Health inspection·August 29, 2024

F 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for catheter care. The facility failed to change a suprapubic catheter monthly for Resident #1 as ordered by the physician. Resident #1 developed a UTI in June 2024 and his SPT was obstructed and calcified due to lack of adequate care per urology appointment on 8/1/2024. This failure could place residents at risk for urinary tract infections, pain, confusion and sepsis (infections that spread to the blood) and urinary calcifications. Findings include: Record review of Resident #1's face sheet, dated 08/28/2024, indicated [AGE] year-old male who was initially admitted to the facility on [DATE] and recently readmitted [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive functioning), protein-calorie malnutrition (a nutritional status in which reduces availability of nutrients leads to change in body composition and function), atherosclerotic heart disease (condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), stroke with weakness to non-dominant side, language deficit following stroke, hypertension (condition in which the force of the blood against the artery walls is too high), anemia (condition that develops when your blood produces lower than normal amount of health red blood cells), calculus of kidney (hard deposits made of minerals and salts that form inside your kidney) and urinary stents (thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney). Record review of Resident #1's Quarterly MDS assessment, dated 11/09/2023, indicated he was severely impaired cognitively, was dependent for showering/bathing, toileting hygiene, dressing upper and lower body, putting on/taking off footwear, all mobility and required set up and clean up for eating and oral care. He had a catheter for urinary output. Record review of Resident #1's care plan, dated 11/17/2022 and revised on 08/28/2024, indicated he had a Suprapubic Catheter for Obstructive and Reflux Uropathy. Interventions included: The resident had a Suprapubic Catheter. Position catheter bag and maintain tubing below the level of the bladder, make sure tubing was secured. Change dressing at site of suprapubic catheter daily as ordered. Check tubing for kinks as needed. Document and notify physician for signs and symptoms of Page 1 of 11 455952 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 Level of Harm - Actual harm Residents Affected - Few pain/discomfort of catheter, urination, and/or frequency, document and notify physician for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns and maintain catheter bag dependent of bladder for proper drainage. Record review of Resident #1's urology appointment note, dated 11/01/2024, indicated discussion with the facility DON several times regarding the SPT was significantly calcified intraoperatively, indicative of it not being exchanged for several months, facility license staff must exchange SPT every four weeks, next change due 11/27/2023, and instructions provided of how to properly exchange SPT. Record review of Resident #1's progress note, dated 11/01/2023, indicated the resident had an appointment today at 2PM and was transported and accompanied by a staff member to the urology clinic and seen by the urologist with orders for the monthly SPT changes with instructions. Record review of Resident #1's progress note, dated 11/01/2023, indicated order note from urology to exchange 16 straight SPT tube every 4 weeks, infuse 60cc of sterile saline through old catheter and use catheter plug after, clean area with iodine or hibiclens prior to exchanging, deflate balloon until no more water comes out of balloon, remove old catheter and insert new one, inflate balloon with 5cc of sterile water, allow catheter to fully drain and attach bedside bag. Apply dressing around SPT tube one time a day starting on the 1st and ending on the last day of month every month for changing of suprapubic catheter. Record review of Resident #1's progress note, dated 11/01/2023, indicated the DON spoke with the urologist regarding the resident catheter care and the urologist gave order to change suprapubic catheter. Explained to urologist via the phone the resident refused to have catheter changed at the facility and sent to the ER for change and urologist aware of this. Record review of Resident #1's progress note, dated 11/01/2023, indicated the facility staff obtained consent from the PA, MD and RP to administer Ativan 0.5mg 1 tablet by mouth every 24 hours as needed for replacement of suprapubic catheter. Record review of Resident #1's progress note indicated, on 11/11/2023, resident was transferred to the local hospital for blood in urine and blood clots in brief when incontinent care provided. Record review of Hospital records indicated Resident #1 was hospitalized on [DATE] to 11/22/2023 for blood in urine, bleeding from penis, and UTI and urology exchanged suprapubic catheter on 11/21/2023 and next exchange was due in 4 weeks. Record review of Hospital records indicated Resident #1 was hospitalized on [DATE] to 12/19/2023 for blood in urine and generalized weakness and urology exchanged suprapubic catheter on 12/13/2023 and next exchange was due in 1 month. Record review of Resident #1's progress note, dated 01/11/2024, indicated the resident returned from new urologist appointment with new orders to change SPT every 3 weeks. If catheter had blood & clots or if it became clogged with catheter 18 French size (upsize) no new appointment noted. Resident #1's SPT patent and draining to bedside bag clear dark yellow urine. No indication the SPT was changed at appointment. 455952 Page 2 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 Level of Harm - Actual harm Record review of Resident #1's progress note, dated 01/26/2024, indicated Resident #1's SPT was clogged resident brief urine noted attempted to flush catheter per order unable to and notified the DON. The DON changed SPT with 22 French catheter. SPT patent and draining amber colored urine, resident tolerated procedure well. Old/removed SPT catheter noted to be plugged with urine calcification. Residents Affected - Few Record review of Resident #1's progress note, dated 02/05/2024, indicated Resident #1's SPT was clogged unable to flush, resident brief with urine noted attempted to flush SPT per order unable to and notified the DON. The DON changed SPT with 22 French catheter. SPT patent and draining amber colored urine, resident tolerated procedure well. Old/removed SPT catheter noted to be plugged with urine calcification. Record review of Resident #1's progress note, dated 03/09/2024, indicated Resident #1's SPT was changed with 22 French 30 ml bulb. Record review of Resident #1's progress note, dated 04/11/2024, indicated Resident #1's returned to the facility accompanied by facility designee with new appointment 05/10/2024 at 11:30 AM with new urologist for cystoscopy at local hospital. New order received for Diazepam 5mg to be administered 30 minutes prior to urology appointment scheduled 05/10/24 at 11:30 AM. The resident was transported via facility by assigned facility designee. No indication the SPT was changed at appointment. Record review of Resident #1's progress note, dated 05/10/2024, indicated Resident #1's went to appointment with new urologist, returned with progress note for Resident #1 to return to see original urologist for surgery to remove his left kidney stint since it was causing blood in the urine. No indication the SPT was changed at appointment. Record review of Resident #1's progress note, dated 06/05/2024, indicated Resident #1 was diagnosed with a polymicrobial (multiple types of bacteria) UTI. With chronic suprapubic catheter may have chronic colonization but given leukocytosis will go ahead and start antibiotics- Omnicef twice a day for 7 days. Will need to follow up on sensitivities and adjust antibiotics accordingly. Recommend evaluation by urology as soon as possible. Record review of Resident #1's progress note, dated 06/11/2024 indicated wound culture of Suprapubic site obtained at approx. 5am this morning. Drainage brown with some blood noted. No foul smell or abnormal drainage noted. Site without redness. Cover applied to Suprapubic site. Record review of Resident #1's progress note dated 06/11/2024, indicated wound culture of suprapubic catheter insertion site indicated infection and antibiotics of Cipro initiated. Afebrile. Resident has voiced no concerns and no obvious concerns noted. Fluids were offered and encouraged. Will continue to observe for the remainder of this shift. Record review of Resident #1's progress note, dated 06/11/2024, indicated Resident #1's SPT was changed with 20 French 10 ml bulb. No drainage from site. Urine return flow thick brownish mucus in tubing. Resident offered water. Resident accepted sips. Record review of Resident #1's progress note, dated 07/01/2024, indicated Resident #1's foley bag was changed out due to leaking. No indication the SPT was changed. Record review of Resident #1's progress note, dated 07/01/2024 to 07/30/2024, reflected no documentation or indication Resident #1's SPT was changed as ordered. 455952 Page 3 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 Level of Harm - Actual harm Residents Affected - Few Record review of Resident #1's urology appointment note, dated 08/01/2024, indicated discussion with the facility administrator the lack of adequate SPT management. Examination indicated SPT obstructed and calcified. Unable to irrigate. SPT removed with calcification noted at the distal end with obstruction of the lumen. Foul smelling cloudy urine drained with new 20 French catheter. Procedures: Catheter: Type Supra pubic. Procedure New catheter size: 20 French Sterile water infused through catheter into the bladder, the balloon was deflated without difficulty, the old catheter was removed, a new catheter was re-inserted without any difficulty with good urine return, the balloon was inflated with 5 mL of sterile water, the bladder was irrigated with 100 mL of sterile water. Recovery the patient tolerated the procedure well. Record review of Resident #1's progress note, dated 08/19/2024, indicated Resident #1 had a new SPT (22 French/30 cc bulb) placed by the DON and assistance from nursing staff. Record review of a treatment administration record for [DATE], April 2024, May 2024 and July 2024 indicated no documentation of the suprapubic catheter for Resident #1 being changed. Record review of Resident #1's physician orders indicated a physician's order, dated 10/14/2023, with start date of 10/15/2023, change urinary catheter:16 French (suprapubic) every 4 weeks one time a day every 28 day(s) related to obstructive and reflux uropathy with end date of 12/10/2023. Record review of Resident #1's physician orders indicated a physician's order, dated 7/26/2023 with start date of 07/26/2023 Urinary Catheter: Change Suprapubic Catheter and drainage bag as needed due to clinical indications of infection (sediment, foul odor, dark in color), obstruction (slow drainage), or when the closed system is compromised. Infuse 60cc sterile saline through old catheter and use catheter plug after. Clean area with iodine or hibiclens, inflate with 5cc of sterile water. Flush PRN with 400cc of sterile saline if blood appears or tube was not draining. every shift for urinary retention with end date of 12/10/2023. Record review of Resident #1's physician's orders indicated a physician's order, dated 11/01/2023, to exchange 16 straight SPT tube every 4 weeks, infuse 60cc of sterile saline through old catheter and use catheter plug after, clean area with iodine or hibiclens prior to exchanging, deflate balloon until no more water comes out of balloon, remove old catheter and insert new one, inflate balloon with 5cc of sterile water, allow catheter to fully drain and attach bedside bag. Apply dressing around SPT tube one time a day starting on the 1st and ending on the last day of month every month for changing of suprapubic catheter with end date of 12/10/2023. Record review of Resident #1's physician orders indicated a physician's order, dated 01/12/2024 with start date of 01/12/2024, Urinary Catheter:(/Suprapubic) Catheter in place. Size: 16 French Bulb:10mL. change catheter every three weeks irrigate with saline. may up size to 18fr if becomes clogged, with end date of 01/26/2024. Record review of Resident #1's physician orders indicated a physician's order, dated 01/12/2024 with start date of 01/12/2024, Urinary Catheter: Change (Suprapubic) catheter and drainage bag PRN due to clinical indications of infection (sediment, foul odor, dark in color), obstruction (slow drainage), or when the closed system was compromised as needed for catheter care prn every shift on hold from 03/18/2024 01:50 to 03/21/2024 01:49 with no end date identified. Record review of Resident #1's physician orders indicated a physician's order, dated 01/26/2024 with start date of 01/26/2024, Urinary Catheter:(/Suprapubic) Catheter in place. Size: 20 French, 455952 Page 4 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 Bulb:10mL change catheter every three weeks irrigate with saline every shift, with end date of 03/13/2024. Level of Harm - Actual harm Record review of Resident #1's physician orders indicated a physician's order, dated 03/13/2024 with start date of 03/13/2024, Urinary Catheter:(/Suprapubic) Catheter in place. Size: 22 French, Bulb:30mL. change catheter every three weeks irrigate with saline every shift on hold from 03/18/2024 01:50 to 03/21/2024 01:49, with end date of 08/01/2024. Residents Affected - Few Record review of Resident #1's physician orders indicated a physician's order, dated 08/01/2024 with start date of 08/02/2024, Urinary Catheter:(/Suprapubic) Catheter in place. Size: 22 French, Bulb: 30mL. change catheter every three weeks irrigate with saline. Every day shift every 21 day(s) related to obstructive and reflux uropathy, change suprapubic catheter on today with end date of 08/03/2024. Record review of Resident #1's physician orders indicated a physician's order, dated 08/19/2024 with start date of 09/09/2024, Urinary Catheter:(/Suprapubic) Catheter in place. Size: 22French, Bulb:30mL. change catheter every three weeks irrigate with saline every day shift every 21 day(s) related to obstructive and reflux uropathy, change suprapubic catheter on today with end date of 08/28/2024. During an interview on 08/28/2024 at 2:30 PM, LVN A said Resident #1's SPT was changed every 3 weeks and as needed if blocked or clogged. LVN A said Resident #1's orders for the SPT to be changed several times over the last few months from every month to every 3 weeks. LVN A said the CN had to assess the SPT ever shift and report any concerns to the PA/MD. LVN A said she changed Resident #1's SPT and assisted the DON in changing Resident #1's SPT due to resident was restless and did not like the SPT changed. LVN A said the facility staff flushed the SPT if needed and would replace SPT if needed. LVN A said Resident #1 would refuse SPT to be changed and would have to send to the local ER for assessment or for SPT to be changed if clogged or blocked and the resident refused for it to be changed. LVN A said when orders for the SPT to be changed were received from the MD, licensed facility staff would write the order in the electronical medical record and assign the task to be done on the scheduled date. LVN A said the SPT change would generate of the treatment task to be done on the scheduled date. LVN A said the treatment task would also have a task to perform SPT change PRN if clogged or blocked and order to flush as needed. LVN A said she recalled assisting the DON with changing Resident #1's SPT earlier this month but could not recall prior to that date when she changed the SPT, she said she would have documented it in the resident's progress note and on the treatment administration record when done. During an interview on 08/28/2024 at 3:30 PM, CNA C said he provided catheter care at the beginning and end of every shift or when needed. CNA C said he provided catheter care to Resident #1 which included cleaning the catheter tubing, tube insertion site, keeping tubing secured to leg and unkinked, and emptied the catheter drain bag. CNA C said any drainage from the insertion site, cloudy, dark, blood, and/or foul-smelling odor from urine or insertion site, decreased urine output, blocked catheter and/or leaking drain bag was reported to the CN immediately. CNA C said Resident #1's urine was normally a dark amber with some sediment in the tubing but would clear with fluid intake and the CN was aware of Resident's #1 urinary output. The CNA said he would the clean catheter insertion site with soap and water and pat dry, keep the area clean and dry due to located in abdominal fold. CNA C said he would report to the CN any redness, foul odor, draining at the catheter insertion site. During an interview at on 08/29/2024 at 2:30 PM, LVN D said Resident #1's SPT was changed every 3 455952 Page 5 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 Level of Harm - Actual harm Residents Affected - Few weeks and as need if blocked or clogged. LVN D said the CN had to assess the SPT every shift and report any concerns to the PA/MD. LVN D said she had changed Resident #1's SPT but did not recall the date she last changed it or when it was due to be changed. LVN D said it will be populated in the TAR on the next scheduled date it needs to be changed. LVN D said she received training on changing and caring for SPT and was competent in providing the care. LVN D said facility staff flushed the SPT if needed and would replace SPT if needed. LVN D said Resident #1 would refuse SPT to be changed and they would have to send to the local ER for assessment or for SPT to be changed if clogged or blocked and the resident refused for it to be changed. LVN D said when orders for the SPT to be changed were received from the MD, licensed facility staff would write the order in the electronical medical record and assign the task to be done on the scheduled date. LVN D said the SPT change would generate of the TAR to be done on the scheduled date. LVN D said the TAR would also have a task to perform SPT change PRN if clogged or blocked and order to flush as needed. LVN D said if she had changed Resident #1's SPT it would be documented in the treatment administration record and progress note. During an interview on 8/29/2024 at 5:30 PM, the DON said Resident #1 SPT should have been changed as ordered by physician or documentation indicating why the SPT was not changed. The DON said Resident #1 went to the ER and several urologist appointments where the SPT was changed but those records should have been requested by facility staff and verified if SPT was changed and if the SPT was changed by during urologist appointments it should have been documented on the progress notes. The DON said the SPT was to be changed by nursing staff in the facility, doctor's orders should have been followed, and if not performed the PA/MD and/or urologist should be notified. The DON said she changed Resident #1's SPT and/or assisted staff with changing the SPT and it should be documented on a progress note and e-signed in the treatment administration record. She said residents not receiving appropriate care could make them susceptible to urinary tract infections, blockage and increase calcifications with history of kidney stones. During an interview on 8/29/2024 at 5:45 PM, the Administrator said she expected Resident #1's SPT to be changed as ordered by the PA/MD or urologist. She said if it was not able to be done at the facility as the physician ordered then an appointment should be made for the resident to have the SPT change done at the urologist office or outpatient setting. The Administrator said she was made aware of Resident #1's lack of adequate SPT management on 08/01/2024 by the urologist and added the concern to the QAPI and it was currently being monitored. She said residents not receiving appropriate SPT management could cause an infection, blockage, discomfort, and increase calcification. Record review of the facility's policy Indwelling catheter use and removal indicated it is the policy of this facility to ensure that indwelling urinary catheters that are inserted or remain in place are justified or removed according to regulations and current standards of practice. Compliance Guidelines: 4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures that include but are not limited to: a. Documentation of the involvement of the resident representative in the discussion of the risks and benefits of the use of the catheter, removal of the catheter when criteria or indication for use is no longer present, and the right to decline the use of the catheter; b. Timely and appropriate assessments related to the indication for use of an indwelling catheter; c. Identification and documentation of clinical indications for the use of the catheter; as well as criteria for discontinuation of the catheter when the indication for use is no longer present; d. Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures; e. Response of the resident during the use of the catheter; and f. Ongoing monitoring for 455952 Page 6 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0690 changes in condition related to potential catheter-associated urinary tract infections, recognizing, reporting and addressing such changes Level of Harm - Actual harm Residents Affected - Few 455952 Page 7 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide or obtain laboratory services ordered by a physician, physician assistant, nurse practitioner or clinical nurse specialist in accordance with state law, including scope of practice laws and promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fell outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician orders for 1 of 4 residents (Resident #1) reviewed for laboratory services. The facility failed to report laboratory results received on 11/02/2023 and 11/18/2023 for Resident #1 in a timely manner to the urologist. The facility failed to obtain laboratory results for Resident #1 collected on 11/8/2023 in a timely manner and report the results to the urologist. These failures could place residents at risk of not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for health and well-being. Findings include: Record review of Resident #1's face sheet, dated 08/28/2024, indicated [AGE] year-old male who was initially admitted to the facility on [DATE] and recently readmitted [DATE]. Resident #1 had diagnoses which included dementia (loss of cognitive functioning), protein-calorie malnutrition (a nutritional status in which reduces availability of nutrients leads to change in body composition and function), atherosclerotic heart disease (condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), benign prostatic hyperplasia (a noncancerous enlargement of the prostate gland), stroke with weakness to non-dominant side, language deficit following stroke, hypertension (condition in which the force of the blood against the artery walls is too high), anemia (condition that develops when your blood produces lower than normal amount of health red blood cells), calculus of kidney (hard deposits made of minerals and salts that form inside your kidney) and urinary stents (thin tube inserted into the ureter to prevent or treat obstruction of the urine flow from the kidney). Record review of Resident #1's Quarterly MDS assessment, dated 11/09/2023, indicated he was severely impaired cognitively, was dependent for showering/bathing, toileting hygiene, dressing upper and lower body, putting on/taking of footwear, all mobility and required set up and clean up for eating and oral care. He had a catheter for urinary output. Record review of Resident #1's care plan, dated 11/17/2022 and revised on 08/28/2024, indicated he had a Suprapubic Catheter for Obstructive and Reflux Uropathy. Interventions included: The resident has a Suprapubic Catheter. Position catheter bag and maintain tubing below the level of the bladder, make sure tubing is secured, Change dressing at site of suprapubic catheter daily as ordered, Check tubing for kinks as needed. Document and notify physician for signs and symptoms of pain/discomfort of catheter, urination, and/or frequency, document and notify physician for signs and symptoms of UTI: pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental 455952 Page 8 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few status, change in behavior, change in eating patterns and maintain catheter bag dependent of bladder for proper drainage. Record review of Resident #1's progress note, dated 11/01/2023, indicated the resident had an appointment today at 2PM and was transported and accompanied by a staff member to the urology clinic and seen by the urologist with orders for monthly SPT changes with instructions, labs for 24-hour urine collection, PTH, intact and calcium, BMP, Uric Acid, Stonerisk Diagnostic profile (profile is designed to analyze the chemical composition of urine to help understand the causes of kidney stone formation and prevent future occurrences) follow up appointment in 6 weeks. All care has resume upon return to facility. Staff will continue to monitor for any change in condition during this shift. Record review of Resident #1's urology appointment note, dated 11/01/2023, indicated treatments include labs of Basic Metabolic Panel, Stonerisk diagnostic profile, PTH, intact and calcium and Uric acid to be performed to determine etiology of stone formation. Lab request order, dated 11/01/2023, for test ordered Basic Metabolic Panel, Stonerisk (R) Diagnostic Profile, PTH, Intact and Calcium and Uric Acid with instructions attached on collecting a 24-hour urine sample. Record review of Resident #1's order recap indicated a physician's order, dated 11/01/2023, to obtain labs of intact PTH, basic metabolic panel and uric acid and a physician's order, dated 11/03/2023, to obtain a 24-hour collection of urine when proper container is picked up from local MD's office on 11/06/2023 and return collection along with a smaller urine analysis cup for stone risk testing to both be delivered and performed at the local MD's office lab. Record review of Resident #1's progress notes indicated, on 11/06/2023, the charge nurse received the following: 24-hour collection kit and Stonerisk diagnostic profile, items delivered by the facility transport staff and the urine collection to start on the morning of 11/07/2023. Record review of Resident #1's progress notes indicated, on 11/07/2023, 24-hour urine collection initiated. Record review of Resident #1's progress note indicated, on 11/08/2023, 24-hour urine and urine sample were collected, and sample transported to the local MD office for testing. Record review of Resident #1's Treatment Administration Record (TAR) for November 2023 indicated the treatment order start date of 11/06/2023 and discontinued on 11/10/2023 to obtain a 24-hour collection of urine when proper container was picked up from local the MD's office on 11/06/2023, return collection along with a smaller urinalysis cup for Stonerisk testing to both be delivered and performed at the local MD's office lab every shift for reminder, facility staff e-signed the treatment was completed on 11/06/2023, 11/07/2023 and 11/08/2023. Record review of Resident #1's final Laboratory Report for Basic Metabolic Panel, PTH, intact and calcium and Uric acid indicated collection date of 11/02/2023 and received, reported and reviewed date of 11/02/2023 no abnormal results indicated but notes to interpret results with caution due to slight or moderate hemolysis of blood sample. The Facility staff provided a final report for Protein, total and protein electrophoresis, 24 hour urine and immunofixation report collection date 11/08/2023 and received and reported date of 11/18/2023. No results uploaded in Resident #1's medical records of lab results for Stonerisk (R) Diagnostic Profile. No indication the final lab results of Basic Metabolic Panel, PTH, intact and calcium and Uric acid indicated collection date of 11/2/2023 and final report for Protein, total and protein electrophoresis, 24-hour urine and immunofixation report 455952 Page 9 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0773 Level of Harm - Minimal harm or potential for actual harm collection date 11/08/2023 was reported to the ordering urologist and no indication the ordering urologist was notified of Stonerisk (R) Diagnostic Profile results or omitted lab test. Record review of Resident #1's progress note indicated, on 11/11/2023, the resident was transferred to the local hospital for blood in urine and blood clots in the brief when incontinent care was provided. Residents Affected - Few During an interview on 8/28/2024 at 2:45 PM, LVN A said the process for lab orders was to write the order in the system for the labs requested, submit the lab request to the contracted lab and they would schedule the lab technician to come to the facility and collect the blood sample, if it was related to urine sample, facility staff would collect the urine, label the specimen and leave the request and sample in the refrigerator for the lab technician to pick up. LVN A said once the lab results were completed, the facility received the results were reviewed by facility staff and printed for the facility NP or MD to review or faxed to the ordering physician. LVN A said lab results were uploaded into the system under results and/or miscellaneous tab. LVN A said Resident #1 had labs ordered on 8/1/2024 from his urologist but some of the labs requested could not be done by the facility contracted lab and had to be sent to the local MD's office for a specific lab to collect specimen and give final lab results, those were still pending. LVN A said she called and faxed the urologist office the results from the blood work and was informed the urine sample collected was not completed correctly and requested it to be recollected. LVN A said the urine sample was recollected for the Stonerisk Diagnostic Profile on or around 08/06/2024 and taken to a local MDs office for results to be given by a specific lab and results were pending from the recent specimen collected. LVN A said she asked the MD/PA about the Stonerisk Diagnostic Profile test results during rounds on 8/27/2024, but the MD/PA said this test could take up to 4 weeks. LVN A said once the results from the StoneRisk Diagnostic Profile collected on or around 08/06/2024 were available they should be reviewed by facility staff, the facility MD/PA and faxed to the urologist. LVN A said she was unaware of the lab or urine results from November 2023 ordered by the urologist but would follow the same process. LVN A was unable to locate the Stonerisk Diagnostic Profile results for November 2023 in the electronic medical record system. During an interview on 08/28/2024 at 9:20 AM, MD B said the facility failed to obtain the labs he ordered or failed to provide the results to his office from 11/2023 and this was causing difficultly in treating Resident #1 appropriately. MD B said Resident #1 had a history of kidney stones and had a urinary stent in place and he ordered the Stonerisk Diagnostic Profile test back in November 2023 and recently in August 2024 to help determine Resident #1's treatment plan but he had not received the lab results from the facility. MD B said this test required a 24-hour urine collected and it could not be collected during an office visit. During an interview on 8/29/2024 at 5:45 PM, the DON said Resident #1 had labs ordered following a urologist appointment on 11/01/2023 and 08/01/2024. The DON said the orders were added to the electronic medical records and contracted laboratory was notified of the labs requested. The DON said the standard labs were collected but the urine collection for Stonerisk Diagnostic Profile was not a test that could be completed by the facility contracted lab, so the facility had to recollect the urine sample and send it to a local physician's office to be ran by an outside lab. The DON was unable to provide documents that the routine labs (Basic Metabolic Panel, Uric Acid, PTH, intact and calcium) results ordered on 11/01/2023 and/or the recollect urine specimen for Stonerisk Diagnostic Profile collected on 11/08/2024 (to be ran by outside labs) were reported to the ordering urologist. The DON said Resident #1 was hospitalized on [DATE] and was seen by the urologist during the hospital stay. The DON said when a physician or consulting physician ordered labs the expectation was for the labs 455952 Page 10 of 11 455952 08/29/2024 Cleveland Health Care Center 903 E Houston St Cleveland, TX 77327

F 0773 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to be collected as ordered. The DON said the licensed facility staff receiving the order should write an order in the electronical medical records which indicated the labs ordered, when it was collected and who should receive the results, and staff should notify the facility contracted lab to schedule the ordered labs. The DON said once the labs were completed and results submitted to the facility the licensed facility staff should report the results to the ordering physicians. The DON said a delay in reporting lab results could result in a delay in the physician being able to appropriately treat a potential illness. During an interview on 08/29/2024 at 6:00 PM, the Administrator said the facility needed better a process in place for tracking lab orders, results and physician notification. The Administrator said lab orders needed to be executed and carried out as ordered by the physician and/or consulting physicians. The Administrator said the licensed facility staff receiving the order should write an order in the electronical medical records which indicated the labs ordered, when it was collected and who should receive the results, and staff should notify the facility contracted lab to schedule the ordered labs. The Administrator said once the labs were completed and results submitted to the facility the licensed facility staff should report the results to the ordering physician(s) which included any consulting physicians. The Administrator said some of the specialized tests could not be completed by the facility contracted laboratory services and needed to utilize outside laboratories for these tests. The Administrator said a delay in reporting lab results could result in a delay in the physician being able to appropriately treat a potential illness and/or cause adverse effects. Record review of the facility's policy Physician, Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist Lab Notification indicated it is the policy of this facility to timely notify the physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results. Policy Explanation and Compliance Guidelines: 1. The facility must promptly notify the attending physician, physician assistant, nurse practitioner or clinical nurse specialist of lab results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per ordering physician's orders. Delayed notification may contribute to delays in changing the course of treatment or care plan . Guidelines: 1. Upon receipt of the lab result, document as received in the lab log. 2. Determine if the lab result requires immediate or non-immediate notification, according to the physician order or facility policies and procedures. 3. Immediate notifications - a. Call physician, physician assistant, nurse practitioner or clinical nurse specialist office with lab result and resident current condition. b. Fax result. c. Staple fax confirmation to original fax and place in lab log binder under notifications. d. Place original lab result in medical record and flag for signature. e. Document notification of result and condition (date, time, name of individual reported to, new orders if applicable). f. Notify and document notifications to resident representative, if applicable. g. Implement new orders. 4. Non-immediate notifications - a. Place original lab result in physician, physician assistant, nurse practitioner or clinical nurse specialist folder at desk for physician review and signature. b. Place copy of lab result in medical record. c. Replace copy with signed original, once signature is obtained. 5. If there is no response from the physician, physician assistant, nurse practitioner or clinical nurse specialist within 2 hours of an immediate notification, contact the Director of Nursing or his/her designee for further instructions. 455952 Page 11 of 11