Based on observation, interview, and record review, it was determined that the facility failed to follow procedures in place for self-administration of medications for 2 residents out of 4 residents reviewed for choices in a final survey sample of 16 residents (Resident Identifiers are #38 and #28). Findings include: Resident #38 Observation on 11/4/24 at approximately 9:30 a.m. of Resident #38's walker tray revealed a bottle of premium nasal spray with an expiration date of 6/9/24. Interview on 11/4/24 at approximately 9:30 a.m. with Resident #38 revealed that he/she administers the nasal spray Once in a while, maybe once a week. Review on 11/4/24 of Resident #38's current physician orders revealed that Resident #38 did not have an order for nasal spray. Interview on 11/4/24 at approximately 9:45 a.m. with Staff B (Registered Nurse) confirmed the above findings. Review on 11/5/24 of Resident #38's medical record revealed that Resident #38 did not have an assessment to self-administer medications. Resident #28 Observation on 11/4/24 at approximately 9:40 a.m. of Resident #28's room revealed a bottle of eye drops and a can of lidocaine maximum strength spray on his/her window sill. Interview on 11/4/24 at approximately 9:40 a.m. with Resident #28 revealed that he/she uses the eye drops twice daily and the lidocaine spray when he/she needs it. Review on 11/4/24 of Resident #28's current physician orders revealed that Resident #28 did not have an order for the eye drops or the lidocaine spray. Interview on 11/4/24 at approximately 9:45 a.m. with Staff B confirmed the above findings. Review on 11/5/24 of Resident #28's medical record revealed that Resident #28 did not have an assessment to self-administer medications. Interview on 11/5/24 at approximately 1:15 p.m. with Staff E (Director of Nurses) confirmed that Resident #38 and Resident #28 were not assessed to self-administer medications. Review on 11/5/24 of the facility policy titled, Self Administration of Medication, Revision Date 3/24 revealed: .Residents will be allowed to self-administer medications only after the interdisciplinary team determines it is safe for the resident to self administer before the resident may exercise that right. The interdisciplinary team must also determine who will be responsible (resident or nursing staff) for the storage and documentation of the administration as well as the location of drug administration .

Based on interview and record review, it was determined that the facility failed to ensure that licensed staff had infection control competencies in skills and techniques necessary to care for residents' needs for 6 of 6 staff reviewed (Staff Identifier's are A, B, C, M, N, and O). Findings include: Review on 11/6/24 of the facility's infection control in service competency records revealed that there were no competencies documented for standard universal precautions, donning and doffing of personal protective equipment (PPE), and hand hygiene for Staff A (Licensed Practical Nurse), Staff B (Registered Nurse (RN)), Staff C (RN), Staff M (Licensed Nursing Assistant (LNA)), Staff N (LNA), and Staff O (LNA). Interview on 11/6/24 at 11:02 a.m. with Staff P (Administrator in Training (AIT)) confirmed that the facility was unable to provide documentation that Staff A, Staff B, Staff C, Staff M, Staff N, and Staff O completed competencies for standard universal precautions, donning and doffing of PPE, and hand hygiene. Review on 11/6/24 of the facility's facility assessment with a review date of September 2024 under the section titled, Staff training/education and competencies, revealed .Competency .Some of the competencies and skill sets needed as direct care giver include: .Infection Control - hand hygiene, isolation, standard universal precautions including use of personal protective equipment, MRSA/VRE/CDI precautions, environmental cleaning . Review on 11/6/24 of the facility's policy titled, In-Services Education, undated, revealed: .4. In-Service Education Program: Golden View's in-service education program consists of: A. Continuing in-service education for all personnel. B. Planning in-service classes, lectures, demonstrations, ect. C. Job position orientation for all new personnel. Training shall include demonstrations, practice and supervision of simple procedures applicable to the individual department .

Based on observation, interview, and record review, it was determined that the facility failed to ensure a medication error rate less than 5 percent for 3 of 29 medications observed during medication administration (Resident Identifiers are #22, #47 and #25). Findings include: Resident #22 Observation on 11/4/24 at approximately 12:00 p.m. of Staff A (Licensed Practical Nurse) administering medications to Resident #22 revealed Staff A prepared 1,000 milligrams (mg) of Calcium Carbonate. Review on 11/4/24 of Resident #22's November 2024 Medication Administration Record (MAR) revealed the following physician's order: Calcium Carbonate 500 mg calcium (1,250 mg) give 1 tablet daily, start date 10/28/24. Interview on 11/4/24 at approximately 12:00 p.m. with Staff A confirmed the above findings. Resident #47 Observation on 11/4/24 at approximately 12:20 p.m. of Staff A administering medications to Resident #47 revealed Staff A administering 1 spray of Flonase Allergy Relief to each nostril. Review on 11/4/24 of Resident #47's November 2024 MAR revealed the following physician's order: Flonase Allergy Relief (Over The Counter), 50 micrograms (mcg), 2 sprays each nostril, start date 9/11/23. Interview on 11/4/24 at approximately 12:20 p.m. with Staff A confirmed the above findings. Resident #25 Observation on 11/4/24 at approximately 7:30 a.m. of Staff C (Registered Nurse) administering medications to Resident #25 revealed Staff C prepared Multivitamin with minerals. Review on 11/5/24 of Resident #44's November 2024's MAR revealed the following physician's order: Multivitamin, 1 tablet in the morning, start date 10/11/22. Interview on 11/5/24 at approximately 7:30 a.m. with Staff C confirmed the above findings. In total there were 3 medication errors out of a total of 29 medication pass opportunities resulting in a 10.34% error rate.

Based on observation, interview, and record review, it was determined that the facility failed to ensure sanitization of dishware and failed to label and store food in accordance with professional standards for food safety to prevent foodborne illness for 1 of 1 kitchens and 2 of 2 kitchenettes observed. Findings Include: Refrigerator Temperatures Review on 11/4/24 of the Main Kitchen refrigerator/freezer temperature logs, Cascade/Retreat refrigerator/freezer temperature logs, and the third floor refrigerator/freezer temperature logs for October and November 2024 revealed no logs were available for November 2024 (11/1, 11/2, and 11/3), and missing temperatures for 10/2, 10/22, 10/24, 10/28, 10/29, and 10/31. Observation on 11/4/24 of the third floor refrigerator revealed no thermometer for taking temperatures. Interview on 11/4/24 8:00 a.m. with Staff L (Assistant Kitchen Director) confirmed above refrigerator temperature findings. Review on 11/6/24 of facility policy titled Dining Services: Food and Refrigeration Temperature revision date 3/24 revealed POLICY: .Refrigerator Temperatures shall be taken daily and logged by the cooks . Dish Machine Temperatures Interview on 11/4/24 at approximately 8:20 a.m. of Staff F (Cook) confirmed the dish machines were High Temperature machines. Review on 11/4/24 of the Main Kitchen Dish Machine Temperature logs revealed no logs were available for September through November 2024. Review on 11/4/24 of Cascade/Retreat Kitchenette Dish Machine Temperature logs revealed no logs were available for November 2024 (11/1, 11/2, 11/3). Interview on 11/5/24 at approximately 2:00 p.m. with Staff H (Kitchen Director) confirmed the above findings for dish machine temperature logs. Review on 11/6/24 of facility policy titled Dining Services: Documentation of Dish Machine Temperatures and Third Sink Sanitizer, dated 3/21, revealed: .At the beginning of their shift Inspect equipment to make sure all functions of the dish machine or operational preform testing of the dish machine wash and rinse temperatures .Dish machine wash temp is 150 degrees Fahrenheit Dish machine rinse temp is 180 degrees Fahrenheit Chemical Sanitizing (quaternary ammonium compounds) Review on 11/4/24 of Main Kitchen Sanitizer Sink logs revealed no logs were available for September through November 2024. Observation on 11/4/24 at approximately 8:20 a.m. of Cascade/Retreat sink sanitizer testing with Staff K (Kitchen/Dietary Staff) revealed Staff K dipped the strip into the sanitizer sink and immediately read the result 150 without comparing the strip color to the vial color. Interview on 11/4/24 at approximately 8:20 a.m. with Staff K confirmed the Cascade/Retreat sink sanitizer tested at 50 parts per million (PPM) when compared to the vial. Staff K confirmed that the PPM was outside of effective 150-400 PPM range for quaternary ammonium compounds. Interview further revealed he/she had not tested prior to use on this date. Review on 11/6/24 of manufacturer's instructions for the test strips revealed that the strip should be dipped in the sink sanitizer for 5 seconds and that the acceptable sanitizing ranges of quaternary ammonium compounds was 150-400 PPM. Review on 11/6/24 of facility policy titled Dining Services: Documentation of Dish machine Temperatures and Third Sink Sanitizer reviewed 3/21 revealed .At the beginning of their shift .the PPM (parts per million) of the third (3rd) sanitizer sink and record all the findings . Food Storage Observation on 11/4/24 at approximately 8:30 a.m. of the Main Kitchen refrigerator revealed an open almond milk with an expiration date of 10/29. Further observations revealed soft fresh green peppers with black and gray fuzzy areas on them. Interview on 11/4/24 at approximately 8:30 a.m. with Staff L (Assistant Kitchen Director) confirmed the above refrigerator findings. Observation on 11/4/24 at approximately 8:20 a.m. of the Cascade/Retreat refrigerator revealed 2 metal containers. One metal container was unlabeled, uncovered, and not dated and contained brown wilted lettuce and hard crusted orange slices. The second metal container was partially covered and unlabeled with brown lettuce. Interview on 11/4/24 at approximately 8:20 a.m. of Staff K confirmed the above Cascade/Retreat refrigerator findings. Review on 11/6/24 of facility policy titled Dietary: Labeling and Dating of Facility Supplied Food Items, revised date 3/24, revealed: .Staff shall assess the quality of food items at a minimum of one (1) time per day .PROCEDURE: .4 .and discard food items according to policy and to federal/state and manufacturer guidelines. Review on 11/6/24 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Annex 3, Public Health Reasons/Administrative Guidelines .Chapter 6 Food Storage .6-404.11 Segregation and Location. Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods, equipment, utensils, linens, or single-service or single-use articles. To preclude this, separate and segregated areas must be designated for storing unsalable goods.

Resident # 12 Observation on 11/4/24 at 10:40 a.m. of Resident #12's room revealed that an indwelling catheter bag hanging from Resident #12's wheelchair. There was no sign indicating that Resident #12 was on EBP. Resident #39 Observation on 11/4/24 at 10:48 a.m. of Resident #39's room revealed an indwelling catheter bag hanging from their bed. There was no sign indicating that Resident #39 was on EBP. Interview on 11/4/24 at 10:50 a.m. with Staff A (Licensed Practical Nurse) revealed they were not aware that Resident #12 and Resident #39 were on EBP because there was no sign or PPE outside of their rooms. Review on 11/6/24 of facility policy titled, Contact Precautions/Enhanced Barrier, revised 4/2024, revealed: . Enhanced Barrier Precautions apply where the presence of organism in wounds, ostomy, urinary catheters, g-tube, catheter ports for dialysis, MDROs or other discharges from the body .Enhanced Barrier Precautions expands the use of PPE and Contact precautions to donning gown and gloves during high contact care activities the provide opportunity for transmission of MDRO's to staff hands and clothing. This includes any type of personal care that staff give the residents .2. Enhanced Barrier Precautions signs are placed on top of the PPE containers in the resident's room for direct care staff . Based on observation, interview, and record review, it was determined that the facility failed to follow the Center for Disease Control and Prevention (CDC) guidelines for Enhanced Barrier Precautions (EBP) to prevent the spread of infections for 4 out of 8 residents reviewed for EBP in a final sample of 15 residents (Resident Identifiers are #12, #16, #23, and #39). Findings include: Resident #16 Observation on 11/4/24 at approximately 11:00 a.m. revealed a cart with personal protective equipment (PPE) and a sign for EBP at Resident #16's room. Interview on 11/4/24 at approximately 11:00 a.m. with Resident #16 revealed Resident #16 stated that staff do not wear gowns or gloves while providing his/her care. Review on 11/4/24 of Resident #16's physician orders revealed a current order for EBP due to a urinary catheter. Observation on 11/5/24 at approximately 2:00 p.m. of Staff T (Licensed Nursing Assistant (LNA)) revealed Staff T transferring Resident #16 from their wheelchair to their bathroom for toileting. Staff T was wearing gloves and was not wearing a gown. Interview on 11/5/24 at approximately 2:00 p.m. with Staff T confirmed they did not wear a gown when transferring and toileting Resident #16. Resident #23 Review on 11/6/24 of Resident #23's physician orders revealed a current order for EBP due to open wound. Observation on 11/6/24 at approximately 8:00 a.m. revealed Staff R (LNA) and Staff T transferring Resident #23 from their bed to their wheelchair without wearing gowns or gloves. Interview on 11/6/24 at approximately 8:00 a.m. with Staff R confirmed that he/she wasn't wearing a gown or gloves and Staff R was unaware the Resident #23 was on EBP.

Based on interview, record review, policy review, and manufacturer's instructions, it was determined that the facility failed to inform the resident or resident's representative of the risks and benefits of Antipychotic medication for 2 out of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident Identifiers are #25 and #42). Findings include: Resident #25 Review on 12/14/23 at approximately 2:41 p.m. of Resident #25's current physician order revealed the following: Arpiprazole (Antipsychotic) 10 mg [milligrams] once a day, with a start date of 8/16/23. Further review of Resident #25's medical record revealed no documention of consent for use of the Arpiprazole. Interview on 12/15/23 at approximately 9:30 a.m. with Staff G (Medication Nursing Assistant) confirmed that there was no consent or documentation of consent regarding the Arpiprazole in Resident #25's medical record. Resident #42 Review on 12/15/23 of Resident #42's electronic medical record revealed that Resident #42 has a diagnosis of Dementia with psychotic behaviors and Parkinson's disease. Review on 12/15/23 of Resident #42's December 2023 Medication Administration Record (MAR) revealed the following order: Nuplazid (Pimavanserin) Capsule 34 mg; Give 1 capsule by mouth once daily for Parkinson's disease dated 4/12/23. Review on 12/15/23 of Resident #42's record revealed that there was no consent or documentation of consent for Nuplazid. Interview on 12/15/23 at 12:30 p.m. with Staff G confirmed that there was no consent for Nuplazid for Resident #42. Interview on 12/15/23 at 3:00 p.m. with Staff E (Director of Nursing) confirmed that there was no consent for Nuplazid for Resident #42. Review of 12/18/23 of the manufacturer's instructions for Nuplazid, .5.1: Antipsychotic drugs increase the all-cause risk of death in elderly patients with dementia-related psychosis . Review on 12/15/23 of the facility's policy titled, Psycho Active Medications, revised 2/22, revealed . 4. Discuss Benefit and Risk Statement with Resident/DPOA Health Cre)/ Guardian and document at end of Antipsychotic Risk/Benefit Consent .

Based on interview and record review, it was determined that the facility failed to complete a discharge summary that contains all the necessary elements for 1 out of 1 residents reviewed for discharge (Resident Identifier is #62). Findings include: Review on 12/15/23 of Resident #62's nursing note dated 10/2/23 revealed Was informed this am that this resident is going back to his room on the AL [Assisted Living] floor, the Inn. Resident was sent to the ER [Emergency Room] due to gross hematuria in his Foley bag. Resident was treated for UTI [urinary tract infection] with Cipro. Last dose given on 10/01 in the PM. Hematuria resolved and he was started back on his Eliquis with no further bleeding. Resident received OT/PT [occupational therapy/physical therapy] services and is back at this baseline. Family aware of discharge back to AL and are in agreement. Review on 12/15/23 of Resident #62's medical record did not reveal a documented final summary that contained a summation of Resident 62's medical status at the time of their 10/2/23 discharge, a reconciliation of Resident #62's pre-discharge and post-discharge medications, nor an order for post-discharge services. Interview on 12/15/23 at 3:45 p.m. with Staff E (Director of Nursing) confirmed that there was no discharge summary completed.

Based on record review and interview, it was determined that the facility failed to provide a stop date for an as needed (PRN) psychotropic medication for 1 of 5 residents reviewed for unnecessary medications in a final sample of 18 residents (Resident identifier is #59). Findings include: Record review on 12/15/23 revealed that Resident #59 had an order for Seroquel (Quetiapine) 25 mg [milligrams]; Give 1/2 tablet = 12.5 mg by gastric tube once a day PRN for psychosis, start date: 12/10/23, end date: open ended. Interview on 12/15/23 at 10:10 a.m. with Staff I (Registered Nurse) confirmed that Resident #59's order for PRN Seroquel did not have a stop date of 14 days. Interview on 12/15/23 at 10:30 a.m. with Staff E (Director of Nursing) confirmed that Resident #59's order for PRN Seroquel did not have a stop date of 14 days. Review on 12/15/23 of the facility's policy titled, Psychotropic Medications Prescribed As Needed, revised 11/10, revealed . Psychotropic medications prescribed on an as-needed (PRN) basis are limited to 14 days and must be deemed medically necessary, and require documentation in the medical record for indication of use .

Based on interview and record review, it was determined that the facility failed to promptly notify the ordering practitioner of abnormal laboratory (lab) results according to the facility's policies and procedures for notification for 1 of 1 resident reviewed for lab results in a final survey sample of 18 residents (Resident identifier is #23). Findings include: Review on 12/15/23 of Resident #23 medical record revealed the following lab results for dilantin (a medicine used to treat certain types of seizures): On 11/15/23 result of 3.2 ug/mL [micrograms per milliliter], Low On 12/5/23 result of 4.3 ug/mL, Low. Further review revealed that the reference range for the dilantin was 10-20 ug/mL. Further review revealed the ordering physician had not signed the lab report indicating they reviewed the results. Review on 12/15/23 of Resident #23's medical record revealed that there were no nurses notes or physician notes regarding the above low dilantin levels. Interview on 12/15/23 at approximately 1:39 p.m. with Staff E (Director of Nursing) confirmed the above findings. Interview on 12/15/23 at 2:34 p.m. with Staff F (Medical Doctor) revealed that he/she was not aware of the above low lab levels of dilantin for Resident #23. Staff F was Resident #23 physician. Interview on 12/15/23 at 2:46 p.m. with Staff G (Medication Nursing Assistant) confirmed that there was no documentation that the physician had been notified of the above lab levels in Resident #23's medical record and that the lab report had not been signed. Review on 12/15/23 of the facility's policy titled Tracking and Monitoring Laboratory Results revised on 3/27/17, revealed, .Purpose: To ensure that labs are drawn as ordered results are received and the physician is notified of the results . When results are returned to facility, enter the date onto the LAB BOOK TRACKING SHEET, inform physician via telephone, fax or communication book as clinically appropriate . Review MD [Medical Doctor] notification present column to ensure that all labs filed in the medical record have been signed by the physician.

Based on observation and interview, the facility failed to use facial hair restraints when serving food from the steam table for 2 of 3 units observed for meal service (Units Observed: The Pines Unit and The Cascade Unit). Finding include: The Pines Unit Observation on 12/13/23 at 12:51 p.m. of Staff C (Dietary Assistant) on The Pines Unit revealed that Staff C was serving food from the steam table onto plates. Staff C had a full beard that was over an inch long that was not covered. Interview on 12/13/23 at 1:31 p.m. with Staff C confirmed the above. Staff C revealed that he/she never wears a covering over his/her beard and that the facility does not have any to use. Interview on 12/13/23 at 2:37 p.m. with Staff D (Dietary Manager) confirmed that the facility did not use any coverings for facial hair and that the facility did not have a policy for covering facial hair. The Cascade Unit Observation on 12/14/23 at approximately 12:30 p.m. of the Cascade Unit dining room revealed Staff A (Cook) was preparing food and serving breakfast meals with no covering over facial hair. Interview on 12/14/23 at approximately 12:30 p.m. with Staff A confirmed that they do not wear a covering over their facial hair when preparing or serving food items. Review on 12/18/23 of the Food Code U.S. Public Health Service 2017 U.S. Department of Health and Human Services retrieved from https://www.fda.gov/food/fda-food-code/food-code-2017 revealed the following: .2-4 HYGIENIC PRACTICES . Food Contamination Prevention . Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in ¶ (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE SERVICE and SINGLE-USE ARTICLES . Food Contamination Prevention . Hair Restraints 2-402.11 Effectiveness. Consumers are particularly sensitive to food contaminated by hair. Hair can be both a direct and indirect vehicle of contamination. Food employees may contaminate their hands when they touch their hair. A hair restraint keeps dislodged hair from ending up in the food and may deter employees from touching their hair .

Based on observation, interview and record review, it was determined that the facility failed to notify the physician of medications not administered to the resident for 3 residents in a final sample of 18 residents (Resident Identifiers are #17, #23 and #30). Findings include: Resident #23 Review on 12/15/23 of Resident #23's progress note dated 11/13/23 revealed that Resident #23 re-admitted from the hospital at 7:00 p.m. Review on 12/15/23 of Resident #23's Medication Administration Record from a local hospital dated 11/13/23 at 3:55 p.m. revealed that Resident #23 last received Dilantin (Phenytoin - a seizure medication) on 11/13/23 at 12:29 p.m. Review on 12/15/23 of Resident #23's November 2023 Medication Administration Record (MAR) revealed physician's orders for phenytoin sodium extended release capsule 30 milligrams (mg) twice a day (at 7:00 a.m. to 11:00 a.m. and 6:00 p.m. to 11:00 p.m.) and phenytoin chewable tablet 100 mg three times a day (at 8:00 a.m., 2:00 p.m., and 8:00 p.m.). Further review revealed the following; -On 11/13/23 at 10:59 p.m. the 30 mg was Not Administered: Other Comment: - and 100 mg at 8:00 p.m. was documented H or hospital; -On 11/14/23 at 8:52 a.m. and 8:14 p.m. the 30 mg was documented as Not Administered: Drug/Item unavailable; -On 11/15/23 at 11:40 a.m. the 30 mg was documented as Not Administered: Resident unavailable . -On 11/17/23 at 2:00 p.m. the 100 mg was documented as Not Administered: Resident unavailable Comment: [resident at appointment] -On 11/22/23 at 8:00 a.m. the 100 mg was documented as Not Administered: Resident unavailable Comment [at appointment]; -On 11/23/23 at 2:00 p.m. the 100 mg was documented as Not Administered: Resident unavailable. Review on 12/15/23 of Resident #23's December 2023 MAR revealed physician's orders for phenytoin sodium (Dilantin) extended release capsule 30 mg twice a day (at 7:00 a.m. to 11:00 a.m. and 6:00 p.m. to 11:00 p.m.) and phenytoin chewable tablet 100 mg three times a day (at 8:00 a.m., 2:00 p.m., and 8:00 p.m.). Further review revealed the following: On 12/3/23 at 1:19 p.m. the 100 mg was Not Administered: Resident unavailable Comment: out with family; On 12/4/23 at 10:38 a.m. the 30 mg was Not Administered: Drug/Item unavailable. Interview on 12/15/23 at 1:39 p.m. with Staff E (Director of Nursing) confirmed the above. Staff E revealed that Resident #23's physician should have been notified of the above missed doses. Resident #17 Observation on 12/14/23 at 8:39 a.m. of Staff H (Licensed Practical Nurse (LPN)) administering medications to Resident #17 revealed that Tylenol Arthritis Extended Release 650 mg was not available. Interview on 12/14/23 at 8:39 a.m. with Staff H revealed that the medication had been ordered from the pharmacy on 12/11/23, but had not been delivered. Review on 12/14/23 of Resident #17's December 2023 MAR revealed the following order: Tylenol Arthritis Pain 650 mg tablet scheduled for the day shift (7:00 a.m. to 11:00 a.m.) and evening shift (6:00 p.m. to 11:00 p.m.). Further review revealed the medication was Not Administered: Drug/Item unavailable on 12/13/23 on the evening shift (6:00 p.m. to 11:00 p.m.) and on 12/14/23 on the day shift. Review on 12/14/23 of Resident #17's progress notes revealed no documentation that the physician had been notified of the missed doses. Interview on 12/14/23 at 9:01 a.m. with Staff H revealed that he/she did not notify anyone regarding Resident #17's missed medication. Interview on 12/15/23 at 1:55 p.m. with Staff E confirmed that there was no documentation that the physician had not been notified. Resident #30 Review on 12/15/23 at approximately 9:30 a.m. of Resident #30's November 2023 MAR revealed an order for Tramadol 25 mg to be given at 12:00 a.m., 6:00 a.m., 12:00 p.m., and 6:00 p.m Further review of November 2023 MAR revealed that on 11/22/23 and 11/23/23 the 12:00 a.m. doses and the 6:00 a.m. doses were marked as not given medication, not available. Review on 12/15/23 at approximately 9:30 a.m. of Resident #30's progress notes for November 2023 revealed no documentation that the provider was notified of the medications not being given. Further review Resident #30's progress notes, dated 11/23/23, revealed Resident's pain medication (Tramadol) did not come in from pharmacy. No c/o [complaints of] pain at present. Will continue to monitor remainder 11-7 shift. Interview on 12/15/23 at approximately 10:25 a.m. with Staff G (Medication Nursing Assistant) confirmed that Resident #25 did not get the Tramadol as prescribed on 11/22/23 and 11/23/23. Staff G stated that the medication was available in the facility backup medication supply. Staff G confirmed that there was no documentation that the provider was notified of the missed doses. Review on 12/15/23 of the facility's policy titled Medication Administration Procedures, revised 2/16/22, revealed, . 20. The licensed nurse will notify the physician or licensed physician extender of medications that become unavailable .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined that the facility failed to ensure that residents' formulated advance directives would be followed for 2 out 21 residents reviewed. (Resident identifiers are #31 and #38.) Findings include: Resident #31 Review on [DATE] of Resident #31's Electronic Health Record (EHR) revealed that Resident #31's code status was Do Not Resuscitate (DNR), initiated on [DATE]. Interview on [DATE] at approximately 8:45 a.m. with Staff B (Unit Manager) revealed that if a resident's paper medical chart did not have a pink portable DNR in it, the resident would be considered a full code. Staff B stated that Resident #31 was a full code. Staff B then reviewed the EHR and confirmed that Resident #31 had an order for a DNR status. Resident #38 Review on [DATE] of Resident #38's EHR revealed that Resident #38's code status was a DNR, initiated on [DATE]. Interview on [DATE] at approximately 8:45 a.m. with Staff B revealed that if a resident's paper medical chart did not have a pink portable DNR in it, the resident would be considered a full code. Staff B stated that Resident #38 was a full code. Staff B then reviewed the EHR and confirmed that Resident #38 had an order for a DNR status. Review on [DATE] of the facility policy titled, Establishing Code Status, Date Reviewed Revised: 3/2022 revealed: Purpose The purpose of establishing code status is to be able to carry out the resident's wish for Cardiopulmonary Resuscitation (CPR) or DNR when they are not able to make that determination. A resident who has not determined code status will be treated as CPR. .Procedure . 4. Documentation regarding the Resident's code status will be maintained in the resident's electronic health record 6. A portable DNR Form may be completed but is not required.

Based on observation, interview and policy review, it was determined that the facility failed to ensure professional standards for catheters for 2 out of 3 residents reviewed for catheter / urinary tract infections (UTI) in a final sample of 21 residents. (Resident identifiers are #1 and #3). Findings include: Review on 11/17/22 of the Healthcare Infection Control Practices Advisory Committee (HICPAC), Guideline for Prevention of Catheter Associated Urinary Tract Infections 2009 revealed: .III. Proper Techniques for Urinary Catheter Maintenance . B.2. Do not rest the bag on the floor. Resident #1 Observation on 11/15/22 at approximately 9:30 a.m. revealed Resident #1's catheter drainage bag and tubing lying on the floor next to the resident's bed. Resident #3 Observation on 11/15/22 at approximately 10:00 a.m. revealed Resident #3's catheter drainage bag and tubing lying on the floor next to the resident's bed. The catheter bag was not connected to the bed frame. Observation on 11/16/22 at approximately 1:20 p.m. revealed Resident #3's catheter drainage bag and tubing lying on the floor next to the resident's bed. The catheter bag was not connected to the bed frame. Interview on 11/17/22 at approximately 1:20 p.m. with Staff A (Licensed Nursing Assistant) confirmed that the catheter drainage bag and tubing should not be lying on the floor. Review on 11/17/22 of the facility policy titled, Urinary Drainage Bag Care, Latest Revision Date 4/2022 revealed: Policy . Drainage bag will be covered with a dignity bag to avoid the drainage bag from directly touching the floor .