**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide basic life support, including cardiopulmonary resuscitation (CPR) for 1 of 7 residents reviewed for advanced directives. (Resident #1, #2, #3, #4, #5, #6, and #7). The RN A did not initiate CPR for Resident #1 when Resident #1 was found with no pulse or respirations. Resident #1 was listed as Full Code (all resuscitation procedures are provided to keep a person alive during a medical emergency). This failure could place all residents in the facility who requested a full code status at risk of death. An Immediate Jeopardy situation was identified on [DATE] at 3:20 PM. The Immediate Jeopardy was removed on [DATE] at 3:24 PM The facility remained out of compliance at a scope of isolated incident of and a severity level of potential actual harm due to the facility's need to complete in service training and evaluate the effectiveness of the corrective systems. This failure could place all residents in the facility who requested a full code status (everything is done to keep a person alive) at risk of death. Findings included: Resident #1: Record review of an admission Record dated for Resident #1 showed a [AGE] year old male with an admission date of [DATE] with diagnoses of Secondary malignant neoplasm (a cancer that forms in the cells of the breasts) of other parts of nervous system, Gastro esophageal reflux disease without esophagitis (acid reflux), Constipation, Hyperkalemia (high potassium), Benign prostatic hyperplasia (age associated prostate gland enlargement that can cause urinary difficulty) with lower urinary tract symptoms, Generalized anxiety disorder, Muscle weakness (generalized), Malignant neoplasm of unspecified site of unspecified male breast, History of falling. admission record did not specify Resident #1's code status. Record review of an Entry MDS (Minimum Data Set) assessment dated [DATE] for Resident #1 listed no BIMs (Brief interview for Mental Status). The most recent MDS dated [DATE] did not address advance directives or code status for Resident #1. Record review of Resident #1's care plan for Advance Directives, dated [DATE] revealed Social worker has discussed advanced directives and code status with resident and/or resident representative. The interventions were listed as: The facility staff will assure my advanced directives are discussed and appropriate paperwork is provided to me and placed in my medical record when returned to facility, Assure Advanced directives are discussed, and appropriate paperwork is obtained. No code status listed in orders. The care plan dated [DATE] for Resident #1 did not address code status. Record review of facility provided the code status for Resident #1, titled, Order Group Report (Advance Directive), dated from [DATE] to [DATE], stated: under order name: D/C Code STATUS FULL CODE may use AED, Dx: Secondary malignant neoplasm of other parts of nervous system. D/C date: [DATE] A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE]. Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . Record review of Resident #1's nurse notes, dated [DATE] at 5:34 AM, stated: revealed Resident declined to take any prn pain medication thru the night. Signed and dated by Medication Aide. Record review of Resident #1's nurse notes, dated [DATE] at 8:23 AM, stated revealed: went into patient's room at 0653 to find him pale, not breathing, no pulse was present, no lung or heart sounds were present. Called DON,911, wife and the physician shortly after finding. Signed and dated by RN A Record review of Resident #1's nurse notes, dated [DATE] at 8:50 AM, stated: Med aid went to patients' room and noticed patient was not responding, left room to call RN. RN went in room at 0653, assessed patient. RN checked for a pulse near carotid and brachial, listened for lung and heart sounds. RN found no pulse or sounds. Called DON at 0707 to inform of patient's current status, was ordered to call 911. called 911 at 0715, EMS arrived at 0724. called physician at 0716, no answer. RN left a message for the physician to inform him of patient's status. RN called wife at 0717 to inform of patient's current status. Wife said she can arrive in an hour and a half because she lives out of town. Signed and dated by RN A. Record review of Resident #1's nurse notes, dated [DATE] at 8:23 AM, stated: went into patient's room at 0653 to find him pale, not breathing, no pulse was present, no lung or heart sounds were present. Called DON,911, wife and the physician shortly after finding. Signed and dated by RN A Record review of Resident #1's nurse notes, dated [DATE] at 5:34 AM, stated: Resident declined to take any prn pain medication thru the night. Signed and dated by Medication Aide. Record review of facility provided code status for Resident #1, titled, Order Group Report (Advance Directive), dated from [DATE] to [DATE], stated: under order name: D/C Code STATUS FULL CODE may use AED, Dx: Secondary malignant neoplasm of other parts of nervous system. D/C date: [DATE] Record review of EMS report, titled, Pre hospital Care Report Summary, for Resident #1, dated [DATE], revealed: Record revealed that the call came in at 07:18:12, dispatched at 07:18:26, En Route at 07:18:28, On Scene at 07:21:37, Patient Contact at 07:23:00 Billing Disposition stated: Dead after arrival, patient dead at scene resuscitation attempted (without transport) deceased Patient: Dead After Arrival Assessments: Airway Breathing Rate; Apneic (is a temporary cessation of breathing, where the muscles used for inhalation stop moving). Skin Color: Cyanotic, pale Skin temperature: Cool Skin condition: Normal Comments: Resident is apneic and pulseless Type of CPR Provided: Compressions Manual Ventilation Passive Ventilation with Oxygen ([DATE] 07:51) Reason CPR/Resuscitation Discontinued: Protocol/Policy Requirements Completed. First Arrest Rhythm of the Patient; Asystole (flatline, is a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely). Who first initiated CPR: EMS Responder (transport EMS) Arrest Witnessed: unwitnessed. Narrative History Text: 9742 responded to facility for cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness). Upon arrival at bedside, two caregivers were noted and stated that they just cleaned and changed the patient. The patient was noted to be unresponsive, pulseless, and apneic (is a temporary cessation of breathing, where the muscles used for inhalation stop moving). The patient did not present with rigor (a postmortem change resulting in the stiffening of the body muscles due to chemical changes in the myofibrils). The patient was moved to the floor and CPR initiated CPR (cardiopulmonary resuscitation) initiated. OPA (oropharyngeal airway insertion) and NRB (non rebreather mask) were placed for passive airway and IO (intraosseous vascular) access obtained. Cardiac monitor with stat pads were placed. The initial rhythm of the patient was noted to be asystole. Staff then relayed to EMS (emergency medical services) that the patient was found unresponsive and pulseless at 0658, and that resuscitation (the action or process of reviving someone from unconsciousness or apparent death) was not attempted. The staff reported that the patient is full code. Cardiac arrest medications were administered, and the patient was successfully intubated with end tidal co2 monitoring used to confirm placement, lung sounds auscultated (examine a patient by listening to sounds from the heart, lungs, or other organs). The patient was noted to remain in asystole (flatline, is a cardiac arrest rhythm where the heart's electrical and mechanical activity stops completely) throughout. Signal 28 was called at 0751. Information was given to LPD (police department). EMS (emergency medical services) cleared the scene. During an interview with the Administrator on [DATE] at 11:28 AM,. The Administrator stated that the policy for code status stated was that CPR should be initiated to for a full code resident unless the seven signs of death are present. The Administrator stated that the RN A did not initiate CPR because all seven signs of death were present. The Administrator did not specify the seven signs of death. The Administrator stated that the documentation that the RN A made is incomplete and not finished. The Administrator did not give a reason the RN A had unfinished documentation. The Administrator stated that if the resident was not showing all seven signs of death, then she should have initiated CPR. The Administrator stated that education was provided to the RN immediately. The education that had been provided was through in services on [DATE] for Active Signs of Death, BON guidance positions for nurses (LVN & RN) position statement 15.2 & 15.20, CN are to print code statuses at beginning of every shift and keep on them at all times during shift. During an interview with EMS Staff on [DATE] at 2:37 PM, The EMS Staff member stated that when the team had gotten on scene, that there were two staff members that had already cleaned the resident. The EMS staff member had stated that Resident #1 appeared deceased , no pulse, no respirations, slightly cool to touch, jaw was loose, and did not have any darkening of the skin. The EMS Staff member stated that they had to get the RN to ask what the resident's code status was. The EMS staff member stated that the RN should have initiated CPR immediately when she had found the resident and continued CPR until EMS arrived. The EMS staff member stated that the RN stated that Resident #1 was a full code. The EMS Staff member stated that there was no reason the RN should not have initiated CPR. EMS staff member,, She stated that the body of Resident #1 was not in rigor mortis. During an interview with RN A on [DATE] at 5:00 PM., RN A stated that she arrived on shift at 6 am and received report from LVN. RN stated that during report, Resident #1 was stable, and he had refused his pain medication. RN A stated that CMA E went to give Resident #1's medication before 7 am and that was when she realized he was unresponsive and not breathing. RN A stated that is when the CMA E came to get her, and RN A went to Resident #1's room to assess him. RN A stated that his skin was cold to touch and no movement. RN A stated that Resident #1 was cyanotic (blue) and had rigor mortis. RN A stated that she immediately contacted the DON and was instructed to call 911. RN A then contacted the Physician and he said, Thank you for letting me know. RN A stated that she contacted the wife after the physician. RN A stated that on the computer Resident #1 was DNR, so she did not initiate CPR. RN A stated that a few days ago when he was admitted his vitals were stable, he was cognitive, and no issues other than his cancer. RN A stated, This was unexpected. RN A stated, How long will you be investigating this. During an interview with CNA G on [DATE] at 5:36 PM. CNA G stated that she had worked the evening shift of [DATE] and had gotten off shift the morning of [DATE]. CNA G stated that she had been the only CNA G on shift for three hundred hall and she had one nurse on shift. CNA G stated that Resident #1 had expired later that afternoon because a co worker had called and told her. CNA G stated that she had done her rounds at 4:45 4:50 AM with Resident #1. CNA G stated that Resident #1 was sleeping and had visible respirations when she had gone in Resident #1'shis room to change his foley bag. CNA G stated that Resident #1 had moved a little (changed positions in bed) and she was trying to be quiet and not wake him. CNA G stated that she normally makes made her rounds at 12 am, 2 am, and 4 am. CNA G stated that she will normally walk around and do checks on the residents in between making her rounds. CNA G stated that she was supposed to leave at 6 am that morning and supposed to do report with the on coming CNA G but the oncoming CNA G was late, so she just left. CNA G stated that the resident was breathing and asleep at 4:45 AM and did not show and signs of distress through the night. During an interview with LVN C on [DATE] at 8:46 PM. LVN C stated that she worked the evening of [DATE] and had gotten off the morning of [DATE]. LVN C stated that she had given report to RN A the morning of [DATE]. LVN C stated that she had given report with the RN A at the desk and then they had gone and did the narcotics count. LVN C stated that the nurse would normally check residents when coming onto shift. LVN stated that she would usually check on her resident's every 2 3 hours throughout the night. LVN C stated that she had last seen Resident #1 around 5:30 AM on [DATE] and he was awake and talking to her. LVN C stated that Resident #1he had denied his pain medication and had had told her that he was not in any pain and did not want anything for pain. LVN C stated that she was not surprised because the night before Resident #1 had been in a lot of pain, and Resident #1he had new Fentanyl patches put on earlier that day and had not been in pain since then. During an interview with the DON on [DATE] at 11:39 AM. The DON stated that she was notified by RN A at 707 AM on [DATE] of the unresponsive resident. The DON stated that the RN A had notified her that Resident #1 had no pupil response, no pulse, cold to the touch, and no signs of life. The DON stated that the RN A had not initiated CPR because she told DON that based on her assessment that she had done, he showed signs of death, and it would not have be appropriate to perform CPR. The DON stated that rigor mortis is the settling of blood and starts in face, pale, cyanotic (blue), will turn into blood settling and stiffness. The DON stated that RN A did not complete her notes. The DON did not specify why RN A did not finish her notes. The DON stated that on the nurse notes it stated that resident was cold to touch, pale, but did not state rigor mortis. The DON stated that while she was coming into the facility, the EMS was leaving the building, and they had stopped her and asked her why CPR was not initiated. The DON stated that she had not been here and could not determine what should have been done because she had not done the assessment. The DON stated that RN A stated to her that the resident was, Dead, Dead, The DON stated that per her education from TBON (Texas Board of Nursing), that RN's can make the decision if CPR is appropriate or not upon assessment. The DON stated that she can cannot question another nurse's judgement as a nurse. The DON stated that if a nurse were wrong, she would educate that nurse, but since the DON was not in the facility to do her own assessment, she could not judge the RN's assessment. The DON stated that she immediately started in services for active signs of death, BON guidance positions for nurse's (LVN & RN) position statement 15.2 & 15.20, CN are to print code statuses at beginning of every shift and keep on them at all times during shift. signs of impeding death and code status. During an interview with CMA E on [DATE] at 1: 37 PM. CMA E stated that she was the person that had found the Resident #1 unresponsive in his room the morning of 1/21/.2025. CMA E stated that she was on shift the morning of [DATE], her shift had been from 6 am 2pm. CMA E stated that she had found Resident #1 unresponsive around 6:35 am 6:40 am. CMA E stated that she had gone to Resident #1's room and the door was slightly cracked open, and she had knocked and called out his name. CMA E stated that she did not hear any response from Resident #1, so she had knocked again and called out his name. CMA E stated that she still did not hear anything and then she had opened the door and walked in to check on him. CMA E stated that she had thought it was strange that Resident #1 did not answer because she did not notice any breathing or respirations. CMA E stated that she had shaken Resident #1'shis shoulder and had called his name. CMA E stated that Resident #1's eyes were closed, and he was laying back but to the side a little and his mouth was open, and the head of his bed was slightly elevated. CMA E stated that Resident #1 was not stiff because when she shook him, he was very loose when she had shaken him;, and he wasn't firm or stiff. CMA E stated that she had not seen any different coloration of his ( Resident #1's) face or lips and no blotchiness. CMA E stated that she had immediately left Resident #1's room and went down the hall to get RN A. CMA stated that she and the RN had went back to Resident #1's room and RN A had taken took the pulse by wrist on Resident #1. CMA E stated that when RN A had taken Resident #1's pulse by his wrist, his wrist was loose. CMA E stated that the RN A stated that she did not feel a pulse. CMA E stated that her and RN A had then went to the nurse's station, and the RN A had gotten on the computer to look up a phone number and had then she contacted the DON. CMA E stated that the DON had then instructed RN A to call 911. CMA E stated that she had left the nurse's station after that because she had to administer the medications to other residents. CMA E stated that she did not witness RN A performing any CPR at all. CMA E stated that she would know what the code status of a resident is was because all the nurse's would pull a code status at the beginning of the shift, and they carry that in their pocket to check every resident. CMA E stated that Resident #1 was listed as a full code. During an interview with CNA H on [DATE] at 2:16 PM. CNA H stated that she was on shift the morning that Resident #1 was found unresponsive. CNA H stated that her shift was 6 am 2pm on [DATE]. CNA H stated that she clocked in at 6:37 AM. CNA H stated that when she came in, she went room to room to write down all resident's names down so that she would know who needed showers. CNA H stated that she went to talk to RN A about shower sheets. CNA H stated that while she was talking with RN A about shower sheets, the CMA E came in and stated that a resident is was unresponsive. CNA H stated that when she saw Resident #1, he was pale and foaming out of the mouth. CNA H stated that she did not see RN A initiate CPR. CNA H stated that they had found Resident #1 at 6:42 AM. CNA H stated that RN A thought that Resident #1 was a DNR because RN A stated that Resident #1 was a DNR to her. CNA H stated that Resident #1 was not stiff, and he did not have any discoloration of the skin. CNA H stated that she knew this that because she helped to clean up the body before EMS got to the facility. CNA H stated that Resident #1 was in bed and was turned to the side with his eyes closed. CNA H stated that they usually just ask the nurse of the code status of the residents. Record review of a report provided by the facility on [DATE] at 4:36 PM, between the dates of [DATE] to [DATE]., indicated there were 50 of 93 residents with a full code status. A Cardiopulmonary Resuscitation Advanced Directives Policy dated [DATE] .Indicated, .When a patient is found to be without heartbeat or respirations by any staff member the patient's medical record must be checked to ensure that the patient's wishes are followed. If there are no advanced directives or a Full Code status the licensed staff will start CPR . Record review of facility provided policy, titled, Cardiopulmonary Resuscitation (CPR): Basic Life Support (BLS)/ Hands Only CPR, date revised on February 12, 2020; stated: Policy: CPR (BLS and/or Hands Only) will be initiated for residents that experience a witnessed or unwitnessed cardiopulmonary arrest while in the community. CPR will not be initiated (or continued) for any resident that: a. Has a DNR order on record. b. Shows American Heart Association (AHA) signs of clinical death as defined in the AHA Guidelines. Procedure: Preparations: 1. Licensed clinical staff involved in resuscitative efforts will obtain and/or maintain certification in Basic Life Support (BLS)/Cardiopulmonary Resuscitation (CPR). 2. Unlicensed personnel will receive hands on training annually (at minimum) by DON or designee. 3. DON or designee will conduct a Mock Code (educational simulation of actual arrest) annually at minimum for training purposes. 4. Emergency equipment and supplies necessary for CPR/BLS will be maintained in the community. 5. Information will be provided upon admission on CPR/BLS policies and advance directive to each resident/ representative. General Guidelines; 1. The goal of CPR is to try to maintain life until the emergency medical response team arrives to deliver Advanced Life Support (ALS). 2. If an individual is found unresponsive by an employee of the community the employee will initiate CPR unless: a). It is known that a Do Not Resuscitate order exists for the resident; or b). In the event of an unwitnessed cardiac event an RN may determine that CPR would be futile and an inappropriate intervention if all signs of death are present: i. The resident is unresponsive. ii. The resident has no respiration. iii. The resident has no pulse. iv. Resident's pupils are fixed and dilated. v. The resident's body temperature indicated hypothermia: skin is cold relative to the resident's baseline skin temperature. vi. The resident has generalized cyanosis, and vii. There is presence of livor mortis (venous pooling of blood in dependent body parts). 3. RN must document description of discovery for example: treatment undertaken; findings of assessment; individual notified, result of communication and presence or absence of witness. Equipment and Supplies: 1. Personal Protective equipment including: gloves, masks, gowns, and eyewear as appropriate. 2. Airway delivery device such as: pocket face mask, Ambu bag and/or mouth shields. Heart Association's Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care or community BLS training material. Bystander/Unlicensed Staff: 1. Summon for help 2. Request AED 3. Check for Responsiveness (for example shaking, tap shoulder and shout are you okay etc.) 4. While awaiting AED, if unresponsive begin performing chest compressions (unless known code status is DNR). Continue until licensed staff arrive. 5. If responsive stay with resident until help arrives. CPR Certified Staff: 1. Determine unresponsiveness; if no response 2. Request AED and summon for help 3. Check for no breathing or no normal breathing 4. Check for pulse (no more than 10 seconds) 5. Initiate community emergency response 6. Start CPR as trained Documentation: 1. Document events of episode in residents medical record (if victim is a resident) a. Approximate time and condition in which the resident was found, or the event was witnessed. b. The sequence of resuscitation efforts, including approximate times and AED shock was delivered (if applicable). c. The resident's response to resuscitation efforts. d. Approximate time that EMS team took over. e. Notification of physician and resident family. f. Time resident was transported or time of death. Reporting: Follow community policy regarding reporting. References: American Heart Association. Retrieved from http://www.heart.org/HEARTORG/ on [DATE] Definitions: Cardiopulmonary Resuscitation (CPR) is a group of emergency treatments that are executed when someone's breathing, or heartbeat has stopped. The treatments consist of rescue breathing and chest compressions. CPR allows oxygenated blood to circulate to vital organs such as the brain and heart. Hands only CPR is CPR without rescue breathing. AHA has recommended it for use by untrained layperson/bystander (non licensed) on teens or adults who collapse (observed and unobserved). This involves calling 911 or sending someone to call and pushing hard and fast in the center of the chest. Record review of website viewed for American Heart Association at, date retrieved on [DATE], stated: The American Heart Association (AHA) considers a person clinically dead if they have obvious signs of irreversible death, such as rigor mortis, decapitation, or decomposition. The AHA also considers a person clinically dead if they have a valid advance directive or DNAR order that states they do not want resuscitation. Signs of irreversible death rigor mortis, dependent lividity, decapitation, transection, and decomposition. Advance directives A valid, signed, and dated advance directive that states the person does not want resuscitation. A valid, signed, and dated DNAR order Signs of irreversible death Rigor mortis, which is when the body stiffens after death. Dependent lividity Decapitation Transection Decomposition Advance directives A valid Do Not Resuscitate (DNR) order. A valid, signed, and dated advance directive that states the person does not want resuscitation. A living will, which is a written direction to physicians about the patient's wishes for end of life care. The AHA recommends that rescuers initiate CPR unless they see obvious signs of irreversible death, have a valid DNR order, or could be injured. Record review of facility provided in services, dated [DATE], titled, Active Signs of Death, with forty seven staff signatures including RN A, stated: Signs that someone is near death: 1. Shortness of breath 2. Isolation and drifting away 3. Decreased appetite and thirst 4. Nausea and vomiting 5. Anxiety 6. Constipation 7. Fatigue 8. Incontinence 9. Skin Conditions 10. Delirium 11. The death rattle 12. Pain Record review of facility provided in services, dated [DATE], titled, BON Guidance Positions for Nurses, with seventeen staff signatures including RN A, stated: The Registered Nurse Scope of Practice: The RN takes the responsibility and accepts accountability for practicing within the legal scope of practice and is prepared to work in all health care settings and may engage in independent nursing practice without supervision by another health care provider. The RN is responsible for providing safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs. Record review of facility provided in services, dated [DATE], titled, print code statuses at beginning of every shift and keep on them at all times during shift, with eighteen staff signatures including RN A, stated: How to print Code Statuses: 1. Go to reports in system 2. Select order group report 3. Enter room numbers for your hall 4. Select Active order under order status 5. Search by order group Advanced Directives The Administrator was notified on [DATE] at 3:20 PM., that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was emailed to the Administrator on [DATE] at 3:43 PM. The facility's Plan of Removal was accepted on [DATE] at 8:12 A.M., and included: Summary of Details which lead to outcomes: On [DATE], during a complaint survey initiated at the facility a surveyor. provided an IJ Template notification that the Survey Agency has determined that the conditions. at the center constitute immediate jeopardy to resident health. F678 The notification of the alleged immediate jeopardy states as follows: F678 The resident was a 65 y/o male, admitted on [DATE] with a diagnosis of malignant neoplasm of the breast with secondary malignant neoplasm of other parts of the nervous system. The facility allegedly failed to provide basic life support, including CPR, prior to the arrival of emergency. medical personnel for 1 (Resident #1) of 1 resident. Resident #1's code status was listed as full code. How other residents with the potential to be affected by the same deficient practice. will be identified. Any resident with full code status have potential to be affected by the alleged. deficient practice What measures will be put into place or what systemic changes will be made to ensure that the deficient practice does not recur. DON (Director of Nursing) or designated nurse will in service all licensed nurses on policy and procedure for identifying code status on residents by 10:00 pm on [DATE]. No nurses will be allowed to work until training has been completed. Any nurses who did not receive training before 10:00 P.M. on [DATE] will receive training prior to the start of their next shift. This education was initiated on [DATE]. DON or designee will educate all staff on emergency policy and procedures when residents. are found to be unresponsive by 10:00 pm on [DATE]. No nurses will be allowed to work. until training has been completed. Any nurses who did not receive training before 10:00 P.M. on [DATE] will receive training prior to the start of their next shift. This education was initiated on [DATE]. DON or designee will monitor 10 staff members per week for 4 weeks on competency of 7 signs of death/ active signs of death, competency of nurses printing code statuses from EMR and on person, and CNA competency on code status on POC. This monitoring was initiated. on [DATE]. How the corrective action(s) will be monitored to ensure the deficient practice is being corrected and will not recur (i.e., what program will be put into place to monitor the continued effectiveness of the system changes); and Proof of the education will be submitted to QA committee Involvement of Medical Director Medical Director was notified and met with interdi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for each resident in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 of 7 (Resident #1) residents in that: The facility failed to ensure Resident #1 was treated with respect, dignity, and care when they failed to obtain clear informed consent on 8/11/2024 at approximately 3:30 AM, to perform a straight catheter procedure to collect a urine sample. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 8/19/24 and updated 9/4/2024 prior to the beginning of the survey. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth, psychosocial harm and distrust with staff. Findings Included : Resident #1 Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute kidney failure (kidneys no longer work on their own), muscle weakness (lack of strength), and muscle wasting (thinning of muscle). Record review of Resident #1's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities and goals- Admission, revealed the resident required partial/moderate assistance with toileting hygiene. Section H- Bladder and Bowel revealed Resident #1 was always continent of urinary and bowel and Resident #1 did not have any appliances (indwelling catheters, intermittent catheterization). Record review of Resident #1's care plan dated 8/15/24 revealed Resident #1 was at risk for problems with elimination. The care plan goal reflected, the resident elimination status will be maintained or improved over the next 90 days. Interventions revealed, Assist to toilet as needed. Monitor for signs and symptoms of urinary tract infection. Additionally, the care plan reflected the resident's health condition prior to admission was healthy with no major physical or mental illnesses. Record review of Resident #1's urine analysis collected on 8/9/24 at 2:55PM, revealed a culture result of three or more organisms, probable contamination. Lab result was faxed to the facility on 8/10/24 at 8:03pm. Lab report revealed a written note New specimen obtained 8/11 signed by LVN B. Record review of Resident #1's urine analysis collected on 8/11/24 at 11:00 AM, revealed a culture result of staphylococcus epidermidis (gram-positive bacteria) and a sensitivity to oxacillin, tetracycline, and vancomycin (medication used to treat bacteria infections). Lab result was faxed to the facility on 8/13/24 at 12:07pm. Record review of Resident #1's EMR physician orders provided by the DON, dated 9/4/24 revealed, there were no orders located for the straight catheter procedure that occurred on 8/10/24. Record review Resident #1 hospital records dated 8/13/24 revealed a SANE exam was not conducted as there was no indication to conduct the exam. Furthermore, the exam revealed there was mild edema around the urethral meatus (inflammation, swelling and irritation) and that there was no evidence of trauma otherwise and no vaginal tenderness. Record review of Resident #1's EMR physician orders revealed, Order/Start date: 8/13/24. vancomycin 500 mg (antibiotic) intravenous solution 500 Milligram intravenously 2 times per day 7 Days. Dx: Urinary tract infection, site not specified. Order/Start Date Order Time 08/16/24 2 times per day. Vancomycin 500 mg intravenous solution 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Record review revealed Resident #1 was also receiving vancomycin medication for a dx of Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity, subsequent encounter. Record review of Resident #1 Trauma informed Observation, dated 8/12/24, revealed the assessment was completed with recommendations of resident wishes/goal, There's no reason to. Oriented to notify staff if when needs to talk and or would like therapy. Oh no I just want to get therapy, go home, see my old dog, she's 15 a Chihuahua, was electronically signed by [Name] Social Services Director 8/12/24 at 12:23 PM. During an interview with Resident #1 on 9/4/24 at 12:34 PM, Resident #1 stated she believed she had a UTI around 8/9/24, and she had notified the staff. The staff proceeded to test her for the UTI. She stated she was provided a urine collection hat to urinate in for the urine sample. She stated staff told her that the sample could become contaminated due to the urine collection hats not being in a clean environment. She stated for years she had urinated in a little jar for UA tests. She stated Sunday morning, 8/11/24, at approximately 3am, staff had come into her room and did a catheter ,(small, flexible tube that is used to empty urine form the bladder) when she was unconscious. She stated she was asleep and was unconscious (sleeping), and staff had not told her anything until after she had woken up . She stated on 8/11/2024, the nurse, and the aide told her they came in to do a straight catheter to get a urine sample. She stated she had not known the prior urine specimen was contaminated until after they did the straight catheter. Resident #1 stated she was not told until after the procedure had been done. She stated she had never had a catheter in her life, and she had always refused them before. She stated she would have refused and never have consented to a catheter and that she would have preferred to provide a urine sample herself in a cup. She stated staff did not request another sample; they just took it from her. She stated she did not say anything to the nurses because she felt it was not the right time. Resident #1 stated she felt very violated, and she did not think the facility cared too much about her concerns. She stated the procedure was painful and she reported it on 8/12/24 to the ADM and she was sent to the ER for further evaluation. She stated the EDO physician explained she was swollen down there (vaginal area). Resident #1 stated she was in pain and the procedure was painful. Resident #1 stated she reported the incident to the police on 8/12/2024 when the facility called the local police to the facility. Resident #1 stated she did not understand why they could not wait to ask her for the sample during the day or in the morning instead of when she was unconscious. She stated they took a sample that would not have been sent out until late because it was on a Sunday and the lab place was not open until Monday. Resident #1 stated she felt she was taken advantage of, and that the procedure wasn't handled correctly, and that the catheter procedure was unnecessary. She also stated she felt violated, as if she had been raped and was very upset over the whole incident and had continued to be bothered and upset about it since the time it happened. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed there was no documentation by RN D, for Resident #1 reporting pain and discomfort with urination and requesting to be tested for a UTI on 8/9/24 or the days prior to. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed there was no communication between staff and physician for notification of Resident #1's change in condition. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed no documentation by LVN B or RN D's communication with a physician regarding a contaminated urine analysis. Record review of Resident #1's EMR physician orders revealed there was no order for a UA repeat and method of collection on 8/10/24 or 8/11/24. Record review of physician standing orders dated 6/19/2019 for MD revealed the following, Laboratory .54. Fasting Labs Upon admission: BMP, CBC, U/A, lipid profile. Record review of Police call sheet dated 9/5/24 revealed, Police Sequence #P240807233 as of 9/5/24 11:18:55 . Created: 8/12/24 11:24:58 Entered: 8/12/24 11:57:47 Dispatch: 8/12/24 13:11:46 Enroute: 8/12/24 13:11:49 Onscene: 8/12/24 13:13:49 Closed: 8/12/24 14:07:35 11:54:58 Location: [Facility address], Name: [Redacted], Phone: [Redacted] 11:57:47 Comment: Victim [Redacted] Against a female nurse who went into her room at night/reported advised nurse was doing a procedure to extract urine and victim felt violated. 14:07:27 Comment: I spoke with [Redacted] who advised about 2 nights ago a nurse and a nurse aide woke her up and told her they needed a urine sample. [Redacted] advised she was groggy and still sleepy but advised later they came back in and advised her they put a catheter in to get a clean urine sample. [Redacted] advised she did not authorize a catheter to be put in and she felt violated, but advised she does not remember them even putting the catheter in. I spoke with the Administrator [Redated], who advised there is documentation that the doctor ordered the catheter for [Redacted] advised the nurses chart advised they put the catheter without any complaints from [Redacted], advised the nurse and aide who put the catheter were not at time but advised she would get in contact with them later to see what happened and why [Redacted] would be complaining now. I gave [Redacted] a sequence number for their records. There is clear documentation this was a medical procedure done at the request of the doctor. No crime occurred. 14:07:34 Clear. During an interview on 9/4/24 at 1:30 PM, the DON stated she was on leave when the incident occurred, but she believed the initial urine test was done based on the standing orders the EDO had for admission lab work which includes a urine test. She stated she knew the urine test was redone because the lab said it was contaminated. She stated they always do UA's every morning because the lab staff come in the mornings to draw labs and facility staff draw the UAs in-house. She stated Resident #1's admitting labs were dated on 8/13/24, she had UA lab results dated on 8/9/24. She stated she believed they were the results from a UA test done on 8/5/24, but she was not sure. She stated the rest of the standing order labs were done on 8/14/24. She stated she did not see an order for the UA in the EMR, only for the bloodwork, which were dated 8/14/24. She stated usually when a lab is contaminated, they would send a request to the FNP for a retest and a lot of times they prefer to redo the UA by straight catheter when they come back contaminated because it is cleaner. She stated she had not located an order for the straight catheter procedure. She stated she did not locate any documentation showing that the physician was notified of the straight catheter or that there was an order for the straight catheter. She stated she was not aware of any of those issues until the next day and she had not spoken to the resident. She stated she had not spoken to the nurse about the issue until now because she was not aware of it. She stated she expected for staff to document proper steps. She stated she was not aware if staff were trained how to document properly and the proper steps to take in those situations. She stated the original lab was faxed on 8/9/24 at 4:04 PM, which showed an abnormality, the facility received the contaminated lab results on 8/9/24 at 20:03 PM (8:03 PM). She stated the evening shift (2 PM-10 PM) would have been responsible to take care of it. She stated she had not seen any documentation that the evening shift took care of it. She stated it was not typical for a staff to do a procedure like that at 3:00 AM because residents were asleep, and it was not okay to take samples at that time because residents may not be clear on what was going on because they were in a dead sleep. She stated the UA recollection should have been done close to the time the fax was received between 8:00 PM-10:00 PM. She did not know why the culture was not done during the 2PM/10PM shift. She stated a potential negative outcome could be that the resident may not completely understand what was going on which could cause them to have felt something inappropriate went on. She stated the resident was not aware of what staff were doing which could make them think something else could be going on. She stated typically staff would have explained to the resident that the doctor ordered a straight catheter as well as explain why it is needed, which is how staff typically obtain consent from residents. She stated consent for straight cath procedures were obtained verbally from the resident and a lot of the time residents say no and the physician are then notified. She stated there should have been progress notes of communication with physician and verbal orders should have been documented in the EMR. She stated she never spoke to the resident because she had already been assessed and it was the end of the situation when she returned to work. DON stated the facility did in-service staff on abuse/neglect, customer services, resident rights, and for staff to explain the procedure before they start. During an interview on 9/4/24 at 4:03 PM, the ADM stated on 8/12/2024, she was told Resident #1 wanted to speak with her. The ADM stated Resident #1 told her she wanted to speak to her about an incident she was concerned about. The ADM stated Resident #1 told her she peed in a cup and was told the test came back contaminated. She stated Resident #1 told her that staff came in to repeat the UA and that it was at night and said, I felt I was raped. The ADM stated she explained that a straight catheter went into the urethra (hollow tube that lets urine, a waste product, leave the body) and asked Resident #1 if something went into her vagina, and she said she did not know. She stated Resident #1 said she would not have wanted a straight catheter. The ADM stated she told Resident #1 she would report it. She stated she called law enforcement and reported the incident to HHS. She stated they completed a skin assessment and there were no findings. She stated Resident #1 was sent to the hospital and asked for a rape kit, but the rape kit was not done due to the information Resident #1 provided to hospital staff about the incident during that examination. She stated Resident #1 stated she understood she was not raped and just did not want a catheter done and said she would have refused it. She stated she spoke to LVN B who said she was passed on report from RN D who told her the test was contaminated and that it needed to be repeated. She stated CNA A went in with LVN B because she wanted a second person for help in case the bed needed to be changed. The ADM stated both LVN B and CNA A said Resident #1 was awake and asked questions during the procedure, and that LVN B explained the procedure. She stated she was told Resident #1 tolerated the procedure without any issue and she appeared to be awake. She stated she was told Resident #1 said ouch, but that was all. She stated she was told Resident #1 had not expressed having an issue with the procedure. She stated RN D reached out to the FNP who gave the order to repeat the UA. She stated there should be an order to do a straight catheter. She stated consent was typically obtained by a resident verbally after the procedure was explained to them. She stated she thought [LVN B] did the procedure at 3:30 AM because she was trying to get it done before her shift ended. She stated it was typical to get a straight catheter sample to prevent getting another contaminated sample. She stated it could have delayed treatment if another contaminated sample was received. She stated staff called physicians or talked to them in person when they were in the building to obtain orders and that there should have been a progress note in the record when orders were received or documented in the 24-hour report. During an interview on 9/4/24 at 5:57 PM, the EDO stated he would have been fine with a resident providing their own urine sample when they were able to but would want the urine sample to be obtained by a straight catheter for residents who were unable to provide a urine sample on their own. He stated he felt nurses would know the best way to obtain the sample. He stated he believed the FNP was contacted about the UA orders for Resident #1. He stated he was aware Resident #1 reported feeling abused and violated by the straight catheter procedure and that she was sent to the emergency room for an examination. He stated after speaking with Resident #1, she realized she was not assaulted but insisted she did not like the way it was handled. He stated he was not sure if he saw Resident #1 afterwards. He stated he was not aware staff completed the straight catheter procedure on Resident #1 at 3:30 AM. He stated he hoped staff would not do a straight catheter procedure on a resident at that time of night. During an interview on 9/4/24 at 11:38 PM, CNA A stated LVN B asked her to help her get a urine sample from Resident #1, on 8/10/2024 after she arrived for the night shift but could not recall the exact time. She stated they got supplies together to go see Resident #1. She stated Resident #1 was asleep when they entered her room. She stated the dim lights were on in the room when they entered, and they turned the big light on during the procedure. She stated she asked Resident #1 to wake up and Resident #1 hummed like she did not want to wake up. CNA A stated she stayed in the room the whole time. She stated LVN B stepped out to get a collection bag. CNA A stated she had spoken to Resident #1 because she was still kind of knocked out (drowsy, did not stay awake, continued to fall back asleep). CNA A stated she asked Resident #1 if she needed water or anything else, and she said no. She stated then LVN B reentered the room. She stated Resident #1 asked what was going on and LVN B explained she needed a clean urine sample, Resident #1 replied that she already gave one, and then LVN B explained it was not a clean sample and they needed another one. CNA A stated Resident #1 said, Well I guess., then she undid the straps on the brief, and she wiped Resident #1 front to back. CNA A stated Resident #1's brief was dry when she undid the brief straps. She stated then LVN B wiped the area with a cotton swab that had alcohol/brown liquid on it. She stated she could not recall if LVN B told Resident #1 she was going to clean her with the cotton swab, but she did recall that LVN B told Resident #1 she was going to feel some pressure. She stated LVN B inserted the catheter and got the urine sample, removed the catheter, and completed her part. She stated Resident #1's eyes were open during the procedure, and she watched what was going on. She stated Resident #1 loudly said ouch when the catheter went in, and LVN B told her she had to insert a catheter to get a sample. CNA A stated LVN B did not explain where she was going to insert the catheter to get the sample. She stated after the procedure was over Resident #1 said, I guess this was a rude awakening. and she told Resident #1 she was sorry. She stated LVN B said, Sorry but it needed to be done. She stated there were no other words said between Resident #1 and LVN B after that. CNA A stated she stayed about five minutes to clean after LVN B stepped out. CNA A stated she put a clean brief on Resident #1 and picked up trash. She stated she changed the brief because it had dye and other stuff on it. She stated Resident #1 woke up after LVN B left. She stated Resident #1 was upset afterwards and said she felt like it was rude of them to go in at that time of night. She stated she checked on Resident #1 that shift a few more times and Resident #1 expressed it was rude each time she went into her room. CNA A stated she told LVN B that Resident #1 was upset and LVN B told her she would chart what all happened. CNA A stated she could not say if doing the procedure at 3:30 AM was not a good time. CNA A stated she saw Resident #1 right before she left her shift and Resident #1 told her she was not able to go back to sleep because she was mad and said it was rude of them to go in there and get the sample and she had not slept much because they woke her up. She stated Resident #1 did not express having pain afterwards. CNA A stated during the procedure, she held a box to make sure they didn't get urine on the bed sheet, and she did not assist with the straight catheter procedure. She stated Resident #1 always wore a brief at night but was not sure if she wore one during the day, but she knew Resident #1 went to the bathroom during the day. She stated Resident #1 had about four brief changes at night. She stated sometimes Resident #1 used the call light to request her brief be changed but sometimes her brief was wet during brief checks. CNA A stated the DON told her she needed to come in and speak with her and the ADM about the incident. CNA A stated she was suspended for a day because Resident #1 made allegations of being raped. CNA A stated no one expected have a catheter inserted in the middle of night. CNA A stated she also assisted LVN B during another straight catheter procedure that night with another female resident on hall 200 that was Spanish speaking. She stated she translated information between the resident and LVN B and translated the catheter process to that resident during the procedure. CNA A stated that procedure was before the procedure with Resident #1. She stated that resident was sitting on the side of her bed when they entered the room and said she needed to pee but could not go. She stated LVN B got the UA sample, and she cleaned the resident afterwards. CNA A provided information on recent in-service received on abuse/neglect, resident rights, customer service after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by CNA A revealed, [LVN B] asked me to go with her to help with the supplies while she was doing a straight catheter on [Resident #1]. [Resident #1] was asleep, and she woke her and said we have to get a sample from you. I made sure that she was awake. Resident #1 said she had already given a sample and asked why we needed another sample. [LVN B] explained it was contaminated and needed to redo it. [LVN B] prepped and completed the procedure, [LVN B] was explaining the whole time to [Resident #1] what was going on. [Resident #1] asked a few questions and was awake during the procedure. [Resident #1] said that it was painful at the time of the procedure. Throughout the night I continued to round on her, and she asked for water which I provided, she continued to thank me throughout the shift. During an interview on 9/5/24 at 12:25 AM, LVN B stated she arrived for her shift that night around 9:45 PM on 8/10/2024 and got report from RN D, who was the off-going nurse. She stated RN D told her Resident #1's urine test was contaminated, and they needed another specimen. LVN B stated she confirmed with RN D that Resident #1 was incontinent at night but could not recall if they discussed in report about doing a catheter. LVN B stated she remembered seeing the lab slip and that it said the specimen was contaminated, but she could not remember if the slip said to recollect a urine sample or if there was an order on the lab slip. LVN B stated she could not remember if RN D told her he spoke to anyone about the lab. LVN B stated she told CNA A they needed to collect a specimen and asked when she was doing care on Resident #1 so they could do the straight catheter procedure at the same time. She stated it was easier to have a CNA present to facilitate the process. She stated lab staff came every day any time after 5:00 AM to pick up specimens, so she was trying to get it done before then. LVN B stated Resident #1 was asleep when they entered her room, so they woke her up. She stated she explained to Resident #1 she was there to do the straight catheter procedure to get a urine sample and Resident #1 replied that she had already done one. She stated Resident #1 asked why she could not do it on the toilet, and she explained they needed a clean sample. LVN B stated she did not recall if Resident #1 had any other questions after that. LVN B stated she told Resident #1 that the UA was contaminated, and they needed another specimen. LVN B stated Resident #1 did not say anything to her after that, so she began the procedure. LVN B stated she explained to Resident #1 that she was going to put a tube in her. She stated Resident #1 said ouch, so she stopped and asked if she was okay, Resident #1 said yes, so she collected the specimen and completed the procedure, and then her brief was changed by CNA A. LVN B stated again she did not remember Resident #1 saying anything after she explained the procedure. She stated she felt she got informed consent from Resident #1 to complete the procedure because Resident #1 was cooperative during the procedure by spreading her legs when asked and Resident #1 allowed her to do the pre-cleaning without any issues. She stated Resident #1 also did not refuse the procedure when she told her about it, or she would not have done it. She stated she explained to Resident #1 every time she was going to do something and told her it would be uncomfortable. She stated she did the straight catheter procedure because Resident #1 was incontinent and symptomatic by complaining of not feeling well. LVN B stated Resident #1 had lab work done as well, and she believed they did the lab work when they did the first UA. She stated the facility did admission labs when residents first came in. LVN B stated she did not ask Resident #1 if she wanted to provide a urine sample by urine collection hat because she was incontinent at night and because the previous sample that was collected in that manner was contaminated and she wanted a clean specimen. LVN B stated part of the consent was verbal and part of it was demeanor. She stated Resident #1 responded to what she asked her to do and did not state she did not want to do it. She stated she did not know if residents had to say the exact words I agree, or I refuse. She stated, If they don't agree but they cooperate .I recall her saying okay and being aware of what we were doing. If she had said don't do that, then I wouldn't have done it. I believe she consented. She stated she felt Resident #1 was fully awake during the procedure because Resident #1 cooperated when she asked her to do things, such as scoot her bottom down and then spread her legs. LVN B stated she did not recall if there was any other conversation during the process. LVN B stated Resident #1 did not say anything afterwards and she left. LVN B stated later during the shift, she went to give Resident #1 some medication and Resident #1 asked LVN B why she did that to her and LVN B explained to Resident #1 that the previous test was contaminated, and they needed to get another urine sample and Resident #1 said okay. LVN B stated she did not call the FNP to get orders to perform the straight catheter procedure on Resident #1 because she was under the impression from report given to her by RN D that there was a physician's orders for the collection of the urine specimen from Resident #1, but she did not check to verify if there were orders. LVN B stated staff were supposed to have orders before doing an invasive procedure like that. She stated the order usually specified the way the urine specimen was collected, but she would clarify if that information was not written on the order. She stated she did not recall if RN D told her there was an order in the chart. She stated she was trained to verify orders before performing a procedure. LVN B stated, I don't guess I did that day. I do not remember seeing any physician orders. I don't recall if [RN D] told me he had notified the physician or if he had gotten an order. I just knew that I needed to collect a UA through the conversation with [RN D]. She stated no one told her that day that Resident #1 was upset. She stated she did not remember if the ADM or the DON spoke to her about the incident. She stated she was told Resident #1 was sent for a medical exam. She stated she did not recall if she was told the reason for the exam. She stated she was off the next day. She stated she went into the facility and explained the procedure to the ADM and the DON. She stated she did not recall if they told her the incident was reported. She stated she was suspended for one day so they could investigate things, but it was her day off, so she did not miss any scheduled work. She stated when she returned to work the nurse giving report told her Resident #1 was upset because of the procedure that had been done collecting the UA. She stated then Resident #1 confronted her again and asked why she did the procedure and asked who told her to do it. She stated she told Resident #1 she had been told they needed another sample and it needed to be recollected by a catheter. She stated Resident #1 told her she usually provided the sample in a cup and that she was upset, and she told Resident #1 that the sample was contaminated. LVN B stated she told Resident #1 she was sorry she felt that way. LVN B stated Resident #1 never told her she did not want to see her again and she continued to provide care to Resident #1 while she was at the facility. LVN B stated she was not aware of anything being inserted into the vaginal canal during the procedure. LVN B stated Resident #1 was easy to catheterize anatomically and that she wiped her with betadine. LVN B stated she believed the initial urine sample was done because it was an admission thing and because she was also having symptoms. She stated admission labs were usually done by the night shift; therefore, the initial urine test was not done timely. LVN B stated she had received training on abuse and neglect and informed consent, but she did not remember when because most of the training is done on the computer. LVN B stated they had been told that at night, not to send stuff to the FNP's if it was not critical, she would fax or send a picture to them, and then document a nurse note of what the item was and what the response was. LVN B stated she had been stressed about work and did not remember time well. LVN B stated she did not recall doing another straight catheter procedure that night. She stated she had another resident she needed to do a straight catheter procedure on, but she ran out of time and was not able to do it. LVN B provided information on recent in-service received on abuse/neglect, resident rights, customer service, explaining procedure, obtaining consent prior to a procedure after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by LVN B revealed, When I came on shift there was a report on the fax machine that [Resident #1's ] UA was contaminated. In verbal report from [RN D], I knew that she needed it collected again. During the day she is continent and at night she's fully incontinent and she doesn't communicate when she is wet. So, I knew that I needed to do a straight catheter due to the fact that the first UA was contaminated and that she is incontinent at night. [CNA A] and I went in together so that she could help me. I always bring a CNA with me so that she wouldn't have to change the whole bed afte[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from abuse for 2 of 7 residents (Resident #1 and Resident #2) reviewed for abuse in that: 1. The facility staff failed to protect Resident #1 from abuse when staff woke up the resident at approximately 3:30 AM on 8/11/24 and performed an invasive straight catheter procedure which caused Resident #1 physical pain and mental anguish, and Resident #1 reported she felt violated, traumatized, abused, and raped. 2. The facility failed to protect Resident #2 from verbal abuse from CNA C, when CNA C continued call Resident #2 names and belittle him and made a threat to do it again (call him names), at the nurse's station after being told to stop. An Immediate Jeopardy (IJ) situation was determined to have existed on 8/11/24. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance on 8/29/24, updated 9/4/24 prior to beginning of the survey. These failures could place residents at risk of physical harm, mental anguish, and emotional distress. Findings Included: 1. Resident #1 Record review of Resident #1's undated face sheet revealed an [AGE] year-old female originally admitted to the facility on [DATE]. Resident #1 had a medical history of acute kidney failure (kidneys no longer work on their own), muscle weakness (lack of strength), and muscle wasting (thinning of muscle). Record review of Resident #1's MDS dated [DATE] revealed, Section C- Cognitive patterns revealed a BIMS score of 13 which indicated Resident #1 was cognitively intact. Section GG- Functional Abilities and goals- Admission, revealed the resident required partial/moderate assistance with toileting hygiene. Section H- Bladder and Bowel revealed Resident #1 was always continent of urinary and bowel and Resident #1 did not have any appliances (indwelling catheters, intermittent catheterization). Record review of Resident #1's care plan dated 8/15/24 revealed Resident #1 was at risk for problems with elimination. The care plan goal reflected, the resident elimination status will be maintained or improved over the next 90 days. Interventions revealed, Assist to toilet as needed. Monitor for signs and symptoms of urinary tract infection. Additionally, the care plan reflected the resident's health condition prior to admission was healthy with no major physical or mental illnesses. During an interview on 9/4/24 at 12:34 PM, Resident #1 stated she believed she had a UTI around 8/9/24, and she had notified the staff. The staff proceeded to test her for the UTI. She stated she was provided a urine collection hat to urinate in for the urine sample. She stated staff told her that the sample could become contaminated due to the urine collection hats not being in a clean environment. She stated for years she had urinated in a little jar for UA tests. She stated Sunday morning, 8/11/24, at approximately 3am, staff had come into her room and did a catheter ,(small, flexible tube that is used to empty urine form the bladder) when she was unconscious. She stated she was asleep and was unconscious (sleeping), and staff had not told her anything until after she had woken up . She stated on 8/11/2024, the nurse, and the aide told her they came in to do a straight catheter to get a urine sample. She stated she had not known the prior urine specimen was contaminated until after they did the straight catheter. Resident #1 stated she was not told until after the procedure had been done. She stated she had never had a catheter in her life, and she had always refused them before. She stated she would have refused and never have consented to a catheter and that she would have preferred to provide a urine sample herself in a cup. She stated staff did not request another sample; they just took it from her. She stated she did not say anything to the nurses because she felt it was not the right time. Resident #1 stated she felt very violated, and she did not think the facility cared too much about her concerns. She stated the procedure was painful and she reported it on 8/12/24 to the ADM and she was sent to the ER for further evaluation. She stated the EDO physician explained she was swollen down there (vaginal area). Resident #1 stated she was in pain and the procedure was painful. Resident #1 stated she reported the incident to the police on 8/12/2024 when the facility called the local police to the facility. Resident #1 stated she did not understand why they could not wait to ask her for the sample during the day or in the morning instead of when she was unconscious. She stated they took a sample that would not have been sent out until late because it was on a Sunday and the lab place was not open until Monday. Resident #1 stated she felt she was taken advantage of, and that the procedure wasn't handled correctly, and that the catheter procedure was unnecessary. She also stated she felt violated, as if she had been raped and was very upset over the whole incident and had continued to be bothered and upset about it since the time it happened. Record review of a police call sheet dated 9/5/24 revealed, Police Sequence #P240807233 as of 9/5/24 11:18 AM: Created: 8/12/24 11:24:58 Entered: 8/12/24 11:57:47 Dispatch: 8/12/24 13:11:46 Enroute: 8/12/24 13:11:49 On scene: 8/12/24 13:13:49 Closed: 8/12/24 14:07:35 11:54:58 Location: [Facility address], Name: [Redacted], Phone: [Redacted] 11:57:47 Comment: Victim [Redacted] Against a female nurse who went into her room at night/reported advised nurse was doing a procedure to extract urine and victim felt violated. 14:07:27 Comment: I spoke with [Redacted] who advised about 2 nights ago a nurse and a nurse aide woke her up and told her they needed a urine sample. [Redacted] advised she was groggy and still sleepy but advised later they came back in and advised her they put a catheter in to get a clean urine sample. [Redacted] advised she did not authorize a catheter to be put in and she felt violated, but advised she does not remember them even putting the catheter in. I spoke with the Administrator [Redated], who advised there is documentation that the doctor ordered the catheter for [Redacted] advised the nurses chart advised they put the catheter without any complaints from [Redacted], advised the nurse and aide who put the catheter were not at time but advised she would get in contact with them later to see what happened and why [Redacted] would be complaining now. I gave [Redacted] a sequence number for their records. There is clear documentation this was a medical procedure done at the request of the doctor. No crime occurred. 14:07:34 Clear. Record review of Resident #1's EMR physician's orders provided by the DON, dated 9/4/24 revealed, there were no orders located for the straight catheter procedure that occurred on 8/11/24. There were no orders for nighttime medications that would induce sleep. Record review of Resident #1 Trauma informed Observation, dated 8/12/24, revealed the assessment was completed with recommendations of resident wishes/goal, There's no reason to. Oriented to notify staff if or when needs to talk and or would like therapy. Oh no I just want to get therapy, go home, see my old dog, she's 15 a Chihuahua, was electronically signed by [Name] Social Services Director 8/12/24 at 12:23 PM. Record review Resident #1 hospital records dated 8/13/24 revealed a SANE exam was not conducted as there was no indication to conduct the exam. Furthermore, the exam revealed there was mild edema (inflammation, swelling and irritation) around the urethral meatus (opening that allows urine to exit the body) and that there was no evidence of trauma otherwise and no vaginal tenderness. During an interview on 9/4/24 at 1:30 PM, the DON stated she was on leave when the incident occurred with Resident #1 on 8/11/2024, but she believed the initial urine test was done based on the standing orders the EDO had for admission lab work which included a urine test. She stated she knew the urine test was redone because the lab said it was contaminated. She stated they always did UAs every morning because the lab staff came in the mornings to draw labs and facility staff drew the UAs in-house. She stated Resident #1's admitting labs were dated on 8/13/24, she had UA lab results dated on 8/9/24. She stated she believed they were the results from a UA test done on 8/5/24, but she was not sure. She stated the rest of the standing order labs were done on 8/14/24. She stated she did not see an order for the UA in the EMR, only for the bloodwork, which was dated 8/14/24. She stated usually when labs are contaminated, they would send a request to the FNP for a retest and a lot of times they prefer to redo the UA by straight catheter when they come back contaminated because it was cleaner. She stated she had not located an order for the straight catheter procedure. She stated she had not located any documentation showing that the physician was notified of the straight catheter or that there was an order for the straight catheter. The DON stated she was not aware of concerns Resident #1 voiced, until the next day 8/12/2024, and she had not spoken to the resident. The DON stated the ADM had spoken to Resident #1 and she was not at the facility because she had been sent to the ED. She stated she had not spoken to the nurse about the issue of the orders not received or documented, until now because she was not aware of it. She stated she expected for staff to document the proper steps. She stated she was not aware if staff were trained how to document properly and the proper steps to take in those situations (documented orders, care, consent). She stated the original lab was faxed to the facility on 8/9/24 at 4:04 PM, which showed an abnormality, the facility received the contaminated lab results on 8/9/24 at 20:03 PM (8:03 PM). She stated the evening shift (2 PM-10 PM) would have been responsible to take care of it. She stated she did not see any documentation that the evening shift took care of it. She stated it was not typical for a staff to do a procedure like that at 3:00 AM because residents were asleep, and it was not okay to take samples at that time because residents may not be clear on what was going on because they were in a dead sleep. She stated the UA recollection should have been done close to the time the fax was received between 8:00 PM-10:00 PM. She did not know why the culture was not done during the 2PM/10PM shift. She stated a potential negative outcome could be that the resident may not completely understand what was going on which could cause them to have felt something inappropriate went on. She stated the resident was not aware of what staff were doing which could make them think something else could be going on. She stated typically staff would have explained to the resident that the doctor ordered a straight catheter as well as explain why it is needed, which is how staff typically obtain consent from residents. She stated consent for straight cath procedures were obtained verbally from the resident and a lot of the time residents say no and the physician are then notified. She stated there should have been progress notes of communication with physician and verbal orders should also be documented in the EMR. She stated she never spoke to the resident because she had already been assessed and it was the end of the situation when she returned to work. She stated the facility started in-service with staff on abuse/neglect, resident rights, customer service, and explaining procedure before you start. During an interview on 9/4/24 at 4:03 PM, the ADM stated on 8/12/2024, she was told Resident #1 wanted to speak with her. The ADM stated when she went to speak with Resident #1, they both realized they knew each other from years ago when Resident #1's family member lived at a facility the ADM previously worked at. The ADM stated Resident #1 mentioned she was previously at another nursing home for rehabilitation services that the ADM was the ADM at, and they discussed how they did not have any contact with each other at that facility. The ADM stated Resident #1 told her she wanted to speak to her about an incident she was concerned about. The ADM stated Resident #1 told her she peed in a cup and was told the test came back contaminated. She stated Resident #1 told her that staff came in to repeat the UA and that it was at night and said, I felt I was raped. The ADM stated she explained that a straight catheter went into the urethra (hollow tube that lets urine, a waste product, leave the body) and asked Resident #1 if something went into her vagina, and she said she did not know. She stated Resident #1 said she would not have wanted a straight catheter. The ADM stated she told Resident #1 she would report it. She stated she called law enforcement and reported the incident to HHS. She stated they completed a skin assessment and there were no findings. She stated Resident #1 was sent to the hospital and asked for a rape kit, but the rape kit was not done due to the information Resident #1 provided to hospital staff about the incident during that examination. She stated Resident #1 stated she understood she was not raped and just did not want a catheter done and said she would have refused it. She stated she spoke to LVN B who said she was passed on report from RN D who told her the test was contaminated and that it needed to be repeated. She stated CNA A went in with LVN B because she wanted a second person for help in case the bed needed to be changed. The ADM stated both LVN B and CNA A said Resident #1 was awake and asked questions during the procedure, and that LVN B explained the procedure. She stated she was told Resident #1 tolerated the procedure without any issue and she appeared to be awake. She stated she was told Resident #1 said ouch, but that was all. She stated she was told Resident #1 had not expressed having an issue with the procedure. She stated RN D reached out to the FNP who gave the order to repeat the UA. She stated there should be an order to do a straight catheter. She stated consent was typically obtained by a resident verbally after the procedure was explained to them. She stated she thought [LVN B] did the procedure at 3:30 AM because she was trying to get it done before her shift ended. She stated it was typical to get a straight catheter sample to prevent getting another contaminated sample. She stated it could have delayed treatment if another contaminated sample was received. She stated staff called physicians or talked to them in person when they were in the building to obtain orders and that there should have been a progress note in the record when orders were received or documented in the 24-hour report. During an interview on 9/4/24 at 4:17pm, RN D stated he received the lab report of the contaminated urine sample for Resident #1 the evening of near the end of his shift on 8/10/2024. He stated it had been a busy shift so at the end of the shift he told the oncoming nurse, LVN B, that he had not had time to report the lab and asked her to follow up on it. He stated he asked LVN B to notify the FNP. RN D stated he never spoke to the FNP on 8/10/24 and delegated it to LVN B. He stated he believed he collected the first UA sample via urine collection hat that came back contaminated. He stated Resident #1 complained of burning and discomfort during urination, so he had notified the FNP on 8/09/2024. He stated at that same time he noticed the admitting labs had not been completed and the FNP stated okay, so he went ahead and did the UA. RN D stated Resident #1 was very modest and did not like the male nurses to assist her. He stated she was adamant that she used the urine collection hat to provide the sample as that was how they usually collected her urine. RN D stated in his experience the urine collection hat often resulted in an anomaly. He stated he told Resident #1 if the sample came back contaminated, they may have to do a straight catheter. He stated Resident #1 said okay at that time, but he didn't think too much about it. He stated he did not remember if he had put a progress note in the EMR about her having the urinary discomfort. He stated the nurse who admitted the resident was responsible for initiating the admission labs. He stated all communication should have been documented in the progress notes to protect themselves, especially if it was a new order. He stated if he had reported the contaminated lab to the FNP, they probably would have said to do a straight catheter. He stated if he could not get ahold of the FNP, he would have waited until he received an order. He stated he would not have gone outside of his scope of practice. RN D provided information on recent in-service received on abuse/neglect, resident rights, customer service, and explaining procedure before you start, after the incident with Resident #1 and Resident #2. Record review of Resident #1's urine analysis collected on 8/9/24 at 2:55PM, revealed a culture result of three or more organisms, probable contamination. The lab result was faxed to the facility on 8/10/24 at 8:03pm. The lab report revealed a written note New specimen obtained 8/11, signed by LVN B. Record review of Resident #1's urine analysis collected on 8/11/24 at 11:00 AM, revealed a culture result of staphylococcus epidermidis (gram-positive bacteria) and a sensitivity to oxacillin, tetracycline, and vancomycin (medications used to treat bacterial infections). The lab result was faxed to the facility on 8/13/24 at 12:07pm. Record review of Resident #1's EMR physician orders revealed, Order/Start date: 8/13/24. vancomycin 500 mg (antibiotic) intravenous solution 500 Milligram intravenously 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Order/Start Date Order Time 08/16/24 2 times per day. Vancomycin 500 mg (antibiotic) intravenous solution 2 times per day 7 Days Dx: Urinary tract infection, site not specified. Record review revealed Resident #1 was also receiving vancomycin medication for a dx of Unspecified open wound of abdominal wall, unspecified quadrant without penetration into peritoneal cavity (space in the abdomen that contains the stomach, liver and intestines) subsequent encounter. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed, there was no documentation by RN D, for Resident #1 reporting pain and discomfort with urination and requesting to be tested for a UTI on 8/9/24 or the days prior to. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed, there was no documented communication between staff and physician for notification of Resident #1's change in condition. Record review of Resident #1's nurses notes dated 8/04/24- 9/4/24 revealed no documentation by LVN B or RN D's communication with a physician regarding a contaminated urine analysis. Record review of Resident #1's EMR physician's orders revealed, there was no order for a UA repeat and method of collection on 8/10/24 or 8/11/24. Record review of the physician's standing orders dated 6/19/2019 for the MD revealed the following, Laboratory .54. Fasting Labs Upon admission: BMP, CBC, U/A, lipid profile. During an interview on 9/4/24 at 5:57 PM, the EDO stated he would have been fine with a resident providing their own urine sample when they were able to but would want the urine sample to be obtained by a straight catheter for residents who were unable to provide a urine sample on their own. He stated he felt nurses would know the best way to obtain the sample. He stated he believed the FNP was contacted about the UA orders for Resident #1. He stated he was aware Resident #1 reported feeling abused and violated by the straight catheter procedure and that she was sent to the emergency room for an examination. He stated after speaking with Resident #1, she realized she was not assaulted but insisted she did not like the way it was handled. He stated he was not sure if he saw Resident #1 afterwards. He stated he was not aware staff completed the straight catheter procedure on Resident #1 at 3:30 AM. He stated he hoped staff would not do a straight catheter procedure on a resident at that time of night. During an interview with CNA A on 9/4/24 at 11:38 PM, CNA A stated LVN B asked her to help her get a urine sample from Resident #1, on 8/10/2024 after she arrived for the night shift but could not recall the exact time. She stated they got supplies together to go see Resident #1. She stated Resident #1 was asleep when they entered her room. She stated the dim lights were on in the room when they entered, and they turned the big light on during the procedure. She stated she asked Resident #1 to wake up and Resident #1 hummed like she did not want to wake up. CNA A stated she stayed in the room the whole time. She stated LVN B stepped out to get a collection bag. CNA A stated she had spoken to Resident #1 because she was still kind of knocked out (drowsy, did not stay awake, continued to fall back asleep). CNA A stated she asked Resident #1 if she needed water or anything else, and she said no. She stated then LVN B reentered the room. She stated Resident #1 asked what was going on and LVN B explained she needed a clean urine sample, Resident #1 replied that she already gave one, and then LVN B explained it was not a clean sample and they needed another one. CNA A stated Resident #1 said, Well I guess., then she undid the straps on the brief, and she wiped Resident #1 front to back. CNA A stated Resident #1's brief was dry when she undid the brief straps. She stated then LVN B wiped the area with a cotton swab that had alcohol/brown liquid on it. She stated she could not recall if LVN B told Resident #1 she was going to clean her with the cotton swab, but she did recall that LVN B told Resident #1 she was going to feel some pressure. She stated LVN B inserted the catheter and got the urine sample, removed the catheter, and completed her part. She stated Resident #1's eyes were open during the procedure, and she watched what was going on. She stated Resident #1 loudly said ouch when the catheter went in, and LVN B told her she had to insert a catheter to get a sample. CNA A stated LVN B did not explain where she was going to insert the catheter to get the sample. She stated after the procedure was over Resident #1 said, I guess this was a rude awakening. and she told Resident #1 she was sorry. She stated LVN B said, Sorry but it needed to be done. She stated there were no other words said between Resident #1 and LVN B after that. CNA A stated she stayed about five minutes to clean after LVN B stepped out. CNA A stated she put a clean brief on Resident #1 and picked up trash. She stated she changed the brief because it had dye and other stuff on it. She stated Resident #1 woke up after LVN B left. She stated Resident #1 was upset afterwards and said she felt like it was rude of them to go in at that time of night. She stated she checked on Resident #1 that shift a few more times and Resident #1 expressed it was rude each time she went into her room. CNA A stated she told LVN B that Resident #1 was upset and LVN B told her she would chart what all happened. CNA A stated she could not say if doing the procedure at 3:30 AM was not a good time. CNA A stated she saw Resident #1 right before she left her shift and Resident #1 told her she was not able to go back to sleep because she was mad and said it was rude of them to go in there and get the sample and she had not slept much because they woke her up. She stated Resident #1 did not express having pain afterwards. CNA A stated during the procedure, she held a box to make sure they didn't get urine on the bed sheet, and she did not assist with the straight catheter procedure. She stated Resident #1 always wore a brief at night but was not sure if she wore one during the day, but she knew Resident #1 went to the bathroom during the day. She stated Resident #1 had about four brief changes at night. She stated sometimes Resident #1 used the call light to request her brief be changed but sometimes her brief was wet during brief checks. CNA A stated the DON told her she needed to come in and speak with her and the ADM about the incident. CNA A stated she was suspended for a day because Resident #1 made allegations of being raped. CNA A stated no one expected have a catheter inserted in the middle of night. CNA A stated she also assisted LVN B during another straight catheter procedure that night with another female resident on hall 200 that was Spanish speaking. She stated she translated information between the resident and LVN B and translated the catheter process to that resident during the procedure. CNA A stated that procedure was before the procedure with Resident #1. She stated that resident was sitting on the side of her bed when they entered the room and said she needed to pee but could not go. She stated LVN B got the UA sample, and she cleaned the resident afterwards. CNA A provided information on recent in-service received on abuse/neglect, resident rights, customer service after the incident with Resident #1, and abuse/neglect, resident rights, customer service after the incident with Resident #2. Record Review of an undated written statement provided by the facility of a statement given by CNA A revealed, [LVN B] asked me to go with her to help with the supplies while she was doing a straight catheter on [Resident #1]. [Resident #1] was asleep, and she woke her and said we have to get a sample from you. I made sure that she was awake. Resident #1 said she had already given a sample and asked why we needed another sample. [LVN B] explained it was contaminated and needed to redo it. [LVN B] prepped and completed the procedure, [LVN B] was explaining the whole time to [Resident #1] what was going on. [Resident #1] asked a few questions and was awake during the procedure. [Resident #1] said that it was painful at the time of the procedure. Throughout the night I continued to round on her, and she asked for water which I provided, she continued to thank me throughout the shift. During an interview on 9/5/24 at 12:25 AM, LVN B stated she arrived for her shift that night around 9:45 PM on 8/10/2024 and got report from RN D, who was the off-going nurse. She stated RN D told her Resident #1's urine test was contaminated, and they needed another specimen. LVN B stated she confirmed with RN D that Resident #1 was incontinent at night but could not recall if they discussed in report about doing a catheter. LVN B stated she remembered seeing the lab slip and that it said the specimen was contaminated, but she could not remember if the slip said to recollect a urine sample or if there was an order on the lab slip. LVN B stated she could not remember if RN D told her he spoke to anyone about the lab. LVN B stated she told CNA A they needed to collect a specimen and asked when she was doing care on Resident #1 so they could do the straight catheter procedure at the same time. She stated it was easier to have a CNA present to facilitate the process. She stated lab staff came every day any time after 5:00 AM to pick up specimens, so she was trying to get it done before then. LVN B stated Resident #1 was asleep when they entered her room, so they woke her up. She stated she explained to Resident #1 she was there to do the straight catheter procedure to get a urine sample and Resident #1 replied that she had already done one. She stated Resident #1 asked why she could not do it on the toilet, and she explained they needed a clean sample. LVN B stated she did not recall if Resident #1 had any other questions after that. LVN B stated she told Resident #1 that the UA was contaminated, and they needed another specimen. LVN B stated Resident #1 did not say anything to her after that, so she began the procedure. LVN B stated she explained to Resident #1 that she was going to put a tube in her. She stated Resident #1 said ouch, so she stopped and asked if she was okay, Resident #1 said yes, so she collected the specimen and completed the procedure, and then her brief was changed by CNA A. LVN B stated again she did not remember Resident #1 saying anything after she explained the procedure. She stated she felt she got informed consent from Resident #1 to complete the procedure because Resident #1 was cooperative during the procedure by spreading her legs when asked and Resident #1 allowed her to do the pre-cleaning without any issues. She stated Resident #1 also did not refuse the procedure when she told her about it, or she would not have done it. She stated she explained to Resident #1 every time she was going to do something and told her it would be uncomfortable. She stated she did the straight catheter procedure because Resident #1 was incontinent and symptomatic by complaining of not feeling well. LVN B stated Resident #1 had lab work done as well, and she believed they did the lab work when they did the first UA. She stated the facility did admission labs when residents first came in. LVN B stated she did not ask Resident #1 if she wanted to provide a urine sample by urine collection hat because she was incontinent at night and because the previous sample that was collected in that manner was contaminated and she wanted a clean specimen. LVN B stated part of the consent was verbal and part of it was demeanor. She stated Resident #1 responded to what she asked her to do and did not state she did not want to do it. She stated she did not know if residents had to say the exact words I agree, or I refuse. She stated, If they don't agree but they cooperate .I recall her saying okay and being aware of what we were doing. If she had said don't do that, then I wouldn't have done it. I believe she consented. She stated she felt Resident #1 was fully awake during the procedure because Resident #1 cooperated when she asked her to do things, such as scoot her bottom down and then spread her legs. LVN B stated she did not recall if there was any other conversation during the process. LVN B stated Resident #1 did not say anything afterwards and she left. LVN B stated later during the shift, she went to give Resident #1 some medication and Resident #1 asked LVN B why she did that to her and LVN B explained to Resident #1 that the previous test was contaminated, and they needed to get another urine sample and Resident #1 said okay. LVN B stated she did not call the FNP to get orders to perform the straight catheter procedure on Resident #1 because she was under the impression from report given to her by RN D that there was a physician's orders for the collection of the urine specimen from Resident #1, but she did not check to verify if there were orders. LVN B stated staff were supposed to have orders before doing an invasive procedure like that. She stated the order usually specified the way the urine specimen was collected, but she would clarify if that information was not written on the order. She stated she did not recall if RN D told her there was an order in the chart. She stated she was trained to verify orders before performing a procedure. LVN B stated, I don't guess I did that day. I do not remember seeing any physician orders. I don't recall if [RN D] told me he had notified the physician or if he had gotten an order. I just knew that I needed to collect a UA through the conversation with [RN D]. She stated no one told her that day that Resident #1 was upset. She stated she did not remember if the ADM or the DON spoke to her about the incident. She stated she was told Resident #1 was sent for a medical exam. She [TRUNCATED]