Health inspection·August 24, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement an indwelling urinary catheter plan of care for 1 of 1 resident reviewed for Urinary Catheters from a total sample of 41 residents, (#110). Finding: Review of resident #110's medical record revealed the resident was admitted to the facility on [DATE] from an acute care hospital and had diagnoses that included urinary tract infection (UTI), multiple sclerosis, Bell's Palsy, Vestibular Schwannoma (brain tumor), pressure ulcer of sacral region, gastrostomy (feeding tube), and muscle weakness. The Minimum Data Set (MDS) admission assessment with Assessment Reference Date (ARD) 6/16/2023 noted the resident scored 12 out of 15 on the Brief Interview for Mental Status that indicated the resident was not cognitively impaired. The Functional Status on the assessment showed she required extensive staff assistance to complete Activities of Daily Living (ADL). Bladder and Bowel section noted the resident had frequent urinary incontinence during the 7 day look back period. On 8/21/2023 at 10:51 AM, resident #110 was observed awake and lying in bed. A urinary catheter bag was noted on the left side of the bed. The resident said she was upset because the nursing staff had not assisted her with the urinary catheter. She said the catheter felt uncomfortable, and she wasn't sure the catheter was fully inserted in her bladder. She indicated, I keep telling them, and it's not checked by nurses or CNAs (Certified Nursing Assistants) . Review of the Nursing Progress Notes dated 6/10/2023 noted the resident was admitted to the facility with an indwelling urinary catheter. The Matrix CMS-802 (10/2022) provided to the survey team on 8/21/2023 included resident #110 but there was no indication that the resident had an indwelling urinary catheter in place. The Physician Order Report from 6/09/2023 to 8/22/2023 did not include orders for care, services, or monitoring of the urinary catheter. The report showed medications for antibiotics were ordered to treat urinary tract infections that included Macrobid 100 milligrams (MG) twice daily for UTI from 6/18/2023 to 6/24/2023, and Cipro 750 MG every 12 hours from 7/05/2023 to 7/14/2023. The Comprehensive Care Plan included monitoring for the use of antibiotic medications to treat UTIs. It did not include care, services, or monitoring of an indwelling urinary catheter. Page 1 of 4 105528 105528 08/24/2023 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0656 Level of Harm - Minimal harm or potential for actual harm On 8/23/2023 at 10:56 AM, Certified Nursing Assistant (CNA) B said her duties included checking residents' catheters to make sure they were draining properly, and emptying and measuring the urine. She explained CNAs recorded their completed assignment tasks in the Point of Care program. She said the computer software told CNAs everything about the resident and what care and services were to be provided. She said she was not sure if resident #110 had a catheter. Residents Affected - Some On 8/23/2023 at 12:31 PM, the Regional Nurse Consultant said all CNA tasks were located in the Point of Care medical record and recorded through the program when CNAs entered the information into the system. She explained CNA tasks were imported there from physician's orders, and that is where CNAs obtained information for the care needs of a resident. Review of the Point of Care History report did not include tasks or information for CNAs to indicate resident #110 had a urinary catheter. On 8/23/2023 at 12:34 PM, Registered Nurse (RN) A said all treatments and medication were included on the Electronic Medication Administration Record (EMAR) for nurses to see the resident's status and plan of care. She said care, services, and monitoring were documented by nurses and recorded on the EMAR. She explained that nurses entered orders when residents were admitted , and then they were updated as needed. She said she was not sure if resident #110 had a urinary catheter. She checked the resident's medical record and acknowledged there were no orders for care and services for the urinary catheter. During a joint observation on 8/23/2023 at 12:38 PM, RN A checked resident #110 while she was lying in bed. RN A acknowledged the resident had an indwelling urinary catheter in place with a collection bag hooked to the left side of the bed. She said, it should have been in the computer. On 8/24/2023 at 3:33 PM, the MDS Director said resident #110's MDS admission assessment with ARD 6/16/2023 was coded incorrectly for bladder function and did not include the resident's urinary catheter. On 8/23/2023 at 12:51 PM, the MDS Director stated she was responsible for coordinating and ensuring comprehensive care plans were up to date and information was obtained from the medical record, Interdisciplinary Team (IDT), and from her own physical assessment. She explained the facility had multiple processes in place to retrieve updated information and ensure care plans were inclusive and comprehensive. She checked resident #110's medical record and acknowledged there was not a plan of care for an indwelling urinary catheter. She said the resident's active orders did not include care and services for the catheter. She said orders were entered when residents were admitted by nurses, and they must have missed it. She stated she had not implemented the plan of care because she did not know the resident had a catheter. She could not explain why it had been missed for over 2 months through the processes the facility had in place. Review of the nursing Progress Notes dated 6/21/2023, completed by the Assistant Director of Nursing read, (Late Entry on 7/07/2023 at 08:42 PM) SOC (Standards of Care) meeting was held to discuss 6/19-24 (6/19/2023 through 6/-24/2023) Ms. (resident name) utilization of Macrobid 100 mg for her UTI .The care plan has been reviewed by the IDT and deemed appropriate at this time. On 8/24/2023 at 9:27 AM, the Director of Nursing (DON) said resident #110 had an indwelling urinary catheter in place since she was admitted to the facility on [DATE]. She stated the MDS Director was responsible for updating the comprehensive care plans. She explained the facility processes for 105528 Page 2 of 4 105528 08/24/2023 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0656 Level of Harm - Minimal harm or potential for actual harm reviewing residents' plan of care done during Standards of Care meetings and order reviews. She stated the resident had a history of UTIs, and it was important that proper care and services were provided to reduce the risk of complications. She said it should have been addressed throughout the review process and could not explain why the resident's comprehensive care plan had not included monitoring of an indwelling urinary catheter for over 2 months. Residents Affected - Some The facility's Care Plans Comprehensive Person-Centered policy dated November 2020 read, The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; . g. Incorporate identified problem areas; incorporate risk factors associated with identified problems; . l. Identify the professional services that are responsible for each element of care . 105528 Page 3 of 4 105528 08/24/2023 Terrace of St Cloud, The 3855 Old Canoe Creek Road Saint Cloud, FL 34769

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview, and record review, the facility failed to demonstrate the effectiveness of a Performance Improvement Plan (PIP) for timely transmissions of Minimum Data Set (MDS) assessments. Residents Affected - Some Findings: On 08/24/23 at 11:00 AM, the MDS Regional Nurse Consultant stated the facility had an employee turnover at the end of May 2023, and an entire facility MDS assessment audit was conducted. She noted a problem was identified for late transmittals of MDS assessments. She explained a Quality Assurance and Performance Improvement Plan (QAPI) plan was discussed and the Regional Nurse presented the MDS plan to the monthly QAPI team in the August 2023 meeting. On 08/23/23 at 5:12 PM, during an interview, the MDS Director was unable to answer if a Performance Improvement Plan (PIP) was currently in place for Minimum Data Set (MDS) assessment transmittals. She noted she was unsure of what a PIP was. The Administrator was present and noted there was no PIP in place for MDS assessments. On 08/24/23 at 1:35 PM, the DON stated there was a discussion at the last QAPI meeting about PIP and MDS submissions. She recalled they reviewed the PIP. On 08/24/23 at 7:59 PM, the Administrator, and Regional Nurse, acknowledged the root cause for the MDS PIP was a transmittal issue. Review of MDS PIP read, Opportunities to Improve Quality 2023-2024, with a date of 8/9/23, with goal to transmit MDS assessments timely ., it showed a performance improvement indication related to employee turnover, and a plan for the MDS Coordinator to electronically submit, within 14 days of completion of a resident's assessment. The plan was dated for one month and included the MDS Corporate Nurse Consultant to in-service, and educate the MDS Coordinators, and the DON to conduct weekly reviews. The actions noted the Corporate Nurse Consultant to complete a two-week audit of all MDS residents assessments to ensure assessments had been submitted timely, provide assessments to the DON to conduct weekly reviews and then report findings to the QAPI committee. The MDS Corporate Nurse Consultant provided a copy of the first facility wide audit dated 8/9/23. On 8/24/23 at 11:00 AM, the MDS Corporate Nurse Consultant was unable to provide a copy of a second facility audit and stated, have not done it yet. It was noted that MDS assessments identified as not transmitted timely still had not been transmitted after the first audit was completed. Review of facility Quality Assurance and Performance Improvement (QAPI) Plan Policy dated revised 4/2014 showed the facility shall develop, implement and maintain an ongoing, facility wide QAPI Plan designed to monitor and evaluate the quality and safety of residents care, pursue methods to improve care quality, and resolve identified problems. Under the section of authority, it revealed the Administrator is responsible assuring the QAPI Program complies with Federal, State and local regulatory requirements. Listed under the section for implementation it showed the QAPI Committee oversee the implementation of QAPI Plans. 105528 Page 4 of 4