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Based on interview and record review, the facility failed to ensure medication errors did not occur for 1 of 3 residents reviewed for medication administration. (Resident C) Findings include: 1. The clinical record for Resident C was reviewed on 1/17/24 at 1:02 p.m. The diagnoses included, but were not limited to, congestive heart failure, depression, anxiety and hypertension. The incident report, dated 6/10/23 at 1:33 p.m., indicated Resident C had a medication error. The resident was sent to the hospital and diagnosed with a urinary tract infection. The progress note, dated 6/10/23 at 8:15 a.m., indicated QMA (Qualified Medication Aide) 4 administered the wrong medication to Resident C. The physician was notified with orders to obtain vital signs every 4 hours, check blood sugars every shift, hold the resident's morning medication, and to administer the resident's 12 p.m. medications as ordered. Review of the medication error report, dated 6/15/23, indicated QMA 4 administered Resident D's morning medications to Resident C which included the following: - Baclofen (medication for muscle spasms) 20 mg (milligrams) - Centrum Silver supplement - Divalproex (medication for convulsions) 1,500 mg - Metformin (medication for diabetes) 500 mg - Neurontin (medication used for pain) 400 mg - Oxcarbazepine (medication used for seizures) 600 mg - Paxil (antidepressant) 30 mg The clinical record lacked documentation of a physician's order for the above medications. The written statement from QMA 4, dated 6/13/23, indicated on 6/10/23, QMA 4 had two residents left to pass medications to, Resident C and Resident D. QMA 4 had both resident's medications ready. Prior to administration, QMA 4 was distracted when her aides asked her some questions along with a resident. She planned to go to Resident C's room. She grabbed Resident D's cup of medications instead of Resident C's and administered Resident D's medications to Resident C. When she returned to the medication cart, QMA 4 immediately realized the mistake and the physician was notified. During an interview on 1/17/24 at 1:19 p.m., QMA 4 indicated on the morning of 6/10/23, she only had two residents left to administer medication. She had gotten distracted when a couple of aides approached her during her medication pass. She planned to administer medication to Resident C and then Resident D. She grabbed Resident D's medications rather than Resident C's. She realized what she had done right after that. She reported to the charge nurse, DON, family and physician and followed the orders provided by the physician. On 1/18/24 at 10:49 a.m., QMA 4 indicated the 5 rights of medication administration were right person, right medication, right time, right dose and right route. On 1/18/24 at 9:40 a.m., the Executive Director provided a current copy of the document titled Medication Errors dated 11/02. It included, but was not limited to, Policy .It is the policy of this provider to ensure residents residing in the facility are free of medication errors . On 1/18/24 at 9:40 a.m., the Executive Director provided a current copy of the document titled Medication Administration dated 2/2010. It included, but was not limited to, Procedure Steps .Medications are prepared for one resident at a time .Perform the 5 rights of medication .Right Resident 2. The clinical record for Resident D was reviewed on 1/18/24 at 9:51 a.m. The diagnoses included, but were not limited to, cerebral palsy, convulsions, diabetes and depression. Review of the June 2023 medication administration record indicated the resident had the following morning medications ordered: - Baclofen 20 mg at 8:00 a.m. - Centrum Silver, one tablet between 7:00 a.m. and 11:00 a.m. - Divalproex 1,500 mg between 7:00 a.m. and 11:00 a.m. - Metformin 500 mg between 7:00 a.m. and 11:00 a.m. - Neurontin 400 mg at 8:00 a.m. - Oxcarbazepine 600 mg between 7:00 a.m. and 11:00 a.m. - Paxil 30 mg between 7:00 a.m. and 11:00 a.m. The Past noncompliance began on 6/10/23. The deficient practice was corrected by 6/15/23 after the facility implemented a systemic plan that included the following actions: All staff were educated on Medication pass policy/procedure which included the preparation of medications for one resident at a time and performing the 5 rights of medication administration of right person (6/15/23); one on one teaching and a medication pass observation completed with QMA 4. (6/15/23) 3.1-48(c)(2)

Based on observation, record review, and interview, the facility failed to ensure accuchecks (blood glucose level monitoring) were performed as ordered, and insulin pens were primed prior to administration of insulin for 2 of 3 residents reviewed for insulin administration. (Residents 258 and 9) Findings include: 1. During an observation on 5/17/22 at 8:42 a.m., LPN (Licensed Practical Nurse) 1 dispensed medications for Resident 258. She prepared amlodipine 5 mg (milligrams), aripiprazole 2 mg, citalopram 40 mg, ezetimibe 10 mg, farxiga 5 mg, and meloxicam 7.5 mg, by removing the medications out of the packaging and placing them directly into her bare, ungloved hand, and then placing the medication into a clear medication cup with bare fingers. The resident's order for an accucheck to be completed at 7:00 a.m. was highlighted in red as late. During an interview 5/17/22 at 8:45 a.m., LPN 1 indicated the Unit Manager had performed her accuchecks for her. She did not know if Resident 258 had received her accucheck and insulin, she would have to ask the unit manager if she had completed the task. During an interview on 5/17/22 at 8:48 a.m., the Unit Manager indicated she had not completed Resident 258's accucheck or administered her insulin. During an observation on 5/17/22 at 8:52 a.m., the Unit Manager obtained supplies and tested Resident 258's blood glucose level. The resident indicated during this time she had already eaten her breakfast. The resident's blood glucose level was 152 mg/dL. During an observation on 5/17/22 at 9:00 a.m., the Unit Manager attached the pen needle to Resident 258's tujeo insulin pen and dialed the pen to 35 units and administered the insulin to the resident's left upper quadrant. She did not prime the pen prior to the administration. The clinical record for Resident 258 was reviewed on 5/20/22 at 10:55 a.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus without complications. The physician's order, dated 5/13/22, indicated the resident received Tujeo SoloStar U300 Insulin 35 units twice daily between 7:00 a.m. and 11:00 a.m., and between 5:00 p.m., and 10:00 p.m. The physician's order, dated 5/14/22, indicated staff were to perform an accucheck daily at 7:00 a.m. and notify the physician if the accu check was below 60 or greater than 250 mg/dL. During an interview, on 5/17/22 at 8:55 a.m., the Unit Manager indicated she didn't realize the resident had an accucheck due. Typically the nurses did their accuchecks, and she was not necessarily responsible for them, but the nurse was the only nurse on the hall and they decided the Unit Manager would do the accuchecks for her to give some relief to the nurse. 2. During an observation on 5/17/22 at 11:37 a.m., The Unit Manager checked Resident 9's blood glucose level. The resident's blood glucose level registered as 216 mg/dL (milligrams per deciliter). The unit manager indicated the resident would receive her sliding scale insulin as well as the routine insulin. During an observation on 5/17/22 at 11:40 a.m., the Unit Manager applied a disposable needle to Resident 9's Humalog Kwikpen and dialed the pen to 20 units. She did not prime the needle or perform an air shot. She entered Resident 9's room, and administered 20 units of Humalog subcutaneously to the resident's left upper quadrant. The clinical record for Resident 9 was reviewed on 5/20/22 at 10:09 a.m. The diagnoses included, but were not limited to, type 2 diabetes mellitus with diabetic polyneuropathy. The care plan, initiated on 11/10/21 and last revised on 2/21/22, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to use of glucose lowering medications and or diagnosis of diabetes mellitus. The interventions included, but were not limited to, medications as ordered and monitor blood sugars as ordered. The physician's order, started on 3/30/22, indicated the resident received humalog kwikpen 100 unit/mL (milliliter) per sliding scale, as follows: If Blood Sugar is less than 60, call MD. If Blood Sugar is 0 to 150, give 0 Units. If Blood Sugar is 151 to 200, give 2 Units. If Blood Sugar is 201 to 250, give 4 Units. If Blood Sugar is 251 to 300, give 6 Units. If Blood Sugar is 301 to 400, give 8 Units. If Blood Sugar is 401 to 450, give 10 Units. If Blood Sugar is 451 to 500, give 12 Units. If Blood Sugar is greater than 500, call MD three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. The physician's order, started on 11/9/21, indicated the resident received insulin lispro insulin pen 100 unit/mL, 16 units subcutaneously three times daily at 7:00 a.m., 11:00 a.m., and 4:00 p.m. During an interview on 5/20/22 at 9:56 a.m., the DON (Director of Nursing) indicated Resident 9's accucheck had been performed late by the Unit Manager because the order for the accu check had not been put on the correct flowsheet. When the resident admitted , it had been put in her medications flowsheet instead of the diabetic flowsheet. Her accu check order being on the wrong flow sheet was the root cause of the late administration. If an administration was scheduled for 7:00 a.m., they had from 6:00 a.m. to 8:00 a.m. to administer it. An hour after the administration time it would turn red, and when it turned red it indicated the medication was late. Nursing staff had been instructed to prime insulin pens prior to use. Priming insulin pens was a standard of practice and the pharmacy had instructed them on how to do the priming when the pens first came out. During an interview on 5/20/22 at 10:33 a.m., the DON indicated she did not have a policy on the timing of accu checks, however she would expect staff to adhere to the same standards of medication administration for timing. If it was an accucheck for sliding scale insulin, the accucheck would be obtained before meals. The Insulin Pen Administration Skills Competency Procedure Steps, last reviewed 10/2019, provided on 5/17/22 at 2:11 p.m. by the DON, included, but was not limited to, . 8. Attach pen needle by twsting the needle onto the end of the insulin pen. 9. Pull off and remove outer pen needle protective cap and cover. 10. Prime the pen by dialing 2 units. (A small drop of insulin should be visible. If insulin does not appear, repeat) . 3.1-37(a)

Based on observation, and interview, the facility failed to ensure the nurse staffing informaatiion was posted daily for 4 of 5 survey days. Findings include: The following observations were made between 5/16/22 and 5/20/22: The staff posting could not be located on 5/17/22 at 9:30 a.m. The ED (Executive Director) indicated the location was in the hall by the DON (Director of Nursing). The holder was empty. The staff posting on 5/18/22 at 9:00 a.m., and 12:00 p.m., indicated a date of 5/17/22. The staff posting on 5/19/22 at 8:50 a.m., and 11:10 a.m., indicated a date of 5/17/22. The staff posting on 5/20/22 at 9:48 a.m. indicated a date of 5/19/22. During an interview on 5/20/22 at 11:15 a.m., the ED indicated the scheduler was responsible for posting the daily staff schedule. During an interview on 5/20/22 at 11:38 a.m., the DNS indicated the scheduler had worked the night shift and posted yesterday's staffing schedule that night, so she couldn't get the schedule out during the day. The Posted Nurse Staffing Data and Retention Requirements policy, dated July, 2019, was provided by the DON on 5/20/22 at 11:38 a.m. The policy included, but was not limited to, . The facility must post the following information at the beginning of each shift . 11. The nurse staffing data must be posted in a prominent place readily accessible to residents and visitors. 12. The Nursing Staffing Data should be updated each shift if there are changes to the daily posting . 3.1-17(b)

Based on observation, record review, and interview, the facility failed to ensure timely administration of medication for 2 of 34 administrations observed. (Residents 257 and 33) Findings include: 1. During an observation of medication administration on 5/17/22 at 8:37 a.m., LPN (Licensed Practical Nurse) 1 administered buspirone 5 mg, lorazepam 1 mg, and four tablets of primodone 50 mg to Resident 257. The medications were scheduled to be given at 7:00 a.m. and were highlighted in red in the EMAR (electronic medication record) as late. The clinical record for Resident 257 was reviewed on 5/20/22 at 11:15 a.m. The diagnoses included, but were not limited to, Parkinson's disease, depression, generalized anxiety disorder, and polyneuropathy. The physician's order, dated 5/2/22, indicated to administer buspirone tablet 5 mg three times daily at 7:00 a.m., 12:00 p.m., and 5:00 p.m. The physician's order, dated 5/4/22, indicated to administer primodone 50 mg tablet with a dosage of 200 mg, three times daily at 7:00 a.m., 12:00 p.m., and 5:00 p.m. The physician's order, dated 5/5/22, indicated to administer lorazepam 1 mg tablet three times daily at 7:00 a.m., 12:00 p.m., and 5:00 p.m. 2. During an observation of medication administration on 5/17/22 at 9:16 a.m., LPN 1 administered labetalol 300 mg, baclofen 5 mg, and hydralazine 50 mg to Resident 33 The medications were scheduled to be given at 7:00 a.m. and were highlighted in red in the EMAR (electronic medication record) as late. The clinical record for Resident 33 was reviewed on 5/20/22 at 11:11 a.m. The diagnoses included, but were not limited to, nontraumatic intracerebral hemorrhage, essential hypertension benign neoplasm of unspecified adrenal gland, traumatic hemorrhage of cerebrum with loss of consciousness of unspecified duration, hyperlipidemia, and hyperaldosteronism. The physician's order, dated 5/11/21, indicated to administer baclofen 5 mg three times daily at 8:00 a.m., 12:00 p.m., and 4:00 p.m. The physician's order, dated 11/22/21, indicated to administer hydralazine 50 mg four times daily at 8:00 a.m., 12:00 p.m., 4:00 p.m., and 8:00 p.m The physician's order, dated 11/29/21, indicated to administer labetalol 300 mg (millikgrams) twice daily at 7:00 a.m. and 5:00 p.m. During an interview, on 5/17/22 at 9:27 a.m., LPN 1 indicated she was the only nurse on the hall and had to administer medications to 26 to 28 residents. She typically ran late when she had that patient load. During an interview, on 5/20/22 at 9:56 a.m., the DON (Director of Nursing) indicated they tried to use four hour time frames for medications but if the medication had a specific time of administration, such as 7:00 a.m., they had to be administered within an hour before or after the scheduled time. One hour after the scheduled time it would turn red on the EMAR, which indicated the medication was late. The most current Medication Pass Procedure policy, last reviewed 12/2016, provided on 5/17/22 at 2:11 p.m., by the DON, included, but was not limited to, . Procedure Steps . 1. Medications administered within 60 minutes before and/or after time ordered . 3.1-48(c)(1)

Based on observation, record review, and interview, the facility failed to ensure proper catheter care, handling of the indwelling urinary catheter bag or tubing, and monitoring of urinary output or fluid intake for 4 of 4 residents reviewed for indwelling urinary catheters. (Residents 29, 25, 31, and 55) Findings include: 1. During an observation on 5/16/22 at 11:30 a.m., Resident 29's indwelling urinary catheter was at the bedside with 500 mL (milliliters) of tea colored urine in the catheter bag and tubing with a heavy amount of yellow mucus in the tubing but clear urine in the catheter bag. The resident indicated he had an infection and blood clots in the catheter bag. He wished the staff would take the catheter out. During an observation on 5/17/22 at 10:42 a.m., the resident was in his wheelchair participating in an activity in the dining room. The indwelling urinary catheter was hanging below the wheelchair. The catheter tubing was directly touching the floor. The urine in the bag was visible with 400 mL of yellow gold colored urine. The catheter tubing was resting directly on the floor. During an observation of catheter care for Resident 29, on 5/19/22 at 8:59 a.m., CNA (Certified Nursing Aide) 3 pulled down the resident's brief and with 3 swipes of the same area of the wipe and cleaned the crease to the right of the penis. She obtained another wipe and with 2 swipes of the same area of the wipe cleaned the right crease again. The resident was rolled onto his left side and the bowel was cleaned from the rectal area, using 2 swipes with the same area of the wipe from the testicles to the coccyx. She did this in the same manner 11 times. The resident was rolled onto his right side and the catheter bag was raised over the resident and placed onto the left side of the bed. LPN (Licensed Practical Nurse) 4, obtained a wipe and with 7 swipes with the same area of the wipe, she cleaned from the testicles to the coccyx. She obtained a wipe and cleaned the resident with 7 swipes again with the same area of the wipe from the testicles to the coccyx. She obtained a wipe and with 3 swipes with the same area of the wipe, cleaned under the testicles. She obtained a wipe and with 13 swipes with the same area of the wipe, cleaned from the testicles up the right and left creases in a back to front direction. The clinical record for Resident 29 was reviewed on 5/18/22 at 1:36 p.m. The diagnoses included, but were not limited to, Parkinson's disease, Iron deficiency anemia, benign prostatic hyperplasia with lower urinary tract symptoms, urinary tract infection, obstructive and reflux uropathy, and retention of urine. The care plan, dated 04/26/22 and last revised on 4/26/22 indicated the resident required an indwelling urinary catheter due to: obstructive uropathy related to BPH. The interventions, dated 4/26/22, included, but were not limited to, avoid obstructions in the drainage, change the catheter per MD (physician's) order, do not allow tubing or any part of the drainage system to touch the floor, encourage fluids, keep catheter system a closed system as much as possible, manipulate tubing as little as possible during care, monitor urinary output, position the bag below the level of the bladder, provide assistance for catheter care, report signs of a UTI (urinary tract infection), staff to record urinary output in mL, and store collection bag inside a protective dignity pouch. The Quarterly MDS (Minimum Data Set) assessment, dated 3/2/22, indicated the resident was cognitively intact. The resident was dependent with assistance for toileting. The physician's orders indicated the following: - Foley catheter care, the nurse was to record the output every shift with a start date of 4/25/22. - Document in mLs all fluids taken with medications, every shift with a start date of 11/16/18. - Urinalysis/Culture and Sensitivity Indications: complaints of pain in left lower quadrant dated 4/8/22. - Urinalysis/Culture and Sensitivity with a date of 4/11/22. - Cefdinir capsule 300 mg (milligrams) orally every 12 hours with a start date of 4/26/22. Discontinued on 4/27/22. - Bactrim DS tablet 800-160 mg (milligrams) orally daily with a start date of 4/27/22. Discontinued on 4/27/22. - Bactrim DS 800-160 mg orally twice daily with a start date of 4/28/22 to 5/1/22. - Lasix tablet 20 mg once daily starting 7/29/21. The Treatment Administration History, on 5/2/22 and 5/14/22 during the 10:00 p.m. to 6:00 a.m. shift, lacked documentation of urine output. On 5/10/22 during the 6:00 a.m., to 2:00 p.m. shift, lacked documentation of urine output. The Treatment Administration History, on 4/13/22 during the 6:30 a.m., to 2:30 p.m. shift, lacked documentation of fluid intake. The Treatment Administration History, on 3/7/22 during the 6:30 a.m. to 2:30 p.m. shift, lacked documentation of fluid intake. The nurse's note, dated 4/07/22 at 8:50 p.m., and recorded late on 4/8/22 at 12:12 a.m., indicated the resident was yelling out with complaints of pain to the left lower quadrant of the abdomen. He indicated he had a kidney stone and wanted to go to the emergency room. The nurse's note, dated 4/15/22 at 1:24 p.m., indicated the physician had reviewed the resident's recent laboratory results and ordered an appointment with a nephrologist, related to the resident's deteriorated kidney function. The nurse's note, dated 4/25/22 at 9:42 p.m., indicated the resident returned at 9:20 p.m., from a local hospital. He had a foley catheter 16 French placed and a diagnosis of a UTI. The physician ordered Cefdinir to start 4/26/22. The physician's order note, dated 4/27/22 at 12:49 a.m., indicated the resident was seen on 4/26/22 for transitional care and a follow-up from an emergency room visit. The follow-up call to the emergency room indicated from the information scanned, clearly revealed the patient had a foley catheter placed and it was difficult with a smaller caliber foley catheter being used. He had bacteria in his urine, which could be due to the urinary retention and not a classic UTI. In either case his bacteria was present and the ER doctor started him on an antibiotic and this will continue for short time. The nurse's note, dated 4/27/22 at 09:21 p.m., indicated the resident's urine was yellow with mucous present and was started on Bactrim DS today. The nurse practitioner 30 day visit note, dated 5/02/22 at 11:50 a.m., indicated the resident went to the ER last week for a UTI and urinary retention. The Urinalysis revealed 3+ blood and 4+leukocytes. The resident had a follow up appointment tomorrow with a urology center to evaluate the need for the ongoing indwelling foley catheter and/or to treat the resident for a bladder outlet obstruction. During an interview, on 5/19/22 at 9:25 a.m., CNA 3 indicated when performing catheter care she would wipe from front to back on the creases to each side of the penis, using one wipe with each downward motion. She would clean the penis in a circular motion at the tip of the penis. She would then clean down the tubing, from the penis down. 2. During an observation, on 5/18/22 at 9:42 a.m., Resident 25's indwelling urinary catheter was hanging on the left side of his bed. The catheter bag was full and the drain tube was hanging loose toward the floor. During an observation on 5/18/22 at 12:17 p.m., CNA 5 performed catheter care on Resident 25 with CNA 6, present. CNA 5, used sanitary wipes and with 3 swipes of the same area of the wipe and cleaned to each side of the penis. She obtained another wipe and with 2 swipes of the same area of the wipe cleaned down the crease to the left side of the penis. With 2 swipes of the same area of the wipe she cleaned the scrotum. She obtained a fresh wipe and with 2 swipes of the same area of the wipe cleaned the tip of the penis around the catheter tubing. The clinical record was review for Resident 25 on 5/18/22 at 8:55 a.m. The diagnoses included, but were not limited to, hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, focal traumatic brain injury, dementia, neuromuscular dysfunction of the bladder, morbid (severe) obesity due to excess calories, and lack of coordination. The care plan, dated 4/26/22 and last revised on 4/26/22, indicated the resident required an indwelling urinary catheter due to neuromuscular dysfunction of the bladder. The interventions, dated 4/26/22, included, but were not limited to, avoid obstructions in the drainage, change the catheter per MD order, do not allow tubing or any part of the drainage system to touch the floor, encourage fluidsc, keep the catheter system a closed system as much as possible, manipulate tubing as little as possible during care, monitor urinary output, position the catheter bag below the level of the bladder, provide assistance with catheter care, report signs of UTI, staff to record urinary output in mL, and store collection bag inside a protective dignity pouch. The Quarterly MDS assessment, dated 3/9/22, indicated the resident was cognitively intact. The resident was dependent for assistance for toileting. The physician's orders included the following: - Foley catheter care, nurse to record output every shift every shift with a start date of 12/8/21. - Document in mLs all fluids taken with medications every shift with a start date of 1/13/21. The nurse's note, dated 3/02/22 at 6:21 a.m., indicated the resident had blood coming out of his catheter and it was leaking out from the catheter tubing. The nurse's note, dated 4/12/22 at 6:33 a.m., indicated the nurse noticed a substantial amount of blood in the urine this morning, on the last bed check. The nurse's note, dated 4/12/22 at 9:31 p.m., indicated the resident continued to have blood in urine this shift, only had 100 mL of bloody urine output this shift. The nurse's note, dated 4/13/22 at 12:09 p.m., indicated the hospice nurse was in the facility and she irrigated the catheter. The input of the solution went in easily with no return noted. She removed the foley catheter and gave orders to monitor the urine output, if no output was observed and there was no abdominal distention by 4:00 p.m. today, to call the hospice company to get further instructions and notify a hospital. The nurse's note, dated 4/13/22 at 4:07 p.m., indicated the resident voided at this time, two small bloody lines were noted, not clumped, like a clot would be, but was in a line approximately 1 cm (centimeter) long. The urine on the blanket was clear in color. The hospice nurse was notified the resident had voided. She indicated she was coming to visit him later this evening. The nurse practitioner's note, dated 4/18/22 at 11:59 a.m., indicated a recent urine culture was reviewed. Bactrim 800 mg, two times daily for 7 days, through 4/25/22, was ordered for a 3 organism UTI. The bacteria was proteus, mrsa (methicillin resistant staphylococcus aureus), and pseudomonas (carbapenem resistant). The nurse's note, dated 4/20/22 at 7:01 p.m., indicated the hospice nurse was in this shift and an 18 French with 10 mL bulb foley catheter was inserted. The nurse's note, dated 5/07/22 at 9:29 p.m., indicated the resident had some urine leaking around the foley catheter bulb. It was deflated and only 8 mL was in the bulb and 10 mL of NS (Normal Saline) was put back in. Positive urine flow was attained and there was no complaints of pain or discomfort. The nurse's note, dated 5/11/22 at 1:32 p.m., indicated the indwelling urinary catheter was patent to bedside drain with dark yellow urine of an adequate amount. The Treatment Administration History, on 5/12/22 during the 6:00 a.m. to 2:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 5/13/22 during the 10:00 p.m. to 6:00 a.m. shift lacked documentation of urinary output. The Treatment Administration History, on 4/21/22 during the 10:00 p.m., to 6:00 a.m. shift lacked documented urinary output. The Treatment Administration History, on 3/2/22, 3/4/22, and 3/24/22 on the 10:00 p.m., to 6:00 a.m. shift on 3/2/22, 3/4/22, and 3/23/22 lacked documentation of urinary output. The Treatment Administration History, on 3/4/22 during the 10:00 p.m. to 6:00 a.m. shift lacked documentation of additional 240 mL of fluid intake. The Treatment Administration History, on 313/22 during the 6:00 a.m. to 2:00 p.m. shift lacked documentation of additional 240 mL of fluid intake. The Treatment Administration History, on 3/5/22, 3/8/22, 3/13/22, and 3/31/22 on the 6:00 a.m., to 2:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 2/25/22 on the 6:00 a.m., to 2:00 p.m., shift lacked documentation of urinary output. The Treatment Administration History, on 1/10/25, 1/21/22, 1/25/22, and 1/29/22 on the 10:00 p.m. to 6:00 p.m. shift lacked documentation of urinary output. The Treatment Administration History, on 1/22/22 on the 6:00 a.m. to 2:00 p.m., shift lacked documentation of urinary output. 3. During an observation on 5/16/22 at 10:10 a.m., the urine in the indwelling urinary catheter tubing and bag was a rusty red color for Resident 31. The resident indicated the catheter was supposed to be removed, but his appointment at the hospital appointment was cancelled. He wanted it removed, because of the discomfort. During an observation on 5/18/22 at 9:40 a.m., of the resident's indwelling urinary catheter bag and tubing, the urine in the lower half of the tubing was bloody, but the upper half of the urine in the tubing was yellow in color. There was only slight sediment in the tubing. The catheter bag was a quarter full of bloody urine. During an observation of catheter care on Resident 31, on 5/19/22 at 9:50 a.m., by CNA 7, she pulled down the brief and obtained a wipe. She cleaned the penis down the shaft to the tip of the penis. She cleaned in a downward motion, down the creases to the side of the penis. She obtained a wipe and with 2 swipes with the same area of the wipe, cleaned the right crease. She obtained a wipe and cleaned the penis down the shaft to the tip of the penis and obtained a clean wipe and cleaned down the penis to the tip again. She obtained a wipe and cleaned under the penis to the tip. She cleaned down onto the scrotum. She cleaned down the left crease, in a back to front direction. She cleaned down the shaft to the tip of the penis with 2 swipes with the same area of the wipe. She obtained a wipe and cleaned under the penis. She lifted the catheter bag above the resident, who was lying flat on his back, to remove the pajama bottoms. She folded the catheter bag to slip it down the pant leg. Orange urine with sediment was observed running back toward the urethra. She again lifted the catheter bag to slip the brief off the resident. She lifted the catheter bag again to remove the brief. She lifted the catheter bag again to put a clean brief on the resident. She lifted the catheter bag again to remove and readjust the brief. She lifted the catheter bag again to put it through the pajama bottoms, folding it in half to pull it through. Urine was observed running up and down the tubing. The clinical record for Resident 31 was reviewed on 5/16/22. The diagnoses included, but were not limited to, disorganized schizophrenia, bipolar disorder, hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, benign prostatic hyperplasia with lower urinary tract symptoms, Obstructive and reflux uropathy, anemia, hydronephrosis, muscle weakness, unsteadiness on feet, lack of coordination, dehydration, presence of urogenital implants, and retention of urine. The care plan, dated 3/28/22 and last revised on 4/13/22, indicated the resident required an indwelling urinary catheter for obstructive bladder outlet due to benign prostatic hyperplasia with lower urinary tract symptoms, was at risk for infection related to indwelling catheter. The interventions, dated 3/28/22, included, but was not limited to, observe for leakage, record outputs, notify the MD of any abnormal observations, avoid lying on top of tubing. measure and record intake and output, position the bag below the level of the bladder, and provide catheter care every shift and as needed. The admission MDS assessment, dated 4/3/22, indicated the resident was cognitively intact. The resident required partial to moderate assistance for toileting. The physician's orders included the following: - cephalexin capsule; 500 mg orally, three times daily, with a start date of 5/16/22. - Change the foley catheter and urinary drainage bag as needed for dislodgement, leakage or occlusion, as needed with a start date of 3/28/22. - Foley catheter care, nurse to record the output every shift with a start date of 3/28/22. The Urinalysis, dated 5/15/22, indicated >100 HPF, 4+ bacteria, 4+ WBC (white blood cell) clumps, occult blood fecal positive. >100,000 cfu/ (colony forming unit) escherichia coli. A nurse's note, dated 4/14/22 at 1:46 p.m., indicated the resident's indwelling urinary catheter was patent and draining clear yellow urine to the bedside drainage bag. A physician's note, dated 5/11/22 at 11:40 p.m., indicated the resident was going to have his indwelling urinary catheter taken out tomorrow. The physician talked with the resident about his creatinine of 2.9 mg/dL (per deciliter). He discussed needing to see nephrologist with the resident. The indwelling urinary catheter was damaged and was taken out. A nurse's note, dated 5/15/22 at 6:29 a.m., indicated the resident had 600 mL (milliliters) of urine in the indwelling urinary catheter bag. The resident had a large amount of urine in his brief. The catheter was removed, and the bulb had only 3 mL of sterile water. The catheter was hardly inserted. 2 unsuccessful indwelling urinary catheter insertion attempts were performed. A second nurse made a successful insertion of the indwelling urinary catheter. The urine was cloudy and yellow upon insertion A nurse's note, dated 5/15/22 at 1:33 p.m., indicated resident had bright red blood in his brief. The bathroom was checked, and bright red blood was observed on the floor and in the toilet. The resident had a large bowel movement in the toilet and the urine in catheter bag was bloody. The resident was weak, dizzy, and shaking. His blood pressure dropped when going from a lying to a sitting position. The resident was sent to a local hospital at 10:15 a.m. The local hospital was called at 1:30 p.m., and he was being admitted to the hospital for a gastrointestinal bleed. A nurse's note, dated 5/15/22 at 9:00 p.m., indicated the resident returned from the hospital emergency room with a diagnosis of a UTI, chronic anemia, and dehydration. The resident was given fluids while at the hospital and Rocephin. On 5/16/22 the resident was to start Keflex 500 mg 3 times daily for 10 days for the UTI. The indwelling urinary catheter was patent and draining well. The urine in the catheter bag was bloody. A nurse's note, dated 5/16/22 at 5:37 a.m., indicated the resident's indwelling urinary catheter was draining well through the night. 1000 mL of blood-tinged urine was measured. The antibiotic was started on this date for the UTI. During an interview on 5/16/22 at 10:10 a.m., the resident indicated he was recovering from a bad kidney infection. The catheter was changed yesterday, and it turned bloody afterwards. His urine had been yellow before it was changed. During an interview on 5/19/22 at 10:05 a.m., CNA 7 indicated for catheter care on a male resident, she would clean the front area. She would then pull back the foreskin away from the opening and clean from the tip down. She would fold the wipe between swipes and toss it. She would clean from the outside in (creases to each side, then the penis). She would then hold the tubing and clean down it. During an interview, on 5/19/22 at 12:39 p.m., the DON, indicated the resident had e-coli (escherichia coli bacteria) in the urine when the urinalysis was completed. He was able to take himself to the bathroom for bowel movements and was educated on keeping clean. 4. During an observation, on 5/19/22 at 9:36 a.m., CNA 6 performed catheter care for Resident 55. She unfastened the brief and obtained a wipe. She cleaned down the shaft of the penis, using 2 swipes with the same area of the wipe. The bed was lowered and the catheter bag in a dignity pouch landed on the floor. The clinical record for Resident 55 was reviewed on 5/10/22 at 2:03 p.m. The diagnoses included, but were not limited to chronic kidney disease stage 4 (severe), type 2 diabetes mellitus with diabetic chronic kidney disease, Urinary tract infection, benign prostatic hyperplasia without lower urinary tract symptoms, and neuromuscular dysfunction of the bladder. The care plan, dated 1/14/21, indicated the resident required an indwelling urinary catheter due to: neurogenic bladder. The interventions, dated 1/14/21, included, but were not limited to, do not allow tubing or any part of the drainage system to touch the floor, encourage fluids, manipulate tubing as little as possible during care, monitor urinary output, position bag below level of bladder, provide assistance for catheter care, and staff to record urinary output in mL. The Quarterly MDS assessment, dated 3/31/22, indicated the resident was cognitively intact. He was dependent on assistance for toileting. The nurse's note, dated 3/23/22 at 11:50 a.m., indicated a family member and the renal doctor discussed the current BMP (basic metabolic panel) focusing in on the creatinine level with concern on the increase in the lab. She spoke with both the resident and the family about their wishes to not proceed with treatments to aid in lowering the level specifically dialysis. Both resident and family agreed that dialysis was not an option with the health of the resident and the NP agreed it would not improve his quality of life. Palliative care was suggested. The nurse's note, dated 3/24/22 at 10:00 a.m., indicated the resident was complaining that the foley catheter was hurting and it was, replaced without difficulty instant returning light yellow urine. The nurse's note, dated 5/11/22 at 2:24 a.m., indicated the indwelling urinary catheter changed without incident. A number 18 French catheter with 10 mL bulb anchored to the bedside with clear yellow urine. The physician's orders included, but were not limited to the following: - Furosemide tablet 40 mg, orally, once a day starting on 8/30/21 - Cath orders: foley catheter care, Nurse to record output every shift, starting on 1/14/21 - Change foley catheter every 3 weeks once a day on Tuesdays, starting on 12/12/21. During an interview on 5/19/22 at 12:39 p.m., the DON indicated catheter care was ordered for every shift. Staff should perform hand hygiene and apply gloves. They should clean the creases to each side of the penis first, then the penis. They should clean in a circular motion, from the tip of the meatus of the penis and work around and down. The wipe should be discarded after each swipe, but could be folded and swiped. The tubing should then be cleaned by holding the tube at the tip of the penis and cleaning down the tube. During an interview, on 5/20/22 at 10:51 a.m., LPN 2, indicated she monitored residents for symptoms of a UTI, such as temperature, urinary output, sediment, urine color, pain, burning, fluid intake. The Indwellling Urinary Catheter Care, Emptying Drainage Bag & Catheter Removal, last reviewed December 2012 was provided by the Executive Director on 5/19/22 at 1:43 p.m. The policy included, but was not limited to, . 7. Using the non-dominant hand retrieve a wet soaped washcloth, cleanse the catheter in circular motion for about 10 cm (4 inches). Start where the catheter enters the meatus and down toward the drainage tube. 8. Change area on the washcloth or retrieve a new washcloth for consecutive passes along the catheter tubing. Do not rewipe the catheter . 3.1- 41(a)(1)