**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility's policies, the facility failed to provide services that meet professional standards for one of six residents observed for medication administration (Resident #41). Specifically, blood pressure monitoring was not provided following physician's orders before administering a medication. Findings include: Review of the undated facility policy titled, Administering Medications, noted: Policy Statement: Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation . 2. The director of nursing services supervises and directs all personnel who administer medications and/or have related functions . 4. Medications are administered in accordance with prescriber orders, including any required time frame . 11. The following information is checked/verified for each resident prior to administering medications: a. Allergies to medications; and b. Vital signs, if necessary. [sic] Review of the medical record for Resident (R) #41, showed that the resident was admitted to the facility on [DATE] with diagnoses that included diabetes, major depressive disorder, cerebrovascular disease, and edema. Review of the Physician ' s orders for R#41 for April 2025 included, Furosemide [a diuretic used to treat fluid retention] Tablet 20 MG [milligram]. Give 40mg by mouth one time a day for Edema. Hold for SBP [systolic blood pressure] < [less than] 100, SBP <60. [sic] During a medication administration observation on the 300 Hall, on 4/23/25 at 8:38 a.m., Licensed Practical Nurse (LPN) AA prepared medications for R#41. The LPN reviewed the Physician ' s order from R#41 ' s electronic medical record for each medication, as she retrieved each of R#41 ' s individual blister packet from the 200-300 Hall medication cart, and poured each of the nine medications, which included furosemide 40mg, into a medicine cup. The LPN then locked the cart, performed hand hygiene, and brought the medications to R#41. The LPN observed the resident while the resident swallowed the medications. During an interview, on 4/23/25 at 8:45 a.m., LPN AA stated, I didn't check [R#41 ' s name] BP [blood pressure] before giving the medication [furosemide]. It [blood pressure monitoring] was last done with a BP of 124/70 on 4/17/25 at 0354 [3:54 a.m.] according to the chart. [sic]The LPN confirmed that the BP should have been taken before administering the furosemide medication following the physician ' s orders, to ensure that the BP parameters were met before administering the medication. During an interview, on 4/24/25 at 10:45 a.m., the Director of Nursing (DON) stated, I expect the nurse to check the blood pressure within an hour before administering the medication if it requires a blood pressure check. [sic]The DON confirmed that the blood pressure needed to be obtained, following physician ' s orders, prior to administering the furosemide medication to R#41. During a telephone interview, on 4/24/25 at 12:32 p.m., with R#41 ' s primary care physician for the facility, the physician stated, Giving the medication [furosemide 40mg] could lower the blood pressure a little bit. I don't think giving the medication without checking the blood pressure first, would cause major harm for this resident [R#41]. Her blood pressures have been stable, the medication might not work as well for her edema if her blood pressure is low. They [nurses] should be checking the blood pressure routinely before giving the medication though. I have not been notified of any lower blood pressure issues that the resident has had recently. [sic]

Based on observations, staff interviews, and review of the facility's policies, the facility failed to appropriately store medications in three of three medication storage carts (200-300 Hall cart, 400 Hall cart, and 500 Hall cart). Findings include: Review of the undated facility policy titled, Medication Labeling and Storage, noted: Policy Statement: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys. Policy Interpretation and Implementation. Medication Storage: 1. Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. [sic] During a medication storage observation of the 500 Hall medication cart, on 4/23/25 at 2:40 p.m., with Licensed Practical Nurse (LPN) CC, the second and third drawer of the medication cart contained individually sealed and labeled resident medication blister packets [packaging used to keep the medication safe from damage, moisture, and contamination]. Further observation revealed there were five loose pills of various sizes, shapes, and colors lying on the bottom of the second drawer, and four loose pills of various sizes, shapes, and colors lying on the bottom of the third drawer of the cart. During an interview on 4/23/25 at 2:47 p.m., Nurse Supervisor DD stated, I think that the night nurses clean out the [medication cart] drawers. They have more time on their shift. I don't know if they do it every night. It's every nurse's responsibility to keep the cart clean and make sure there are no loose medications in the drawer. During a medication storage observation of the 400 Hall medication cart, on 4/23/25 at 2:50 p.m., with LPN BB, the second drawer of the medication cart contained sealed and individually labeled resident medication blister packets. Further observation revealed there were two loose pills of various sizes, shapes, and colors lying on the bottom of the second drawer of the cart. During a medication storage observation of the 200-300 Hall medication cart, on 4/23/25 at 2:58 p.m., with LPN AA, the third drawer of the medication cart contained sealed and individually labeled resident medication blister packets. Further observation revealed there were 14 and one-half loose pills of various sizes, shapes, and colors lying on the bottom of the third drawer of the cart. During an interview on 4/24/25 at 10:45 a.m., the Director of Nursing (DON) stated, The medication storage carts should be cleaned routinely. All nurses are responsible for checking the medication cart. I expect there might be one or two pills in the bottom of the drawer during a shift, because the medications come out of the packs easily, but there should not be several pills in each drawer found. [sic]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facilities policy, the facility failed to accommodate resident's food allergies, intolerances, and preferences for seven (7) residents that had been identified to have a latex allergy to include sampled residents. [Residents (R) #7, R#13, R#27, R#39, R#49, R#51and R#247]. Specifically, the facility failed to provide an appropriate alternative as evident by dietary staff plating food from the tray line using their hands donning latex gloves. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: Review of the facility policy titled, Food Allergies, undated, revealed: Procedure 4, The facility must determine a practice for patient/resident identification for food allergy. The policy does not specifically identify latex allergies. Review of the facility policy titled, Bare Hand Contact with Food and Use of Plastic Gloves, not dated, revealed, Procedure 2, staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Procedure 3, gloves are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready-to-eat (RTE) food or with raw animal food, used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation. Procedure 5 (f), clean gloves are to be used anytime hands would otherwise touch food directly. Anytime a contaminated surface is touched, the gloves must be changed, and hands must be washed. Review of the facility policy titled, Employee Hygiene for Food Safety, not dated, revealed Procedure 6, Use utensils to handle food, avoiding bare hand contact with food. Disposable gloves are a single use item and should be discarded after each use. Hands must be washed prior to using gloves and after removing gloves. A review of the best practice statement provided the Mayo Clinic, titled Latex Allergy, dated November 6, 2024, revealed a latex allergy, the immune system identifies latex as a harmful substance and triggers certain antibodies to fight it off. The next time there is a latex exposure, these antibodies tell the immune system to release histamine and other chemicals into the bloodstream. This process produces a range of allergy symptoms. The more times someone is exposed to latex, the more strongly their immune system is likely to respond. This is called sensitization. Latex allergy can happen by direct contact. The most common cause of latex allergy involves touching latex-containing products, including latex gloves . A review of the electronic medical record (EMR) for R#7 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#13 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#27 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#39 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#49 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#51 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. A review of the EMR for R#247 revealed, she was admitted on [DATE] and was diagnosed with a latex allergy at admission. During the dietary tray line observation on 4/23/25, at 11:15 a.m., food service [NAME] #FF was observed serving dinner biscuits from the steamtable for 85 residents using a latex gloved hand. During an interview, on 4/23/25, at 11:15 a.m., [NAME] FF revealed she prefered to use the latex gloves rather than the vinyl or nitril based gloves. She stated she should have used a tong to plate the rolls and was not aware of any residents with latex allergies. During an interview, on 4/23/25 at 11:20 a.m., the Dietary Manager revealed her staff can use their preference of type gloves, either vinyl or rubber latex. She stated it had never been brought to her attention that there were residents in the facility with latex allergies. She confirmed that [NAME] FF should have used tongs to serve the rolls than her gloved hand. During an interview, on 4/23/25 at 12:33 p.m., the Director of Nursing (DON) revealed the facility did not have a policy restricting the use of latex gloves. He stated he was not aware that latex gloves were being used in dietary services. He confirmed he had learned this was the only area of the facility that was using latex gloves. He identified the serious risk of anaphylactic reaction if anyone in the facility was exposed to latex that had a noted allergy and stated they should not be used anywhere in the facility. He confirmed that the facility identified there were seven (7) residents with documented latex allergies. During an interview, on 4/25/25 at 8:26 a.m., the Infection Control Nurse revealed she was not aware of any residents with latex allergies, but she was aware the dietary staff were using latex gloves. She revealed she was not aware of a policy restricting the use of latex but if the facility had residents that had a latex allergy, anyone caring for them should not use latex as it could cause a serious allergic reaction. During an interview, on 4/25/25 at 8:55 a.m., the Administrator revealed he was not aware of the use of latex being used in the facility. He stated that with residents in the facility being identified to have latex allergies, the facility should not be stocking latex gloves for use. He stated his concerns include the possibility of a resident that had a latex allergy could have a serious allergic reaction if exposed to latex products.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure that proper sanitation and food handling practices to prevent the outbreak of foodborne illness were followed and safe food handling for the prevention of foodborne illnesses throughout the facility's food handling processes, and failed to ensure proper hand hygiene or donning (putting on) of a protective apron during meal service tray line. Specifically, two freezers, one walk in refrigerator, three juice coolers, and one front and back ice cream cooler failed to have documentation verifying the temperatures of each. The deficient practice had the potential to affect all residents who receive an oral diet from the kitchen. Findings include: Review of the facility policy for reference cold and warm temperatures was requested, however the facility failed to provide the requested policy. Review of the facility policy titled, Employee Hygiene for Food Safety, not dated, revealed all food and nutrition service employees will practice personal hygiene and safe food handling procedures. Procedure 2, wash hands before handling food using posted handwashing procedures. Procedure 6, Use utensils to handle food, avoiding bare hand contact with food . Review of the facility policy titled Sample Freezer and Refrigerator Temperatures Form 1, stated Record both internal and external temperatures of freezers and refrigerators at least twice a day (approximately 6:00 a.m. and 7:00 p.m.). Any unit not at the proper temperature must be reported to the supervisor at once for corrective action. Refrigeration/freezer units may include milk or ice cream coolers, or any unit used to keep foods cold or frozen. All units must be monitored daily. Review of the facility policy titled Sample Freezer and Refrigerator Temperature Form 2, stated Take AM and PM Temperatures and document corrective action, which is to be initialed by the staff performing the check. Review of the facility policy titled Sample Food Temperatures Form to be dated weekly, revealed record food temperatures prior to service and again after half of the meal has been served for each meal service daily. Hot foods should be equal to or greater than 165 degrees Fahrenheit prior to tray line and 135 degrees Fahrenheit through end of tray line. Cold foods must be maintained at equal to or less than 41 degrees Fahrenheit. Report any foods that are in the temperature danger zone of greater (>) 41 degrees Fahrenheit to less than (<) 135 degrees Fahrenheit to the supervisor immediately for corrective action. An observation on 4/22/25 at 11:17 a.m., revealed a walk-in refrigerator temperature revealed an external thermometer to read at 36? with an internal temperature reading at 32 degrees Fahrenheit. A review of the Sample Freezer and Refrigerator Temperature Form 1, dated April 2025 revealed, from 4/1/25 to 4/21/25, no temperatures had been documented. On 4/21/25 and 4/22/25, a negative (-10 degrees Fahrenheit) was documented. An observation on 4/22/25 at 11:25 a.m., of a walk-in freezer temperature to read at +10 degrees Fahrenheit. A review of the Sample Freezer and Refrigerator Temperature Form 1, dated 4/1/25 to 4/22/25 revealed no temperatures had been documented per policy of twice a day, every day. An observation on 2/22/25 at 11:35 a.m., of the front and back ice cream freezers failed to have an internal thermometer. A review of the temperature log from 4/1/25 to 4/22/25 for both freezers revealed no documentation of the temperatures being checked on either AM or PM shift. An observation on 4/22/25 at 11:45 a.m., of juice cooler #1, #2, and #3 revealed an internal thermometer located inside of each cooler and all reading +32 degrees Fahrenheit. A review of the Sample Freezer and Refrigerator Temperature Form 2, for cooler #1, cooler #2 and cooler#3 from 4/1/25 to 4/21/25 for day shift (AM) and evening shift (PM) revealed no temperatures had been documented for either shift. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the walk-in refrigerator temperature revealed the Sample Freezer and Refrigerator Temperature Form 1, dated 3/1/25 to 3/30/25 revealed no temperatures had been documented twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the walk-in freezer temperature revealed the Sample Freezer and Refrigerator Temperature Form 1, dated 3/1/25 to 3/30/25 revealed no temperature documented twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the Sample Freezer and Refrigerator Temperature Form 1, dated March 2025 for the front and back ice cream freezer revealed, from 3/1/25 to 3/30/25, no temperatures were documented on the AM shift. From 3/28/25 to 3/30/25, no temperatures were documented from the PM shift twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, a review of the sample food temperature form revealed food temperatures were not documented prior to service and again after half of the meal service for 3/1/25 on the dinner meal, on 3/2/25 on the breakfast and lunch meals and on 3/7/25 for the breakfast and lunch meals. On 3/10/25 there was no food temperature documented for the dinner meal. On 3/16/25 and 3/19/25, there were no food temperatures documented on the dinner meal. On 3/25/25, no food temperatures were documented on the breakfast and lunch meals. On 4/2/25 there were no food temperatures documented for the breakfast and lunch meals. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the sample freezer and refrigerator temperature form 2, dated March 2025 of juice cooler #1, #2, and #3 revealed from 3/1/25 to 3/30/25 revealed no temperatures had been documented for the AM shift and 3/28/25 to 3/30/35, no temperatures documented on PM shift of twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the walk-in refrigerator temperature revealed the sample freezer and refrigerator temperature form 1, dated 2/23/25 to 2/28/25 revealed no temperatures had been documented on the AM shift. No temperatures from 2/20/25 to 2/28/25 were documented on the PM shift twice on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the walk-in freezer temperature revealed the sample freezer and refrigerator temperature form 1, dated 2/20/25 to 2/28/25 revealed no temperatures had been documented on the AM shift twice on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the sample freezer and refrigerator temperature form 1, dated February 2025 for the front and back ice cream freezer revealed, from 2/23/25 to 2/28/25, no temperatures were documented on the AM shift. From 2/23/25 to 2/28/25, no temperatures were documented from the PM shift twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the sample freezer and refrigerator temperature form 2, dated February 2025, juice cooler #1, #2, and #3 revealed from 2/24/25 to 2/28/25 revealed no temperatures had been documented for the AM shift twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, a review of the sample food temperature form revealed food temperatures were not documented prior to service and again after half of the meal service for each meal. On 2/3/25 at the lunch meal, on 2/5/25 at the breakfast and lunch, and on 2/25/25, at the dinner meal, there were no food temperatures documented. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, of the sample freezer and refrigerator temperature form 1, dated January 2025 for the back ice cream freezer revealed, from 1/13/25 to 1/31/25, no temperatures were documented on the AM shift twice a day on each shift daily. An observation on 4/22/25 at 11:45 a.m., with the Dietary Manager, a review of the sample food temperature form revealed food temperatures were not documented prior to service and again after half of the meal service for each meal. On 1/5/25 at the breakfast and lunch meal, on 1/17/25 and 1/18/25 at the breakfast and lunch, on 1/24/25 and 1/25/25 at the dinner meal, and on 1/29/25 at the breakfast and lunch meal, there were no food temperatures documented. An observation on 4/23/25 at 11:15 a.m. with [NAME] FF revealed multiple observations during meal service, of her leaving the steamtable area with gloves and apron on and returning to the steamtable without proper hand hygiene or glove change. These observations included contact with surfaces that were outside of the work duty that were transported by other food service staff, then she continued to serve dinner biscuits with the same gloved hands. An observation on 4/23/25 at 12:30 p.m. of a dietary aid receiving the plated food from the cook to drop 3 warming covers into the floor. She picked them up with gloved hands and placed them to the side and continued to serve resident food trays without changing gloves after performing proper hand hygiene. During an interview, on 4/25/25 at 8:51 a.m., the Dietary Manager revealed she expected her staff to check all temperatures of the cold and hot units in the kitchen and document their findings. She stated she had been doing ongoing in-services with the staff on the checking of temperatures, but the staff just don't follow the policy. Her concerns included the risk of food born illness and the residents getting sick. She stated that all staff were expected to follow good hand hygiene during meal preparation and services to reduce the risk of cross contamination. During an interview, on 4/25/25 at 9:05 a.m. with the DON, stated he expected the dietary staff to follow the policy on checking storage temperatures and food temperatures and to document their findings. Failure to ensure temperatures were within the normal range could cause food born illness and residents to become ill. During an interview, on 4/25/25 at 9:09 a.m. with the Administrator he revealed he expected the dietary staff to follow safe food service policies to eliminate the risk of resident illness.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident family and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, the facility failed to report an incident of sexual abuse for one of three sampled residents (R) (R1). This failure had the potential for abuse to other residents by staff. Findings include: Review of the facility policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating states under Policy Statement: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Under Policy Interpretation and Implementation, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative: d. Adult Protective Services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. the facility medical director. Review of the electronic medical record (EMR) revealed R1 was admitted to the facility with diagnoses of, but not limited to fracture of lumbar vertebra, anxiety disorder, depression, Alzheimer's type dementia, and major depressive disorder. Review of most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R1 had a Brief Interview for Mental Status (BIMS) score of 5, indicating significant cognitive impairment. Review of the care plan indicated R1 has impaired cognitive function related to Alzheimer's related dementia; a mood problem related to a diagnosis of mood disorder due to known physiological condition with mixed features; limited physical mobility r/t (related to) vertebrae fracture. Observation on 4/8/2025 at 12:49 pm of R1 with spouse present revealed R1 was not able to be interviewed, but the spouse stated that he did not have any concerns about the incident. He stated that his stepdaughter told him that she observed her mother get upset with CNA AA because R1 mistook CNA AA for the stepdaughter's husband. He stated he felt bad for CNA AA. During an interview on 4/7/2025 at 10:30 am with the Administrator, they presented exhibit 7, wherein the investigation for sexual abuse had been requested. There was no evidence of police involvement in the exhibit. The Administrator revealed, at the request of the family, the police not be notified nor the resident be sent to the hospital for a sexual assault evaluation. The Administrator indicated that Adult Protective Services had not been notified. Interview on 4/8/2025 at 10:47 am with CNA BB revealed that she reported any allegations of abuse to the Director of Nursing (DON). Interview on 4/7/2025 at 3:26 pm with the Ombudsman revealed that she was not notified of the allegation of sexual abuse. She was concerned not to have been involved in the process. Interview on 4/8/2025 at 11:15 am with the Social Service Director (SSD) revealed that the DON was the Grievance Officer, and that in any allegations of abuse or neglect you have two hours to report to the state agency, Ombudsman, local police, Adult Protective Services, family and the doctor. She revealed she was not involved directly in the grievance process but would have expected the police to have been notified if there were an allegation of sexual abuse. The Ombudsman and Adult Protective Services should have been notified in the case of an allegation of rape. Interview on 4/8/2025 at 11:22 am with Unit Manager LPN CC, she revealed any allegations of abuse were required to be reported to the DON who was the Abuse Coordinator. The DON did the investigation. She didn't know if notifying the police was a requirement. LPN CC said LPN DD asked R1 what she wanted to do, and R1 said to call the police. Interview on 4/8/2025 at 12:09 pm with the DON revealed that they thought that reporting to the State, speaking to the family, and doing their own investigation was all they had to do. Interview on 4/8/2025 at 1:39 pm with the Administrator revealed that the morning of the incident, R1's husband did not want his wife sent to the hospital to be assessed nor have the police involved. When asked why the Administrator did not call the police according to their own facility policy, he stated, If we think it really happened, we would have followed the policy completely. We didn't think it happened.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of the facility policy titled Dignity, the facility failed to ensure that 12 of 24 sampled residents (R) (R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, R#18, and R#67) were treated in a dignified manner related to (1) placing medical instruction signage in an area easily viewed by other residents/visitors for R#48, R#58, R#26, R#69, R#440, R#29, R#51, R#38, R#54, R#33, and R#18; and (2) an uncovered catheter bag for R#67. Findings Included: 1. A Review of the policy titled Dignity dated 2001 and revised 2/21/22 revealed the policy statement to be: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation section line numbered 10.b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information or safety reasons is permissible. A review of the resident's most recently quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of three indicating a severe impaired cognition. The resident was also coded as having an indwelling foley catheter and requiring extensive assistance for bed mobility, transfers, toileting. A review of the care plan revealed a catheter bag and tubing below the level of the bladder with the use of a privacy bag. During an observation of R#67 on 3/1/23 at 10:31 a.m., the resident was observed sitting in his Geri Chair beside his bed, closest to the hallway, with door open to its entirety. His catheter bag and tubing were revealed hanging from his chair without covering. During an interview with Certified Nursing Assistant (CNA), KK on 3/1/23 at 11:23 a.m. regarding the care of the catheter and the policy issues associated with the covering of the resident's urinary drainage bag, the CNA stated she has had training related to dignity as it pertains to catheter bags and she is aware of the facility policy to assist with resident rights and privacy needs. 2. Review of the policy titled Dignity dated 2001 and revised 2/21 revealed the policy statement to be: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy interpretation and implementation section line numbered 10.b. Signs indicating the resident's clinical status or care needs are not openly posted in the resident's room unless specifically requested by the resident or family member. Discreet posting of important clinical information or safety reasons is permissible. On 2/28/23 at 1:02 p.m. and 3/1/23 at 8:50 a.m. observations of R#58 revealed her to be self-propelling in a wheelchair in her room. Observation of the room revealed signage on the wall above the head of bed to read Hip Precautions, no bending over past 90 degrees, no crossing legs, no [NAME] toes. R#58 revealed she did not know who put the signs on the wall or why they are there. She revealed she did not feel like she needed them on the wall. R#58 was an [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia and aftercare following joint replacement surgery. Review of the quarterly minimum [NAME] set (MDS) dated [DATE] reveled R#58 had a brief interview for mental status (BIMS) of 13, indicating was cognitively intact, required extensive assistance for transfers, dressing, toileting, and set-up assistance for eating. Further review revealed she had a fall with injury prior to the look back period and received occupational therapy (OT) and physical therapy (PT) three of seven days. Review of the physician's orders revealed an order for weight bearing as tolerated, posterior hip precautions. Review of the care plan include a focus area of is at risk for falls due to poor safety awareness, weakness, poor balance and unsteady gait. The goal was for risk for falls would be minimized while maintaining the highest level of functioning. Interventions included to educate resident to use call device for assistance, anticipate and meet the resident's needs, auto break on wheelchair, non-skid socks when shoes not worn. On 2/28/23 during the initial screening of all residents the following resident rooms were also observed to have clinical information signage secured on the wall above the head of the bed: R#26 - No blood pressure in right arm R#69 - No blood pressure in right arm R#440 - Lift only x 2 assist; Wash eyes with warm washcloth R#29 - Nightshift to put TED hose before getting out of bed R#51 - Minimal assist x1 plus with rolling walker R#38 - Lift only for transfers R#54 - Latex allergy R#33 - Gait belt x2 assist for all transfers R#18 - Hoyer lift for all transfers On 3/1/23 at 11:15 a.m. an interview with certified nursing assistant (CNA) KK revealed she had received training to include falls prevention, nutrition, hydration, abuse, and resident rights. She revealed R#58 required limited assistance with activities of daily living (ADLS) and desired to be as independent as possible. She revealed she followed the instructions displayed on the wall for residents and was unsure who placed the signage on the walls. On 3/1/23 at 10:55 a.m. an interview with Licensed Practical Nurse (LPN) LL revealed R#58 had an unwitnessed fall in December 2022 sustaining a fractured hip. R#58 required surgery and returned to the facility. She revealed R#58 received therapy services and was discharged from therapy after having met her therapy goals. She revealed therapy department placed signage on the walls in resident rooms to inform staff of resident needs and therapy recommendations, such as transfer status, need for lifts, therapeutic dietary needs such as thickened liquids. On 3/1/23 at 12:10 p.m. an interview with Speech Language Pathologist (SLP) MM she revealed R#58 had been discharged from therapy due to meeting her goals. She revealed the therapy department provided a communication form to the nurse with therapy recommendations for continued cares. She revealed recommendations include instructions for post therapy cares such as resident needs for transfers, splint or brace application, therapeutic dietary needs such as thickened liquids. She further revealed therapy did not place signage on resident walls and revealed the nursing staff placed the signage on resident walls to inform staff of resident needs. On 3/2/23 at 8:50 a.m. an interview with the Director of Nursing (DON) revealed he was aware of the instructional signage on resident walls and revealed the signage were placed by the nursing staff and the therapy staff to provide instructional reminders for resident care staff. He revealed his expectations for instructional care signage in resident rooms were for the signage to be located in an area not easily viewed by visitors and other residents and he further revealed only staff should have viewable access to the information. He revealed signage had or would be removed from the resident room walls and be located inside the resident's closet door. He further revealed he had initiated education to all resident care staff of the location of instructional signage location.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policy titled admission Criteria the facility failed to conduct a Level II Preadmission Screening and Resident Review (PASARR) screening for one of 40 sampled residents (R) (R#39) following a new diagnosis of major depressive disorder and mild intellectual disabilities. Findings included: Review of facility policy 'admission Criteria' revealed: All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. g. Residents will be evaluated at least quarterly for mental status or new diagnosis of mental disorder. A review of the clinical record revealed that R#39 was admitted to the facility 11/30/16 with diagnoses including but not limited to obesity, hyperlipidemia, and hypertension. On 2/19/20 diagnoses of mild intellectual disabilities and major depressive disorder were added. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section I-Active Diagnosis revealed depression (other than bipolar) and psychotic disorder (other than schizophrenia) both checked. During an interview on 3/2/23 at 9:10 a.m. with the Social Worker revealed a Level II PASARR screening was not done after resident's new diagnoses of mild intellectual disabilities and major depressive disorder. Stated she has just recently started auditing residents' charts with their assessment scheduled. Further revealed a Level II PASARR should have been conducted for R#39 after the new diagnoses, but she had not submitted a referral for the Level II PASARR for the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of facility policy 'Care Plan, Comprehensive Person-Centered', the facility failed to develop a person-centered comprehensive care plan related to nutrition/hydration needs for one of 40 sampled residents (R) (R#74). Findings included: Review of facility policy 'Care Plans, Comprehensive Person-Centered' last revised March 2022 revealed 'A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS (Minimum Data Set) assessment (Admission, Annual or Significant Change in status), and no more than 21 days after admission. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. A review of the clinical record revealed that R#74 was admitted to the facility 5/2/22 with diagnoses including but not limited to diabetes mellitus, hypertension, and dementia. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. A review of R#74's care plan revealed no care plan in place to address resident's nutrition and hydration needs. During an interview on 3/2/23 at 10:25 a.m. with MDS Coordinators/Licensed Practical Nurse (LPN) QQ and LPN RR, they confirmed that the resident's care plans are not person-centered or comprehensive. Stated residents care plans should be updated with the MDS assessment. Further revealed R#74's last MDS assessment was done on 1/26/23 and the care plan should have been reviewed at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to document weekly skin assessments in accordance with Physician orders for one of 40 sampled residents (R) (R#77). Findings included: A review of the clinical record revealed R#77 was admitted to the facility 6/22/22 with diagnoses including but not limited to frontotemporal neurocognitive disorder, dementia, and atrial fibrillation. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 99, indicating severe cognitive decline. A review of R#77's Physician orders dated March 2023 revealed an order for weekly skin assessments every Sunday on night shift. Further observation of February and March 2023 orders did not reveal orders for a treatment to the right elbow. During review of R#77's skin assessments the last skin assessment was performed 2/13/23. This skin assessment did not document any skin conditions. During observation on 2/28/23 at 2:20 p.m. R#77 was observed with a bandage to the right elbow area dated 2/18/23. During observation on 3/1/23 at 9:30 a.m. R#77 was observed in hallway with bandage to right elbow area dated 2/18/23. During an interview on 3/2/23 at 8:25 a.m. with Licensed Practical Nurse (LPN) SS revealed R#77's skin assessments are done weekly. Stated resident's skin assessments are scheduled for Mondays on dayshift. During an interview on 3/2/23 at 8:32 a.m. with LPN TT revealed skin assessments are done by the charge nurse's weekly. Stated the resident's skin assessments are documented in the electronic medical record (EMR). Stated she was unaware resident had a bandage on his right elbow. Revealed the nurses usually notify her when residents have a change in skin condition. During interview on 3/2/23 at 9:10 a.m. with LPN Unit Manager NN revealed he was unaware resident had a bandage on his right elbow. Confirmed there was no documentation in the EMR of resident having an area to the right elbow. Further confirmed resident had not had a skin assessment done since 2/13/23. Stated resident should have had a skin assessment done 2/20/23 and 2/27/23. Stated if the missed skin assessments had been done, the area would have been identified and appropriate orders for treatment put into place.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record and policy reviews, the facility failed to ensure the safety for one of 40 sampled residents (R) (R#28) related to ensuring safe smoking practices. Findings include: A review of the policy titled Smoking Policy Update dated 5/13/13 revealed a statement of: (The facility) will become a smoke-free facility. Effective date for clients in our facility to be smoke free will be June 15, 2013. For all new clients, the policy will be effectively immediately. The policy was signed by the Administrator. A review of the clinical record revealed that R#28 was a [AGE] year-old male admitted on [DATE] with diagnosis including unspecified vascular injury of the head and vascular dementia. On 2/28/23 at 10:46 a.m. and 3/1/23 at 9:20 a.m. interviews with R#28 revealed he is allowed to go outside to smoke when his family visits and accompanies him outside. He revealed he normally goes to the parking lot or to an area just outside of the building and smokes with his family but did not go to the employee smoking area. He revealed staff is aware that he smokes while outside with family member and staff do not accompany him outside to smoke. A review of the admission Minimum Data Set (MDS) dated [DATE] revealed R#28 had a Brief Interview for Mental Status (BIMS) of 14, indicating was cognitively intact and required the assistance of two persons for Activities of Daily Living (ADLS) and set-up assistance for eating. A review of the physician's orders revealed no orders to permit smoking. A review of the care plan revealed a focus area of: The resident is a smoker. Resident goes outside to smoke with supervision. Granddaughter keeps smoking materials for the resident with her. The goal was: The resident will not smoke without supervision through the review date. Interventions were: The resident will not suffer injury from unsafe smoking practices through the review date. Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Monitor oral hygiene. Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. The resident requires supervision while smoking. A review of the clinical record revealed there was not a smoking assessment for R#28. During an interview on 2/28/23 at 9:30 a.m. with the Administrator, he revealed R#28 goes outside of the building with family members and smokes. He revealed the facility does not provide staff or scheduled times for smoking and revealed the facility had a no smoking policy for residents. On 3/1/23 at 10:30 a.m. an interview with Licensed Practical Nurse (LPN) LL revealed R#28 goes outside and smokes when a family member takes him out. She revealed staff did not keep smoking supplies and did not accompany resident to smoke. She further revealed the family member does not sign resident out of facility when they go outside to smoke. On 3/2/23 at 12:15 p.m. an interview with the Director of Nursing (DON) revealed he was aware that R#28 goes outside, and smokes accompanied by a family member. He revealed the facility had a no smoking policy for residents and administration had allowed R#28 to go outside with a family member and smoke. He verified a safe smoking assessment for R#28 had not been performed and revealed one should have been performed since the facility was aware of him smoking. He revealed he planned to have a safe smoking assessment performed for R#28 and ensure resident's family is aware of the designated smoking areas.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the policy titled Psychotropic Medication Use, the facility failed to ensure that psychotropic medications/antianxiety medications were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents (R) (R#66 and R#77) reviewed for unnecessary medications. Findings included: Review of the policy titled Psychotropic Medication Use dated 2001 and revised July 2022 revealed the policy statement of: Residents will not receive medications that are not clinically indicated to treat a specific condition. The Policy and Interpretation and Implementation section revealed line numbered 12a.: As needed (PRN) orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are not antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. Review of the clinical record for R#66 revealed she was admitted to the facility on [DATE] with diagnoses including but not limited to anxiety disorder, major depressive disorder, type 2 diabetes, atrial fibrillation. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed R#66 had a Brief Interview for Mental Status (BIMS) of 15, indicating was cognitively intact, mood severity score of 0, no behaviors exhibited, required supervision for activities of daily living (ADLS). A review of the physician's orders revealed an order dated 10/3/22 for Ativan (a medication used to treat anxiety) 0.5 milligram (MG) one tablet by mouth every six hours as needed for anxiety. Review of the physician's orders did not indicate that the use of PRN medications had been evaluated by the physician for continued use beyond 14 days. A review of the Medication Administration Record (MARS) dated December 2022 and January 2023 revealed R#66 did not receive Ativan 0.5mg on any dates. Review of the MARS dated February 2023 revealed R#66 received Ativan 0.5mg on 2/12/23, 2/16/23, and 2/20/23. A review of the Gradual Dose Reduction (GDR) document dated 8/28/22 and 2/26/22 revealed the medication Ativan 0.5mg was not documented as being reviewed. A review of the last six months of the monthly medication review (MMR) revealed there were no changes recommended for the medication Ativan 0.5mg. A review of the nurse's notes revealed no behaviors documented. On 3/1/23 at 11:05 a.m. an interview with Certified Nursing Assistant (CNA) KK revealed R#66 had no exhibited mood or behaviors in her presence. She revealed she had worked at the facility for one month. On 3/1/23 at 11:10 a.m. an interview with Licensed Practical Nurse (LPN) LL revealed she had worked at the facility for 17 years. She revealed R#66 had not exhibited mood or behavior changes in the past three months. She revealed the pharmacist conducts a monthly medication regimen review and nursing staff follows physician orders for medications. On 3/1/23 at 11:15 a.m. an interview with LPN NN revealed the pharmacist reviews resident medications monthly. He verified in the facility electronic medical record (EMR) that a MMR had been conducted for R#66 for the past six months and no recommendations were made. He verified R#66 had a physician's order for Ativan 0.5mg one tablet every six hours as needed for anxiety that was dated 10/3/22. On 3/2/23 at 8:55 a.m. an interview with the Director of Nursing (DON) revealed his expectations were for psychotropic medication orders to be limited to fourteen days unless documented by the physician as being clinically necessary. He verified that R#66 had a physician's order dated 10/3/22 for Ativan Tablet 0.5 mg one tablet by mouth every six hours as needed for anxiety. He revealed the consultant pharmacist performed a monthly review of all resident medications and verified there were no recommendations for the Ativan, and verified there was not a GDR recommendation for the Ativan. He further revealed a nurse transcribes the physician orders into the EMR and his expectation was for the nurse to place a fourteen-day end date on prn psychotropic medication orders. He revealed he planned to provide education to nursing staff to place a fourteen-day end date for prn psychotropic medication orders. On 3/2/23 at 9:50 a.m. a telephone interview with Consulting Pharmacist OO revealed she performs MMRs for all medications for each resident and a GDR every six months for all psychotropic medications to include prn orders. She further revealed her recommendations were for any prn medications to be discontinued if not taken in 60 days. She further revealed orders for prn antipsychotic medications should be discontinued after fourteen days unless documented as clinically necessary by the physician. She offered no explanation for R#66 not having a GDR recommendation documented for Ativan 0.5mg one every six hours as needed for anxiety. 2. Record review revealed R#77 was admitted to the facility 6/22/22 with diagnoses including but not limited to frontotemporal neurocognitive disorder, dementia, and atrial fibrillation. Review of quarterly MDS dated [DATE] revealed a BIMS score 99, indicating severe cognitive decline. Review of R#77's March 2023 orders revealed and order for lorazepam injection solution 2 milligrams (MG)/millileter (ML) Inject 2 mg intramuscularly as needed for severe agitation and aggression, lorazepam tablet 0.5 MG give 1 tablet by mouth every six hours as needed for agitation ok to give rectally if patient refuses to take orally, and trazodone HCl Tablet 50 MG give 25 mg by mouth as needed for every hour of sleep as needed for insomnia. There was no stop date for these orders. During an interview on 3/2/23 at 10:48 a.m. with the DON it was revealed he was unaware of the regulation regarding as needed psychotropic medications needing a stop date or rationale for use beyond 14 days. Stated he has spoken to the pharmacy for the facility and the pharmacy for hospice and that they were unaware of the requirement for a stop date.

Based on observations, interviews, and review of the policies titled, Storage of Medications, the facility failed to ensure that one of three medication carts (400 Hall Medication Cart) was locked and secured when the carts were out of view of the nurse. The Deficient practice had the potential to allow unauthorized staff, visitors, and residents access to unsecured medications. Findings included: Review of the policy titled Storage of Medications dated November 2020 revealed the policy heading for the facility is to store all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and implementation number 6 stated: Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. potentially available to others. An observation on 3/1/23 at 2:00 a.m. on the 400 Hall revealed that one medication cart located in the hallway outside resident rooms to be unlocked two times as the nurse left the cart unattended to administer medications. At 2:30 p.m. Licensed Practical Nurse (LPN) XX approached the cart and verified she was responsible for the cart and that she left it unattended and unlocked. An interview on 3/1/23 at 3:30 p.m. with the Director of Nursing (DON) revealed his expectations are for all medication carts and medication storage rooms to be locked and secured when unattended and only accessed by authorized nurses. He also revealed that Unit Managers had nurses to lock the medication cart when not in use. The DON revealed he plans to provide further in-service about security of the medication carts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews, and review of facility policy 'Resident Hydration and Prevention of Dehydration', the facility failed to ensure adequate hydration was provided to three of 40 sampled residents (R) (R#48, R#67, and R#285) and follow the fluid restriction for one of 40 sampled residents (R#26). Findings included: A review of facility policy 'Resident Hydration and Prevention of Dehydration' last revised October 2017 revealed 'This facility will strive to provide adequate hydration and to prevent and treat dehydration. Policy Interpretation and Implementation: Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments, using current standards of practice. Physician orders to limit fluids will take priority over calculated fluid needs. The dietitian may refer calculated needs to the physician if restrictions potentially increase risk for dehydration. The dietitian and nursing staff will educate the resident and family regarding hydration and preventing dehydration. Nurses will assess for signs and symptoms of dehydration during daily care. Nurses' aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of daily care.' 1. A review of the clinical record revealed that R#48 was admitted to the facility 8/12/19 with diagnoses including but not limited to Alzheimer's disease, dementia, and chronic kidney disease. Review of significant change Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating severe cognitive decline. Section G-Functional Abilities revealed R#48 required supervision with one-person physical assistance with meals. Section K-Swallowing/Nutritional Status revealed no swallowing disorders and a loss of 5% or more in the last month or loss of 10% or more in last 6 months, not on Physician prescribed weight loss regimen. A review of Physician orders for March 2023 revealed R#48 was prescribed a 'No Added Salt Diet Regular' consistency. During observation on 2/28/23 at 9:33 a.m. of R#48's room, no fluids were observed at the bedside. During observation on 2/28/23 at 2:40 p.m. of R#48's room resident was observed sitting in wheelchair at bedside with no fluids available. During an interview on 3/2/23 at 9:34 a.m. with Licensed Practical Nurse (LPN) PP stated residents should have hydration within reach at all times. Stated R#48 should have a water pitcher on her bedside table. Confirmed there was not a water pitcher at the bedside. During an interview on 3/2/23 at 9:36 a.m. LPN Unit Manager NN confirmed R#48 did not have water pitcher or glass of water at the bedside. Stated residents should have water available for hydration. 2. A review of the clinical record revealed that R#67 was admitted to the facility 10/27/22 with diagnoses including but not limited to pressure ulcer stage 4, personal history of traumatic brain injury and protein-calorie malnutrition Review of significant change MDS dated [DATE] revealed a BIMS score of three, indicating severe cognitive decline. Section G-Functional Abilities revealed R#67 required supervision with one-person physical assistance with meals. During an observation on 3/1/23 at 8:34 a.m. it revealed R#67 not having water at bedside to assist with resident hydration through the shift. During the interviewed with Certified Nursing Assistant (CNA), AAA on 3/1/23 at 10:37 a.m. it revealed CNA reasons she did not assist or offer the resident water while she was passing ice. CNA states the resident is on the thicker and she will have to go to get thicker out of kitchen. Hydrations of the non-verbal residents. CNA states liquids are offered during mealtimes and snack times. During the interviewed with the Speech Pathologist (SLP) on 3/2/23 at 9:43 a.m. regarding the evaluation of resident swallowing. The SLP stated the resident has been discontinued with services due to the updated Hospice services. During the interviewed with LPN LL on 3/2/23 at 10:12 a.m., she stated R#67 family signed a Refusal of Medical Care or Nutrition Declaration to have regulars liquids throughout the shift. 3. A review of the clinical record revealed that R#285 was admitted on [DATE] with diagnosis including, but not limited to, hypotension, vascular dementia, muscle weakness, myocardial infarction. On 2/28/23 at 11:05 a.m. and 3/1/23 at 2:00 p.m. observations of R#285 revealed was self-propelling in a wheelchair in his room. Observation revealed there was not a water container or a drinking cup in his room. He revealed he had liquids to drink with his meals and was unsure if he had ever had a water container or drinking cup in his room. On 2/28/23 at 2:00 p.m. a staff member was observed to pass ice to resident rooms and was observed to deliver ice to R#285's roommate but did not deliver a container or ice to R#285. A review of the admission MDS dated [DATE] revealed a BIMS of three, indicating severely impaired cognition, all other sections of the MDS were marked as in progress. A review of the physician's orders revealed admit to nursing services, regular diet, memantine (a medication used to treat dementia) 5 milligram (MG) two times a day. A review of the care plan revealed R#285 had self-care deficit and required set-up assistance for eating. A review of the nurse's notes dated 2/26/23 revealed no signs of a swallowing disorder. A review of the dietary notes dated 2/9/23 revealed no added sodium (NAS) Level 7 Diet Liquid Level 0, indicating resident did not required altered liquids. On 3/1/23 at 11:25 a.m. an interview with CNA KK revealed R#285 required assistance with transfers and self-propels self in a wheelchair. She revealed he goes to the dining room for meals. She further revealed ice and water were passed out to all residents without a fluid restriction order or altered fluids order two times on the day shift. On 3/1/23 at 11:35 a.m. an interview with LPN NN revealed R#285 was admitted on [DATE] and had not had a room change since admission. He further revealed resident's diet order was a regular diet with regular liquids and he was not on fluid restrictions or altered liquids. He revealed 500 Hall resident ice/water containers were cleaned by the dietary department one time a week on Friday. He revealed containers are normally out of resident rooms from 8:00 a.m. to 10:00 a.m. while being cleaned and sanitized. At 11:40 a.m. LPN NN verified there was not an ice/water container or a drinking cup in R#285's room. He revealed there should have been a container containing ice and/or water at R#285's bedside and within his reach. He provided an ice container with ice water with a straw to R#285. On 3/2/23 at 8:55 a.m. an interview with the Director of Nursing (DON) revealed his expectations are for residents to have water available at their bedside and within reach and was unsure why R#285 did not have a water/ice container in his room. He revealed all residents should have appropriate liquids available. He revealed his plan was to educate resident care staff to ensure each resident had appropriate liquids available to them in their room. 4. A review of the clinical record revealed that R#26 was admitted to the facility on [DATE] with diagnoses including but not limited to end stage renal disease, congestive heart failure, and dysphagia. Review of annual MDS dated [DATE] revealed a BIMS score of 10, indicating mild cognitive decline. A review of R#26's care plan revealed resident had care plan in place for 'The resident is at risk for dehydration or potential fluid deficit related to fluid restriction and nectar liquids'. Review of R#26's Physician orders did not reveal orders for a fluid restriction. During an interview on 3/2/23 at 9:11 a.m. with LPN Unit Manager PP revealed resident should have a breakdown of his fluid restriction so that it is clear how much fluid he is getting daily. Confirmed there was not an order in the electronic medical record (EMR) for resident to have fluid restriction and that there was no way for staff to know how much fluids resident should be getting with meals, meds, or snacks. Stated resident fluid intake was only being tracked by CNA at mealtimes when they document.

Based on observation, staff interviews and policy reviews, the facility failed to maintain an effective infection control program related to the unsanitary conditions for three out of three medication carts, failed to ensure that a blood pressure cuff was properly disinfected after each resident use, failed to use barriers with multi-use medications, failed to wash and/or sanitize hands while administering medications to prevent possible cross-contamination, and failed to transport soiled linen in a covered container. The facility census was 93. Findings included: Review of facility policy titled Storage of Medications revised November 2020, revealed number three listed under Policy Interpretation and Implementation states: The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. Review of facility policy titled Cleaning and Disinfection of Resident-Care Items and Equipment. Revised September 2022 revealed Number one C. (1) states non-Critical resident-care items include bedpans, blood pressure cuffs, crutches, and computer, Number five states Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). Review of policy titled Handwashing/Hand Hygiene revised August 2019 revealed Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections, number seven c under Policy interpretation and Implementation states before preparing or handling medications, and letter m. states after removing gloves. Review of the policy titled Laundry and Bedding soiled revised October 2018 revealed Policy Statement Soiled laundry/bedding shall be handled, transported, and processed according to best practices for infection prevention and control. Observation on 3/1/23 at 8:00 a.m. medication cart on the 200 hall was visibly soiled with brown and white substances on the top, sides and back of the cart. Observation on 3/1/23 at 8:05 a.m. with Licensed Practical Nurse (LPN) XX revealed LPN not sanitizing hands before and after donning and doffing gloves, not using a barrier for multi-use medications to prevent cross contamination. Observation on 3/1/23 at 9:00 a.m. revealed housekeeping WW was walking down the 200 Hall rolling a cart of soiled linens that were not bags nor did the cart have a lid to cover soiled linens. Observation on 3/1/23 at 2:00 p.m. revealed LPN XX using a wrist blood pressure cuff on three different residents without sanitizing in between residents. Observation on 3/2/23 at 9:30 a.m. revealed three out of three medication carts remained in unsanitary conditions with brown and white substances on the top, sides, and back of the carts. The sides of each cart were sticky with splatters of multicolored substances. Interview on 3/1/23 at 9:00 a.m. with housekeeping WW revealed she did have a lid for the soiled linen cart but had left it in the soiled linen room. She stated I should have had the lid on the cart. Interview on 3/2/23 at 8:45 a.m. with LPN XX revealed night shift nurses are supposed to clean the medication carts, she acknowledged she should have washed/sanitized her hands before and after donning and doffing gloves and used a barrier with multi-use medications that go in and out of a resident's room. She also revealed she should sanitize the blood pressure cuff in between every resident. Interview on 3/2/23 at 9:30 a.m. with LPN LL Unit Manager revealed confirmation of the three out of three unsanitary medication carts and night shift nurses are supposed to wipe down and clean out the medication carts. Interview on 3/2/23 at 2:50 p.m. with Director of Nursing (DON) revealed he does expect nurses use barriers for medications that go in and out of residents rooms, nurses should be sanitizing hands according to policy, and medication carts should be clean and sanitized.

Based on observations, interviews, and policy review, the facility failed to ensure a safe environment related to unsafe employee smoking practices on facility grounds. Findings include: 1. A review of the policy titled Smoking Policy - Employees with a date of 2001 and a revision date of May 2019 revealed the policy statement of: It is the policy of this facility to provide our employees with as near a smoke-free environment as possible and to ensure safe smoking practices for those who smoke. The policy Interpretation and Implementation section revealed line numbered 1. Employee smoking is permitted only in places where it is designated. Smoking is prohibited in all other areas. The section titled Visitors revealed line numbered 2. Visitors are not permitted to smoke in any area that is not designated as a smoking area. On 3/1/23 at 1:20 p.m. observation of an area located outside of the dining area revealed two picnic tables on a grass area. Observation of the area around the tables revealed dry grass and dry, brown leaves covering the ground. Observation revealed one dark brown cigarette butt and one light brown cigarette butt with ashes attached lying on the ground. There was not a fire extinguisher, a receptible for cigarette butts/ashes, or a water hose in the area. On 3/1/23 at 1:30 p.m. an interview with the Administrator revealed the facility had a no smoking policy for residents and he revealed staff is allowed to smoke in the designated smoking area. Observation of the designated smoking area with the Administrator revealed an area outside of the building and close to the entry door to the activities room, with wooden benches and a roof. There was a fire extinguisher attached to a post at the area, and a metal receptacle for cigarette ashes/butts. The Administrator revealed employees are informed of the location of the designated smoking area. He revealed he was aware of employees smoking in areas not designated for smoking and revealed his expectations are for employees to only smoke in designated smoking areas. On 3/2/23 at 8:30 a.m. an interview with the Administrator revealed his plans were to educate staff of the designated smoking area and ensure staff who smoke were only smoking in the designated smoking area. On 3/2/23 at 2:00 p.m. to 2:15 p.m. brief interviews with six staff members revealed six of six were able to identify the location of the designated employee smoking area.

3. During a review of the clinical record for Resident (R)#50 on 3/3/2020 at 1:19 p.m., the undated Condition Alert page of the Admissions section documented the resuscitation status (Code Status) as Full Code, which requires cardiopulmonary resuscitation to be performed in the event of cardiopulmonary arrest. However, review of the Physician's Orders for Life-Sustaining Treatment (POLST) dated 11/6/19 documented the Code Status as Do Not Resuscitate (DNR) which would allow natural death to occur. 4. Review of the clinical record for R#74 on 3/3/2020 at 1:24 p.m., revealed the undated Condition Alert page of the Admissions section documented the Code Status for R#74 as Full Code but the POLST, dated 12/6/2019, documented the Code Status as DNR. Based on record review, staff interviews, and review of the facility policy titled, Advance Directives (AD), the facility failed to ensure that the process for documenting and communicating the resident's wishes related to advance directives, to facility staff, was consistent and accurate for four (4) Residents (R) (R#57, R#31, R#50 and R#74 of 40 sampled residents. Findings include: A review of the facility's policy titled, Advance Directives revised 12/2016, documented under section Policy Interpretation & Implementation at No. 6, that prior to or upon admission of a resident, the Social Service Director or designee will inquire of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directives. At No. 7, documentation reflects that information about whether-or-not the resident has executed an advance directive shall be displayed prominently in the medical record. At No. 10, documentation reflects that the plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 1. Record review revealed that R#57 was admitted with diagnoses, that included, but was not limited to; long term use of anticoagulants, history of urinary tract infections, hyperlipidemia, general anxiety disorder, hypertension, atherosclerotic heart disease, chronic atrial fib, gastro-esophageal reflux disease (GERD), low back pain, hemiplegia and hemiparesis following cerebral infarction affecting left non dominant side, dysuria, retention of urine unspecified. Review of the Quarterly Minimum Data Set (MDS) assessment dated , 1/16/2020 revealed: A Brief Interview for Mental Status (BIMS) of 15, indicating the resident was cognitively intact. Record review of the hard copy record for R#57 revealed a yellow condition alert sticker, located just inside the cover of the record with Full Code status check marked. Record review of the hard copy record revealed the form titled, Physician Orders for Life-Sustaining Treatment (POLST) signed by the resident and the facility's Nurse Practitioner on 1/29/2020 and the Physician on 2/5/2020. The POLST form reflected to allow a natural death, and do not attempt resuscitation (DNR) code status. Review of the electronic health record (EHR), revealed that the active Physician's Orders as of 3/5/2020 for R#57 does not reflect a code status. Review of the EHR care plan for R#57 does not reflect a code status. An interview on 3/4/2020 at 4:00 p.m. with the Social Services Director (SSD) confirmed R#57 has a DNR code status. 2. Record review for R#31 revealed that the resident was admitted with diagnoses of chronic obstructive pulmonary disease (COPD), cough, generalized muscle weakness, chronic kidney disease, Stage 3, gastro-esophageal reflux disease (GERD), hyperlipidemia, personal history of healed traumatic fracture, history of other diseases of urinary system, endocarditis/valve unspecified, cognitive communication deficit, non-infective gastroenteritis and colitis, restless leg syndrome, generalized Anxiety Disorder, dependence on supplemental oxygen, presence of urogenital implants, congestive heart failure (CHF), major depressive disorder, urinary tract infection, obstructive sleep apnea (OSA), morbid obesity, osteoarthritis, anemia, essential hypertension. Review of the Quarterly MDS assessment, dated 12/20/2019, reflected a BIMS score of 12 indicating the resident is cognitively intact. Review of the hard copy record R#31 revealed no Advance Directive Checklist form or other determination information was found. There was no yellow condition alert sticker that would indicate a code status for the resident was found. Review of the EHR active Physician's Orders did not contain an AD determination. Review of the EHR care plan, last reviewed/updated 4/4/2019, revealed no AD determination. An interview on 3/4/2020 at 10:20 a.m. with the Social Service Director (SSD) who explained the Advance Directive (AD) process is started in admission where the Advance Directive Checklist form is filled out, and if desired, the resident and family will be given information regarding choices for the full code status and DNR code status information to review at that time. She confirmed the Director of Nursing (DON) and the facility's Nurse Practitioner (NP) will follow up with the resident and/or family for their final decision, and the nurses will follow up with the order and confirm with the family. Further interview with the SSD revealed that at some point the resident's record must have been thinned and that a copy of the Advance Directive Checklist form, dated 7/22/2014 for R#31, had been found it in the thinned chart. An interview on 3/3/2020 at 8:40 a.m. with Licensed Practical Nurse (LPN) AA, for the 200 hall/500 hall revealed that if a resident arrest then she will look in the hard copy chart at the sticker for the code status. An interview on 3/3/2020 at 9:00 a.m. with LPN FF, for the 300 Hall, revealed that in an emergency, she would look in the hard copy chart for the sticker or for the paper chart for AD information. An interview on 3/3/2020 at 9:05 a.m. with LPN GG, for the 400 Hall, revealed he was new to the facility, starting four days prior, but he would look in the front of the resident's chart kept at the nurse's station. An interview on 3/3/2020 at 3:00 p.m. with the DON revealed that he was not aware that there was conflicting advance directive information on a few of the records.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policies titled, Catheter Care, Urinary, and Emptying a Urinary Drainage Bag, the facility failed to ensure that one (1) Resident (R) (R#8) of eight (8) residents with indwelling catheters, maintained and secured the catheter appropriately during and after catheter care. Findings Include: Record review of the facility's policy titled, Catheter Care, Urinary, last revised 9/2014, that documented the propose of the procedure is to prevent catheter-associated urinary tract infections. Section titled, General Guidelines at No. 2, documents that if breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment as ordered. Section titled, Maintaining Unobstructed Urine Flow, at No. 3, documents the urinary bag must be held or positioned lower than the bladder at all time to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. Section titled, Changing Catheters, documents at No. 2, to ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: catheter tubing should be strapped to the resident's inner thigh.) Section titled, Steps in the Procedure, documents after peri care and cleaning of the catheter tubing at No. 18, to secure catheter utilizing a leg band, and at No. 19 to check the drainage tubing and bag to ensure that the catheter is draining properly. Record review of the facility's policy titled, Emptying a Urinary Drainage Bag, revised date 10/2010 that documents under section General Guidelines, at No. 3, do not allow the drain spout to come into contact with the measuring container, hands, or any other object. (Note: if accidental contaminations occur, wipe the drain spout with an alcohol sponge or swab.) No. 8 documents to keep the drainage bag below the level of the resident's bladder. No. 9 documents to keep the drainage bag and tubing off the floor always, to prevent contamination and damage. Record review for R#8 that revealed resident was admitted to the facility on [DATE] with diagnoses of: dementia, feeding difficulties, muscle wasting and atrophy of the right hand, upper right and left arm, lack of coordination, reduced mobility, cognitive communication deficit, aphasia, retention of urine, history of urinary tract infections; a need for personal care assistance, cellulitis of the left lower limb, a urinary tract infection, gastro-esophageal reflux, cardiovascular disease and anti-coagulation use. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed the following: Section C. Brief Interview for Mental Status (BIMS) score of 2, indicating severe cognitive impaired. Section H. Bowel & Bladder- incontinent for bladder/indwelling catheter, occasional incontinence for bowel. Section N. Medications- antibiotic. Review of the March 2020 Physician Orders revealed orders for urinary catheter to change Foley catheter, 18 French (F-a sized measurement for catheters) with 10 cubic centimeters (cc) bulb every 30 days, provide catheter care and secure with leg strap unless contraindicated, every day and night shift related to retention of urine, weekly skin assessments. Review of the resident's care plan lists a problem/risk onset on 3/27/2019 for the potential injury and complications related to the presence of an indwelling catheter, due to chronic urinary retention, and a goal that R#8 will be free from trauma related to presence of indwelling Foley catheter on 6/25/19. Approaches are to empty the Foley (catheter) and provide catheter care every shift and as needed, position the catheter tubing below the level of the bladder, and position the urine collection bag below the level of the bladder. Resident has history of frequent urinary tract infections (UTIs) and remains at risk for same issue- monitor for signs and symptoms of a UTI, notify Physician for complications or worsening of symptoms; monitor/record and report any adverse effects of medications used to treat UTIs. Further review revealed that the resident is at risk for dehydration due to recent and frequent UTIs- monitor for signs and symptoms of dehydration, provide water and favorite beverages at bedside and offer frequently. Problem onset 3/27/2019, resident complains often of pain, pressure, burning, itching and general discomfort related to an indwelling Foley catheter, urethral/vaginal discomfort dominates her thoughts daily, has been seen by medical doctors regarding this complaint- goal to continue treatment as ordered in attempts to reduce resident's daily discomfort 6/25/19. Give pain medications as ordered/indicated, including creams and gels to peri area, pain assessment every shift, assist with appointments and transports to urology and gynecology appointments. Resident has potential for skin breakdown and increased risk for UTI related to bowel incontinence, has very thin dry skin that tears and bruises easily. Bleeds easily related to use of Plavix and Aspirin. Goal to maintain intact skin integrity, the goal is to be free of untreated signs and symptoms of an UTI, cleanse perineal area after each incontinent bowel episode. Observation on 3/1/2020 at 10:20 a.m. revealed that R#8 was in her shared room, sitting in her wheelchair next to her bed. The resident was well-groomed with no odors detected. The catheter bag was observed in a blue privacy bag attached to the wheelchair, free from touching the floor although a catheter tubing leg strap was not in use. An observation of catheter care on 3/5/2020 at 12:00 p.m. by Certified Nurse Assistant (CNA) DD revealed the resident was initially observed lying supine on top of her bed and the head of the bed was flat. The catheter drainage bag was observed attached to the bed, out of the blue privacy bag, with the bag lying on the floor, the drainage spout was clamped, but out of the its holder/cover, and was touching the floor. Prior to the cleaning of the peri area, the CNA lifted the catheter bag and placed it alongside the resident's leg, where the catheter was observed not to be lower than bladder level. The CNA provided catheter care appropriately with cleaning the peri area and tubing. However, after catheter care was performed, CNA DD attached the catheter bag to the bed without the privacy bag, the bag was observed touching the floor mat, with the drainage spout clamped, but not in the spout holder, and observed to be touching the floor mat and there was no leg strap in place. At this time, CNA DD revealed that they don't use leg straps and left the room. Immediately after, Licensed Practical Nurse EE was notified of a new skin tear observed by the surveyor on the resident's foot during catheter care and about the catheter bag on the floor. The LPN EE entered the room, placed the urine drainage spout into its covering without cleaning it, then placed the catheter bag into the blue privacy bag. LPN EE confirmed the resident should have a leg strap applied, and then asked CNA DD when she returned to the room, to obtain one. Both CNA DD and the LPN EE confirmed having had training in catheter care. An interview on 3/5/2020 at 11:00 a.m. with the Director of Nursing (DON) revealed that catheter bags and tubing should not touch the floor. He confirmed that the facility had in-services on infection control throughout the year and provided a list of in-services provided including an in-service on 4/26/2019 subject titled, Blood or Body Fluids (catheter change and care, sharps handling).

Based on observations, interviews, and the facility policy titled Administering Medications the facility failed to label three medications with an open date and expiration date for two insulin multi-use bottles and one insulin pen in one medication cart out of three medication carts. And the facility failed to secure one medication cart out of three carts. Findings include: Review of the policy and procedure document titled Administering Medications (December 2012) revealed medications shall be administered in a safe and timely manner, and as prescribed. Policy interpretation and implementation revealed number nine stated; When opening a multi-dose container, the date opened shall be recorded on the container. Number 16 stated; The medication cart will be kept closed and locked when out of sight of the medication nurse or aide. An inspection was conducted on medication cart for the 400 hall along with Licensed Practical Nurse (LPN) CC on 3/3/2020 at 11:15 a.m. The medication cart revealed one Lantus insulin multi-use bottle with no open date or expiration date labeled, one Humalog insulin multi-use bottle with no open date or expiration date labeled, and one Lantus insulin pen with no open date or expiration date labeled. LPN CC revealed she could not find an opened date or expiration dated written on the insulin bottles or pen. Resident Care Coordinator (RCC) BB acknowledged no documentation of an opened date or expiration date on two bottles of insulin and one insulin pen. An interview was conducted with LPN CC on 3/3/2020 at 11:16 a.m. LPN revealed she did not know why the insulin bottles and pen did not have an expiration date written on them and this was the first time she noticed it. LPN revealed when a new insulin bottle or pen is opened by the nurse, the nurse is supposed to write the open date and expiration or use by date on the bottle. An observation of the medication cart for 500 hall was made on 3/4/2020 at 12:02 p.m. The medication cart was sitting in the hallway against the wall unlocked, the nurse was not around the cart. At 12:03 p.m. an observation of the medication cart was made along with RCC BB. RCC acknowledged the cart was unlocked. An interview was conducted with RCC on 3/4/2020 at 12:03 p.m. RCC revealed the medication cart is always supposed to be locked when the nurse steps away from the cart. RCC stated she is not sure why the nurse did not lock the cart. RCC revealed the nurses receive training on the policy and procedures of medication pass upon being hired. An interview was conducted on 3/4/2020 at 12:05 p.m. with LPN AA. LPN revealed she had to leave her medication cart in a hurry to a resident's room and stated she pushed the lock but must not have pushed the lock hard enough. LPN stated she usually always locks the medication cart when she walks away from it. An interview was conducted with the Director of Nurses (DON) on 3/5/2020 at 12:00 p.m. DON revealed whichever nurse is on a particular medication cart, it typically is their responsibility for checking their medication cart for expired medications and making sure the insulin multi dose vials and the insulin pens have expired or good through dates written on them, and for securing their medication carts when they step away from it. DON stated he posted the insulin expiration date guidelines in the front of the narcotic book on each medication cart. DON revealed the nurses receive medication pass training during orientation on the medication cart by a nurse preceptor. DON stated any time a nurse leaves their medication cart, that cart should be locked, and said that is an important part of the training process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the Annual MDS dated [DATE] the R#50 was assessed with an indwelling catheter. During an observation of R#50 on 3/3/2020 at 11:49 a.m., revealed that she was seated in the hallway outside of her room, in her wheelchair, with the urinary catheter bag was rested on the floor underneath the wheelchair. Based on observation, staff interview and review of facility's catheter care infection control policies, the facility failed to ensure catheters were maintained in a sanitary manner to prevent potential urinary tract infections for three residents (R) ( R#31, #57 & R#50) of eight residents with indwelling catheters. Findings include: A review was conducted of the facility's policy titled, Catheter Care, Urinary, revised last 9/2014, that documented the propose of the procedure is to prevent catheter-associated urinary tract infections. Section titled, General Guidelines at No. 2, documents that if breaks in aseptic technique, disconnection, or leakage occur, replace the catheter and collecting system using aseptic technique and sterile equipment as ordered. Section titled, Maintaining Unobstructed Urine Flow, at No. 3, documents the urinary bag must be held or positioned lower than the bladder at all time to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. A review was conducted of the facility's policy titled, Emptying a Urinary Drainage Bag, revised date 10/2010 documents under General Guidelines, at No. 3, do not allow the drain spout to come into contact with the measuring container, hands, or any other object. (Note: if accidental contaminations occur, wipe the drain spout with an alcohol sponge or swab.) No. 8 documents to keep the drainage bag below the level of the resident's bladder. No. 9 documents to keep the drainage bag and tubing off the floor always, to prevent contamination and damage. 1. Record review revealed that R#31 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), chronic kidney disease, Stage 3, history of other diseases of the urinary system, cognitive communication deficit, presence of urogenital implants, congestive heart failure (CHF), a urinary tract infection. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that in Section H, the resident was assessed with an indwelling catheter. Observation on 3/2/2020 at 1:38 p.m. of R#31 in her wheelchair in the hall near the nursing station watching activities. The resident's catheter bag was located in a blue privacy cover bag was attached to the wheelchair. Observation, at this time, revealed that the privacy bag and tubing were dragging on the floor as R#31 propelled herself. Observation on 3/2/2020 at 3:28 p.m. of R#31 who was in her wheelchair at the Nurse's Station. Observation at this time revealed the catheter bag was in a in blue privacy bag, attached to the wheelchair, however, the privacy bag was lying on the floor. Observation on 3/3/2020 at 10:14 a.m. revealed that R#31 was participating in activities, with the assistance of staff, in her wheel chair with the catheter bag inside of the blue privacy bag. The catheter privacy bag and the tubing were dragging on the floor. Observation on 3/4/2020 at 9:58 a.m. revealed that R#31 was sitting in a wheelchair reading, in her shared room, with the catheter bag in a privacy bag attached to the wheelchair. The privacy bag was sitting on the floor beneath the wheelchair. Review of the resident's care plan reflected problems/risks with a onset date of 1/2/2018, for the potential for urinary tract infections (UTI) related to presence of an indwelling catheter- interventions to give catheter care every shift, Foley catheter to bedside drainage bag, secure with leg strap unless contraindicated. Position catheter tubing below level of bladder, and change catheter every 30 days as ordered. 2. Record review revealed that R#57 was admitted to the facility on [DATE] with diagnoses including: history of urinary tract infections, hemiplegia and hemiparesis following cerebral infarction affecting left side, dysuria, and retention of urine. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed in Section H. Bowel & Bladder- indwelling catheter, occasional incontinence for bladder, always continent for bowel. Observation on 3/2/2020 at 2:42 p.m. revealed R#57 in her shared room, sitting in her wheelchair, with the catheter, in a privacy bag, and catheter tubing touching the floor. Observation on 3/3/2020 at 10:33 a.m. revealed R#57 sitting in a wheelchair in her room. The resident's catheter was in a blue privacy bag that was attached to her wheelchair with the catheter tubing was touching the floor. Observation on 3/4/2020 at 9:39 a.m. revealed R#57 sitting in her wheelchair, in the hallway, with the catheter bag and tubing on the floor.