**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure catheter care was provided to Resident #7. This affected one (Resident #7) of one resident reviewed for urinary catheter care. The census was 64. Findings include: Review of Resident #7's medical record revealed he was admitted to the facility on [DATE] with diagnoses that included pleural conditions-hydropneumothorax, hemiplegia/hemiparesis, difficulty walking, muscle weakness, chronic atrial fibrillation, constipation, hypertension, dysphagia, ataxia, vertigo, major depressive disorder, hypothyroidism, anxiety, insomnia, restlessness/agitation, and cerebrovascular disease. Review of Resident # Minimum Data Set (MDS) assessment dated revealed the resident was alert and oriented. Review of Resident #7's physician orders revealed an order for catheter care with a start date of 04/19/23. Review of Resident #7's Medication Administration Record (MAR) and Treatment Administration Record (TAR) for June, July, and August of 2023 revealed no evidence of catheter care being done. Review of Resident #7's Point of Care history from 07/17/23 to 08/17/23 revealed no evidence of catheter care being done. Interview on 08/14/23 at 12:49 P.M. and on 08/15/23 at 11:15 A.M. with Resident #7 revealed his catheter was not cleaned very often and he was very upset about it. Interview on 08/15/23 at 11:20 A.M. with Licensed Practical Nurse (LPN) #227 revealed Resident #7 was ordered catheter care every shift and as needed. Interview on 08/16/23 at 12:48 P.M. with Regional Nurse Consultant #315 confirmed there was no evidence of catheter care being done for Resident #7. Interview on 08/16/23 at 1:32 P.M. with Administrator also confirmed there was no evidence of catheter care being done for Resident #7.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified that an antidepressant medication was not obtained and administered to one resident for nine days. This affected one (Resident #131) of five residents reviewed for unnecessary medications. The facility census was 64 residents. Findings include: Resident #131 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety disorder. The Comprehensive Assessment had not been completed at the time of the survey. Review of the physician orders for April 2019 revealed the resident had an order dated 04/08/19 for Buspirone (antianxiety medication) 15 mg three times a day. Review of the Medication Administration Record (MAR) dated April 2019 revealed on the 8th the resident was not given the Buspirone because the resident had received the medication in the hospital before her admission to the facility. Continued review of the MAR revealed there was a gap in time between 04/08/19 and 04/14/19, with no documentation of the Buspirone being administered for nine days (24 doses). Documentation revealed on 04/14/19 at 1:33 P.M. stated Not Administered: Drug/Item unavailable; on 04/14/19 at 9:07 P.M. Not Administered: waiting for delivery; 04/15/19 10:06 A.M. Not administered: drop ship; 04/15/19 1:26 P.M. Not Administered: patient care; 04/16/19 Not Administered: drop shipment; on 04/17/19 Late Administration: Charted late: pt care. Review of the progress notes dated 04/08/19, 04/09/19, 04/15/19, 04/16/19, and 04/16/19 did not indicate the residents' physician was notified of the omitted medication. Further review of the nurse practitioners' notes dated 04/09/19 or 04/15/19 did not document she had been informed of the medication omission. Interview 04/17/19 at 10:34 A.M. with the Assistant Director of Nursing (ADON) revealed she would have to check into why the resident didn't get Buspirone timely and get back to me. Interview 04/17/19 at 12:18 P.M. with the Director of Nursing (DON) revealed she wasn't sure why the facility didn't have the medication and why nursing would not have documented on the missing days. The DON reviewed the resident record and verified the physician had not been notified of the medication omission.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an antianxiety medication was obtained for one (Resident #131) of five residents reviewed for unnecessary medications. The facility census was 64 residents. Findings include: Resident #131 was admitted to the facility on [DATE] with diagnoses including major depressive disorder and anxiety disorder. Review of the physician orders for April 2019 revealed the resident had an order dated 04/08/19 for Buspirone (antianxiety medication) 15 mg three times a day. Review of the Medication Administration Record (MAR) dated April 2019 revealed on the 8th the resident was not given the Buspirone because the resident had received the medication in the hospital before her admission to the facility. Continued review of the MAR revealed there was a gap in time between 04/08/19 and 04/14/19, with no documentation of the medication being administered for nine days (24 doses). Documentation revealed on 04/14/19 at 1:33 P.M. stated Not Administered: Drug/Item unavailable; on 04/14/19 at 9:07 P.M. Not Administered: waiting for delivery; 04/15/19 10:06 A.M. Not administered: drop ship; 04/15/19 1:26 P.M. Not Administered: patient care; 04/16/19 Not Administered: drop shipment; on 04/17/19 Late Administration: Charted late: pt care. Further review of the nurse practitioners' notes dated 04/09/19 or 04/15/19 did not document she had ben informed of the medication omission. Interview 04/17/19 at 10:34 A.M. with Assistant Director of Nursing revealed she would have to check into why the resident didn't get Buspirone timely and get back to me. Interview 04/17/19 at 12:18 P.M. with the DON she stated she wasn't sure why the facility didn't have the medication and why nursing would not have documented on the missing days.