Health inspection·January 25, 2024

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff and resident interviews, the facility failed to ensure suprapubic catheter care was completed and documented in the medical record. This affected three (#9, #14, #45) of three residents reviewed for catheter care. The facility census was 83. Findings include: 1. Medical record review for Resident #45 revealed an admission on [DATE] with diagnoses including but not limited to bipolar disorder, suicidal ideation's, neuromuscular dysfunction of bladder, anxiety, major depression, history of mental and behavioral disorders, and history of urinary tract infections. Review of the admission Minimum Data Set (MDS) assessment for Resident #45 revealed an intact cognition. Resident #45 is independently ambulatory, and requires set up assistance for eating, toileting, and transfers. Resident #45 has an indwelling urinary catheter. Review of the plan of care for Resident #45 revealed resident has a need for supra-pubic catheter. Interventions include monitor for signs and symptoms of urinary tract infections and report to physician, report signs of perineal redness, irritation skin excoriation to physician, change catheter and drainage system as indicated, keep tubing free of kinks and twists, maintain drainage bag below the bladder, privacy cover to drainage bag and catheter care as needed. Review of the physicians' orders for Resident #45 for the month of December 2023 were silent for catheter care. Review of the physicians' orders for Resident #45 for the month of January 2024 revealed an order dated 01/25/24 for suprapubic catheter care: wash with soap and water, pat dry every day as needed, may apply a T-sponge if needed and every day-on-day shift. Interview on 01/25/24 at 12:20 P.M. with Licensed Practical Nurse (LPN) #2 verified she added the order for the catheter care today at the direction of the corporate nurse. LPN #2 verified Resident #45 did not have physician orders for catheter care until 01/25/24. Interview on 01/25/24 at 12:50 P.M. with LPN #5 assigned to Resident #45 verified she did not complete catheter care for Resident #45 on 01/24/24 as there were not any orders for the task. Interview on 01/25/24 at 1:17 P.M. with State Tested Nursing Assistant (STNA) #3 assigned to Page 1 of 3 365900 365900 01/25/2024 Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380

F 0690 Level of Harm - Minimal harm or potential for actual harm Resident #45 verified she did not complete any catheter care for Resident #45 as it was not on the facility [NAME] (care card) for them to complete and the nurses did all the application of dressing for the residents. Interview on 01/25/24 at 1:39 P.M. with STNA #6 stated she was not given any information regarding a catheter for Resident #45 in report and had no idea she even had a catheter. Residents Affected - Few Observation of catheter care for Resident #45 on 01/25/24 at 3:04 P.M. with Registered Nurse (RN) #26 revealed Resident #45 did not have a dressing to the insertion site of the supra-pubic catheter. Resident #45 was utilizing a leg bag drainage system and verified she empties it herself. Interview on 01/25/24 at 3:15 P.M. with Resident #45 stated facility staff have not cleaned her catheter site for a long time, additionally stated she tries to keep it clean herself. Review of the [NAME] report for Resident #45 with an admission dated 12/14/23 was silent for any instructions for STNA to clean catheter insertion site. 2. Medical record review for Resident #14 revealed an admission date on 09/01/21 with diagnoses including but not limited to hypertension, cerebral infarction, multiple sclerosis and neuromuscular dysfunction of the bladder. Review of the quarterly MDS for Resident #14 dated 12/28/23 revealed an impaired cognition. Resident #14 required maximum assistance for toileting, transfers, bed mobility. Resident #14 was coded supervision for eating. Resident #14 was coded with an indwelling urinary catheter during the assessment period. Review of the plan of care for Resident #14 dated 09/14/23 revealed the resident had a suprapubic urinary catheter related to neuromuscular dysfunction of the bladder with obstruction. Intervention includes monitoring for signs and symptoms of infection, catheter bag to be emptied each shift, and provide catheter care every shift and as needed. Review of the physicians' orders for Resident #14 for the month of December 2023 were silent for catheter care. Review of the physicians' orders for Resident #14 for the month of January 2024 revealed an order dated 01/25/24 for suprapubic catheter care: wash with soap and water, pat dry every day as needed, may apply a T-sponge if needed and every day-on-day shift. Interview on 01/25/24 at 12:55 P.M. with Resident #14 states some of the nurses do urinary catheter care and use a dressing and others do not. Further Resident #14 states urinary catheter care is not always daily. Interview on 01/25/24 at 12:20 P.M. with LPN #2 verified she added the order for the catheter care today at the direction of the corporate nurse. LPN #2 verified there were not any orders previously for catheter care for Resident #14 until 01/25/24. 3. Medical record review for Resident #9 revealed an admission date on 01/08/22 with diagnoses including but not limited to urinary tract infection, anxiety disorder, cerebral ischemic, spinal stenosis, bladder neck obstruction and kidney failure. 365900 Page 2 of 3 365900 01/25/2024 Versailles Rehabilitation and Health Care Center 200 Marker Road Versailles, OH 45380

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the plan of care for Resident #9 dated 12/06/23 revealed the resident had a suprapubic urinary catheter related to neuromuscular dysfunction of the bladder with obstruction. Intervention includes monitoring for signs and symptoms of infection, catheter bag to be emptied each shift, and provide catheter care every shift and as needed. Review of the comprehensive MDS dated [DATE] for Resident #9 revealed an impaired cognition. Resident #9 required limited assistance with activities of daily living. Resident #9 was coded with an indwelling urinary catheter during the assessment period. Review of the physicians' orders for Resident #9 for the month of December 2023 were silent for catheter care. Review of the physicians' orders for Resident # 9 for the month of January 2024 revealed an order dated 01/25/24 for suprapubic catheter care: wash with soap and water, pat dry every day as needed, may apply a T-sponge if needed and every day-on-day shift. Interview on 01/25/24 at 12:20 P.M. with LPN #2 verified she added the order for the catheter care on 01/25/23 at the direction of the corporate nurse. LPN #2 verified Resident #9 did not have physician orders previously for catheter care until 01/25/24. Interview on 01/25/23 at 3:00 P.M. with Corporate RN #101 verified the facility did not have orders for catheter care for Resident #9, #14 or #45 on the treatment records and was unable to provide any documentation catheter care was provided for residents. Request for facility policy related to catheter care was not provided for review during the survey. This deficiency represents non-compliance investigated under Complaint Number OH00149824. 365900 Page 3 of 3