. He indicated the CNA assignment sheet needed to be updated. During an interview, on 07/14/23 at 1:01 p.m., LPN 2 indicated she was at her medication cart parked across the hall. She did not hear anything. CNA 1 came out of the room and asked her to come into the room. LPN 2 entered the room and found Resident 2 on the floor with her leg bent behind her. She had the CNA remain with Resident 2 and left to get the vital sign instruments. Once she had finished assessing the resident, both her and CNA 1 transferred the resident to her bed via two people and a gait belt. She indicated it was more of a lift and carry to the bed due to the observation of the leg and the resident was not able to assist with transfer. Once the resident was in bed, she displayed seizure activity. LPN 2 indicated she knew how to transfer the resident because it was documented on the care card. During a telephone interview, on 07/17/23 at 3:15 p.m., the family member of Resident 2 indicated her mother did not self-transfer due to weakness and paralysis on her right side. She was dependent on 2 staff members and a gait belt to be transferred. The resident had at least three (3) gait belts in her room. A facility document, titled Job Description .CERTIFIED NURSING ASSISTANT, dated as last reviewed in August 2007 and received from the Executive Director on 07/14/23 at 1:47 p.m., indicated .To receive and complete resident care assignments .in accordance with facility policies .To perform all nursing procedures in accordance with facility policy .These procedures/tasks include but are not limited to the following .Correctly transfers the resident in accordance with the CNA Assignment Sheet A current policy, titled Transferring Residents, dated as last reviewed in 04/2022 and received from the Executive Director on 07/14/23 at 1:47 p.m., indicated .C.N.A.s assigned to the resident need to review the assignment sheet/care plan to determine if the resident requires more than a one person assist 3.1-45(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a resident at risk for development of pressure ulcers received the necessary care, treatment, and services, consistent with professional standards of practice, to prevent a pressure ulcer and promote healing and failed to ensure the correct dose of Dakin's (an antimicrobial cleanser) was used during wound care for 3 of 7 residents reviewed for pressure ulcers. (Resident 299, 21, 112) Resident 299 acquired a stage 3 presure ulcer while in the facility. Findings include: 1. The record for Resident 299 was reviewed on 12/19/22 at 3:00 p.m. Diagnosis included, but were not limited to, end stage renal disease, diabetes, and heart failure. An admission summary, dated [DATE] at 6:35 p.m., indicated Resident 299 was admitted to the facility for rehabilitation due to altered mental status. She ambulated with an assist of two with a gait belt, walker, and wheelchair. A nurse-to-nurse report, dated 11/26/22, indicated Resident 299 had a red area to the coccyx which was blanchable. A skilled evaluation, dated 11/27/22 to 11/29/2022 at 5:04 p.m., indicated Resident 299's skin was warm, dry, normal skin color and turgor. A Braden Scale was conducted, on 11/27/22, and indicated Resident 299 was at risk for skin breakdown. A progress note, dated 11/30/22 at 4:26 p.m., indicated a family member had concerns regarding a cushion patch on Resident 299's coccyx was soiled which was applied at the hospital prior to her discharging to the facility on [DATE]. The patch was removed, and the skin was intact beneath. A wound progress note, dated 12/2/22, indicated Resident 299 had a stage 3 pressure wound on her coccyx which measured 1 cm by 1.3 cm by 0.1 cm with 100 percent granulation, and a small amount of serosanguinous drainage. Treatment indicated to cleanse wound with wound cleanser or normal saline, apply collagen, cover with foam, and secure. Change every Monday, Wednesday, Friday, and as needed. The wound progress notes indicated therapy would be notified to upgrade the wheelchair cushion for Resident 299. A communication progress note, dated 12/2/22, indicated family member was notified of treatment orders to coccyx. A progress note, dated 12/2/22, indicated a coccyx wound was observed, and was facility acquired. The progress note indicated epithelial tissue was present and pink in color. The wound measured 3.2 cm by 3.4 by 0.1 cm. Wound care included applying triad cream and to cover with Duoderm every three days. A care plan, dated 12/6/22, indicated Resident 299 had acquired a stage one pressure ulcer on her coccyx. Interventions included, but were not limited to, administer treatments as ordered, follow facility policies and protocols for prevention and treatment of skin breakdown, monitor nutritional status and serve diet as ordered, monitor intake, and record, and use a pressure relieving device on the bed and in the wheelchair. An admission MDS assessment, dated 12/7/22, indicated Resident 299 was at risk for pressure ulcers and she currently had a stage 2 pressure wound which was not present upon entry and required extensive assistance from staff for all activities of daily living. She had a pressure relieving device to the chair and bed, was not receiving pressure care and was not on a turning and repositioning schedule. A Care Area Assessment, dated 12/7/22, indicated Resident 299 triggered the CAA due to requiring assistance with bed mobility, incontinence, impaired skin integrity. A care plan would be developed to monitor complications and the risk of developing pressure ulcers. A physician progress note, dated 12/7/22 at 4:00 p.m., indicated it was his first visit for the wound. The pressure wound on the coccyx was due to pressure and classified as a stage 3. A small layer of fat was exposed and measured 1 cm by 1.3 cm by 0.1 cm. A small amount of serosanguineous drainage was noted and a large area of pink granulation within the wound bed. The wound care order included to clean the wound with wound cleanser, or normal saline, apply collagen, cover with foam dressing, and secure. Change Monday through Friday, and as needed. Provide offloading to Resident 299, do not sit for long periods of time, turn, and reposition per policy, and upgrade cushion in her wheelchair. A wound care note, dated 12/15/22, indicated Resident 299 was seen on wound rounds for a stage 3 pressure wound on coccyx which was acquired on 12/2/22. The pressure wound area measured 0.9 cm by 1.2 cm by 0.1 cm and had 100 percent granulation tissue with a small serosanguinous drainage. Treatment to the area included to cleanse with wound cleanser or normal saline, apply collagen powder followed with Triad daily. The facility would notify therapy to upgrade wheelchair cushion. Resident 299's [NAME] indicated she required assistance by staff to turn and reposition in bed and as necessary. Physician orders included, but were not limited to: a. On 12/2/22 at 7:00 a.m., to clean area of coccyx, apply triad, and cover with Duoderm change every three days for open area. b. On 12/9/22, to cleanse with wound cleanser or normal saline, apply collagen, cover with foam, and secure. Change one time a day every Monday, Wednesday, Friday, and as needed for pressure wound. c. On 12/15/22 at 3:00 p.m., to cleanse the wound with wound cleanser or normal saline, apply collagen powder, and a layer of triad daily for a pressure wound. A review of Resident 299's Treatment Administration Record, dated 12/22, lacked indication wound care was provided on 12/7/22. A review of Resident 299's Occupational Therapy progress note, dated 11/29/22 to 12/19/22, lacked indication a pressure relieving device for her wheelchair was requested or needed to be upgraded. A review of Resident 299's Physical Therapy progress note, dated 11/30/22 to 12/19/22, lacked indication a pressure relieving device for her wheelchair was requested or needed to be upgraded. During an interview, on 12/14/22 at 2:30 p.m., a family member indicated she came into the facility to visit Resident 299 and she could smell an odor. She observed her back and coccyx area she noticed her bandage was soiled and she had concerned the bandage was the same one when she was discharged from the hospital. During an interview, on 12/20/22 at 3:53 p.m., the ADON indicated no measurement of the redness was documented when Resident 299 was admitted to the facility for the coccyx. The pressure wound was found on 12/2/22. During an interview, on 12/21/22 at 11:12 a.m., the ADON indicated the nurse did not document an accurate assessment and finding of the pressure wound. 2. The record for Resident 21 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), urinary tract infection, kidney transplant, pancreas transplant, diabetes, dementia, and pressure ulcer (injury which breaks down the skin). A care plan, dated 2/28/22, indicated Resident 21 was at high risk for pressure ulcer development related to decreased mobility, nutritional status, and a history of pressure ulcers. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, educate the resident, family, and caregivers as to causes of skin breakdown, including transfer, positioning, importance of taking care during ambulating, mobility, good nutrition, and frequent repositioning, and if the resident refused treatment, discuss with the resident, Interdisciplinary team, and family to determine why, and try alternative methods to gain compliance. Document alternative methods. Inform Resident 21, family, and caregivers of any new area of skin breakdown, provide a low air loss mattress to the bed with settings as ordered by physician, monitor nutritional status, and serve diet as ordered, monitor and record intake, monitor, document, and report as needed any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length by width by depth), and stage. Obtain and monitor lab or diagnostic work as ordered. Report results to physician and follow up as indicated. Teach Resident 21 and family the importance of changing positions for prevention of pressure ulcers and encourage small frequent position changes. The care plan indicated he had an unstageable pressure ulcer to the right heel and right ankle. Interventions included, but were not limited to, administer treatments as ordered and monitor for effectiveness, and assess, record, and monitor wound healing as ordered. A Care Area Assessment (CAA), dated 5/18/22, indicated Resident 21 triggered for pressure injury and required extensive assist with ADL's, transfers, and mobility, which could lead to or contribute to increased risk of developing pressure ulcers. A care plan would be developed to monitor for complications related to the pressure ulcer risk. A Braden Scale was conducted, on 6/3/22, and indicated Resident 21 was at a high risk for skin breakdown. A quarterly Minimum Data Set (MDS) assessment, dated 11/3/22, indicated Resident 21 was at risk for pressure injuries and had no pressure wounds at the time of assessment. Current treatments were pressure reducing device for the chair, and pressure reducing device for bed. Resident 21 required extensive assistance of two staff to provide physical assist for locomotion, dressing, eating, toilet use, bed mobility. He was totally dependent on staff for personal hygiene and bathing. During an observation, on 12/15/22 at 11:07 a.m., Licensed Practical Nurse (LPN) 15 and LPN 12 entered Resident 21's room to provide wound care to his right heel. Resident 21 was lying in his bed as LPN 15 removed his Prevalon boot (a cushioned bottom boot which floats the heel off the surface of the mattress) from his right lower extremity. Resident 21 made a grunting noise and pointed to his right foot. LPN 15 continued to remove the bandage from his right foot, cleanse the foot, and applied the ointment to the back of the heel/ankle. She placed a foam pad, wrapped with gauze, and secured with that had the date 12/15/22. The Prevalon boot was than replaced on the right foot. Resident 21 begun to grunt out and point to his right foot and shake his head with the look of frustration. During an interview, on 12/15/22 at 11:20 a.m., LPN 15 indicated she performed wound care to Resident 21's left heel. When asked what the order indicated for wound care she did not respond. Resident 21's Medication Administration Record (MAR), dated 12/22, indicated: a. On 12/8/22 to 12/14/22, start betadine solution to his right heel every day related to changes in skin texture. b. On 12/15/22, apply Santyl ointment to right heel wound for dislodgement. c. On 12/16/22 to 12/19/22, apply Santyl ointment to Resident 21's right heel for a pressure ulcer. Physician orders included, but were not limited to, a. On 12/15/22, staff were to apply Santyl ointment 250 unit/gram (Collagenase.) Apply to the right heel wound bed topically, cover and secure one time a day and as needed. A skin/wound progress note, dated 11/24/22 at 1:36 p.m., indicated Resident 21 had a 3.0 cm (centimeter) by 2.5 cm intact firm eschar noted to his right ankle. No signs or symptoms of pain or discomfort. He had a low air loss mattress and utilized Prevalon boots while in bed. A progress note, dated 11/24/22 at 1:40 p.m., indicated Nurse Practitioner gave an order for betadine ointment to right ankle wound and leave open to air. A progress note, dated 11/30/22, indicated Resident 21 presented with an unstageable pressure wound to the right heel measuring 1.8 by 1.6 by 0.1, and 100 percent necrotic tissue with no drainage. Treatment would be betadine daily and pressure reducing boot. A progress note, dated 12/7/22, indicated Resident 21 had an unstageable pressure wound to the right heel measuring 1.7 cm by 1.5 cm by 0.1 cm, and 100 percent necrotic tissue with no drainage. The pressure wound was facility acquired on 11/24/22. A progress note, dated 12/14/22, indicated Resident 21 had an unstageable pressure to right heel measuring 1.4 cm by 1.5 cm by 0.1 cm, and 100% necrotic tissue with no drainage.3. During an observation, on 12/20/22 at 10:12 a.m., RN 5 was observed to put two 3 milliliter (ml) containers of normal saline into a medication cup. She then poured a one-quarter concentration of Dakin's solution into the cup for a total of 10 ml of fluid. She placed a gauze dressing into the cup and once finished cleaning the wound, packed the wound with the Dakin's and normal saline soaked gauze. The record for Resident 112 was reviewed on 12/19/22 at 2:36 p.m. Diagnoses included, but were not limited to, Alzheimer's disease with late onset, disorder of the skin and subcutaneous tissue and muscle weakness. A physician's order, dated 12/1/2022, indicated to use Dakin's (1/4 strength) 0.125 % Solution; cleanse wound with wound cleaner or normal saline and pack lightly with fluffed gauze moistened with 1/4 strength Dakin's, cover and secure daily. During an interview, on 12/20/22 at 1:43 p.m., RN 5 indicated she did add 6 ml of normal saline to the Dakin's because it was to be at 1/4 strength per the order. RN 5 reviewed the label of the solution which indicated the solution was 1/4 strength. She indicated she was not aware the solution (in the bottle) was 1/4 strength. During an interview, on 12/21/22 at 10:25 a.m., the Assistant Director of Nursing indicated she expected nursing to follow the physician's orders and check medications prior to using/administering. A facility policy, titled Skin Management Program, dated 6/22, indicated the facility would ensure each resident received care consistent with the professional standards of practice to prevent pressure ulcers and did not develop a pressure ulcer. The policy described a stage 3 pressure ulcer as a full thickness skin loss were fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. A facility policy, titled Physician Orders, dated as revised in 03/2022 was provided by the Assistant Director of Nursing on 12/20/22 at 2:30 p.m., indicated .No orders shall be changed .by anyone other than the physician .Nursing shall follow all orders as written 3.1-40(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 2 residents reviewed for catheter care. (Resident 21 and 86) Resident 21 and Resident 86 was not provided care to address concerns which developed after a urinary catheter was not changed for multiple months. Findings include: 1. During an observation, on 12/12/22 at 2:12 p.m., when entering Resident 21's room a strong odor of urine was in the room. He was lying in his hospital bed and his catheter bag hung from the side with dark amber colored urine. The clear extension catheter tubing was lined inside with sediment. During an observation, on 12/13/22 at 1:31 p.m., Resident 21's room had an odor of strong urine as you entered the room. The clear extension catheter tubing was lined inside with sediment and amber colored urine was in the Foley bag. During an observation, on 12/14/22 at 2:30 p.m., Resident 21's urine appeared amber in colored, and sediment lined the inside of the catheter extension tubing. During an observation, on 12/15/22 at 9:33 a.m., Resident 21's room had a strong urine odor. The clear extension catheter tubing was lined inside with sediment and dark amber colored urine was in the Foley bag. During an observation and interview, on 12/15/22 at 9:40 a.m., nursing assistant (NA) indicated she did not smell urine in Resident 21's room and had no concerns to report to the nurse. She indicated maybe the tubing needs to be changed because of the white build up. During an observation and interview, on 12/15/22 at 9:49 a.m., Licensed Practical Nurse (LPN) indicated she had not had any report of concerns for Resident 21's catheter tubing or the odor in his room. The LPN entered his room and indicated there was a strong odor of concentrated urine and Resident 21 may need more fluids. The LPN indicated the catheter extension tubing was coated on the inside with white sediment and the tubing should be changed. The record for Resident 21 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, cerebral infarction (stroke), urinary tract infection, kidney transplant, pancreas transplant, diabetes, dementia, and pressure ulcer (injury which breaks down the skin). A care plan, dated 4/13/21, indicated Resident 21 had an indwelling catheter related to a neuromuscular dysfunction of bladder. Interventions included, but were not limited to, position catheter bag and tubing below the level of the bladder and away from entrance room door, monitor and document intake and output as per facility policy, monitor for signs and symptoms of discomfort on urination and frequency, and monitor and document for pain or discomfort due to catheter. Monitor, record, report to the medical doctor signs and symptoms of urinary tract infection such as pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. A Care Area Assessment, dated 5/18/22, indicated Resident 21 triggered for catheter, and diagnoses of UTI, neuromuscular dysfunction of the bladder, and status post kidney transplant. He required extensive assist with activities of daily living, transfers, and mobility, which could lead to or contribute complications related to catheter. Resident 21's CAA indicated his care plan would be developed to monitor for complications related to a Foley catheter. A Quarterly Minimum Data Set (MDS) dated [DATE], indicated he had an indwelling catheter and was totally dependent on staff for personal hygiene. Physician's orders, included, but were not limited to, a. On 4/13/21, change catheter as needed for leakage or decreased output. b. On 4/13/21, provide catheter care daily. c. On 6/11/21, change catheter on the 8th day of every month one time a day every 30 days related to chronic kidney disease. The order was entered as a diagnostic order. d. On 9/23/21, irrigate the Foley catheter with 60 milliliters (ml) of sterile water as needed every 8 hours as needed for hematuria. e. On 9/24/21, Resident 21 had an order indicating he may have a Foley catheter. The catheter size was a 16 French with a 10 ml bulb for neuromuscular dysfunction of bladder. Staff were to document urine output. Resident 21's hospital progress note, indicated he was hospitalized on [DATE] related to sepsis (life-threatening complication of an infection), pneumonia, and UTI. A physician's progress note, dated 5/13/22, indicated he was seen for a readmission visit after having an UTI. A hospital history and physical, dated 5/20/22, indicated he was diagnosed with sepsis related to aspiration pneumonia and urinary tract infection possible Foley associated. He had a recent Serratia (bacteria in urine) UTI, history of klebsiella (bacteria in urine) UTI, and Enterobacter aerogenes (bacteria in urine) UTI. Resident 21's hospital Discharge summary, dated [DATE], indicated he was hospitalized from [DATE] to 5/26/22, related to sepsis, UTI, positive for Methicillin-resistant Staphylococcus aureus (MRSA), and impacted stool. A hospital history and physical, dated 10/23/22, indicated the resident was treated for sepsis, UTI with a chronic foley catheter. Resident 21 had also had a history of UTI on 5/5/20, and 5/20/22 with hospitalizations. During an interview, on 12/15/22 at 3:54 p.m., the Assistant Director of Nursing (ADON) indicated Resident 21's catheter order was entered as a diagnostic order, nursing staff would not see this, and it would not direct staff to change the order which had been entered 6/11/21. During an interview, on 12/15/22 at 4:34 p.m., the ADON indicated Resident 21 last had his catheter changed when he was admitted in the hospital in 10/22, when he was treated for sepsis related to UTI. Staff should have changed the catheter per the physician's order, and there was no order to specify the frequency to change the catheter. She had observed the catheter tubing and indicated the significant amount of sediment caked on the tubing and this put Resident 21 at risk for urinary tract infection. During an interview, on 12/15/22 at 5:30 p.m., the Director of Nursing (DON) indicated Resident 21 did not have his catheter changed since his last hospitalization in 10/22, when he had been hospitalized for sepsis related to UTI. He had multiple UTI since 5/22, and indicated the catheter not being change put Resident 21 at risk for another hospitalization and UTI. During an interview, on 12/16/22 at 8:57 a.m., the ADON and Risk Management Nurse indicated the nurse should clarify with the Physician upon admission or as needed the frequency of the catheter change if not indicated in the orders. Nursing staff should follow standing orders for on how and when catheter care should be provided. Nursing staff should report concerns immediately when they discover concerns regarding with the catheter such as strong odor or buildup of sediment in the urine. The ADON indicated she was unsure if the provider was notified of the concerns of the buildup in the extension tubing. Resident 21 had been hospitalized for UTI with sepsis and been treated for UTI which put him at risk. During an interview, on 12/19/22 at 9:00 a.m., the Transplant Coordinator indicated Resident 21 was at an increased risk for UTI which could cause an infection in his transplant kidney. She recommended good catheter care was provided including changing the catheter as ordered. During an interview, on 12/19/22 at 11:45 a.m., the Nurse Practitioner indicated she was notified, on 12/15/22, concerns regarding the catheter. Her recommendations for Resident 21 were to have monthly catheter changes because of chronic urinary retention and with his history of UTI with sepsis. She was not made aware Resident 21 had not had monthly catheter changes and his hospitalizations related to UTI and sepsis could have been from not having routine catheter changes. It was a concern for him not having routine catheter care. Staff should notify her if they were made aware of, or observed concerns related to odorous urine, blood in the urine, and sediment. 2. During an observation, on 12/12/22 at 1:30 p.m., upon exiting the second-floor elevator on Unit 2A, a strong foul smell of urine permeated into the hallway. The smell of urine became stronger as you walked towards Resident 86's room. During an observation, on 12/13/22 at 9:49 a.m., a strong foul smell of urine permeated into the hallway outside Resident 86's room. During an observation, on 12/13/22 at 1:30 p.m., a strong foul smell of urine permeated Resident 86's room. During an observation and interview, on 12/13/22 at 2:00 p.m., Resident 86 was observed lying her bed with the Foley catheter bag attached on the left side of the bed facing the door. The strong foul urine smell filled the room. Resident 86 indicated she notified the nurse the other day when staff emptied her catheter the urine had smelled strong. The resident had a history of urinary tract infections and required antibiotics. The record for Resident 86 was reviewed on 12/14/22 at 10:55 a.m. Diagnoses included, but were not limited to, urinary retention, chronic kidney disease, heart failure, urinary tract infections, and diabetes. Physician's orders, included, but were not limited to, a. On 8/12/22, provide catheter care daily. b. On 8/12/22, place a dignity bag. c. On 8/12/12, the order indicated Resident 86 may have a Foley catheter, 16 French bulb size 10 ml, every shift for retention of urine. d. On 12/14/22, give Ciprofloxacin HCL (antibiotic to treat urinary tract infection) by mouth two times a day until 12/21/22. e. On 12/16/22, change catheter as needed. A review of Resident 86's physician orders lacked indication staff were directed to change her catheter from 8/12/22 to 12/16/22. A Care Area Assessment, dated 1/17/22, indicated Resident 86 triggered for catheter and had a diagnosis of UTI and urinary retention. She required extensive assist with activities of daily living, transfers, and mobility, which could lead to or contribute complications related to Foley catheter. Her care plan would be developed to monitor for complications related to Foley catheter. Resident 86's care plan lacked indication she had an indwelling catheter for urinary retention or direction to staff to provide catheter related care. A Treatment Administration Record (TAR), dated 1/22, indicated Resident 86 had her catheter changed on 1/3/22. A TAR, dated 2/22, indicated Resident 86 had refused her catheter change on 2/2/22 and staff did not change of offer any other days in the month. A progress note, dated 2/2/22, indicated Resident 86 refused to have her catheter changed. A progress note, dated 2/24/22, indicated Resident 86 had a catheter inserted related to dislodgement. A TAR, dated 3/22, indicated Resident 86 had a catheter change on 3/18/22. A TAR, dated 5/22, indicated Resident 86 had been hospitalized on [DATE], and no catheter changed was completed. A urine culture, dated 5/9/22, indicated she had a positive urine culture for urinary tract infection. A urine culture, dated 5/26/22, indicated she had a positive urine culture for urinary tract infection. A progress note, dated 7/4/22 at 8:23 p.m., indicated Resident 86 had her catheter changed while in the hospital. A progress note, dated 7/6/22 at 6:16 p.m., indicated Resident 86 was to have her Foley catheter changed once a month. She indicated to staff she had just got back from the hospital where the catheter was changed. A progress note, dated 7/10/22 at 10:02 p.m., indicated Resident 86 had her catheter changed while at the hospital. A progress note, dated 7/13/22 at 10:35 p.m., indicated Resident 86 had her catheter changed while at the hospital. A Long-Term Care Evaluation, dated 7/16/22, indicated Resident 86 last had her catheter changed on 6/27/22. A progress note, dated 7/26/22 at 10:35 p.m., indicated Resident 86 refused to have her catheter changed due to having it changed when she was in the hospital. A Hospital History and Physical, dated 8/9/22, indicated Resident 86 had a Foley catheter related to urinary retention and facility staff indicated it was changed monthly. The progress notes indicated it was unclear when the catheter was last changed. A progress note, dated 9/1/22 at 6:04 a.m., indicated Resident 86 had her catheter changed due to low urine output. A urine culture, dated 9/8/21, indicated she had a positive urine culture for urinary tract infection. A TAR, dated 10/22, indicated she had a catheter changed on 10/14/22, related to leukocytosis. A communication progress note, dated 12/16/22 at 11:11 a.m., indicated the resident was notified she had her catheter changed on 12/13/22, when the nurse sent out a laboratory sample of urine to obtain an analysis, culture, and sensitivity. A TAR, dated 12/22, indicated Resident 86 had a Foley catheter and to document urine output every shift. On four different occasions, the TAR lacked documentation of urine output. An order was placed for staff to change the Foley catheter on 12/16/22. During an interview, on 12/15/22 at 5:04 p.m., the ADON indicated Resident 86 had not had a catheter change since 10/14/22. Resident 86's order did not indicate the frequency of when the catheter should be changed. During an interview, on 12/15/22 at 5:38 p.m., the Director of Nursing indicated the catheter should be change per physician order's and going two months was probably too long not to have the catheter changed. The facility policy, titled Urinary Catheter Insertion and Removal, dated as revised 7/18, indicated an indwelling urinary catheter shall be inserted only, when necessary, based upon physician's order. 3.1-41(a)(2)