**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep the urinary catheter (flexible tubing which drains urine from the bladder) drainage bag and tubing from touching the floor for a resident being treated for an urinary tract infection (UTI) for 1 of 4 residents reviewed for urinary catheter. (Resident 70) Findings include: On 1/27/25 at 2:34 p.m., Resident 70 was observed to be resting in her bed with her urinary catheter tubing touching the floor. On 1/28/25 at 2:46 p.m., Resident 70 was observed to be resting in her bed with the urinary catheter tubing touching the bottom of the rolling table beside her bed. On 1/29/25 at 9:32 a.m., Resident 70 was observed to be resting in her bed with the urinary catheter tubing touching the floor. On 1/29/25 at 1:40 p.m., Resident 70 was observed to be sitting in her wheelchair with her urinary catheter tubing touching the floor. On 1/30/25 at 2:10 p.m., Resident 70 was observed to be resting in her bed with the urinary catheter drainage bag touching the floor. On 1/30/25 at 2:15 p.m., Resident 70's clinical record was reviewed. The diagnoses included, but were not limited to, UTI, weakness, and neuromuscular dysfunction of the bladder (a condition where the bladder muscles and nerves do not function properly). Resident 70's January 2025 Physician Order indicated the following: - 18 French 5-30 ml (milliliters) (size of catheter) catheter for neuromuscular dysfunction, initiated on 12/8/24. - Provide catheter care each shift and maintain the drainage bag below the bladder. Do not allow the tubing or the bag to drag/touch the floor, initiated 12/10/24. - Amoxicillin-Pot Clavulante (antibiotic) 875-125 mg (milligrams) by mouth two times a day for UTI, initiated 1/27/25. The care plan, revised 1/25/25, indicated Resident 70 had a UTI. The interventions were to administer medications and treatments as ordered and to observed to side effects of the antibiotic. The care plan lacked documentation of placement of the catheter tubing or drainage bag. The Hospital discharge instructions, dated [DATE], indicated Resident 70 had been in the hospital with a diagnosis of UTI. The Infection Charting, dated 1/30/25 at 10:17 p.m., indicated Resident 70 was on Amoxicillin-Pot Clavulante for a UTI. The progress notes indicated the following: - On 1/28/25 at 1:29 p.m., Resident 70 continued to be on an antibiotic for UTI. - On 1/28/25 at 5:55 p.m., Resident 70 continued to be on an antibiotic for UTI. - On 1/29/25 at 7:38 a.m., Resident 70 continued to be on an antibiotic for UTI. Her urine was dark with no sediment. - On 1/30/25 at 1:45 p.m., Resident 70 continued to be on an antibiotic for UTI. Her urine was amber (color of urine) with no sediment. During an interview on 1/30/25 at 2:20 p.m., Licensed Practical Nurse (LPN) 1 indicated Resident 70 had a urinary catheter due to urinary retention and Resident 70 had a history of UTI's. During an interview on 1/30/25 at 2:23 p.m., CNA 1 indicated Resident 70 had a catheter. When Resident 70 was in bed, the catheter bag or tubing should not touch the floor. CNA 1 observed Resident 70's drainage bag touching the floor and indicated it should not touch the floor. On 1/31/25 at 12:14 p.m., the Administrator provided the facility's policy, Indwelling Catheter Use and Removal, undated, and indicated it was the policy currently being used by the facility. A review of the policy indicated, .4. If an indwelling catheter is in use, the facility will provide appropriate care for the catheter in accordance with current professional standards of practice and resident care policies and procedures . 3.1-41(a)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received the physician ordered therapeutic diet for 1 of 3 residents reviewed for therapeutic diets. (Resident B) Finding included: On 3/11/24 at 8:41 a.m., observed a meal tray sitting on a meal cart in front of room [ROOM NUMBER] with a meal tray for Resident B. The meal ticket for Resident B, dated 3/11/24, indicated the tray was for breakfast. Resident B was on a controlled carbohydrate diet and Resident B was to receive a waffle with syrup, sausage patty, and scrambled eggs. A 1.5 ounce packet of [NAME] Farms table syrup was observed that did not indicate if the syrup was sugar free on Resident B's tray. At that time, observed CNA 1 take Resident B's tray from the cart and into Resident B's room. During an interview on 3/11/24 at 8:42 a.m., CNA 1 indicated Resident B was on a controlled carbohydrate diet. The 1.5 ounce packets of [NAME] Farms table syrup was not sugar free. During an interview on 3/11/24 at 9:05 a.m., CNA 2 indicated Resident B should have received sugar free syrup on the meal tray. The staff should have returned the regular syrup to the kitchen and exchanged it for sugar free syrup. During an interview on 3/11/24 at 9:22 a.m., the Dietary Manager indicated the facility ran out of sugar free syrup for breakfast. The clinical record for Resident B was reviewed on 3/11/24 at 9:48 a.m. The diagnoses included, but were not limited to, Diabetes Mellitus and renal insufficiency. An admission MDS (Minimum Data Set) assessment, dated 2/2/24, indicated Resident B was cognitively intact and received a therapeutic diet. A care plan, initiated on 1/30/24, indicated Resident B was at risk for altered nutritional status. The interventions included, but were not limited to, diet as ordered and provide meals and snacks based on residents food preferences and physician's orders. A physician's order initiated on 1/30/24, indicated controlled carbohydrate diet with regular texture and regular fluid consistency. During an interview on 3/11/24 at 11:00 a.m., Resident B indicated she had diabetes and was on a controlled carbohydrate diet. Resident B was not aware she was served regular table syrup instead of sugar free syrup. Resident B did not request regular syrup. On 3/11/24 at 11:44 a.m., the Administrator provided a copy of an undated facility policy, titled Therapeutic Diets, and indicated this was the current policy used by the facility. A review of the policy indicated the facility will provide a therapeutic diet that is individualized to meet the clinical needs of each resident. This citation relates to Complaint IN00428670. 3.1-20(a)

Based on observation, interview, and record review, the facility failed to label the eye drop bottle with an open date for 2 of the 3 medications carts observed. (Long Short Medication Cart, South Front Medication Cart) Findings include: 1. On 2/15/24 at 10:45 a.m., the long short medication cart was observed to have Resident 65's Ofloxacin (antibiotic eye drops) bottle. The eye drop bottle lacked an open date. The Assistant Director of Nursing (ADON) could not find an open date. On 2/15/24 at 11:20 a.m., Resident 65's clinical record was reviewed. The diagnoses included, but were not limited to, right fibula (bone in the leg) fracture, cerebral palsy (disorder that affect a person's ability to move and maintain balance), and conjunctivitis (pink eye). A Physician's Order, dated 2/1/24, indicated Ofloxacin 0.3 % solution was ordered four times a day for conjunctivitis for 7 days. 2. On 2/15/24 at 10:50 a.m., the south front medication cart was observed to have Resident 49's eye drop bottle. The eye drop bottle lacked an open date. The ADON could not find an open date. On 2/15/24 at 11:30 a.m., Resident 49's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, dry eye syndrome, and seasonal allergies. The February 2024 Physician Orders indicated ketotifen fumarate ophthalmic 0.025% (medication for itching eyes) one drop in both eyes as needed for dry eyes (start date of 7/15/23). On 2/15/24 at 11:00 a.m., the Director of Nursing (DON) provided the facility's policy, Medication and Biological Storage Requirements, dated 5/20/22 and indicated it was the policy being used by the facility. A review of the policy lacked documentation of dating opened eye drops bottles. 3.1-25(k)(6)

Based on observation, interview, and record review, the facility failed to ensure a urinary drainage bag attached to a Foley catheter F/C (flexible tube which passed through the urethra and into the bladder to drain urine) was positioned off the floor for 1 of 1 resident reviewed for urinary catheter. (Resident 59) Findings include: On 2/13/24 at 10:22 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 9:15 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 11:09 a.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to be touching the floor. On 2/14/24 at 3:13 p.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed to have been touching a mat that was lying on the floor. On 2/15/24 at 11:17 a.m., Resident 59 was observed to be awake in bed. A urinary drainage bag attached to a F/C was observed to have been touching a mat that was lying on the floor. On 2/15/24 at 2:36 p.m., Resident 59 was observed to be asleep in bed. A urinary drainage bag attached to a F/C was observed sitting in a gray tub touching the floor. Resident 59's clinical record was reviewed on 2/15/24 at 11:30 a.m. The diagnosis included, but was not limited to, neuromuscular dysfunction of the bladder. Physician orders, dated 2/15/24, for Resident 59 indicated . Foley catheter 16 french 30 ml [milliliter] balloon to gravity drainage every shift for neurogenic bladder . During an interview on 2/15/24 at 9:36 a.m., Certified Nursing Assistant (CNA) 1 indicated the urinary drainage bag should be positioned off the floor. During an interview on 2/15/24 at 11:18 a.m., the Assistant Director of Nursing (ADON) indicated the urinary drainage bag should be positioned off the floor. During an interview on 2/15/24 at 2:35 a.m., the ADON and CNA 2 indicated they had just been told they now have to start putting the urinary drainage bags in tubs and Resident 59 had not been known to play with his F/C tubing. CNA 2 indicated, he has been out of it all week. On 2/15/24 at 12:35 p.m., the DON provided the facility's policy,Policy for Using Urinary Catheter Drainage Bags/Dignity Covers with a revised date of 11/22, and indicated it was the policy currently being used by the facility. A review of the policy indicated, . Hang closed Foley drainage bag on resident's bed . preventing Foley bag from touching the floor . The policy did not indicate putting the urinary drainage bag in a tub to prevent it from being on the floor. 3.1-18(b)(1)

Based on observation, interview, and record review, the facility failed to ensure a room containing soiled linens and biohazard materials was secured when unattended by staff during 1 of 1 continuous observation of the room. (Southwest Hallway) Findings include: On 2/11/24 from 10:30 a.m. to 12:45 p.m., the biohazard/soiled linen room on the southwest hallway was observed to be unlocked and unattended by staff. Three residents were observed ambulating by the room and 2 residents were observed passing the room via wheelchairs during this time period. An observation of the biohazard/soiled linen room keypad lock at 12:40 p.m., indicated the lock had been disengaged so as to enable access to the room without the use of the keypad. Inside the room were 3 uncovered linen bins filled with soiled linens, one trash can filled with soiled linens, and a biohazard container which contained a full sharps container and 2 specimen cups which contained a yellow liquid. An unlocked cabinet contained a spray bottle labeled Bleach, a spray bottle of glass cleaner, and a spray bottle labeled 7 in One Concentrate and .Hazardous to humans . During an interview on 2/11/24 at 1:00 p.m., the Administrator indicated the keypad to the door had been disengaged, the room was unattended by staff, and this could have posed a risk to residents. On 2/14/24 at 10:15 a.m., the facility Administrator provided the policy and procedure entitled Homelike Environment, effective date 12/1/23 and indicated this was the policy used by the facility. A review of the policy indicated, .it is the policy of the facility that the residents are provided with a safe .environment . 3.1-19(f)

Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS (Centers for Medicare and Medicaid Services) for Quarter 4 (July 1 through September 30) of fiscal year 2023. Findings include: On 2/12/24 at 11:30 a.m., the facility's Payroll Based Journal (PBJ) Staffing Data Report was reviewed. The report indicated the facility had no RN coverage on 8/5/23, 8/13/23, 8/20/23, and 9/10/23. On 2/14/24 at 3:25 p.m., a review of the fourth quarter staffing schedules indicated there was no RN coverage for 8 hours a day on 8/5/23, 8/13/23, 8/20/23, and 9/10/23. During an interview at that time, the Executive Director (ED) indicated the PBJ report was correct and there was not 8 hours of RN coverage on those days. On 2/14/24 at 10:15 a.m., the ED provided the facility policy, Nursing Services RN Coverage, revised on November, 2023, and indicated it was the policy currently being used. A review of the policy indicated, . except when waived, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week . 3.1-17(b)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the Notice of Transfer or Discharge were provided to the residents or resident representatives for 2 of 2 residents reviewed for discharge.(Resident 125, Resident 15) Findings include: 1. On 1/3/23 at 2:55 p.m., Resident 125's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on [DATE]. There was no documentation the resident or resident's representative had been provided the Notice of Transfer or Discharge. 2. On 1/3/23 at 2:55 p.m., Resident 15's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on [DATE] and 11/29/22. There was no documentation the resident or resident's representative had been provided the Notice of Transfer or Discharge. During an interview on 1/4/22 at 3:00 p.m., the Executive Director indicated the notice of transfer requirements had been sent to the hospital with the resident's paperwork. There was no other documentation or policy available for review. On 1/4/23 at 3:00 p.m., the Executive Director provided the facility policy, Notice Requirements before Transfer/Discharge, undated, and indicated it was the policy currently being used. A review of the policy indicated, It is the policy of the facility to notify the resident and or their legal guardian of the before [sic] transfer and/or discharge according to state and federal regulations . 3.1-12(a)(8)(D)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that a bed hold policy was provided to residents that transferred to the hospital for 2 of 2 residents reviewed for hospitalization. (Resident 125, Resident 15) Findings include: 1. On 1/3/23 at 2:55 p.m., Resident 125's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on [DATE]. Review of the resident's clinical record revealed no documentation that a bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. 2. On 1/3/23 at 2:55 p.m., Resident 15's clinical record was reviewed. The progress notes indicated the resident was sent to the hospital on [DATE] and 11/29/22. Review of the resident's clinical record revealed no documentation that a bed-hold policy permitting the resident to return and resume resident in the facility was provided to the resident or resident's representative. During an interview on 12/30/22 at 1:16 p.m., the Executive Director indicated the bed-hold policy was sent to the hospital with the resident. There was no other documentation or policy available for review. 3.1-12(a)(26)

Based on observation, interview, and record review, the facility failed to ensure the resident had a care plan developed for insulin and antipsychotic medication use for 1 of 5 residents reviewed for unnecessary medications. (Resident 64) Finding includes: On 12/30/22 at 12:19 p.m., Resident 64 was observed to be watching her television. On 1/4/23 at 9:49 a.m., Resident 64 was observed to be lying in her bed asleep. On 12/29/22 at 3:06 p.m., Resident 64's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus, schizoaffective disorder bipolar type, and psychosis. Resident 64's January 2023 Physician Orders included, but were not limited to: - Insulin glargine solution (long acting insulin), inject 10 units subcutaneously at bedtime for diabetes mellitus, initiated 11/7/22. - Quetiapine fumarate 25 mg (milligrams) tablet (antipsychotic medication) by mouth at bed time for schizoaffective disorder bipolar type, initiated 11/7/22. Resident 64's clinical record lacked documentation of a diabetes mellitus care plan for the use of insulin and a psychosis care plan for the use of quetiapine fumarate medication. During an interview on 1/4/23 at 3:34 p.m., the Director of Nursing (DON) indicated the clinical record lacked a care plan related to insulin and antipsychotic use. On 1/4/23 at 3:11 p.m., the Executive Director provided the facility's policy, Care Plans Protocol, undated, and indicated this was the policy currently being used by the facility. A review of the policy indicated .The care plan should be revised and on and on-going basis to reflect changes in the resident and the care the resident is receiving. 3.1-35(a)

Based on interview and record review, the facility failed to ensure staff provided necessary care and services consistent to the resident's needs and choices for 1 of 1 resident reviewed for ADLs (activities of daily living). (Resident B) Findings include: During an interview on 12/30/22 at 12:17 p.m., Resident B indicated she did not receive consistent showers while she resided at the facility. On 12/30/22 at 12:30 p.m., Resident B's closed clinical record was reviewed. The diagnoses included, but were not limited to, fracture of left talus (broken leg), person injured in motor-vehicle accident, injury of head, pain in left ankle and joints of left foot, and acute pain due to trauma. An admission MDS (Minimum Data Set) assessment, dated 4/12/22, indicated the resident was cognitively intact and required the supervision of 1 staff member with personal hygiene. A care plan, dated 4/6/22, indicated the resident was at risk for self-care deficit as evidenced by the resident needed assistance with ADLs. An intervention included staff supervision with personal hygiene. The clinical record indicated the resident was scheduled for showers on Wednesdays and Saturdays. A review of the resident's bathing/shower logs indicated the resident did not receive a shower between 5/8/22 and 5/19/22 (discharge). This was 12 days without a shower. On 1/4/23 at 3:30 p.m., the MDS Coordinator indicated she could not find any additional documentation in regard to the resident's showers. On 12/27/22 at 2:00 p.m., the Executive Director provided the policy, Resident Rights, updated 3/15/17, and indicated it was the policy currently being used. A review of the policy indicated, .You have the right to . Receive the services and/or items included in the plan of care. This Federal tag relates to Complaint IN00396323. 3.1-38(a)(2)(A)

Based on observation, interview, and record review, the facility failed to ensure wheelchair arm pads were in good repair, call light and overbed light cords were repaired, and a resident wall was clean for 8 of 24 residents reviewed for environmental. (Resident 20, Resident 45, Resident 46, Resident 59, Resident 63, Resident 60, Resident 25, and Resident 51) Findings include: 1. On 12/28/22 at 11:20 A.M. and on 1/3/23 at 2:40 P.M., the armpad coverings of Resident 20's wheelchair were observed to be cracked, revealing the underlying padding. 2. On 12/28/22 at 11:40 A.M. and on 1/3/23 at 2:50 P.M., the left armpad covering of Resident 45's wheelchair was observed to be cracked, revealing the underlying padding. 3. On 12/28/22 at 11:50 A.M. and on 1/3/23 at 2:55 P.M., the right armpad of Resident 46's wheelchair was observed to be missing. 4. On 12/28/22 at 12:05 P.M. and on 1/3/23 at 3:10 P.M., the armpad coverings of Resident 59's wheelchair were observed to be cracked, revealing the underlying padding. 5. On 12/28/22 at 12:15 P.M. and on 1/3/23 at 3:20 P.M., the armpad coverings of Resident 63's wheelchair were observed to be cracked, revealing the underlying padding. 6. On 12/28/22 at 9:43 A.M. and on 1/4/23 at 2:00 P.M., the call light cord in Resident 60's bathroom was observed to be broken, with approximately 2 inches of cord remaining. 7. On 12/28/22 at 10:25 A.M. and on 1/4/23 at 2:10 P.M., the wall next the the bed of Resident 25 was observed to be stained with a dry brown substance. 8. On 12/28/22 at 2:22 P.M., the light above the head of Resident 51's bed was observed to be broken, with approximately 2 inches of cord remaining. During an interview on 1/4/23 at 2:21 P.M., the Administrator indicated the wheelchair arm pads, bathroom call light cord, and the bed light cord were in need of repair, and the dirty wall was in need of cleaning. 3.1-19(f)