**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, interview, and policy review the facility failed to ensure urinary catheter care was provided and failed to assess the resident's urinary status and condition when the resident experienced no urinary output for two days and minimal output the third day resulting in transfer to the hospital for treatment of a clogged urinary catheter. This affected three residents (#14, #66, and #80) of three residents reviewed for urinary catheters. Actual Harm occurred on 02/12/25 when the facility failed to provide timely and necessary indwelling urinary catheter care to Resident #80 resulting in increased pain and the resident being transferred to the hosptial. Hospital care included replacing the urinary catheter, treatment with continuous bladder irrigation, and pain management due to the facility failure to properly and timely irrigate the urinary catheter, accurately assess the resident's condition, and monitor urinary output. Findings Include: 1. Closed medical record review revealed Resident #80 was admitted on [DATE] with diagnoses including chronic lymphocytic leukemia of B-Cell, stage four chronic kidney disease, malignant neoplasm of kidney and brain, neuromuscular dysfunction of bladder, and benign prostatic hyperplasia with lower urinary tract symptoms. The resident discharged to the hospital on [DATE] and did not return to the facility. Review of Resident #80's alternation in elimination plan of care initiated 02/07/25 and revised on 04/22/25 (after the resident discharged from the facility) revealed to assess for abdominal distention as needed initiated on 04/22/25, change Foley catheter per physician orders and as needed initiated on 02/07/25, empty Foley catheter every shift and as needed initiated on 02/07/25, irrigation per physician orders initiated on 04/22/25, and medicate per physician order initiated on 04/22/25. Review of the five-day minimum data set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of four indicating the resident had severe cognitive impairment. The assessment also revealed the resident had an indwelling urinary catheter (Foley catheter). Review of Resident #80's urinary output dated 02/2025 revealed no output was documented for 02/10/25 or 02/11/24, and only 100 ml on 02/12/25. Review of Resident #80's progress note authored by the Assistant Director of Nursing (ADON) dated 02/11/25 at 10:49 A.M., revealed the resident's urine in the foley was clear, yellow, and patent. The note included the resident had not had any significant changes in the last 24 hours. Review of Resident #80's progress note authored by Licensed Practical Nurse (LPN) #104 dated 02/12/25 at 11:35 A.M., revealed urine was normal. There had not been any significant changes in the last 24 hours with the resident. Review of Resident #80's progress note authored by LPN #104 dated 02/12/25 at 3:45 P.M., revealed the resident continued to have bright red blood draining into the Foley. The physician was notified and stated if the bleeding or discomfort continued tomorrow to send the resident to the emergency room and keep attempting to flush the Foley. Review of Resident #80's progress note authored by Registered Nurse (RN) #102 dated 02/12/25 at 7:00 P.M., revealed the family came to the nurse's station just after shift change around 6:35 P.M. and asked for the resident's Foley to be irrigated. The author informed the family that she would be down as soon as possible. The wife also asked if there was anything else that could be done and the author informed her that the doctor said that staff could send the resident to the emergency room. The wife stated, No I don't want him going over there. The author told the wife once again she would be down as soon as possible. At 6:50 P.M., a certified nursing assistant (CNA) came and told the author that the resident's wife told her that if her husband was not sent to the emergency room within 20 minutes she was going to call the police about the lack of care. The transport company was called, and the resident left the facility via stretcher at 7:00 P.M. Review of Resident #80's progress note authored by RN #102 dated 02/12/25 at 11:42 P.M., revealed the resident returned from the emergency room with a new three way 16 french Foley and continuous bladder irrigation (CBI) was done at the emergency room. New orders to follow up with the urologist within one week. Review of Resident #80's emergency room notes dated 02/12/25 revealed at 7:16 P.M. and 7:30 P.M. the resident's blood pressure was 132/91 mg/Hg and pulse was 118 (beats per minute). The resident's wife reported his heart rate was normal for him, but he was also in pain from his distended bladder. The resident appeared quite uncomfortable and was administered Toradol 15 milligrams (mg) IV for pain, Urispas and Pyridium for bladder spasms. A bladder scan was performed at 7:32 P.M., that indicated the resident had greater than 600 milliliters (ml) of urine in the bladder. At 8:43 P.M., there was minimal drainage noted from the foley catheter after multiple attempts to flush the current catheter. A three-way catheter was placed. Several small and moderate size clots were noted in the tubing with flushes. The note included continuous bladder irrigation (CBI) ordered. At 10:56 P.M., CBI was completed with 2500 ml of clear pale colored urine returned. Review of Resident #80's hospital discharge summary records dated 02/12/25 revealed the resident was seen for Foley malfunction and the resident was brought in from the skilled nursing facility for complaints of blood in his urine after having his catheter removed today. There was a large amount of gross red blood noted in the catheter bag. The resident was in pain from a distended bladder. The bladder scan noted greater than 600 milliliters (ml) of urine. It was noted the resident had a clot blocking the catheter passage. A triple-lumen catheter was placed instead of a two way which can be irrigated properly. The discharge summary included to follow-up with urologist in one week. Further review of Resident #80's progress notes dated 02/12/25 revealed no evidence the urinary Foley was changed or irrigated and no documented evidence included as to when the blood was first noted in the Foley. Review of Resident #80's orders and medication and treatment administration records dated 02/2025 revealed no evidence Resident #80's Foley catheter was changed by facility staff or irrigated. Further review revealed on 02/12/25 LPN #104 administered Tylenol 650 milligrams (mg) at 3:54 P.M., for a pain rated an eight out of 10 (1-10 pain scale). The follow up indicated the Tylenol was effective however there was no time noted when the medication was effective or pain rating noted. Interview on 04/21/25 at 9:29 A.M. with Resident #80's wife (a retired nurse) revealed on 02/11/25 she noticed blood in the resident's Foley bag. Staff told her it was due to the resident pulling on his Foley sometime during the night. On 02/12/25 when she came to visit her husband she stated there was blood in the Foley bag. She stated she had to beg for the nurse to irrigate and change the Foley. LPN #104 attempted to irrigate the Foley while the resident was in his wheelchair, which was not effective. The wife reported the resident should have been laid down in bed to properly irrigate the Foley. The LPN got blood on the floor in the resident's room and did not clean it up. LPN #104 then changed the Foley about 2:00 P.M. and no urine was ever obtained, just frank blood. There was no urine output for the rest of the afternoon. The wife asked the evening change shift nurse (Registered Nurse (RN) #102) to check the blood and she reported she would get to it later that she had discharges, tube feeds, and had no time to check the blood with no urine out in the foley bag. The resident's wife stated the resident was in so much pain she had requested the resident to go to the emergency room. The emergency room inserted a three-way catheter and continuously flushed the catheter until it was clear. The resident was transported back to the skilled facility. RN #102 never came back to the room to check the resident in. The emergency squad remarked that nurse should have come back to check the resident in. The next day, 02/13/25 the wife stated she had spoken to the Director of Nursing (DON) who defended the nurses stating the nurse had to triage care. Interview on 04/22/25 at 1:52 P.M., with Licensed Practical Nurse (LPN) #104 revealed she recalled Resident #80. The LPN recalled the resident had blood in his Foley bag for a couple days because he was attempting to get out bed unattended and was pulling on his Foley. The LPN confirmed she had changed the resident's urinary Foley and attempted to irrigate the Foley without success. The LPN reported the resident ended up going to the emergency room for treatment. Interview on 04/23/25 at 7:21 A.M., with the Director of Nursing (DON) confirmed there were no orders to change Resident #80's Foley or irrigate the Foley. The DON confirmed the resident had 100 ml output on 02/12/25 and there was no documentation of urine output on 02/10/25 or 02/11/25. The DON also confirmed there was no documented evidence the physician was notified the Foley irrigation was not successful or the resident had no output after the Foley was changed. The DON confirmed to irrigate a Foley the resident should have been laid down and irrigation should not have been attempted while the resident was sitting up in a wheelchair. Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 2. Medical record review revealed Resident #66 was admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of the bladder, cerebrovascular disease, diabetes, chronic kidney disease, and paralysis. Review of Resident #66's alteration in elimination (indwelling Foley catheter) dated 09/26/25 and revised on 04/21/25 revealed to empty Foley catheter every shift and as needed, irrigation per physician orders, monitor for signs and symptoms of urinary tract infection (UTI) including foul smelling urine. Report to physician to seek diagnoses and treatment promptly. Review of Resident #66's infection care plan related to indwelling Foley catheter dated 09/26/24 revealed to monitor for signs and symptoms of UTI: foul smelling urine, cloudy urine, sediment, and decreased output. Review of Resident #66's urinary output revealed at 5:20 A.M. on 04/22/25 the resident had 500 ml of urine output. Review of Resident #66's progress notes dated 04/21/25 and 04/22/25 revealed no evidence of milky urine. The last urinary assessment completed was dated 03/23/25 that indicated the resident had a Foley catheter that was draining cloudy yellow urine. Review of Resident #66's progress notes dated 04/22/25 and 04/23/25 revealed no evidence the physician had followed up on the resident's foul milky urine. Review of Resident #66's orders and medication and treatment administration orders dated 03/2025 to 04/2025 revealed no evidence to change the Foley drainage bag or irrigation. The Foley was last changed on 03/13/25. Observation on 04/22/25 at 7:18 A.M. of Resident #66's Foley catheter with Certified Nurse Aide (CNA) #113 revealed the urine was not visible due to the Foley bag was tinted and the urine was not visible. This observation was confirmed with CNA #113. At this time, CNA #113 emptied the Foley catheter and the urine was milky in color and had a strong odor. Resident #66 had 150 ml out (was just emptied at 5:20 A.M). Observation on 04/22/25 at 7:40 A.M. of Resident #66 with the DON revealed the bag was tinted and the urine was not visible. The DON requested the nurse to change out the bag and tubing and to update the doctor on the resident's urine being milky and see if he wanted a urinalysis. Interview on 04/22/25 at 10 :00 A.M. with Licensed Practical Nurse (LPN) #173 and the DON revealed LPN #173 changed the Foley bag but had not faxed the doctor yet regarding the milky urine. The DON confirmed the order to change the urinary bag, and irrigation was just added today. Interview on 04/22/25 at 10:51 A.M. LPN #161 revealed she had provided care to Resident #66 last week and her urine was orange in color which was normal for her because she had a diagnosis diabetes. Interview on 04/23/25 at 8:45 A.M., with the DON revealed the nurse had faxed the physician yesterday (04/22/25) regarding the resident's urine being milky and had an odor, however there was no evidence the physician had responded back to the fax yet. Interview on 04/23/25 at 9:16 A.M., with the DON revealed the physician had called back this morning and he wanted a urinalysis with a culture and sensitivity to be done tomorrow since the resident was not having symptoms. Interview on 04/28/25 at 10:20 A.M., with the DON via email revealed Resident #66's urine culture and sensitivity was positive for Proteus Vulgaris (Bacteria) and Klebsiella Aerogene (Bacteria) on 04/26/25 and the physician ordered Cipro 250 mg twice daily for seven days this morning (04/28/25). Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. 3. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including transient cerebral ischemic attack, multiple sclerosis, neuromuscular dysfunction of bladder and heart failure. Review of Resident #14's alteration in elimination care plan related to supra pubic catheter and neuromuscular bladder dated 09/26/24 revealed to change appliance per physician orders, intermittent catheterization per orders, irrigation per physician orders and change supra pubic catheter every 30 days in the morning, if unable to get in, send the resident to the hospital per physician. Review of the urology note dated 03/18/25 revealed to change supra pubic catheter every 30 days in the A.M. If unable to get in, send the resident to the hospital per urologist in the morning every 30 days. Review of Resident #14's current orders dated 04/2025 revealed no evidence of orders to change the resident's catheter every 30 days, irrigation, or changing equipment (bag). Interview on 04/21/25 at 1:10 P.M., with the DON confirmed the resident did not have current orders to change the supra pubic catheter every 30 days, irrigation, or changing the catheter bag. The DON reported the resident was hospitalized last month and the orders were not re-written on re-admission. Interview on 04/22/25 at 7:15 A.M., with the DON revealed the resident had to be sent to the emergency room due to staff attempted to change the supra pubic catheter but were not successful. The last time the resident's catheter was changed was on 03/22/25 because he refused to have it changed on 03/21/25. Review of the facility's policy titled Foley Catheter Care, undated, revealed the Foley catheter bag would be changed as needed, the catheter would be replaced as needed, or in accordance with physician orders. The staff would monitor intakes and output and record finding on the MAR, as needed. The staff would observe and report to the licensed nurse any signs or symptoms of UTI to include blood, odor, cloudiness, pain, elevated temperature, or absence or decrease in urine output. This deficiency represents non-compliance investigated under Master Complaint Number OH00164936, Complaint Number OH00164233.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide one resident (Resident #23), who required staff assistance for activities of daily living, adequate assistance during toileting and locomotion to prevent accidents. Actual Harm occurred on 12/03/18 when Resident #23 was being assisted in the bathroom by State Tested Nursing Assistant (STNA) #600. After assisting the resident to stand, the STNA let go of the resident, resulting in the resident falling. The resident exhibited increased pain, resulting in an emergent hospital visit and diagnosis of a right hip fracture. Actual Harm occurred on 02/15/19 when Resident #23 was being escorted by STNA #553 in her wheelchair to the dining room without her required right foot pedal, resulting in the resident's foot bending under the wheelchair resulting in an ankle fracture. In addition, facility failed to provide adequate supervision and follow-up investigation related to wandering behavior exhibited by Resident #19. This affected two of six residents reviewed for accidents. Findings include: 1. a) Record review revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including history of falling, need for assistance with personal care, muscle weakness, difficulty walking, right foot drop, and hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side. Review of Resident #23's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident's cognition was intact. The assessment indicated the resident required extensive two person assistance with transfers and toileting, and had impairment on one side of the upper and lower extremity. Review of Resident #23's health status note, dated 12/03/18 at 7:05 P.M. revealed the nurse was called to the resident's room by STNA #600 and notified that the resident had fallen. On entering the room, the nurse observed the resident lying on the bathroom floor with her right shoulder and head against the door frame. Resident #23 complained of pain to the right hip and ringing in the ears. Resident #23 continued to verbalize pain in the right hip throughout the assessment, and orders were obtained to transfer the resident to the emergency room. Review of Resident #23's x-ray report, dated 12/03/18 revealed the resident had a comminuted right intertrochanteric fracture (right hip fracture). Review of the facility fall investigation related to Resident #23's fall on 12/03/18 revealed STNA #600's hand written witness statement, dated 12/03/18 indicating she took Resident #23 to bathroom to get ready for bed. The STNA was providing care without assistance. The statement indicated Resident #23 stood up off the toilet just fine, but when the STNA turned away to get toilet paper off the back of the toilet, the resident started to fall. STNA #600 stated she tried to grab her but was not quick enough and the resident landed hard on her right hip. The fall investigation contained no evidence STNA #600 was using a gait belt. Review of the health status note, dated 12/04/18 at 11:09 A.M. revealed the interdisciplinary team noted the resident was in the bathroom with STNA #600 assisting with peri care and changing the resident into bed clothes. Resident #23 stated she was holding onto the bar when her right leg gave out and she fell onto her right side landing on floor. Resident #23 had a history of hemiplegia and hemiparesis to the right side following a stroke, and she complained of pain rated an eight out of ten to her right hip and shoulder. Resident #23's right hip and shoulder were slightly reddened. Resident #23 was sent to the emergency room and was admitted with a right hip fracture. Review of Resident #23's health status note, dated 12/08/18 at 5:43 P.M. revealed the resident was re-admitted to the facility and was yelling out in pain stating she could not do this anymore and stated both hips hurt. The note indicated the resident had been medicated for pain one hour prior and it was ineffective. Resident #23 was sent to the emergency room for a change in condition. Review of Resident #23's health status note, dated 12/10/18 at 5:30 P.M. revealed she returned to the facility and had new orders obtained for pain management. The resident had orders for the narcotic analgesic, Oxycodone hydrochloride 10 milligrams as needed every four hours ordered on 12/10/18 and Oxycodone immediate release 10 milligrams as needed every four hours ordered on 12/11/18. Review of Resident #23's Mediation Administration Record for December 2018, revealed she received Oxycodone daily for pain relief starting on 12/08/18. Review of Resident #23's quarterly MDS 3.0 assessment dated [DATE] revealed the resident's cognition was intact and she was totally dependent on staff for transfers. b.) Review of Resident #23's health status note, dated 02/15/19 at 3:00 P.M. revealed the resident complained of pain to her right foot. The resident's right foot was assessed and noted to have swelling and slight bruising to the top of foot. The right side was the resident's flaccid side and the resident was not able to lift her foot with normal range of motion. When asked what happened the resident stated she was being pushed to the dining room in her wheelchair by STNA #553 and her foot dropped and bent under the wheelchair. New physician orders for an x-ray were obtained at that time. Review of Resident #23's health status note, dated 02/15/19 at 5:25 P.M. revealed the resident continued to complain of right ankle and foot pain. Staff were waiting for the x-ray to be done and the resident was medicated for pain. Resident #23 stated the medication did not help much. Review of Resident #23's health status note, dated 02/15/19 at 10:02 P.M. revealed x-ray results of the right foot showed acute bimalleolar fractures (ankle fractures). New physician orders were received to monitor and elevate the right ankle to control swelling until and an orthopedic consult on 02/18/19. Review of Resident #23's x-ray results dated 02/15/19 confirmed she had acute bimalleolar fractures. Review of Resident #23's health status note, dated 02/16/19 at 11:52 P.M. revealed the interdisciplinary team noted the resident stated the fracture occurred on 02/15/19 when her foot fell under the wheelchair. Review of the facility fall investigation regarding Resident 23's injury on 02/15/19 revealed Resident #23 stated she was being pushed to the beauty shop to get her hair done in her wheelchair, the beauty shop was closed so she asked STNA #553 to push her to the dining room instead. While pushing her in her wheelchair, her right foot dropped to the ground (flaccid side) and her right foot bent under her. Resident #23 stated she usually had her foot pedal on the right side but after she was assisted to the wheelchair, staff forgot to put it back on. Review of STNA #553's Employee Performance Conference, dated 02/16/19 revealed the reason for the conference was to inform the STNA to make sure foot pedals were on for all residents with foot drop/strokes as Resident #23 had sustained a fracture of her right ankle. Review of Resident #23's health status note, dated 02/18/19 at 2:11 P.M. revealed the resident returned to the facility in a right leg below the knee hard cast, complained of numbness and denied pain unless her foot was moved. Following the injury, Resident #23 required a mechanical (Hoyer) lift for transfers. Interview on 04/11/19 at 8:12 A.M. with Resident #23 revealed when she fell in December 2018 she was getting in the wheelchair off the commode, and she did not have any support because the STNA let her go. Resident #23 revealed her pain could not be managed after she broke her hip and she stated she had never had pain like that before. Resident #23 revealed when she injured her ankle in February 2019 the STNA's forgot to put the foot pedal on her wheelchair and they wheeled her down to get her hair done. Resident #23 revealed her foot got heavy, it slipped to the floor and it went under the wheelchair, but the STNA kept pushing her in the chair. Resident #23 revealed her ankle still hurt, she had swelling to the area and and her doctor explained the pain in her hip and ankle had also gone to her knee which resulted in knee pain. Interview on 04/11/19 at 8:20 A.M. with the Director of Nursing (DON) revealed even though the MDS 3.0 assessment from October 2018 revealed the resident required extensive assistance from two staff for transfers and toileting she believed the resident only required one person assistance with transfers and toileting when she fell on [DATE]. The DON confirmed the STNA was assisting the resident with peri care and the resident was hanging on the grab bar and then fell onto her right side onto the floor when she could no longer support herself to stand. The DON revealed when Resident #23 sustained the ankle fracture on 02/15/19 the STNAs that transferred her to her wheelchair did not put her foot pedal on her wheelchair as required. Interview on 04/11/19 at 10:17 A.M. with the DON revealed all staff should use a gait belt during transfers, and should keep a hold of the gait belt when transferring. The DON did not know if STNA #600 had used a gait belt and confirmed the STNA did not have a hold of Resident #23 while assisting the resident prior to her falling on 12/03/18. 2. Record review revealed Resident #19 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease, contracture to the left hand, vascular dementia, schizophrenia, pain in the left leg, low back pain, heart failure, anxiety and Alzheimer's disease. Review of a plan of care dated 11/06/18 revealed Resident #19 was as risk for falls with the potential for injury related to a history of falls. Interventions included to keep the resident in the common area to monitor for attempts to stand unassisted. Review of the quarterly MDS 3.0 assessment, dated 02/09/19 revealed Resident #19 had severely impaired cognition and required extensive assistance from staff for all activities of daily living. Review of a nursing progress note, dated 02/12/19 at 5:52 A.M. revealed Resident #19 was found in the kitchen by the on duty nurse at around 4:30 A.M. with a variety of dishes scattered across the floor. The resident appeared to have over turned a service cart in the kitchen. The resident was combative with the nurse when the nurse attempted to remove her from the area and she continued to wander after being removed from the kitchen. An interview on 04/11/19 at 2:41 P.M. with Dietary Manager #512 revealed the main door to the kitchen out in the lobby was locked every night at 9:00 P.M. when the dietary staff left for the night. However, the two doors into the kitchen from the resident's dining room were not locked at night. He indicated those doors were left unlocked in case nursing staff needed to get into the kitchen. An interview on 04/11/19 3:15 P.M. with the DON revealed there was never an investigation completed when Resident #19 was found in the kitchen unsupervised. She indicated no interventions were implemented following the incident to prevent Resident #19 or any other resident from entering the kitchen unsupervised again.