Based on observation, interview, and record review, the facility failed to label and discard medications for 1 of 1 medication rooms observed. (Resident 24, Resident 12, Resident 13) Findings include: On 6/2/25 at 11:55 a.m., in the refrigerator of the medication room the following was observed. - Two Ozempic injector pens (an injectable medication used to treat type 2 diabetes, which is a condition that occurs when the body doesn't produce enough insulin), for Resident 24 and Resident 12, were not dated with an open date and/or an expiration date. Resident 24's Ozempic pen had a date of 4/25/25 written on the box. The Director of Nursing (DON) verified there was only one date and could not specify if this was an open or expiration date. Resident 12's Ozempic pen had no date written on the box or pen. The DON verified there was no date on the medication. The DON indicated every medication that was open should have an opened date and an expiration date on the vial or the pen. The DON indicated that Ozempic pens should be discarded 56 days after first use. - A bottle of liquid Omeprazole (a medication used to treat frequent heartburn), for Resident 13, was observed with an expiration date of 5/20/25. The DON verified the date written on the bottle and indicated the medication should have been discarded on 5/20/25. The DON indicated this medication had been discontinued on 5/12/25 and was not currently being administered to the resident. On 6/2/25 at 3:00 p.m., the Administrator provided the facility's policy on Storage of Medications and Biologicals, dated 5/21/18, and indicated it was a current policy being used by the facility. A review of the policy indicated .21. Disposal of medications should be completed for medications that are without secure closure, outdated . The policy did not indicate how to label medications when they were opened. The Administrator indicated she could not find a policy regarding labeling of medications when they were opened. 3.1-25(j) 3.1-25(o)

Based on observation, interview, and record review, the facility failed to implement infection control practices for 1 of 2 residents reviewed for urinary catheters. The urinary catheter tubing and drainage bag was touching the floor. (Resident 33) Findings include: On 5/27/25 at 11:03 a.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor and drainage bag on the floor. On 5/28/25 at 10:03 a.m., Resident 33 was observed to be resting in a recliner with the urinary catheter tubing on the floor. On 5/28/25 at 2:05 p.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor. On 5/29/25 at 1:44 p.m., Resident 33 was observed to be resting in a low bed with the urinary catheter tubing on the floor. On 6/2/25 at 12:06 p.m., Resident 33 was observed to be sitting in a recliner with the urinary catheter tubing on the floor. On 5/29/25 at 11:42 a.m., Resident 33's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, cerebral infarction (stroke), and neurogenic bladder (condition where the nerves controlling the bladder are damaged). Resident 33's physician order, dated 2/22/25, indicated to change indwelling 14 fr (French) (size of catheter) catheter once a month. The care plan, dated 4/9/25, indicated Resident 33 had urinary retention related to chronic kidney disease. The care plan lacked documentation on placement of the catheter tubing while in the bed or recliner. During an interview on 6/2/25 at 12:35 p.m., CNA 1 indicated at times, Resident 33's urinary catheter tubing was on the floor. The catheter tubing was not to be on the floor. On 6/2/25 at 3:00 p.m., the Administrator provided the facility's policy, Catheter Management, revised date 4/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .j. collecting bags should always be kept below the level of the bladder, and not resting on the floor . 3.1-18(b)(1)

Based on interview and record review, the facility failed to ensure the written notification required for facility-initiated transfers was given to the resident or the resident representative for 1 of 1 resident reviewed for hospitalization. (Resident 21) Findings include: A review of Resident 21's progress notes on 4/10/23 at 10:30 a.m., indicated the resident was sent out to the hospital on 2/24/23. There was no documentation that the resident or resident's representative had been notified of the transfer in writing and provided the appeal rights information in writing including the contact information of the Office of the State LTC (Long-Term Care) Ombudsman after the resident was sent out to the hospital. During an interview on 4/10/23 at 11:01 a.m., the Clinical and Quality Support staff member indicated the transfer and discharge forms were sent with the resident during the transfer to the hospital and the representative was notified by phone. On 4/10/23 at 3:00 p.m., the Clinical and Quality Support staff member provided the facility policy . Transfer and Discharge Policy with a revised date of 10/2022, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 7. Before the facility transfers or discharges a resident, the facility will notify the resident and the resident's representative of the transfer and reasons for the move in writing and in a language the resident understands . 3.1-12(a)(6)(A)(i) 3.1-12(a)(6)(ii)

Based on interview and record review, the facility failed to ensure the notification of the bed hold policy required for residents who transferred to the hospital was provided for 1 of 1 resident reviewed for hospitalization. (Resident 21) Findings include: A review of Resident 21's progress notes on 4/10/23 at 10:30 a.m., indicated the resident was sent to the hospital on 2/24/23. There was no documentation that a written notice that specified the facility's bed-hold policy permitting the resident to return and resume in the facility was provided to the resident or the resident's representative. During an interview on 4/10/23 at 11:01 a.m., the Clinical and Quality Support staff member indicated the bed hold policy forms were sent with the resident during the transfer to the hospital and the representative was notified by phone. On 4/10/23 at 3:00 p.m., the Clinical and Quality Support staff member provided the facility policy, . Bed Hold Policy with a revised date of 10/2017, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . 2. At the time of transfer for a resident for hospitalization or therapeutic leave, the facility will provide to the resident and the resident representative written notice . 3.1-12(a)(25) 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure a resident's weight was monitored as ordered by the physician's plan of care for 1 of 3 residents reviewed for nutrition. (Resident 37) Findings include: On 4/4/23 at 2:50 p.m., Resident 37 was observed in her wheelchair in the hallway. She appeared to be thin and lethargic. On 4/5/23 at 11:50 a.m., the resident was observed in the dining area. A staff member was assisting the resident with her meal. On 4/6/23 at 10:20 a.m., Resident 37's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction and flaccid hemiplegia. The resident's care plan indicated she was at risk of malnutrition related to her condition and her weights were to be monitored as ordered by the physician. A current physician's order, with a start date of 2/9/22, indicated, the resident's weight was to be monitored one time a week on Wednesday mornings. The clinical record indicated since that physician's order, the resident's weight was obtained 17 times out of 61 opportunities. During an interview on 4/11/23 at 12:20 p.m., the facility Administrator indicated the resident's weights were not documented as the physician's order directed. 3.1-35(g)(2)