Based on interview, record review, and facility policy review, the facility failed to provide the Resident, or the Resident Representative (RR), written notification of the bed hold policy at the time of transfer for one (1) of 19 sampled residents. (Resident #60) Findings Include: A review of the facility's policy tiled, Bed Hold Notice Upon Transfer/Leave, dated 12/23, revealed, Bed Hold Agreement . If bed-hold due to hospital transfer or therapeutic leave becomes necessary, the facility will notify the resident or resident's representative of the bed-hold option . A review of the Progress Notes, dated 7/21/24 for Resident #60, revealed that the resident was transferred to the local hospital at 6:13 PM per local ambulance, due to bleeding from the dialysis shunt. On 10/02/24 at 2:14 PM, during an interview, the Accounts Manager (AM) stated that if the resident is their own Responsible Representative (RR), she provides the bed-hold and transfer letter to the resident. She further explained that if a resident is on Medicare, they must pay the facility for each day they are hospitalized . The AM emphasized the importance of residents receiving both letters each time they are transferred to the hospital, as Medicare will not pay both the hospital and the facility. The AM confirmed that she did not provide Resident #60 with the bed-hold letter for their hospitalization on 7/21/24, stating that she forgot to do it. She reiterated that residents must be informed each time they are hospitalized so they are aware that they must pay to hold their bed while in the hospital. On 10/03/24 at 3:30 PM, during an interview, the Licensed Nursing Home Administrator (LNHA) stated that she expects staff to follow the facility's policies and procedures regarding bed-hold notifications. A review of Resident #60's admission Record revealed that the facility admitted the resident on 04/02/24 with current diagnoses that included End Stage Renal Disease.

Based on staff interviews, record reviews, and facility policy review, the facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one (1) of 19 residents reviewed. (Resident #77). Findings Include: A review of the facility's policy titled, Resident Assessment, with the revision date of 09/19, revealed, An assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment. The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental, and psychosocial well-being . A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed, The ARD (Assessment Reference Date) (item A2300) must be set within 366 days after the ARD of the previous OBRA (Omnibus Budget Reconciliation Act) comprehensive assessment (ARD of previous comprehensive assessment + 366 calendar days) AND within 92 days since the ARD of the previous OBRA Quarterly or SCQA (ARD of previous OBRA Quarterly assessment + 92 calendar days). The MDS completion date (item Z0500B) must be no later than 14 days after the ARD (ARD + 14 calendar days) . A record review of Resident #77's admission Record revealed the facility admitted the resident on 08/29/23 and had current diagnoses that included Essential (Primary) Hypertension. A record review of Resident #77's admission MDS revealed an ARD of 09/07/23, and the last Quarterly MDS revealed an Assessment Reference Date (ARD) of 05/01/24. A record review of Resident #77's Annual MDS revealed Section A2300 with an ARD of 07/24/24 and Section Z0500B with a completion date of 09/17/24, which was more than 14 days after the ARD and greater than 366 days from the admission MDS and greater than 92 calendar days from the last quarterly assessment. A record review of the facility's Final Validation Report, with a submission date of 10/02/24 for Resident #77, revealed, Assessment completed late: Z0500B (assessment completion date) is more than 14 days after A2300 (assessment reference date). On 10/02/24 at 4:06 PM, during an interview with Licensed Practical Nurse (LPN) #1/MDS nurse, she explained that her corporate nurses had informed her that there was no such thing as a too early assessment. In August 2024, she realized Resident #77 had too many quarterly MDSs completed, and the quarterly assessment with an ARD of 07/04/24 was completed in error and inactivated, requiring her to redo the assessment as an annual assessment. She confirmed that Resident #77's Annual Assessment had an ARD of 09/07/23, and the last Quarterly Assessment had an ARD of 05/01/24. On 10/02/24 at 4:30 PM, during an interview with Registered Nurse (RN) #1, she confirmed that Resident #77's Annual Assessment was completed late. On 10/03/24 at 3:30 PM, during an interview with the Administrator, she explained that she was not aware of the late annual comprehensive MDS assessments. She explained that she expects her staff to follow the facility's policy and the RAI manual for completing and submitting MDS assessments on time and accurately, as this is critical to ensure that residents receive appropriate care, as well as reimbursement for services rendered.

Based on interviews, record reviews, and policy review, the facility failed to submit discharge and annual Minimum Data Set (MDS) assessments in a timely manner for three (3) of (19) resident MDSs reviewed. (Resident #55, #60, and #77). Findings Include: A review of the facility's policy titled, Resident Assessment, with the revision date of 09/19, revealed, An assessment will be completed on each resident utilizing the MDS. The reason for assessment, schedule and timeframes will be according to the guidance of the Resident Assessment Instrument (RAI) Manual. The Registered Nurse (RN) is responsible for verifying the completion of the assessment. The completed assessment guide the staff in identifying key information about the resident and serves as a basis for identifying resident specific issues and objectives in order to develop a care plan. This process assists the resident in reaching the highest practicable physical, mental, and psychosocial well-being . A review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). All other MDS assessments must be submitted within 14 days of the MDS Completion Date (Z0500B + 14 days). Resident #55: Rewritten A record review of the Batch #13 report revealed Resident #55 was discharged on 5/6/24 with return not anticipated. A record review of Resident #55's Discharge MDS with an Assessment Reference Date (ARD) of 05/06/24 revealed the discharge was completed on 10/02/24, more than 14 days after the required submission date. A record review of the facility's Final Validation Report for Resident #55 revealed that the assessment had a target date of 05/06/24 and was marked as completed late due to the delayed submission. A record review of Resident #55's admission Record revealed the facility admitted the resident on 05/01/24 with diagnoses that included Heart Failure, Unspecified. Resident #60: A record review of Resident #60's Progress Notes dated 07/21/24 indicated the resident was transferred to the hospital. A record review of Resident #60's Discharge MDS revealed that the assessment for the 07/21/24 discharge was in progress but had not yet been completed. A record review of Resident #60's admission Record revealed the facility admitted the resident on 04/02/24 with diagnoses that included Diverticulitis of the Large Intestine without Perforation or Abscess, End-Stage Renal Disease, and Type 2 Diabetes Mellitus. Resident #77: A record review of Resident #77's Annual MDS Section A2300 revealed an ARD of 07/24/24, while Section Z0500B indicated a completion date of 09/17/24, more than 14 days after the required submission date. A record review of the facility's Final Validation Report revealed that the assessment was submitted on 10/02/24, well beyond the required timeframe. A record review of Resident #77's admission Record revealed the facility admitted the resident on 08/29/23 and had current diagnoses that included Essential (Primary) Hypertension. On 10/02/24 at 4:10 PM, during an interview with Licensed Practical Nurse (LPN) #1/MDS nurse explained that Resident #55 was discharged to the hospital and passed away there. She confirmed that the discharge assessment was missed and that she planned to complete it that day. At 4:30 PM on 10/02/24, during an interview with Registered Nurse (RN) #1, she confirmed that the assessments for Resident #55 and Resident #77 were submitted late. On 10/03/24 at 3:00 PM, during an interview, LPN #1/MDS nurse confirmed that Resident #60's Discharge MDS with an ARD of 07/21/24 had not yet been completed, but she had started working on it. She emphasized that the facility follows the RAI manual for accurate and timely assessments. On 10/03/24 at 3:30 PM, during an interview with the Administrator, she explained that she was unaware of the missed and late MDS assessments. She stated that she expects staff to follow the facility's policy and the RAI manual for timely and accurate submission of MDS assessments, as they are critical to providing appropriate resident care and ensuring accurate reimbursement for services.

Based on observations, staff interviews, record reviews, and facility policy review, the facility failed to implement residents' care plans for three (3) of (19) care plans reviewed. (Residents #9, #36, and #68) Findings Include: A review of the facility's policy titled Care Plan Process, with the latest revision date of 08/17, revealed: Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive standardized assessment of each resident's functional capacity and needs, in relation to a number of specified areas (e.g., customary routine, vision, and continence). The results of the assessment, which must accurately reflect the resident's status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care . Care Area Assessments (CAA's) assist in guiding an individualized plan of care and should provide structure for the care and services that are needed . Resident #9: A record review of Resident #9's Comprehensive Care Plan with a problem onset date of 10/20/2023 revealed the resident had a suprapubic catheter with a diagnosis of urinary retention and bladder spasms, approaches included Secure cath (catheter) to prevent pulling. On 10/02/24 at 2:50 PM, an observation revealed Resident #9's suprapubic catheter was noted to be stretched and pulling taut on the skin over the resident's right flank. The catheter bag was hung on the wheelchair, and no catheter stabilizing device was in place to prevent pulling on the skin. At 3:15 PM on 10/02/24, during an interview, CNA #1 confirmed that the suprapubic catheter did not have a securement device, though it was required by the care plan. She explained that the device should have been in place. A record review of Resident #9's admission Record revealed the facility admitted the resident on 10/26/23, with a diagnosis of Urinary Retention. Resident #36: A record review of Resident #36's Comprehensive Care Plan revealed care concerns related to an indwelling catheter due to urinary retention, with interventions including enhanced barrier precautions (gown and gloves) during high-contact resident care activities. On 09/30/24 at 10:29 AM, during an observation Resident #36 was noted to have a catheter with bedside drainage and cloudy, yellow urine. Enhanced barrier signage was observed on the door and above the headboard. On 09/30/24 at 11:30 AM, during an interview, Licensed Practical Nurse (LPN) #2 explained that Resident #36 had been using a catheter for as long as she had worked at the facility. She also mentioned that the resident was on medication for Urinary Tract Infection (UTI) prophylaxis but could not recall when the resident had last experienced an infection. On 10/02/24 at 9:35 AM, during an interview, Resident #36, who was alert and oriented, stated she did not have any issues with her catheter. On 10/02/24 at 10:45 AM, an observation CNA #3 performing catheter for Resident #36, revealed the CNA applied gloves, however, the CNA did not wear a gown. On 10/02/24 at 2:45 PM, during an interview with CNA #3, she stated that while providing catheter care, she only wore gloves and did not wear a gown. CNA #3 explained that gowns were only required for other residents on contact isolation. However, signage on Resident #36's door and above the headboard indicated the need for a gown and gloves. At 3:00 PM on 10/03/24, during a follow-up interview, CNA #3 confirmed that the enhanced barrier signage required the use of both gown and gloves, and she acknowledged that she should have worn a gown. She confirmed that she had been trained in enhanced barrier and infection control protocols. A record review of Resident #36's admission Record revealed the facility admitted the resident on 02/17/21 with diagnoses that included Paraplegia. Resident #68: A record review of Resident #68's Comprehensive Care Plan with a date initiated of 8/18/24 revealed a plan for PEG tube care, with interventions including Enhanced Barrier Precautions to be worn during high-contact resident care activities. On 10/02/24 at 2:04 PM, during an observation of PEG (Percutaneous Endoscopic Gastrostomy) tube site care performed by Registered Nurse (RN) #3/Wound Care Nurse, the nurse gathered supplies in the hallway while wearing gloves but did not apply other Personal Protective Equipment (PPE), including a gown. Enhanced barrier signage was observed on the door. After completing the care, RN #3 disposed of the supplies and sanitized her hands in the hallway. On 10/02/24 at 4:24 PM, during an interview, RN #3 confirmed she had not worn a gown while providing PEG site care. She explained that she had not been trained in Enhanced Barrier Precautions and was unaware that gown use was required, despite the signage on the door indicating the need for both gown and gloves. A record review of Resident #68's admission Record revealed the facility admitted the resident on 08/01/23. Current diagnoses included Dysphagia following an unspecified Cerebrovascular Accident (CVA) with Hemiplegia and Hemiparesis. On 10/03/24 at 10:30 AM, during an interview with the Director of Nursing (DON), she explained that all staff had been trained on catheter care and Enhanced Barrier Precautions. She emphasized that she expects staff to always follow the policies and the residents' care plans. On 10/03/24 at 11:45 AM, during an interview with Registered Nurse (RN) #4/Care Plan Nurse, she confirmed that all residents with catheters have care plans requiring securement devices and enhanced barrier precautions, as indicated by signage on the resident's door. She emphasized that staff are expected to follow care plans while providing resident care, as the care plan provides essential interventions.

Based on observation, interviews, and facility policy review, the facility failed to ensure medications were secured in a locked storage area and available to only authorized personnel when medications were left at a resident's bedside for one (1) of (19) sampled residents. (Resident # 47) Findings Include: A review of the facility's policy titled Medication Storage, with revision date of 11/17, revealed .Medication storage shall meet all applicable federal, state, and local guidelines . At 10:30 AM on 09/30/24, during the initial tour, Resident #47's door was open, but the resident was not in the room. An observation revealed two (2) medications in boxes, including nasal spray and an inhaler, on the bedside table. At 11:54 AM on 09/30/24, during an observation and interview, Resident #47 was observed sitting in a wheelchair, ready for lunch, with the bedside table in front of the resident. The two (2) medications, including nasal spray and an inhaler, were still on the bedside table. Resident #47 explained that the nurse had left the medications there earlier that morning and stated, This happens sometimes, but the nurse gives me the medications. At 12:35 PM on 09/30/24, during an observation and interview, Licensed Practical Nurse (LPN) #2 was seen with the medication cart outside Resident #47's door. LPN #2 confirmed that she had accidentally left the medications and boxes in the room. She had just removed the two (2) medications from the room. LPN #2 stated that medications are not to be left in any residents' rooms at any time. At 10:35 AM on 10/03/24, during an interview with the Director of Nursing (DON), she stated that she was not aware that medications had been left in Resident #47's room. The DON explained that all medications should only be stored on the medication cart, and she does not expect medications to be left in any resident's room. She confirmed that Resident #47 did not have orders for self-administration of medications and should not have medications at the bedside. At 3:50 PM on 10/03/24, during an interview, the Administrator stated that she had been made aware of the incident involving medications being left at a resident's bedside. She confirmed that this was not standard practice and emphasized that all nurses were expected to follow practice standards to avoid complications. A record review of Resident #47's admission Record revealed that the facility admitted the resident on 07/13/22, with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD) with Acute Exacerbation and Allergic Rhinitis, Unspecified. A record review of Resident #47's Order Summary Report, with active orders as of 10/02/24, revealed an order with a start date of 7/1/24 for Azelastine HCl Nasal Spray 0.15% (205.5 mcg (microgram)/spray), two (2) sprays in both nostrils twice daily, for allergic rhinitis and an order dated 7/23/24 for Advair HFA Inhalation Aerosol 230/21 mcg/act (Fluticasone-Salmeterol), two (2) puffs orally twice daily, for COPD. No orders were noted for self-administration of medications or for medications to be left at the bedside. A record review of Resident #47's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/03/24 revealed a Brief Interview for Mental Status (BIMS) score of fifteen (15), which indicated the resident was cognitively intact.

Based on interviews, observations, record review, and facility policy review, the facility failed to provide a resident with a physician-ordered diet of chopped bite-size meats for one (1) of (19) sampled residents. Resident #1. Findings Include: A review of the facility's policy titled Dental Soft Mechanical Soft Diet, revised 2016, revealed . The diet should be individualized to meet a particular patient's needs . meats may be ground or diced based on the individual's tolerance . On 09/30/24 at 11:40 AM, during an interview, Resident #1 stated that her meat was supposed to be served in bite-size pieces, but it was often pureed. She expressed that she disliked pureed meat and would refuse to eat it. Resident #1 further noted that her meal ticket specified bite-size meat, but it was not consistently provided. On 09/30/24 at 11:58 AM, an observation of Resident #1's food tray revealed a baked pork chop that was shredded instead of being cut into bite-size pieces, as ordered. On 10/02/24 at 11:53 AM, during an observation and interview, Resident #1 was served ham that was cut into bite-size pieces on her lunch tray. She stated that the meat had been shredded the day before and was typically shredded, except for today. She explained that she preferred bite-size pieces, saying, It feels different in my mouth. I won't eat it if it's shredded. The resident was observed eating the bite-size ham during the interview. On 10/02/24 at 3:01 PM, during an interview, the Dietary Manager (DM) explained that a mechanical soft diet included soft food with chopped meat, emphasizing that there was a difference between bite-sized chopped meat and shredded meat. The DM stated that the diet orders should be followed exactly as written and that she expected her staff to adhere to those orders. On 10/03/24 at 3:35 PM, during an interview, the Licensed Nursing Home Administrator (LNHA) stated that she expected the dietary staff to serve residents meat in bite-sized portions, as per the physician's order. A review of Resident #1's admission Record revealed the resident was admitted by the facility on 02/10/22. The resident had diagnoses that included Dyspnea and Gastroesophageal Reflux Disease (GERD). A review of Resident #1's Order Summary Report, with active orders as of 10/3/23, revealed a diet order, with a start date of 7/1/24 revealed LCS/NSOT (low concentrated sweets)/(no salt on tray) Mechanical soft texture, Regular consistency, WITH BITE SIZED MEATS. A review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24 revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. A review of Resident #1's meal ticket dated 10/2/24 revealed the diet listed as LCS/NSOT/BITE SIZE Mechanical Soft.

Based on observations, staff and resident interviews, record review, plan of correction review, and facility policy review, the facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) Program, as evidenced by one (1) re-cited deficiency originally cited in February 2023 on an annual recertification survey for (1) of two (2) annual recertification surveys reviewed. Findings Include: A review of the facility's policy titled Preface - QAPI, dated 11/22, revealed: Our residents are the primary concern of this facility. This facility is committed to providing the highest quality of life supported by quality care for the aged and convalescent resident. To ensure resident health, safety, and proper care and treatment, each facility shall maintain a manual consisting of policies and procedures to detail effectively the scope of services .This manual shall serve as a guideline for the staff to .accomplish the goals and objectives of the facility . During observation, interviews, and record review on 10/2/24, the facility failed to maintain proper infection control practices related to hand hygiene during percutaneous endoscopic gastrostomy (PEG) tube and catheter care. A record review of the facility's previous federal recertification survey, dated 02/02/2023, revealed the facility was cited for failing to follow hand hygiene guidelines during catheter care, and a plan of correction (POC) was developed and accepted. On 10/03/24 at 1:00 PM, during an interview with the Administrator, she explained that the Quality Assurance and Assessment (QAA) committee meets quarterly to discuss high-risk areas, including hand hygiene. She stated that the team regularly reviews concerns and develops action plans to address deficiencies. On 10/03/24 at 3:00 PM, during a follow-up interview with the Administrator, she confirmed that the facility had been cited for deficiencies in hand hygiene during the previous survey and acknowledged that while the facility implemented the POC, it failed to maintain compliance with the hand hygiene policy. She attributed the ongoing issue to high staff turnover, particularly among the Directors of Nursing (DON). The Administrator explained that the facility had employed five (5) different DONs in the past two (2) years, with the current DON previously serving as Assistant Director of Nursing (ADON) for six (6) months. The Administrator emphasized that training staff appropriately amid high turnover had been a challenge in implementing the corrections fully. The Administrator further confirmed that she reviewed the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction) and confirmed that while the facility completed all aspects of the correction plan, it failed to consistently implement the hand hygiene protocol.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and facility policy review, the facility failed to ensure infection control measures were followed to prevent the possible spread of infection as evidenced by, not following enhanced barrier precautions, improper hand hygiene and glove changes and allowing a urinary catheter bag to touch the floor for three (3) of (19) sampled residents. (Resident #9, Resident #36, and Resident #68) Findings Include: A review of the facility's policy titled Infection Control, revised on 04/21, revealed The facility will maintain an Infection Control Program, designed to provide a safe, sanitary, and comfortable environment where residents reside with minimal exposure to the development and transmission of disease and infection . Handwashing is the most to effective means of infection prevention . A review of the facility's policy titled, Hand Hygiene, revised on 01/24, revealed, Purpose: To cleanse hands to prevent transmission of infection or other condition . To provide clean, health environment for residents, staff and visitors .Indications for Hand Washing . 3. Before and after procedures. 4. Before and after applying gloves . A review of the facility's policy titled Enhanced Barrier Precautions, revised on 03/24, revealed, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices . A review of the facility's policy titled Urinary Catheter, revised 01/24, revealed, .25. Clip drainage tubing to edge of mattress. Position drainage bag lower than bladder by attaching to fixed part of bed frame. Do not attach to side rails of bed . Resident #9 On 10/2/24 at 2:50 PM, during an observation of catheter care and a suprapubic catheter flush for Resident #9, Certified Nurse Aide (CNA) #1 and CNA #2, as well as Licensed Practical Nurse (LPN) #2 placed the catheter drainage bag on the floor a total of seven (7) times. During an interview of 10/2/24 at 3:15 PM, CNA #1, confirmed that putting the resident's urinary drainage bag on the floor could possibly lead to a urinary tract infection for the resident and could also lead to possible spreading by infection through cross contamination. During an interview on 10/2/24 at 3:20 PM, CNA #2 confirmed that by placing the urinary drainage bag on Resident #9's floor, it could cause infection. During an interview with LPN #2 on 10/3/24 at 9:48 AM, she stated that she did not notice that the catheter drainage bag was allowed to touch the floor, however, she confirmed that allowing contact with the floor, it could cause complication for Resident #9 related to Urinary Tract Infections (UTI's) and other infections from contamination. During an interview with the Director of Nurses (DON) on 10/3/24 at 10:33 AM, the DON revealed that staff are in-serviced yearly and taught to avoid letting the urinary drainage bags touch the floor. The DON confirmed that allowing the urinary drainage bag to lay on the floor could increase the risk of complications related to increased urinary tract infections. A record review of the admission Record revealed the facility admitted Resident #9 to the facility on [DATE]. The resident had diagnoses that included Infection and Inflammatory Reaction due to Cystostomy Catheter, Paraplegia, and Extended Spectrum Beta-Lactamase (ESBL) Resistance. A record review of the Quarterly Minimum Data Set (MDS), with Assessment Reference Date of 7/17/24, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. A record review of the Order Summary Report revealed an order for a Suprapubic Catheter 18 F (French) 30 cc (cubic centimeter), change as needed for malfunction, occlusion or leakage (urinary retention) every 24 hours as needed, dated 7/27/24. Resident #36 During an observation on 10/02/24 at 2:45 PM, during catheter care revealed CNA #3 did not put on a gown and wore only gloves, despite Enhanced Barrier signage requiring both gown and gloves. During care, CNA #3 failed to change gloves after cleaning the resident's bowel movement (BM) and continued to provide care with the same gloves. On 10/02/24 at 3:00 PM, CNA #3 confirmed she should have worn a gown and changed gloves between dirty and clean tasks. A record review of Resident #36's admission Record revealed the facility admitted the resident on 02/17/21. The resident had diagnoses that included Retention of Urine, unspecified. A record review of Resident #36's Order Summary Report, with active orders as of 10/3/24, revealed an order, dated 10/3/24, for an indwelling catheter; 16 FR (French) 10 cc (cubic centimeter). Change as needed for malfunction, occlusion or leakage (Urinary retention) every 24 hours as needed for Urinary Retention. A record review of Resident #36's Annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/11/24, revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. Resident #68 On 10/02/24 at 2:04 PM, during an observation of Percutaneous Endoscopic Gastrostomy (PEG ) tube care performed by Registered Nurse (RN) #3/Wound Care Nurse. During the procedure, the nurse did not wear a gown, despite Enhanced Barrier Precaution signage on the door, requiring the use of gown and gloves during high-contact. RN #3 also failed to perform hand hygiene between glove changes. During the procedure, RN #3 applied a clean dressing without changing gloves or performing hand hygiene. At 4:24 PM on 10/02/24, RN #3 confirmed that she had not followed the facility's infection control protocols and acknowledged that her actions posed a risk of infection to the resident. A record review of Resident 68's admission Record revealed the facility admitted the resident on 08/01/23. The resident had diagnoses that included Dysphagia Following Cerebral Infarction (stroke). A record review of the Order Summary Report, with active orders as of 10/3/24, revealed an order dated 8/18/24 Clean PEG TUBE SITE to ABDOMEN with normal saline. Apply SPLIT GAUZE DAILY . A record review of Resident #68's MDS with an ARD of 08/23/24 revealed a BIMS score of three (3), which indicated the resident had severe cognitive impairment. On 10/03/24 at 9:55 AM, the Director of Nursing (DON) confirmed that the facility had conducted training on Enhanced Barrier Precautions and that staff should wear Personal Protective Equipment (PPE), including gowns, when providing care for residents with wounds, catheters, or PEG tubes

Based on staff and Resident Representative (RR) interviews, record review, and facility policy, the facility failed to protect private health information for one (1) of six (6) sampled residents. (Resident #6) Findings Include: A review of the facility's policy titled, Confidentiality of Resident Information, with a revision date of 05/18 revealed, Policy: The health record is the property of the health care facility and is maintained to serve the resident, the health care providers, and the institution in accordance with legal regulatory requirements. All resident care information shall be regarded as confidential and available only to authorized users . On 6/26/24 at 10:30 AM, during a telephone interview with the RR for Resident #3, she stated that on 6/18/24, she went to the facility to retrieve copies of her brother's medical records from the facility Administrator. The RR stated that she also received three (3) pages of the medical records of Resident #6. A record review of copies of the three (3) pages of medical records belonging to Resident #6 that were given to the RR of Resident #3, revealed that they were copies of a Dialysis Transfer Summary, dated 6/18/24 for Resident #6. On 6/26/24 at 2:48 PM, during an interview with the Administrator, she confirmed that on 6/18/24, she provided the RR of Resident #3 with 1,300 pages of medical records belonging to Resident #3. The Administrator confirmed that she reviewed his medical records prior to giving them to the RR and that to her knowledge, she provided no other residents' medical records. The Administrator stated that the facility is supposed to protect the residents' health records. Since the RR received copies of medical records belonging to Resident #6, then she must have accidentally given the RR of Resident #3 medical records that did not belong to Resident #3. A record review of the Face Sheet, for Resident #3 revealed the facility admitted the resident on 5/6/24. The resident had diagnoses that included Hemiplegia, of the Left Non-dominant Side and Chronic Obstructive Pulmonary Disease. A record review of the Face Sheet, for Resident #6 revealed the facility admitted Resident #6 on 6/6/24. The resident had diagnoses that included End Stage Renal Disease and Type 2 Diabetes Mellitus.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure staff followed the facility's infection control guidelines while disinfecting a glucose meter after use for one (1) of one (1) observations of disinfecting glucose meters. (Resident #67) Additionally, the facility failed to ensure staff followed appropriate hand washing protocol while performing wound care for one (1) of one (1) wound care observations. (Resident 23). Resident #67 Review of the facility's policy, Infection Control and Isolation, with a revision date of 01/12, revealed, Policy: The facility will establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection . Review of the facility's policy, Blood Glucose Quality Control, with a revision date of 08/22, revealed, . Maintenance of Blood Glucose Monitoring Systems .Always clean the meter after each use. Gently wipe and clean surface of the meter with a disinfectant wipe per facility policy . Please follow all facility infection control policies when using the meter . A review of the manufacturer'sGeneral Guidelines For Use guidelines for use for Sani-Cloth® germicidal disposable wipes revealed .3b. Unfold a clean wipe and thoroughly wet surface. 4. Allow treated surface to remain wet for two (2) minutes. Let air dry . On 02/07/23 at 11:45 AM, an observation of Licensed Practical Nurse (LPN) #1 performing a finger stick for glucose monitoring of Resident #67, revealed after use of the multi-resident use glucose meter, the nurse wiped the glucose meter with a Sani-Cloth® for approximately 15 seconds prior to placing it in the red basket on the counter at the nurse's station, containing the glucose test strips, lancets, and alcohol wipes. On 02/09/23 at 10:03 AM, in an interview with LPN #1, she revealed after using the glucose meter, she wiped the meter for 15 seconds, with a bacteria wipe, before placing it back in the red basket at the nurse's station. She explained she should have cleaned it more and let it dry before placing it in the basket. She confirmed residents could get sick with an infection from her not cleaning it properly and using it for other residents. On 02/09/23 at 10:15 AM, in an interview with the Director of Nursing (DON), she confirmed LPN #1 did not properly disinfect the meter, as she did not allow it to air dry before placing it back in the basket. The DON confirmed the actions of LPN #1 could transfer germs to the other supplies in the basket. Record review of the Face Sheet for Resident #67 revealed, the facility admitted the resident on 04/08/22 with diagnoses that included Type 2 Diabetes Mellitus (DM) , Chronic Kidney Disease, and Essential Hypertension. Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/11/23, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Record review of the February 2023 Physician Orders, for Resident #67 revealed an order dated 04/08/22, Blood glucose finger- CHECK BLOOD SUGAR BEFORE MEALS AND AT BEDTIME (DM). Record review of Annual Licensed Nurse Skill Competency Evaluation, dated 11/11/22, revealed LPN #1 was able to correctly demonstrate glucometer usage and cleaning. Resident #23 Record review of the facility's policy Hand Hygiene with latest review date 08/21 revealed . Purpose To cleanse hands to prevent transmission of infection or other conditions. To provide clean, health environment for residents, staff, and visitors . Procedure Indications for Hand Washing . 2. Hand hygiene should be performed between all contact with residents or when entering and exiting a resident's room. 3. Before and after procedures. 4. Before and after applying gloves . On 02/09/23 at 09:00 AM, during an observation of wound care with LPN #2, assisted by Certified Nursing Assistant (CNA) #1 revealed LPN #2 entered Resident #23's room. She did not wash or sanitize her hands upon entering the room or prior to beginning the wound care procedure. She applied a clean pair of gloves, removed, and disposed the soiled dressing, and applied a clean pair of gloves but did not wash or sanitize her hands before applying the gloves. When LPN #2 completed the wound care, she removed her soiled gloves, but she did not wash or sanitize her hands following the completion of the procedure. She did not wash or sanitize her hands upon exiting the resident's room. On 02/09/23 at 09:50 AM, during an interview with LPN #2, she confirmed that she did not wash or sanitize her hands prior to and upon completion of the wound care and when changing her gloves. She stated that not washing or sanitizing her hands could possibly spread infection during wound care. On 02/09/23 at 10:00 AM, during an interview with the DON, she confirmed that nurses should wash or sanitize their hands upon entering or exiting a resident's room and also when removing and applying gloves. She said not performing hand hygiene could cause infection to the wound. On 02/09/23 at 11:55 AM, during an interview with Registered Nurse (RN) #1/Infection Preventionist, she explained LPN #2 should have washed her hands prior to and after wound care and also when she removed her soiled gloves and applied a clean pair of gloves. She said that this practice could cause infection to be spread to the wound, causing the wound not to heal, and the resident could become sick due to infection. Record review of Face Sheet revealed the facility admitted Resident #23 on 11/02/2021 with diagnoses that included Alzheimer's Disease. Record review of Annual MDS with an ARD of 12/22/22, revealed Resident #23 had a BIMS score of four (4), which indicated she had severe cognitive impairment. Section M also revealed that Resident #23 had two (2) unstageable wounds. Record review of Licensed Nurses Orientation Checklist for LPN #2 revealed on 12/21/22 she received training on hand hygiene and wound care.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide privacy during the administration of enteral medication for Resident #64 and for continuous enteral feedings for Resident #72; for two (2) of six (6) residents observed for privacy during medication pass and for residents with enteral feedings. Findings include: A review of the facility policy titled Administering Medications through Nasogastric or Gastrostomy Tube, revised 3/2018, revealed to provide privacy to the resident. A review of the facility policy titled, Resident Rights, dated 11/17, revealed the residents residing at this facility would be provided personal privacy, which included any medical treatment. A review of the facility policy titled, Gastrostomy/Nasogastric Tube, dated 12/18, revealed that during the administration of tube feedings, to provide privacy and explain procedure to resident. Resident #64 An observation on 07/17/19 at 1:54 PM, revealed Licensed Practical Nurse (LPN) #3, while administering enteral medications, left Resident #64's door open and only pulled the middle curtain between the other resident in the room. LPN #3 pulled Resident #64's gown up to under her breast, which was covered, and the sheet was pulled down to the top of the thigh. LPN #3 also went to the door and asked for a cup, but did not close the door. LPN #3 provided the medication per enteral tube, per the Medication Administration Record (MAR) on 7/17/19 at 2:00 PM. An interview on 7/17/19 at 2:15 PM, with LPN #3, revealed it was policy for the door to be closed during care and he usually did close the door, but he was nervous. LPN #3 said that he would expect a reasonable person to want the door closed when administering an enteral medication. In an interview on 7/17/19 at 3:00 PM, the Director of Nursing stated it was not the facility policy to leave the door open during any care, and she would expect the door to be closed while administering the enteral medications for the resident's privacy. A review of Resident #64's Minimum Data Set (MDS) with the Assessment Reference Date (ARD) of 6/14/19, revealed severely impaired cognition. Resident #64 was unable to verbalize when asked about the door being open. A review of Resident #64's face sheet revealed diagnoses of unspecified sequelae of unspecified Cerebrovascular Disease and Aphasia. Resident #72 An observation on 07/16/19 at 12:22 PM, revealed the Certified Occupational Therapy Assistant (COTA) brought Resident #72 to the main dining room, with a percutaneous endoscopic gastrostomy (PEG) tube feeding infusing via a feeding pump; the pump/tube/bag was exposed and not covered. An observation on 07/17/19 at 01:32 PM, revealed Resident #72 to be in the Therapy Department with the PEG tube feeding exposed and not covered. In an interview on 07/17/19 at 02:00 PM, LPN #2 stated, concerning Resident #72, We've never covered the PEG Tube, no one ever told us to do that. In an interview on 07/17/19 at 02:05 PM, Certified Nursing Assistant (CNA) #1 stated, We've never covered the PEG tubes. In an interview on 07/18/19 at 12:02 PM, the Director of Nursing (DON) stated, They have never covered the PEG tube feeding bags up. The DON also stated, I do not have a policy for PEG tubes being covered. In an interview on 07/18/19 at 2:17 PM, Resident #72 stated, I don't understand about the PEG Tube.

Based on observation, staff interview, record review, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) related to discharge for one (1) of 24 resident MDS assessments reviewed, Resident #86. Findings include: A review of the Resident Assessment Instrument (RAI) Manual dated October 2017, chapter 2.1, revealed the RAI process is the basis for the accurate assessment of each resident. A review of the most recent MDS with an Assessment Reference Date (ARD) of 6/24/19, revealed a Discharge End of Prospective Payment System (PPS) Assessment Return not Anticipated was coded with the discharge status being acute hospital. Review of a nurse progress note, dated 6/24/19, revealed Resident #86 was discharged from the facility on 6/24/19, to home. Review of physician's orders, dated 6/24/19, documented to discharge Resident #86 home with all medications, with Home Health Services. On 07/18/19 at 9:21 AM, an interview with the Medical Records Nurse, Licensed Practical Nurse (LPN) #7, revealed Resident #86 was discharged to home. On 07/18/19 at 10:36 AM, an interview with LPN #1 revealed the resident was admitted for short-term rehabilitation, received therapy, and was discharged home. She also confirmed the most recent discharge End of Therapy Assessment indicated the resident was discharged to an acute hospital. She stated that is not an accurate MDS assessment of the resident because she went home. LPN #1 stated she will have to make a correction. On 7/16/19 at 3:05 PM, an interview with the Director of Nurses (DON) revealed she would expect the MDS to be coded accurately.

Based on facility policy review, staff interview, and record review, the facility failed to develop a care plan related to the diagnosis of Depression for one (1) of 24 resident care plans reviewed, Resident #70. Findings include: A review of facility policy titled Care Plan Process, revised 08/17, revealed: Regulations require facilities to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident's functional capacity and need in relation to a number of specified areas. The results of the assessment, which must accurately reflect the residents status and needs, are to be used to develop, review, and revise each resident's comprehensive person-centered plan of care. The Resident Assessment Instrument (RAI) will be used to determine guidelines for revisions and completion dates for the Comprehensive Care Plan. A review of Resident #70's Comprehensive Care Plan, dated 5/24/19, revealed no care plan for Anxiety, or Depression. A review of Physician's Orders, dated 5/24/19, revealed Resident #70 was prescribed Cymbalta and Seroquel with a Diagnosis of Depression. A review of a Physician's Order, dated 6/28/19, revealed to ADD the diagnosis of Anxiety/chronic pain for Cymbalta. The order also showed to decrease Seroquel and taper to discontinue medication. A review of the July 2019 Physician's Orders, revealed Resident #70 was prescribed Cymbalta with a diagnosis of Anxiety and Seroquel for a diagnosis of Depression on 6/28/19. An interview on 07/18/19 at 08:05 AM, with Licensed Practical Nurse (LPN) #5/Assessment Nurse/Care Plan Nurse, revealed, If a care plan is created, then I expect all staff should follow the care plan. If a care plan needs updating, it should be updated. After reviewing Resident #70's care plan, I see it was not developed to reveal diagnoses of Depression and Anxiety. LPN #5 stated that Comprehensive Care plans are developed to provide care for the resident. LPN #5 confirmed that there was no care plan developed for Depression or Anxiety for Resident #70. An interview on 07/18/19 at 08:50 AM, with the Director of Nursing (DON), revealed a care plan should have been created for Resident #70 to show diagnoses of anxiety and depression and the medication Resident #70 was taking at the time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, staff interview, and record review, the facility failed to revise the comprehensive care plan related to an antipsychotic medication for one (1) of five (5) residents reviewed for unnecessary medication review, Resident #34; and, failed to revise the comprehensive care plan related to catheter care for one (1) of four (4) residents care plans reviewed for catheter care, Resident #3. Findings include: A review of facility policy titled, Care Plan Process, revised 08/17, revealed: The results of the comprehensive assessment, which must accurately reflect the residents status and needs, area to be used to develop, review, and revise each resident's comprehensive person centered plan of care. The Resident Assessment Instrument (RAI) will be used to determine guidelines for revisions and completion dates for the Comprehensive Care Plan. Resident #34. A review of the Comprehensive Care Plan, initiated 8/15/18, revealed Resident #34's care plan for Antipsychotic Medications was not updated to reveal current Psychotropic Medication usage of Seroquel, Buspirone, and Zoloft. The care plan included the use of Risperdal. A review of the July 2019 Physician Orders, revealed Resident #34 was prescribed Buspirone 10 milligram (mg) twice daily for Anxiety on 4/23/19; Zoloft 75 mg daily related to Depression on 2/15/19; and Seroquel 12.5 mg at bedtime related to Psychosis on 4/23/19. There was no order for Risperdal. An interview on 07/18/19 at 8:05 AM, with Licensed Practical Nurse (LPN) #5/Assessment Nurse/Care Plan Nurse, after reviewing Resident #34's Comprehensive Care Plan on the computer, confirmed a care plan was not updated for current Psychotropic medication; she stated that the care plan should have been revised. An interview on 07/18/19 at 08:50 AM, with the Director of Nursing (DON), revealed if a care plan is written it should be updated and followed by staff. The DON stated that Resident #34's care plan should have been updated to reveal current antipsychotic medications. A review of face sheet revealed Resident #34 was admitted to the facility on [DATE], with diagnoses of Major Depressive Disorder and Unspecified Psychosis. Resident #3 A review of the Comprehensive Care Plan for Resident #3, with a problem onset of 5/9/17, revealed that the Care Plan for an Indwelling Catheter had not been updated for the use of a leg bag drainage system or positioning while in bed with use of the leg bag. Observation of Resident #3 and interview with LPN #6, on 07/16/19 at 10:00 AM, revealed Resident #3 was lying flat in bed with both legs up on the bed. A Catheter bag was felt on the right leg through the resident's pants to be located below the knee at the lower leg level. Resident #3's pants leg was pulled up slightly to view the bag, which contained urine. LPN #6 confirmed the resident had a leg bag drainage system for the catheter. An interview on 07/18/19 at 08:30 AM, with Licensed Practical Nurse (LPN) #5, Assessment Nurse/Care Plan Nurse, confirmed the Catheter care plan should have been updated to reflect a leg bag catheter, positioning of the resident, and catheter care for Resident #3. An interview on 07/18/19 at 08:50 AM, with the Director of Nursing (DON), revealed catheter care for Resident #3 should have been updated on the care plan to reveal a leg bag and positioning while in bed for proper tube drainage. An interview on 07/18/19 at 08:50 AM, with Registered Nurse (RN) #1/Infection Control Nurse, revealed the Indwelling Catheter Care Plan should reflect positioning of Resident #3 while lying in bed and placing the drainage bag below the level of the bladder. A review of face sheet for Resident #3 revealed the facility admitted the resident on 5/12/16, with a diagnosis of Urethral stricture.

Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent cross contamination and trauma to the bladder for one (1) of two (2) catheter care observations for Resident #3. Findings include: A review of facility policy titled: Perineal Care-Resident with Catheter, revised 10/18, revealed: The purpose of the policy is to prevent irritation or infection. When preparing for care, perform hand hygiene and apply gloves. While performing perineal care, secure the catheter tubing to one leg without causing traction of the urethra. Once perineal care has been provided, unfasten the tubing from the leg. Using one hand hold the catheter close to the urethral opening to prevent tension as you wash the tubing. Do not let the tubing cause traction on the urethra opening at any time. Use a clean washcloth or wash wipe, start as the meatus and wash the tubing in a circular motion away from the body about 4-5 inches. Rinse in the same method. Observe the tubing for any cracks, breaks or occlusions. Observe the urine in the tubing for any sediment, blood or discoloration. Re-secure the tubing to the resident's leg once it has been cleaned. Ensure tubing is not kinked or coiled and is not positioned above the level of the bladder. Remove gloves. Perform hand hygiene. An observation on 07/17/19 at 1:50 PM, revealed Certified Nurse Aide (CNA) CNA #3 performed catheter care on Resident #3 and CNA #2 assisted. CNA #3 gloved and assisted CNA #2 to pull Resident #3 up in bed. CNA #3 used the same gloves to unbutton Resident #3's pants and to pull his pants down. Resident #3 was lying flat on his bed with both legs up on bed. Resident #3's head of bed (HOB) was flat. The Indwelling urinary Catheter was located at Resident #3's right ankle with the strap loosened but intact on his leg. CNA #3 then un-taped Resident #3's brief and when she went to pull the brief from between his legs Resident #3 yelled out, it hurts. The Indwelling catheter bag tubing was noted to be pulled very tight. CNA #3 then removed the brief from between Resident #3's legs and left the brief lying under Resident #3 buttocks. CNA #3 did not change her gloves or wash her hands after pulling Resident # 3 up in bed, pulling Resident #3's pants down or after pulling brief from between Resident #3's legs. The Indwelling Catheter tubing was pulled tight from Resident #3's penis to the bag located at ankle. CNA #3, with assistance from CNA #2, reached and pulled the catheter drainage bag up on Resident #3's leg and reattached the strap to hold the bag above Resident #3's knee. The catheter bag/tubing was never detached from the leg during perineal care. Resident #3's right leg was bent in a position that the bag was pointing down towards the tubing, allowing the urine to possibly flow back into the tubing/bag. Approximately 250 cubic centimeters (cc) of urine was noted in the catheter drainage bag at this time. CNA #3 took an unfolded wash cloth and applied soap and water, wiped Resident #3's right groin with one (1) sweep downward, then tossed the cloth around in her hand and wiped the left groin area downward, and then tossed and flipped cloth again to wipe the left groin a final time. The wash cloth was then discarded in a bag. There was no way to determine the area used on cloth was not a repeat area. CNA #3 then took another wash cloth with soap and water and wiped the right groin area downward then tossed cloth around in hand, wiped the left groin area downward, and then tossed the cloth in her hand again and wiped the left groin a final time. CNA #3 dried the area with a towel. CNA #3 took another washcloth with soap and water, pulled back the foreskin on the head of the penis, and wiped it with the soapy cloth. CNA #3 then tossed the cloth in her hand and took her fingers and held the catheter tubing at the point it joins the catheter bag and wiped the tubing upwards toward Resident #3's penis. CNA #3 was then told by CNA #2 to hold the tubing at the base of the penis. CNA #3 then tossed the cloth in one hand and moved her other hand to hold the catheter at the base entering the penis and wiped down the tubing towards the catheter drainage bag. CNA #3 then rinsed and dried the tubing. CNA #3 then removed the old brief from under Resident #3's buttocks, applied a new brief and pulled Resident #3's pants back up. CNA #3 still had the same gloves on as used during the entire process. An interview on 07/17/19 at 2:12 PM, with Licensed Practical Nurse (LPN) #4, revealed that Resident #3 does have a catheter with a leg drainage bag and it is supposed to be anchored to his thigh so it won't move. LPN #4 stated, We are supposed to keep the bag below the bladder for drainage. LPN #4 stated that the head of the bed should be elevated when Resident #3 is lying in bed. LPN #4 stated that she could see how with Resident #3 lying flat in bed with the catheter drainage bag strapped to his leg and the drainage bag not being below the bladder, could possibly allow the urine to backflow into the tubing and possibly back into the bladder. LPN #4 stated It could very well cause an issue. If the bag is not secured where it will not move, it could cause a problem to the urethra. LPN #4 stated that she didn't think the bag could possibly be below the bladder with Resident #3 lying flat in bed. LPN #4 stated that Resident #3 should always have the head of the bed elevated so that the bag would be below the bladder. LPN #4 confirmed that Resident #3 had numerous appointments with a Urologist. LPN #4 reviewed Resident #3's chart and revealed that Resident #3 had appointments with the Urologist on 4/3/19, 5/14/19, 5/6/19, 6/13/19 and 7/2/19 (appointment rescheduled for 7-10-19 per daughter). Resident had a diagnosis of Urinary Retention. An interview on 07/17/19 at 02:27 PM, with CNA #3, revealed that she had changed Resident #3's linens before doing catheter care and she had left Resident #3 lying flat on the bed. CNA #3 stated that she did not know how long the catheter strap had been loosened or how long the catheter bag had been located at Resident #3's ankle, since she had not assisted him to the restroom today. CNA #3 stated that she remembered holding the catheter at the top of the bag and wiping upward on the catheter tubing towards the head of the penis during catheter care and then she caught herself and moved her hand to hold the tubing at the penis and then she wiped down. CNA #3 stated she did toss the cloth in her hand during catheter care and wiped with the same cloth three (3) times when washing and rinsing Resident #3's catheter tubing and washing his groin area. She stated the cloth was not folded but, I could tell where I was on the cloth, I can assure you. CNA #3 could not demonstrate with a clean cloth how she could determine what area on the cloth was used. CNA #3 stated that she just knew what area had been used . CNA #3 verified the wash cloth was not folded but rather moved around in her hand to different areas. CNA #3 stated she did not wash hands or change gloves after removing the dirty brief from between Resident #3's legs and before doing catheter care. An interview on 07/17/19 at 02:27 PM, with CNA #2, confirmed CNA #3 did wipe upward on the catheter tubing towards the penis while doing catheter care. CNA #2 stated that CNA #3 was nervous and she was trying to talk her through it. She stated that CNA #3 grabbed the tubing at the bag and not at the head of penis and wiped upward on the tubing. CNA #2 stated that CNA #3 did toss the cloth in her hand and she could see where it might be hard to tell where she was on the cloth and to know if she was using a clean area on the cloth. An interview on 07/18/19 at 08:30 AM, with RN #1/Infection Control Nurse, revealed that It was an infection control issue with CNA #3 not washing her hands appropriately through-out the catheter care process. It was an infection control issue with CNA #3 tossing the cloth in her hand after wiping an area and then wiping another area. It could have been cross contamination. RN #1 confirmed CNA #3 holding the catheter tubing at the base of the drainage bag and wiping the catheter tubing upward towards the head of the penis could have caused trauma to the Urethra with the tubing pulled so tight. It could cause a urinary tract infection with him lying flat in bed and the bag being at the ankle. An interview on 07/18/19 at 8:30 AM, with the Director of Nursing (DON), revealed, I agree with the statements made by Registered Nurse (RN) #1. We do work hard at training our CNA's on infection control and catheter care. Record Review revealed Resident #3 had the following diagnoses: Urinary tract infection, Retention of Urine, Benign prostatic hyperplasia with lower urinary tract, Unspecified complication of genitourinary prosthetic device/graft, Chronic kidney disease, and Unspecified urethral stricture. Record Review of Physician Orders dated July 2019, revealed Resident #3 ordered Pyridium 100 milligram (mg) tablet three (3) times a days needed for bladder pain, since 7/7/17. Record Review of Physician Orders dated 5/15/19, revealed Resident #3 received an order for the Antibiotic Ciprofloxacin for Urinary Retention.

Based on observation, staff interview, record review, and facility policy review, the facility failed to prevent possible spread of infection during catheter care by not providing a barrier, washing hands or changing gloves for one (1) of two (2) catheter care observations, for Resident #3. Findings include: A review of facility policy titled, Infection Prevention and Control Program dated 06/14, revealed, The facility has developed and maintains an infection prevention and control program that provides a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. A review of facility policy titled Infection Control Nursing Department Responsibilities dated 6/14, revealed the urinary drainage bags must always be kept below the level of the bladder to prevent the urine from flowing back into the bladder. A review of facility policy titled Infection Control dated 5/11, revealed handwashing is the most simple and effective means of preventing infection. A review of facility policy titled Perineal Care-Resident with Catheter, revised 10/18, revealed: The purpose of the policy is to prevent irritation or infection. When preparing for care, perform hand hygiene and apply gloves. Using one hand hold the catheter close to the urethral opening to prevent tension as you wash the tubing. Do not let the tubing cause traction on the urethra opening at any time. Use a clean washcloth or wash wipe, start as the meatus and wash the tubing in a circular motion away from the body about 4-5 inches. Rinse in the same method. Remove gloves. Perform hand hygiene. An observation on 07/17/19 at 1:50 PM, revealed Certified Nursing Assistant (CNA) #3 performed catheter care with the assistance of CNA #2. CNA #3 placed two (2) clear bags at foot of bed stating that they were for dirty linen and trash. CNA #3 enter the restroom in Resident #3's room and washed her hands, dried them with paper towels, and then turned the faucet off with her bare hands. CNA #3 obtained a wash basin and ran water into basin then took the wash basin over to the Resident #3's bed and placed it on the bed without a barrier under it, then placed it on a towel on the over-bed table. CNA #3 then donned gloves. CNA #3 assisted CNA #2 to pull Resident #3 up in bed. CNA #3 used the same gloves to unbutton Resident #3's pants and to pull his pants down. CNA #3 then un-taped Resident #3's brief and pulled the brief between his legs. CNA #3 removed the brief from between Resident #3's legs and left the brief lying under Resident #3 buttocks. CNA #3 did not change her gloves or wash her hands after pulling Resident # 3 up in bed, pulling Resident #3's pants down or after pulling the brief from between Resident #3's legs. The Indwelling Catheter tubing was pulled tight from Resident #3's penis to the bag located at ankle. CNA #3 pulled the catheter drainage bag up on Resident #3's leg and reattached the strap to hold the bag above Resident #3's knee. CNA #3 performed catheter care tossing the unfolded washcloth around after each wipe of the tubing and groin area, so that it wasn't possible to determine if a different area of the cloth was used. Resident #3's right leg was bent in a position that the bag was pointing down towards the tubing allowing the urine to possibly flow back into the catheter bag. CNA #3 pulled back the foreskin on the head of the penis and wiped it with a soapy cloth. CNA #3 then tossed the cloth in her hand and then CNA #3 took her fingers and held the catheter tubing at the point it joins the catheter bag and then wiped the tubing upwards toward Resident #3's penis. CNA #3 removed the old brief from under Resident #3's buttocks and rolled Resident #3 over and applied a clean brief and pulled the resident's pants back up. CNA #3 picked up the wash basin and dumped the water in toilet, took a paper towel and dried the inside of the basin out. CNA #3 still had the same gloves on as used during the entire process. CNA #3 returned to Resident #3's bedside and removed the towel from the over-bed table and placed it in the dirty linen bag that was on the foot of Resident #3's bed. CNA #3 picked up the bag with the dirty brief in it, tied it, and then placed the dirty bag on top of the over-bed table without a barrier on the table. CNA #2 told CNA #3 to remove the bag containing the dirty brief from the over-bed table and place it back on the bed until she was finished. CNA #3 removed the bag and placed it back on the foot of Resident #3's bed. CNA #3 removed her gloves and went to bathroom where she washed her hands. CNA #3 dried her hands with a paper towel and then turned the faucet off with her bare hands. An interview on 07/17/19 at 02:12 PM, with LPN #4, revealed, We are supposed to keep the bag below the bladder for drainage. LPN #4 stated that if Resident #3 is lying flat in bed, she could see how urine might could possibly drain back up into the catheter tubing. LPN #4 stated It could very well cause an issue. LPN #4 reviewed Resident #3's chart and confirmed that Resident #3 had appointments with the Urologist on 4-3-19, 5-14-19, 5-6-19, 6-13-19 and 7-12-19. She confirmed that Resident #3 had a diagnosis of Urinary Retention. An interview on 07/17/19 at 02:27 PM, with CNA #3, revealed that she recalled holding the catheter at the top of the bag and wiping upward on the catheter tubing towards the head of the penis during catheter care. CNA #3 stated she did toss the cloth in her hand during catheter care and wiped with the same cloth three (3) times when washing and rinsing Resident #3's catheter tubing and washing his groin area. CNA #3 verified the wash cloth was not folded but rather moved around in her hand to different areas. CNA #3 stated she did wash her hands and then turn the faucet off with her clean hands. CNA #3 confirmed she did not wash hands or change gloves after removing dirty brief from between Resident #3 legs and before doing catheter care. An interview on 07/17/19 at 02:27 PM, with CNA #2, confirmed CNA #3 did wipe up on the catheter tubing towards the penis while doing catheter care and did put the dirty bag on the over-bed table after the towel used as a barrier was removed. CNA #2 stated that CNA #3 did toss the cloth in her hand and she could see where it might be hard for CNA #3 to tell where she was on the cloth and to know if she was using a clean area on the cloth. An interview on 07/18/19 at 08:30 AM, with RN #1/Infection Control Nurse, revealed that It was an infection control issue with CNA #3 not washing her hands appropriately through-out the catheter care process and with her touching the faucet to turn it off after washing her hands. RN #1 confirmed it was an infection control issue with CNA #3 tossing the cloth in her hand after wiping an area and then wiping another area; it could have been cross contamination. An interview on 07/18/19 at 08:30 AM, with the Director of Nursing (DON), revealed, I agree with the statements made by Registered Nurse (RN) #1. Record Review of the Physician Orders List dated 5/15/19, revealed Resident #3 received an order for the Antibiotic Ciprofloxacin for Urinary Retention. Record Review of the July 2019 Physician Orders, revealed Resident #3 was ordered Pyridium 100 milligram (mg) tablets three (3) times a days needed for bladder pain. Record Review for Resident #3 revealed diagnoses of the following: Urinary tract infection, Retention of Urine, Benign prostatic hyperplasia with lower urinary tract, Unspecified complication of genitourinary prosthetic device/graft, Chronic kidney disease, and Unspecified urethral stricture.