**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation documentation review, and interview, the facility failed to protect the residents' right to be free from accidents related to an elopement for 1 resident (Resident #6) of 6 residents reviewed for accidents. F689 was cited as past noncompliance and the facility is not required to submit a Plan of Correction. The findings include: Review of facility's undated policy titled, Elopement Risk, revealed .This facility ensures that residents who exhibit unsafe wandering behavior and/or at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to unsafe wandering or elopement risk .Elopement occurs when a resident leaves the premises or a safe area without authorization .and/or any necessary supervision to do so Safe premises refers to the facility and premises or grounds of the property . Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Traumatic Hemorrhage of Cerebrum, Fracture of Base of Skull, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 required set up assistance with activities of daily living (ADL's). Resident #6 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated moderate cognitive impairment Review of the care plan for Resident #6 dated 8/16/2024 and revised on 10/6/2024 revealed .Resident is at risk for elopement [related to] cognitive impairment, exhibits unsafe wandering behaviors, has expressed desire to leave .Resident prepared letter of plan of living arrangements, including monetary means .Resident will be safe in facility and will not exit facility unsupervised .Distract resident from wandering by offering pleasant diversions, structured activities, food . Review of the facility investigation documentation revealed on 10/6/2025 at 12:30 AM, staff became aware Resident #6 was not in the facility. Resident #6 had broken the lock on his bedroom window and exited the building through the window. The resident left a note stating he did not want to stay at the facility any longer. Review of a Social Services note dated 10/6/2025 revealed .On October 2nd, 3rd and 4th I [Social Services Director] had conversations with [Resident #6] regarding discharge. He expressed that he wanted to leave the facility .He mentioned that he had secured a place in Kingsport and was going to social security [office] on Monday to get back his check .I advised that if he could wait until Monday, we would try to do the discharge safely. On October 6th, I was notified that [Resident #6] was not in building. Upon arrival and calling police a note was found that stated he had decided to leave .His letter is consistent with the plans he shared with me when discussing possible discharge . During an interview on 2/25/2025 at 12:50 PM, The Administrator stated .[Resident #6] left me a note saying he wasn't going to stay any longer .we called the police and reported he had left, and we showed them the note .he broke the lock on the window with a butterknife and went out the window . During a telephone interview on 2/26/2025 at 8:15 AM, Local Police Sergeant stated .I got the call that somebody had gone missing .[facility staff] gave me some information on [Resident #6] .what we determined is he had escaped through the window . During a telephone interview on 2/26/2025 at 8:45 AM, Resident #6's sister stated .[Resident #6] eloped out of a window, he had a traumatic brain injury in July of last year he couldn't care for himself so we put him in [the facility] .he would call me .I told the police he went to Kingsport because I knew he had so called friends there .I got a call from [physician's office] that said [Resident #6] came by yesterday [2/25/2025] to reschedule an appointment that he had missed I have no idea where he is at now .he doesn't want help .he has made that clear . The facility was cited F-689 as past non-compliance. The facility's corrective actions were validated onsite by the surveyor on 3/5/2025. The corrective action plan included a Root Cause Analysis (RCA) Review of the corrective action plan revealed the following: 1. Corrective action (s) accomplished for those residents found to have been affected by the deficient practice: a. On 10/6/2024, Resident #6 was not present in room. elopement procedures were put into place per policy including searching for the resident, securing exits, performing head count, and notifying local police. Interview with the Administrator, the Director of Nursing (DON), and Maintenance Director on 3/5/2025 confirmed elopement procedure was put into place. b. The resident did not return to the facility. Review of Resident #6's medical record, current facility census, and interview with the Administrator and DON on 3/5/2025 confirmed the resident did not return to the facility. c. On 10/6/2024, the residents' elopement risk assessment and care plan were reviewed by Administrator and information given to police. Review of Resident #6's risk assessment and care plan revealed the resident was at risk for elopement interview with a local police Sergeant on 2/26/2025 and the Administrator on 3/5/2025 confirmed the information was given to the local police department. d. On 10/6/2024 all windows and doors throughout facility were checked to ensure proper locking mechanisms were in place by the Maintenance Director and the lock on the resident's room was replaced. Observation of the bedroom window Residents #6 eloped through with the Maintenance Director, review of window lock audit dated 10/6/2024, and interview with the Maintenance Director on 3/5/2025 confirmed windows and doors throughout the facility were checked and Resident #6's window lock was replaced. e. On 10/6/2024, all center door codes were changed by facility Maintenance Director. Doors were set to alarm when opened greater than15 seconds. Doors were set to auto lock upon closure. Observation of 9 of 9 doors and interview on 3/5/2025 with the Maintenance Director confirmed all doors were in working order, codes were changed and not visible to the public or residents, and alarms were set and in working condition. 2. Other residents having the potential to be affected by the same practice and corrective actions taken: a. On 10/6/2024 a 100% review of all resident's elopement assessments was completed to ensure resident assessments were up to date and accurate with changes made as needed. All residents care plans were reviewed to ensure the current assessment was reflected appropriately on the care plan. Review was completed by the DON, Assistant Director of Nursing ( ADON) and Wound Care Nurse (WCN). Review of facility resident elopement system audit form, care plans, midnight census report dated 10/5/2024 and interview with the DON, and ADON, on 3/5/2025 confirmed the review was completed. 3. What measures will be put into place or what systemic changes were made to ensure that the practice does not recur: a. Facility Administration including Administrator, and Staff Development Coordinator (SDC) began educating all staff on 10/6/2024 and continued educating all staff prior to beginning work their next scheduled shift. Education included elopement prevention, importance of privacy with door code including new system related to only staff having code, and new signage to be placed on front door. Additionally, the Elopement Risk Policy and the Abuse, Neglect, and Exploitation Policy were also presented. To ensure retention, all staff completed a post test that required 100% compliance. If a staff member did not meet 100% compliance, reeducation was completed until threshold was achieved. Any staff member that was assigned as needed (PRN), on Paid Time Off (PTO), or on Family Medical Leave (FMLA) will require education and the post test before their next scheduled shift. Observation of two signs at the front entrance to remind people to make sure door lock has engaged and instructions to use the doorbell for staff to open the door, review of facility list of employees, education sign in sheets, and post tests confirmed education was completed on 10/7/2024 interview with multiple staff including Dietary Aide, Social Services, Business Office Manager, Occupational Therapist, Environmental Services Director, Multiple Licensed Practical Nurses (LPNs), Certified Nurse Assistants (CNAs) and 2 night shift CNAs, 1 night shift LPN, and 1 night shift Registered Nurse (RN) confirmed education was completed and the staff were knowledgeable. b. Beginning 10/6/2024 elopement drills were completed on each shift by Maintenance Director and will continue to be completed monthly or as needed. Review of facility elopement drills and interview with the Maintenance Director on 3/5/2025 confirmed elopement drills were completed in 10/2025, 11/2024, and 2/2025. Interview with the Administrator revealed elopement drills were continued quarterly after 11/2024 and were ongoing. c. On 10/6/2024, all outside doors alarms were verified to alarm when open greater than 15 seconds by Maintenance Director. Observation on 3/5/2025 with the Maintenance Director confirmed all outside doors were checked and working properly. d. Window audits will be increased to weekly x4 weeks, then biweekly for 4 weeks until 100% compliance is achieved by Maintenance Director. Audits will then revert to monthly audits. Review of weekly and monthly window lock audit checklist and interview with the Maintenance Director on 3/5/2025 confirmed audits were conducted. 4. Corrective action(s) monitored to ensure the practice will not recur: a. Beginning 10/6/2024, the Maintenance Director will perform manual checks on all windows to ensure latches were secured and doors of the facility had proper function of locks and alarms. These audits will be conducted weekly for 4 weeks, then biweekly for 4 weeks, then monthly as previously required. Any concerns identified will be immediately reported and corrected to the Administrator by the Maintenance Director. Audits will be reviewed in monthly Quality Assurance Performance Improvement (QAPI). Review of QAPI sign in sheets dated 10/6/2024 , 10/28/2024, 12/9/2024, 1/13/2025, and 2/24/2025, Window Lock Audits, Exit Door Locks audits, and interview with the Maintenance Director on 3/5/2025 confirmed the Audits were completed, reviewed monthly in QAPI, and were ongoing. b. Any issues with non-compliance will be presented to the Quality Assessment and Assurance (QAA) Committee (Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, MDS Coordinator, Social Services Director, Admissions Director, Maintenance Director, Dietary Supervisor, and Environmental Supervisor) for review and resolution. If non-compliance is identified, audits will start back at the beginning occurring weekly for 4 weeks, then biweekly for 4 weeks, then monthly as regularly scheduled. Review of QAA sign in sheets dated 10/6/2024, 10/28/2024, 12/9/2024, 1/13/2025, and 2/24/2025, interview with the Administrator and Maintenance Director on 3/5/2025 confirmed meeting was held with the required member and no new noncompliance was identified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility documentation, and interview the facility failed to promptly notify family of a room change and of the resident's transportation to a cancelled appointment for 1 Resident (Resident #2) of 5 residents reviewed for resident rights. The findings include: Review of the facility's Policy titled, Notification of Changes undated showed .The purpose of this policy is to ensure the facility promptly informs the resident .resident's representative when there is a change requiring notification .Circumstances requiring notification include .A transfer .from the facility .A change of room .assignment .Additional considerations .Competent individuals .the facility must still .notify resident's representative, if known . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Dementia, and Depression, the resident discharged to a funeral home on 6/17/2023. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #2's Brief Interview of Mental Status (BIMS) score was 10 indicating the resident had moderate cognitive impairment. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of facility's grievance log showed DATE OF GREIVANCE .5/25/2023 .[Resident #2] went to cancelled appointment .DATE COMPLAINANT NOTIFIED .5/25 [5/25/2023] . During an interview on 9/6/2023 at 11:00 AM, the Social Services Director stated .I own that one I messed up there I just forgot to notify them [Resident #2's family] when she [Resident #2] moved rooms I didn't notify the family .she [Resident #2] had 2 different appointment dates for the same doctor she went to the earlier one and the other one got cancelled and I forgot to cancel transportation for the later one but they did get there and realized she didn't have a appointment and they brought her back .I normally call the families and have them meet them there but on that one being cancelled I didn't . During an interview on 9/8/2023 at 10:40 AM, the Administrator stated .she [Social Services Director] did not call her [Resident #2's daughter] right away of the room change .the appointment had been cancelled but the social services director had failed to communicate that with staff and staff did not cancel transportation so staff did get the resident [Resident #2] ready for the appointment transportation did pick her up arrived at the office to find there was not an appointment and brought her back .family would normally be at the appointment but they were not notified .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation, and interview the facility failed to prevent abuse for 1 Resident (Resident #3) of 5 residents reviewed for abuse. The findings include: Review of facility abuse policy titled Abuse, Neglect, and Exploitation undated showed .It is the policy of this facility to provide protections .that prohibit and prevent abuse .Abuse means the willful infliction of injury .Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury . Review of the medical record showed Resident #3 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Anxiety Disorder, and Depressive Episodes. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #3's Brief Interview of Mental Status (BIMS) score was 13 indicating the resident was cognitively intact. The resident required assistance of one or more persons with activities of daily living (ADL's). Review of the medical record showed Resident #4 was admitted to the facility on [DATE] with diagnoses including Dementia, Depressive Episodes, and Anxiety. Review of the quarterly MDS assessment dated [DATE] showed Resident #4's BIMS score was 10 indicating the resident had moderate cognitive impairment. The resident required assistance of one person with ADL's. Review of facility investigation showed on 5/31/2023 at 8:08 PM, License Practical Nurse (LPN) #1 heard yelling at the nurses station she immediately went to the nurses station and saw Resident #4 yelling at Resident #3 in front of the nurses station Resident #3 reported Resident #4 kicked her in the knee Resident #3 had a small scratch/scrape on her left leg it was verified a verbal incident occurred that led to physical contact between the two residents Resident #3 did have a minor abrasion as a result. During a telephone interview on 9/7/2023 at 12:35 PM, LPN #1 stated .I was giving meds and heard a altercation near the desk [nurses station] .[Resident #3] said [Resident #4] kicked her in the leg and we lifted the pants leg and seen a little bit of blood and we got them separated . During an interview on 9/8/2023 at 10:40 AM, The Administrator stated .I was notified that evening that [Resident #3] and [Resident #4] had had an incident and [Resident #3] said [Resident #4] had kicked her .we did conclude that [Resident #4] pushed [Resident #3's] leg and by doing so caused the abrasion .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #30 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Unspecified Dementia, Generalized Anxiety Disorder, and Cognitive Communication Deficit. Review of an admission document dated 8/27/2021, showed consent for admission and treatment, a consent for assignment of pharmacy benefits and a consent for mental health treatment. No documentation showed if the resident had an advance directive or if she wanted to formulate an advance directive. Review of a Physician Orders for Scope of Treatment (POST) form dated 2/1/2023, showed Resident #30 was a Do Not Resuscitate (DNR) with limited additional interventions. Review of a quarterly MDS assessment dated [DATE] showed Resident #30 had severe cognitive impairment. The resident required limited assistance of 1 staff with bed mobility and toilet use, extensive assistance of 1 staff with transfers and supervision with walking and personal hygiene. During an interview on 2/23/2023 at 10:07 AM, the Administrator stated it was the policy of the facility that the staff explained advance directives, and they periodically check to see if a resident or their representative needed to change the status of an advance directive or add a new one. The Administrator confirmed she had no documentation whether the resident had executed an advance directive or not, and she did not have documentation that the facility had given advance directive information to the resident's representative. Based on facility policy review, medical record review, and interview, the facility failed to determine on admission if the resident had formulated an advance directive or to determine whether the resident wished to formulate an advance directive for 2 residents (Resident #13 and Resident #30) of 16 residents reviewed for advanced directives. The findings include: Review of the facility policy titled, Residents' Rights Regarding treatment and Advanced Directives, undated, stated .On admission, the facility will determine if the resident has executed an advanced directive, and if not, determine whether the resident would like to formulate an advanced directive . Resident #13 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Dysphagia, Heart Failure, Anxiety, and Gastrostomy Status. Review of the admission Minimum Data Set (MDS) dated [DATE], showed the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating the resident had severe cognitive impairment. Review of Resident #13's admission Agreement dated 1/6/2023, showed it had not been determined if the resident had an advanced directive or if she wanted to formulate an advanced directive. During an interview on 2/22/2023 at 1:37 PM, the Admissions and Marketing Director stated it was her responsibility to assist residents or their family to complete the admission agreement paperwork with the resident. The Admissions and Marketing Director confirmed Resident #13's admission agreement was incomplete, and the facility had not determined upon her admission if she had formulated an advanced directive or if she desired to formulate an advanced directive. During an interview on 2/23/2023 at 1:09 PM, the Director of Nursing (DON) confirmed it was the policy of the facility to determine upon admission to the facility if a resident had formulated an advanced directive or if the resident desired to formulate an advanced directive. The DON confirmed Resident #13 had not been assessed upon admission to determine if she had formulated or wished to formulate an advanced directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to develop a baseline care plan to address the care and treatment of an indwelling catheter for one resident (Resident #96) of 16 residents reviewed for baseline care plans. The findings include: Resident #96 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, Anxiety Disorder, Inflammation of the Vagina, and post operative Incision and Drainage procedure. Review of a Physician order dated 2/17/2023 revealed, .catheter .every shift for monitoring . Review of Resident #96's current baseline care plan revealed no use of a indwelling catheter, or care and treatment of the residents indwelling urinary catheter. Interview and medical record review with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:08 PM, in the conference room, confirmed the baseline care plan failed to address the use, treatment and care of the indwelling urinary catheter for Resident #96.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to revise a care plan to include changes in the plan of care for two residents (Resident #33 and Resident #41) for contact precautions of 16 residents reviewed for transmission precautions. The finding include: Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety disorder, and Insomnia. Review of a Physician order dated 2/20/2023 revealed, .contact isolation r/t (related to) Gastroenteritis: private room, private toileting, all services provided in room . Continued review showed Resident #33's current Plan of Care revealed no documentation of the contact isolation. Resident #41 was admitted to the facility on [DATE] with diagnoses including Heart Disease, Chronic Kidney Disease, Heart Failure, and Cirrhosis of Liver. Review of a Physician order dated 2/20/2023 revealed, .contact isolation r/t (related to) Gastroenteritis: private room, private toileting, all services provided in room . Continued review showed Resident $41's current Plan of Care revealed no documentation of the contact isolation. Interview and review of the Plan of Care with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed the Plan of Care was not revised to reflect the Contact Isolation for Resident #33 and Resident #41.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, observation, and interview, the facility failed to implement a fall intervention to prevent a fall for 1 resident (Resident #3) of 3 residents reviewed for accidents. The findings include: Review of the facility's undated policy titled, Fall Prevention Program, showed .Each resident will .receive care and services .to minimize the likelihood of falls .Implement person centered interventions . Review of the facility's undated policy titled, Fall Risk Assessment, showed .It is the policy of this facility to ensure the facility provides an environment that is free from accident hazards .An 'At Risk for Fall' care plan will be completed .will include interventions .to reduce the risk of an accident . Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Unspecified Dementia, History of Falling, Muscle Weakness and Difficulty Walking. Review of the Care Plan dated 11/24/2020, showed Resident #3 was at risk for falls related to her diagnosis of Dementia with interventions including, .Dycem [a sticky fabric applied to a surface to prevent sliding] to (L) [left] side of bed . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #3 was cognitively intact and required limited assistance of 1 staff for bed mobility, transfer, dressing and toileting. The resident had no falls since prior assessment. Review of a fall investigation dated 1/7/2023, showed an unwitnessed fall happened when Resident #3 stated she was reaching for something and fell to the floor. No injury was observed, and there was no transfer to the hospital. An observation on 2/22/2023 at 8:45 AM, in Resident #3's room, showed the resident lying in bed without Dycem on the bed. During an interview and observation on 2/23/2023 at 10:16 AM, in Resident #3's room, the Director of Nursing (DON) stated when a resident had a fall, new interventions were added to the care plan by the MDS coordinator after an Interdisciplinary team meeting. The DON stated interventions were dated and put on the care profile so that all staff could see the interventions. The DON stated that it was her expectation that staff implemented the interventions. Continued interview at Resident #3's bedside showed no Dycem was on the bed. Resident #3 stated that she wanted the Dycem back on the bed because it kept her from slipping off her bed. The DON confirmed that the intervention of Dycem to the bed had not been implemented to prevent an accident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #28 was admitted to the facility on [DATE], with diagnoses including Unspecified Dementia, Unspecified Intellectual Disabilities, Xerosis Cutis (dry skin), Cognitive Communication Deficit, and Adult Failure to Thrive. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #28 had a Brief Interview for Mental Status (BIMS) score of 2, indicating the resident had severe cognitive impairment. Review of a physician's order dated 8/2/2022, showed Resident #28 had an order for .hydrOXYzine HCl [medication used for itching] 25 MG [milligrams] .Give 25 mg by mouth two times a day for itching . During an observation and interview on 2/22/2023 at 8:16 AM, showed Registered Nurse (RN) #1 was preparing medications for administration to Resident #28. RN #1 dropped a Hydroxyzine HCl tablet onto the computer laptop and then picked it up and placed it into Resident #28's medication cup for administration. RN #1 then administered the medications to Resident #28. Following administration of the medications, RN #1 confirmed she dropped the Hydroxyzine HCl tablet onto the computer laptop and she should have discarded the tablet. During an interview with the Director of Nursing (DON) on 2/23/2023 at 1:01 PM, the DON confirmed that her expectation was that if a medication was dropped onto a computer the medication should have been discarded as per standard practice. Based on facility policy review, medical record review, observation, and interview the facility failed to maintain infection control for 2 residents (Resident #33 and Resident #41) in contact isolation, failed to maintain infection control for 1 resident (Resident #96) with a foley catheter, and failed to maintain infection control during the medication administration for 1 resident (Resident #28) of 16 residents reviewed. The findings include: Review of the facility policy Isolation Precautions not dated revealed, .Contact precautions are measures that are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the resident or the resident's environment . Resident #33 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hypertension, Anxiety Disorder, and Insomnia. Observation on 2/22/2023 at 8:44 AM, outside Resident #33's room, revealed a sign posted .Stop Contact Precautions .put on gloves before room entry .put on gown before room entry . Continued observation revealed Housekeeper #1 and Housekeeper #2 entered the room and failed to put on gloves or a gown prior to entering the room to obtain dirty linen. Interview with Housekeeper #1 and Housekeeper #2 on 2/22/2023 at 8:45 AM, outside Resident #33's room, confirmed the housekeepers failed to put on gloves or gown prior to entering the contact precaution isolation room. Interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed I would expect them (staff) to follow the policy (isolation precautions policy). Resident #41 was admitted to the facility on [DATE], with diagnoses including Heart Disease, Chronic Kidney Disease, Heart Failure, and Cirrhosis of the Liver. Observation outside Resident #41's room on 2/21/2023 at 12:21 PM, revealed a sign posted .Stop Contact Precautions .put on gloves before room entry .put on gown before room entry . Continued observation revealed Certified Nursing Assistant (CNA) #1 delivered a meal tray and failed to don gloves prior to entering and setting up the meal tray. During an interview with CNA #1 on 2/21/2023 at 12:22 PM, outside Resident #41's room, confirmed the CNA failed to don gloves as required. The CNA stated .It's something I would normally do . During an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 2/23/2023 at 1:06 PM, in the conference room, confirmed I would expect them (staff) to follow the policy (isolation precautions policy). Resident #96 was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Bipolar Disorder, Anxiety Disorder, Inflammation of Vagina, and Post Operative Incision and Drainage procedure. Observation of Resident #96 on 2/21/2023 at 11:19 AM, in the resident room, revealed Resident #96 resting in the bed with a urinary catheter visible and on the floor beside the bed. Interview and observation with Registered Nurse (RN) #1 on 2/22/2023 at 8:55 AM, revealed Resident #96 resting in the bed with a urinary catheter visible and on the floor beside the bed. Continued interview with RN #1 confirmed she was aware the resident's catheter was on the floor She [Resident #96] doesn't like us to attach it (urinary catheter) to the bed. During an interview with the DON and ADON on 2/23/2023 at 1:06 PM, in the conference room, revealed the DON was aware of the resident not wanting the urinary catheter attached to the bed. Continued interview confirmed the DON was aware catheters were to be kept off the floor to maintain infection control practices.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview the facility failed to maintain the hospice care plan on the medical record for 1 resident (#6) of 32 residents sampled. The findings include: Medical record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Malignant Neoplasm (cancer) of Unspecified Kidney, Age Related Cognitive Decline, Type II diabetes, and Heart Failure. Medical record review of the Quarterly Minimum Data Set, dated [DATE] revealed the resident received hospice care. Medical record review of the Order Summary Report dated 9/25/18 revealed .Hospice care as ordered . Medical record review of the medical record revealed no documentation of a hospice care plan or visit notes. Interview with the Director of Nursing (DON) on 10/16/18 at 3:20 PM, in the DON's office, confirmed the resident had been receiving hospice services. Further interview confirmed the hospice care plan and visit notes are to be kept on the resident's medical record. Continued interview revealed no hospice care plan on the current medical record for Resident #6. Interview with the DON on 10/17/18 at 8:09 AM, in the DON's office, confirmed the facility failed to maintain the hospice information including the hospice care plan on the medical record for Resident #6.