**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility did not ensure that a resident who enters the facility with an indwelling catheter receives appropriate treatment and services 1 of 1 residents (R32) reviewed for indwelling catheters. R32 has an indwelling catheter, and a provider was not notified timely when the resident presented with urethral bleeding around the catheter tubing following catheter insertion. R32's catheter was advanced into the bladder and not changed with a new sterile catheter when R32 had no urine output noted 2 hours after insertion. This is evidenced by: Facility policy entitled, Catheter Care, Urinary, dated 9/2014, states, in part: Purpose: The purpose of this procedure is to prevent catheter-associated urinary tract infections . Changing Catheters 1. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised . Complications 1. Observe the resident for complications associated with urinary catheters . c. Notify the physician or supervisor in the event of bleeding, or if the catheter is accidentally removed . Facility policy entitled, Catheterization, Intermittent, Male Resident, dated 10/2010, states, in part: Purpose: The purpose of this procedure is to provide guidelines for the aseptic insertion of an intermittent catheter . Steps in the Procedure . 21. Insert the catheter gently into the meatus (approximately 5-7 inches) until urine begins to flow from the bladder. When urine begins to flow advance the catheter another 2 inches. 22. If slight resistance is met, instruct the resident to take a slow deep breath to relax the perineal muscles and overcome resistance to entry. If resistance continues, do not force the entry. Stop the procedure and notify your supervisor . Reporting . 2. Notify the physician of any abnormalities (i.e. urine output of 800 mL (milliliters), obstruction, etc.) . (Of note: Facility did not provide Surveyor with a Foley or chronic catheter policy.) Facility policy entitled, Acute Condition Changes - Clinical Protocol, dated 3/2018, states, in part: . 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status . Facility policy entitled, Medical Change of Condition and Hospitalization of Resident, dated 4/11/11, states, in part: .D. If the condition is not life threatening: 1. The primary physician or his designated on-call physician will be contact and informed of the medical condition and the licensed nurse's observations and assessments . According to the CDC, with a revision date of 10/24/16 includes, in part: Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when the closed system is compromised. R32 was admitted to the facility on [DATE] with diagnosis that include, in part: type 2 diabetes, chronic kidney disease, stage 3, NSTEMI (heart attack), other idiopathic peripheral autonomic neuropathy (nervous system disorder causing involuntarily bodily functions), congestive heart failure (heart fails to properly provide oxygen to the body's tissues), and a personal history of malignant neoplasm of bladder (bladder cancer). R32's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/2/25, indicates that R32 has a Brief Interview for Mental Status (BIMS) of 15 out of 15 indicating that he is cognitively intact. Section H indicates that R2 is currently utilizing an indwelling catheter. R32's Comprehensive Care Plan states, in part: I need to have a catheter because I have urinary retention related to DM (diabetes mellitus), neuropathy and spinal stenosis. I have dx (diagnoses) kidney cyst and hx (history) of malignant bladder neoplasm and UTI (urinary tract infection). I need my nurses to . care for my catheter, facilitate a urology consult as appropriate, contact MD (medical doctor) as needed. I need my aides to . take care of my catheter equipment and skin and keep track of my urine output .let my nurse know if my urine looks different than usual, sometimes I can get hematuria (blood in urine) in my tubing or my foley bag. If that happened please monitor me closely for a UTI. Usually the hematuria is from the tubing getting pulled and not something more significant. R32's Physician Orders indicate, in part: Change indwelling foley catheter. Reason for indwelling foley: Urinary retention related to DM, neuropathy and spinal stenosis. Size: 16 French 10 ML balloon. As needed. Occlusion or dislodgement. First date: 12/19/24. Change foley bag as needed. First date: 12/19/24. Nursing order. Catheter irrigation with 60 ml normal saline as needed. Occlusion. First date: 12/19/24 FYI Resident is taking anticoagulant = monitor for any unusual bruising or bleeding AM (day shift) PM (evening shift) NOC (night shift) Nursing Order: Change foley catheter every 4-6 weeks 1x (one time) month 3rd Tuesday PM. First date: 1/21/25. [APNP (advanced practice Nurse Practitioner) Name] Dx Urinary retention related to DM, neuropathy, spinal stenosis. Discontinued 1/23/25. Apixaban (blood thinner) 2.5 MG (milligram) tablet dose ordered: (1 tablet/2.5 mg) by mouth twice a day AM HS (at bedtime) first date: 3/5/24. (Of note: All orders were active in January 2025) R32's Medication Administration Record (MAR) indicates R32 received Apixaban: 1/21/25: AM and HS 1/22/25: HS 1/25/25: AM (Of note: This medication was held 1/22/25 AM, 1/23/25 AM and HS, 1/24 AM and HS, and 1/25/25 HS.) R32's Treatment Administration Record (TAR) indicates that no abnormal bruising or bleeding was observed on 1/21/25. On 1/22/25 and 1/23/25 this section is marked See NN (nurses notes). On 1/21/25 on the PM shift, the TAR indicates R32 had his foley catheter changed. On 1/21/25 at 7:28 PM, a Nurses Note is written that states, Scheduled foley catheter change done using sterile technique 16fr with 10ml balloon as per order. Foley placed without resistance, resident did say it was sensitive. Small amount of bright red blood in return. Catheter flushed with 60 ml of normal saline. Resident is on blood thinners. On call [Doctors Name] updated and instructed to just watch to make sure it clears up. Resident later . he felt mild discomfort. (Surveyor notes that several provider notes indicate the difficulty in assessing the patient due to his diagnosed neuropathy and is important to note that R32 is feeling discomfort following catheter placement) On 1/22/25 at 12:35 AM, a Nurses Note is written that states, Superficial open area to mid anterior scrotum, no bleeding at this time. No signs of infection. Area washed, dried and Desitin (skin moisturizer) applied. On 1/22/25 at 1:58 AM, a Nurses Note is written that states, Resident had catheter change after supper on PM shift. RN (Registered Nurse) reported no urinary output since catheter changed and blood filled the tube at 22:30 (10:30 PM). This RN deflated the balloon and advanced the catheter tubing. Red/urine began to flow slightly more into the tubing. Resident had no pain or discomfort during intervention. No discomfort when RN palpated lower abdomen/bladder region. CNA (Certified Nursing Assistant) called RN into room at 0145 (1:45 AM). At that time resident had large clot of blood in catheter bag tubing which seemed to impede the further drainage of urine. Bag changed, catheter irrigated and there was an immediate return of normal saline and pale yellow urine with no hematuria present. Resident continues to have no pain or discomfort and indwelling catheter is draining to gravity. (Of note: The nurse advanced the catheter tubing after being placed for several hours. Foley catheter insertion is a sterile procedure utilizing sterile equipment. There is no way to sterilize the catheter tubing after being in place outside of the urinary tract for several hours.) On 1/22/25 at 5:21 AM, a Nurses Note is written that states, Follow up Hematuria following a scheduled catheter change. Resident's urine clear at end of shift with no hematuria present. Resident had a total of 825mL of urine out this shift. On 1/22/25 at 11:58 AM, a Nurses Note is written that states, in part: . When CNA assisted this resident to the toilet for a bowel movement at 0800 (8:00 AM) there was a significant amount of bright red blood on the brief therefore this writer was called. Upon examination there was found to be clotting of blood around the urethra. The catheter was patent but the urine was blush color with hematuria and a few almond size blood clots were in the catheter tubing. When resident was off the toilet there was a moderate amount of fresh blood in the bowl. Resident was cleansed and the bleeding ceased . Vitals were checked . GU (Genitourinary) discomfort was denied . RN has scheduled monitoring of this condition and this writer added TID (Three times a day) monitoring of vitals. Apixaban scheduled with AM medication held and MD update was to occur but prior to this action resident would be checked to reassess the bleeding. Resident returned to his room at 1130 (11:30 AM) following activities. Upon checking this resident has a light bloody 50 cent size stain in his brief. Upon standing resident to change his undergarment a steady stream[sic] of frank red blood began to flow from the urethra around the catheter. The urine in the catheter was cranberry color. Since the bleeding was uncontrolled resident was assisted into bed and his LE (lower extremities) were elevated. RN was contacted to assess the situation and concurred [Resident's Name] should be evaluated in the ER (emergency room). NP (Nurse Practitioner) was contacted and EMS (Emergency Medical Services) was called. Plan is to recheck vitals prior to this transfer. On 1/22/25, with no time provided, a Progress Note was written by NP C that states: 1/22/25 [Nurse Name], facility nurse, calling reporting patient is having significant bleeding around Foley catheter. Pouring out when he is in a sitting position. Last night, his Foley catheter was changed. No output until nurse re-advanced the catheter then had immediate return of 800 ml. He then had light pink urine with almond sized blood clots. Since this morning, bleeding oozing around Foley catheter through meatus. Eliquis was held. When staff got patient up for lunch, significant bleeding started. Please send to ER for immediate evaluation. Concerning for urethra or prostate issue given amount of bleeding. On 1/22/25 at 11:11 PM, a Nurses Note is written that states: follow-up: [Hospital Name] transfer: resident returned at 1855 (6:55 PM). Traumatic foley insertion with no new orders. VSS (vital signs stable) as entered in TAR. On 1/22/25 at 1:40 PM, a Nursing Emergency Department Note is written by RN D, that states, in part: . presents to ED from [Facility Name] for evaluation of Catheter. Placement of foley 2 days ago, no drainage. Replaced with immediate output of 800 ml of blood urine. Arrives with clear urine draining. Position change causes blood in urine .Denies pain . On 1/22/25 at 1:50 PM, a Physician Emergency Department Note is written that states, in part: . Chief Compliant: Bleeding around Foley History of Present Illness: . presents via ambulance for a Foley concern. He had his 30 day Foley exchanged yesterday. This morning there is no drainage, so they repositioned it and his bladder drained. Since then he has had blood leaking from his penis. He denies significant pain . Physical Exam . GU: Blue Foley catheter tubing in place and patient's urethra, no phimosis/paraphimosis (inability to retract foreskin). Small amount of blood oozing from around the Foley. Good drainage into the Foley bag, no frank blood . Patient appears to have bleeding from a traumatic Foley catheter insertion/adjustment. He does not appear to have any blood in the bag itself, no pain in the penis or lower abdomen, no lightheadedness, minimal blood loss overall. Bladder scan the patient with 0 mL no urinary retention and Foley appears to be in the proper location. Inflated fully an additional 5 cc (cubic centimeters) and pulled[sic] gently towards urethra to assist with tamponade of the likely site of the bleed. Very small amount of bleeding continues, however risks of replacement further traumatize an area outweigh the benefits attempting to replace the Foley. No suspicion for cystitis at this time . On 1/23/25 at 11:00 PM, a Physician's Telephone Order is written providing orders for desitin twice daily for R32's scrotal abrasion and change R32's hemoglobin lab from 1/24/25 to 1/23/25 due to the patient's hematuria. On 1/23/25 at 11:29 PM a note was started by NP C that was not signed until 2/19/25 at 12:23 PM that states, in part: . Gross hematuria: [Hospital Name] ER yesterday for gross hematuria. No labs completed. No imaging completed. Returned from ER without any new orders. Eliquis was given last night as ordered. Today, patient has significant bleeding from meatus again. Clots and dripping visualized by writer today. Foley draining clear yellow urine with occasional sporadic pink tinge urine. Patient denies pain. No fever or chills. Reports no suprapubic tenderness . (Of note: NP copies the Physician Emergency Department Note described previously into her note then continues.).Physical Exam . GU: Gross hematuria from meatus outside of foley catheter tubing. Large clots. Per nursing staff, this has improved since this morning. Assessment/Plan: 1. Acute prostatitis 2. Gross hematuria. Comment: Active, significant bleeding around catheter tubing out meatus which is very possibly related to prostatitis . Has had recurrent hematuria historically and is at further risk of bleeding due to chronic anticoagulation with Eliquis .Complete assessment is impaired due to patient's neuropathic ability . On 1/23/25 at 2:43 PM, a Nurses Note is written that states, in part: Gross hematuria and bleeding from the urethra evaluated at the ER on [DATE] follow up: This morning the foley catheter was patent and the urine was pale yellow/clear. At 1030 (10:30 AM) when resident used the toilet for a bowel movement resident began bleeding from the urethra. When resident stood in the EZ stand for hygiene blood began to stream from the urethra. Resident had no complaints of pain, feeling dizzy, lightheaded, or faint. Vitals were WNL (within normal limits) for [Resident's Name]. RN and NP were called to visualize the amount of bleeding. Resident was assisted into his bed and once laying in bed hygiene was performed. Following the change in position the bleeding slowly subsided to a trickle but the urine was now a light cranberry color .NP visualized the urethral bleeding, some mild scrotal enlargement, and the open skin on the scrotum. New orders were received and transcribed . (Of note: The new orders placed were for Ciprofloxacin, an antibiotic, with an indication of prostatitis (inflammation of the prostate)) On 1/23/25 at 7:37 PM, a Nurses Note is written that states, in part: .Recent Hematuria/Abx for Prostatitis/Recent ER visit. Resident had two times of blood flow come from the catheter . On 1/24/25 at 1:46 PM, a Nurses Note is written that states: follow-up: Follow up for traumatic bleeding in urinary tract. This morning after breakfast res (resident) had a small amount of blood in his brief (about the size of a baseball) and some hematuria. It is a lot less than what res was having. Blood thinner was held this morning and will be held again tonight. Res was up in his w/c (wheelchair) all shift and laid down after lunch. When he laid down he had about a quarter sized spot of blood in his brief. Urine was orange in color. Res denied any pain. On 1/24/25 at 8:51 PM, a Nurses Note is written that states: follow-up: Traumatic bleeding UT: Resident had no c/o (complaint) pain no blood in catheter however there was a small amount in brief. On 1/25/25, with no time indicated, a Physician's Telephone Order is written that provides an order to hold R32's Eliquis for his HS dose and to reassess this order tomorrow if R32 has continued bleeding. On 1/25/25 at 4:52 AM, a Nurses Note is written that states, in part: Catheter change/hematuria/ATB (antibiotic): Cipro (Ciprofloxacin) follow up: Indwelling catheter is patent and draining to gravity. Urine is light/clear yellow. Small amount of blood on catheter tubing and on left thigh . Denies any pain or discomfort . On 1/25/25 at 7:10 PM, a Nurses Note is written that states, in part: follow-up: GU bleeding. CNA alerts writer to blood coming from residents urethra at HS. Blood in brief and in bed after standing in EZ stand as it leaked around and down the catheter. On call MD was updated. Received orders to hold HS dose of Eliquis (Apixaban) tonight . On 1/26/25 at 5:31 AM, a Nurses Note is written that states, in part: Taking Cipro/monitoring for traumatic bleeding following a catheter change and hematuria . Resident continues on Cipro .No complaints of pain or discomfort . Indwelling foley catheter is patent and draining to gravity. Urine is light yellow, no hematuria. Small amount of dried blood along ridge of brief. No active bleeding from urethra . On 2/19/25 at 10:30 AM, Surveyor interviewed CNA E (Certified Nusing Assistant). Surveyor asked CNA E what issues with a catheter she would report to the nurse. CNA E states she would report fluid that looked white, creamy, red, and any bleeding in and around the catheter to the nurse so that they could come and assess the resident. Surveyor asked CNA E how quickly she would notify the nurse if CNA E observed those things. CNA E states, you report it right away when you see it. Surveyor asked CNA E if she was on shift on 1/22/25. CNA E confirms she was and that she was working on R32's unit. Surveyor asked CNA E to describe what happened. CNA E indicates that she saw some blood in the tubing even prior to getting R32 out of bed. She was transferring him to the toilet so he could use the restroom. Once standing in the bathroom, she pulled down R32's brief so he could sit on the toilet. Once she pulled his pants down, she observed blood in his brief and blood was free flowing out of his urethra. CNA E indicates she ensured the resident's safety by sitting him down on the toilet and immediately called the nurse to the room. CNA E states LPN F immediately responded to the room to assess the resident. Surveyor asked CNA E what time this happened. CNA E indicates around 7:30 AM to 8:00 AM, before breakfast. Surveyor asked if R32 was asked if he wanted to go to the hospital. CNA E indicates she believes that they would assume the bleeding would slow on its own. CNA E indicates the resident was asked, however he refused because he wanted to go to an activity that morning. Surveyor asked CNA E what happened after the activity. CNA E indicates R32 was being transferred from his wheelchair to the toilet and when his brief was pulled down, the bleeding coming from his penis was even worse. CNA E indicates R32 was then sent to the hospital. On 2/19/25 at 10:41 AM, Surveyor interviewed LPN F (Licensed Practical Nurse). Surveyor asked LPN F if facility nursing staff have received any recent training on foley catheters. LPN F indicates they have not had any. Surveyor asked LPN F to describe the process for inserting a foley catheter. LPN F indicates you wash your hands, set up your equipment, open the package, maintain a sterile procedure and use sterile gloves, utilize betadine to clean the insertion area, dip catheter into the lubricant, insert the catheter until you get urine return in the tubing, and if you don't get urine, you don't inflate the balloon. Surveyor asked LPN F if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. LPN F indicates that she does not and has never been taught to do that. Surveyor asked LPN F why it would be important not to do that. LPN F indicates there is a high risk for contamination and that she would get a new kit and start the procedure over if there was something wrong with the catheter placement. Surveyor asked LPN F what scenarios would prompt her to notify a physician of problems with a catheter. LPN F indicates if there is good urine output that suddenly stopped, if there was an order without a specific size catheter, any hematuria, and signs and symptoms of infection. Surveyor asked LPN F if it is normal to have blood return when inserting a catheter. LPN F indicates no, and that she would be concerned and contact a physician. Surveyor asked LPN F if she was on shift on 1/22/25. LPN F confirms she was and that she was working on R32's unit. Surveyor asked LPN F to describe what happened. LPN F indicates that her shift occurred 1-2 shifts after R32's catheter was placed. LPN F recalls being called into R32's room because he was bleeding from the urethra. LPN F indicates there was a gross amount of blood, so much so that she doesn't know if she could call it hematuria, that it was just frank bleeding. LPN F also indicates she observed clotting around the urethra, along with blood in the tubing, and a significant amount in the toilet. Surveyor asked LPN F what she did after making these observations. LPN F states she took vital signs, called a RN to perform an RN assessment, and held R32's morning Apixaban. Surveyor asked LPN F if she notified a physician. LPN F states she did. Surveyor asked if it should be documented, along with the timing of the notification. LPN F indicates this information should be documented in R32's medical record. Surveyor asked LPN F how long she has been working at this facility. LPN F indicates she has been employed by this facility for 30 years. Surveyor asked LPN F what she believed was the cause of R32's bleeding. LPN F indicates she would agree with the diagnosis from the ER of the traumatic foley insertion. On 2/19/25 at 11:05 AM, Surveyor interviewed UM G (unit Manager). Surveyor asked UM G if the facility has provided nursing staff with any recent education regarding foley catheters. UM G indicates she does not think so. Surveyor as UM G what the process is for inserting a foley catheter. UM G indicates you make sure you have an order, obtain your equipment, maintain a sterile procedure, utilize sterile gloves, clean the insertion area with iodine, apply lubricant to the tubing, and insert the tubing, making sure urine flows into the tubing. Surveyor asked UM G how long she would wait for urine return before contacting a physician or reattempting the procedure. UM G indicates she would have to check the facility policy but believes 5-10 minutes. UM G also indicates she would notify the physician if she was unable to get urine return. Surveyor asked UM G if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. UM G states that if there is bleeding, she probably wouldn't advance the tubing. Surveyor asked UM G if she thinks there would be a risk of infection if that tubing was advanced. UM G indicates that there would be a risk of infection. Surveyor asked UM G what scenarios would prompt her to notify a physician of problems with a catheter. UM G indicates hematuria, clots, no output, and signs and symptoms of infection. Surveyor asked UM G if it is normal to have blood return when inserting a foley catheter. UM G states some blood return, but you would have to know your resident. Surveyor asked UM G what she believes caused R32's bleeding. UM G indicates she believes it is from the traumatic foley insertion, like the ER said. UM G then stated, [Staff Member Name] should probably have some catheter education. On 2/19/25 at 2:07 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if the nursing staff have received any recent education regarding foley catheters. DON B indicates they have not received any training in at least the past 6 months. Surveyor asked DON B to describe the process of inserting a foley catheter. DON B indicates you obtain the equipment, prepare the resident, clean your hands, prepare your equipment maintaining a sterile procedure, clean the insertion area, lubricate the tubing, insert the catheter until you achieve urine return in the tubing, advance the tubing a little farther, inflate the balloon, and attach the drainage bag. Surveyor asked DON B if you can advance the catheter tubing after the catheter has been inserted and left in the resident for a few hours. DON B indicates, if you felt like there wasn't any further urine return you might try to deflate the balloon and try. Surveyor asked DON B if doing this might cause an infection risk. DON B indicates it could potentially cause an infection risk. Surveyor asked DON B what scenarios would prompt her to notify a physician of problems with a catheter. DON B indicates, if there was bleeding around the area of insertion she would be concerned for trauma, signs and symptoms of infection, hematuria, foul odor, and changes in urine output. Surveyor asked DON B if it is normal to have blood return when inserting a foley catheter. DON B indicates if it is an abnormal finding or if they've had multiple changes there may be some irritation or trauma to the urethra, especially if the resident is taking anticoagulant medication. Surveyor asked DON B that since R32's catheter was placed at 8:00 PM and the catheter tubing was advanced at 10:00 PM, instead of advancing the catheter should a new catheter have been inserted instead. DON B indicates staff should have just replaced the catheter. Surveyor asked DON B if a physician should have been updated regarding R32's two and a half hours without urine output and the need to readjust the catheter. DON B states, yes, however it would be ok to update in the morning instead of calling the on-call line overnight. Surveyor asked DON B if the physician should have been updated on the clotting occurring overnight. DON B indicates, if it occurs once it is ok to wait until morning, if it happens more than once I would expect staff to call the on-call provider. Surveyor asked DON B if the physician should have been notified after R32's initial substantial bleeding episode around 8:00 AM on 1/21/25. DON B indicates the physician should have been contacted at that point.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility policy review, it was determined the facility failed to ensure that misappropriation/exploitation of resident and or property does not occur or 1 of 3 sampled residents. (R47). Registered Nurse (RN) D admitted having been aware of CNA E having the resident's debit card in her possession for several months but did not report this to administration, which placed the resident at risk for misappropriation/exploitation. While the card was in her possession, CNA E used the card to purchase items for her own use, without the resident's knowledge or consent. Findings included: Review of a Face Sheet revealed the facility admitted Resident 47 on 08/04/2020. Review of an annual Minimum Data Set (MDS), dated [DATE], revealed Resident 47 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated the resident was totally dependent on the assistance of two or more people for bed mobility. A review of Resident 47's Plan of Care Summary, not dated, revealed one of the resident's goals was to feel comfortable in the resident's surroundings and feel safe and secure. A review of a facility investigation summary, dated 09/08/2022, revealed the facility began an investigation on 09/01/2022 and substantiated that Certified Nursing Assistant (CNA) E knowingly violated Resident 47's rights as well as misappropriated the resident's funds by using the resident's personal bank card for her own personal purchases. The summary indicated the facility notified law enforcement and terminated the employment of CNA E on 09/01/2022. The summary indicated CNA E acknowledged to both the Director of Nursing (DON) and the Sheriff's deputy that she had used Resident 47's debit card to purchase personal items for herself without Resident 47's permission or knowledge. A review of a Sheriff's Office Incident #22-33047 report, dated 09/01/2022, revealed CNA E was issued a misdemeanor citation for theft less than or equal to $2500, for the unauthorized use of Resident 47's bank card, with a mandatory court date of 11/30/2022. The report noted CNA E used funds from the bank card on three occasions for items for her house. The report indicated there were four separate charges on the resident's bank statement that were not authorized by the resident and totaled $449.56. An interview on 01/04/2023 at 12:05 PM with Registered Nurse (RN) D revealed she was aware that CNA E had possession of Resident 47's debit card for months prior to the unauthorized charges occurring in August 2022. RN D stated she knew that CNA E used the resident's debit card to purchase personal items for the resident with the resident's permission. RN D stated she was made aware that Resident 47 had some concerns about some transactions, but she reminded the resident that the charges were from the store where CNA E usually bought the resident's snacks. RN D stated that was the end of the conversation and she did not report the resident's concerns to anyone at that time. RN D stated she was aware it was a violation of facility policy for staff to take money from any resident. She acknowledged that if she had reported CNA E's possession of the debit card when she first became aware of it, the misappropriation of Resident 47's funds may have been prevented. RN D stated she felt very bad about this and understood going forward, to report any similar concerns. Review of the facility's investigation documentation revealed RN D was interviewed during the investigation; however, there was no indication that she informed the facility of her prior knowledge regarding CNA E being in possession of the resident's debit card. During an interview on 01/05/2023 at 2:28 PM, Director of Nursing (DON) B revealed staff should notify their supervisor right away of any concerns related to abuse/exploitation and indicated it was against facility policy for staff to take any money from residents. DON B stated it did not matter if the money was to buy items for the resident; staff were not allowed to take the money but were allowed to gift residents with items. DON B stated she was not involved in the investigation of misappropriation for Resident 47; therefore, she did not have any specific knowledge of it. DON B stated she was not aware of whether the facility ever identified that RN D had prior knowledge of CNA E having the resident's debit card in her possession for months prior to the unauthorized transactions being made. DON B indicated the CNA having the resident's debit card was a violation of the facility's policy as well. DON B stated she would have expected any staff member who may have been aware of the CNA having possession of a resident's debit card to report that to Social Services or herself immediately. DON B also stated that if RN D had reported to her that CNA E was in possession of a resident's debit card, it would most likely have prevented the unauthorized charges from being made, and the misappropriation might never have occurred. During an interview on 01/05/2023 at 2:56 PM, Nursing Home Administrator (NHA) A revealed any concerns of any type of abuse/exploitation should be reported immediately to the nurse supervisor or a manager in the building. NHA A stated that prior to the incident occurring with Resident 47 and CNA E, it was never clearly defined that a staff could not take a resident's debit card but acknowledged it would not have been appropriate for any staff to take a resident's debit card and keep it in their possession. NHA A indicated she was not sure if the handbook specified that this was a violation of policy; however, she acknowledged there was a possibility that the charges could have been prevented if RN D had reported that CNA E had possession of Resident 47's bank card. NHA A stated she was unaware that RN D had prior knowledge that CNA E was in possession of the resident's card, but she would have expected RN D to report this immediately, as soon as she became aware. NHA A stated if this had been reported, the bank card would have been removed from CNA E's possession and the charges would not have occurred. NHA A stated the prior DON completed the investigation, and she was not sure if RN D's prior knowledge of the situation was ever identified during the investigation. She stated she did not know if RN D was asked about this during the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, it was determined that the facility failed to ensure a care plan was developed to address the necessary monitoring for therapeutic and potential adverse effects from high-risk medications for 2 (Resident 5 and Resident 10) of 5 residents reviewed for unnecessary medications. Findings included: A review of a facility policy titled, Care Planning, dated 12/31/2019, revealed, The care plan should address the key areas of importance for the new admit - for example: hip fracture - focus on transferring, positioning, pain, etc. [et cetera]. As well as any other significant issues, i.e. [such as] blind, diabetic, fall risk, cancer, etc. The policy also indicated, The care plan will be reviewed to assure that it: reflects the resident's current needs, strengths, preferences and choices and has measurable goals and individualized approaches. 1. A review of Resident #10's admission Minimum Data Set (MDS), dated [DATE], revealed the resident had active diagnoses of heart failure and diabetes mellitus. The MDS revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS indicated the resident required extensive assistance with bed mobility and received anticoagulant (blood thinner) medications and insulin injections on seven of the past seven days. A review of Resident 10's Physician Orders, revealed orders dated 11/07/2022 for apixaban (blood thinner) 5 milligrams (mg) by mouth twice a day for prevention of stroke, insulin (to lower blood sugar) 10 units three times a day at meals for diabetes mellitus, and insulin per sliding scale three times a day at meals. Further review of Resident 10's Physician Orders revealed an order dated 11/08/2022 for insulin glargine (to lower blood sugar) 30 units daily in the morning for diabetes mellitus. A review of Resident 10's Care Plan, with care plan problems dated from 09/24/2021 through 12/23/2022, revealed bleeding precautions and monitoring for potential adverse effects of apixaban were not addressed. Additionally, the care plan did not address the necessary monitoring related to the use of insulin, including signs/symptoms of hypo/hyperglycemia. 2. A review of Resident 5's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had an active diagnosis of acute embolism. The MDS revealed Resident 5 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated the resident had severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility and transfer. According to the MDS, the resident received anticoagulant medications on seven of the past seven days. A review of Resident 5's Physician Orders, dated 01/05/2023, revealed an order dated 11/12/2020 for apixaban (blood thinner) 5 milligrams (mg) by mouth twice a day for chronic deep vein thrombosis (blood clot). A review of Resident 5's Care Plan revealed bleeding precautions and monitoring for potential adverse effects of apixaban were not addressed. During an interview on 01/05/2023 at 11:40 AM, Registered Nurse (RN) C indicated she had never done care plans for specific medications other than psychotropic medications. During an interview on 01/05/2023 at 2:41 PM, the Director of Nursing (DON) B indicated she would expect for the insulin and blood thinners to have been addressed on the care plan for monitoring of bleeding and blood sugar. During an interview on 01/05/2023 at 2:56 PM, Nursing Home Administrator (NHA) A indicated if the medications were addressing active health problems, they should have been addressed on the care plan.