Every finding on record at Golden View Health Care Center

Based on interview and record review, the facility failed to ensure that 3 allegations of neglect and 1 injury of unknown source were reported timely to the Administrator of the facility and the State Survey Agency (SSA) for 4 of 8 residents reviewed for Abuse or Neglect. (Resident identifiers are #2, #3, #4, and #5.)Findings include: Resident #2Review on 5/21/26 of Resident #2's medical record revealed the following progress note, dated 3/2/26: Noted a skin tear to guest's left elbow about 2 cm (centimeters) x 0.6 cm. Wound cleansed with wound cleanser and pat dried. Bacitracin and steri strips applied. Non adherent pad placed on top of wound and covered with primapore wound dressing .Interview on 5/21/26 at approximately 12:30 p.m. with Staff A (Director of Nursing) revealed the resident was unable to provide a causative factor for the above skin tear and it was not reported to the SSA.Resident #3Review on 5/21/26 of Resident #3's medical record revealed the following progress note, dated 4/1/26, Found in BR (bathroom) chair, adjacent to toilet, quite agitated, was unhappy w (with) O/N (over night) cares by LNA (Licensed Nursing Assistant) who states was 'Very rough getting me up, and [pronoun omitted] just left me here' .Interview on 5/21/26 at approximately 12:45 p.m. with Staff A confirmed the above allegation was not reported to the SSA.Resident #4 and #5Interview on 5/21/26 at approximately 1:00 p.m with Staff D (LNA) revealed he/she left a note for Staff G (Unit Manager) on 5/20/26 with concerns of Resident #4 and #5 not receiving care on the previous shift. Interview on 5/21/26 at approximately 2:10 p.m. with Staff G confirmed Staff D left a letter with concerns of care not being provided to residents.Review on 5/21/26 of the letter from Staff D, dated 5/20/26 revealed: . I found [name omitted (Resident #4)] and [name omitted (Resident #5)]- in the same room, still in the same clothing I put them in yesterday from 2nd shift. both smelled like sweat.Interview on 5/21/26 at approximately 2:15 p.m. with Staff A revealed they were aware of the above allegations.Interview on 5/21/26 at approximately 2:20 p.m. with Staff F (Administrator) was not aware of the above allegations.Review on 5/21/26 of the facility policy titled, Prohibition of Resident Abuse, Reporting and Investigating Allegations of Resident Abuse & Crimes Against a Resident, Revision Date 1/2026, revealed, Any healthcare professional, . employee, . having information of an alleged violation involving ., including injuries of unknown source, neglect, . shall immediately report the information by following the reporting procedure.1. Internal Reporting: Within the facility any suspicion of abuse, neglect, ., whether supportable or not, will immediately be reported to the employee's department head or the Administrator including non-regular business hours, . Staff members including supervisors and department heads who receive a report will immediately notify the Administrator. External Reporting: The Administrator or her designee shall report allegations meeting the definition of abuse, neglect, . outlined in this policy and procedure to the state survey and certification agency .

Based on interview and record review, the facility failed to maintain evidence demonstrating the result of all grievances and ensure that all written decisions include the necessary elements for 2 out of 2 grievances reviewed.Findings include: Review on 5/21/26 of the facility 2026 Grievance Log revealed the following grievances:Resident #3, dated 4/1/26 and 4/15/26, Issue: [sic] LNA (Licensed Nursing Assistant) put cream on was burning and washed it off and did not come back after placing him/her in front of the sink to brush teeth. Ombudsman reported there was a concerned of nepotism re: LNA. Outcome: No abuse, neglect. Communication/technique. Staff educated.Resident #1, dated 4/1/26 and 4/15/26, LNA is too fast, rushes him/her and makes him/her feel anxious and that LNA left (spouse's) torso uncovered after care. Ombudsman reported there was a concerned of nepotism re: LNA uncovered after care. Reported: No. Outcome: No abuse, neglect. Communication/technique. Staff educated.Interview on 5/21/26 at approximately 1:00 p.m. with Staff A DON (Director of Nursing) revealed a Grievance Form would be completed when grievances are received and there was no grievance form for the above grievances. There was no documentation of the steps taken to investigate the grievance and the date the decision was issued on the grievance log. Interview on 5/21/26 at approximately 1:30 p.m. with Staff F (Administrator) confirmed the above findings.Review on 5/21/26 of the facility policy titled, ASAP Program and Resident Grievances, Revision Date 1/26/26, revealed, Golden View will respond to grievances within 5 working days, unless otherwise required by law, and work collaboratively with Residents towards an acceptable resolution .

Based on observation, interview, and record review, it was determined that the facility failed to implement infection control policies for 1 of 3 residents reviewed for Transmission Based Precautions (TBP) and failed to implement water management control measures, potentially exposing 72 residents to waterborne pathogens. (Resident identifier is #12.) Findings include: Water Management Interview on 1/13/2026 at approximately 10:00 a.m. with Staff A (Maintenance Director) confirmed the above findings. Staff A revealed that there were no time frames for when unoccupied areas should be flushed. Staff A was unable to provide documentation that unoccupied areas were flushed. Staff A confirmed there were empty rooms that would be flushed. Review on 1/13/26 of the facility's Risk management plan for Legionella Control, revised 3/2025, revealed the following: Unoccupied Areas: When units are unoccupied resulting in a decrease of water usage and potential stagnation, the Director of Property Management or designee implements counteractive measures including flushing of the sinks and fixtures with hot and cold water. Further review revealed no indication of how often unoccupied areas would be flushed. Resident #12 Review on 1/14/26 of the facility's policy titled, Residents with COVID-19 Exposure Management, review Date 11/2025, revealed the following .Staff caring for residents with suspected or confirmed COVID-19 will wear full PPE [Personal Protective Equipment] when indicated: gown, gloves, eye protection and N95 respirator (or higher), CDC [Center for Disease Control and Prevention]. Review on 1/13/26 of Resident #12's medical record revealed a progress note, dated 1/13/26, Resident #12 tested positive for COVID-19. Further review revealed a physician order for Transmission Based Precaution (TBP)) for COVID-19, dated 1/13/26. Observation on 1/14/26 at approximately 8:40 a.m. revealed a Droplet Precaution (TBP) sign posted outside Resident #12's room. Further observation revealed Staff C (Licensed Nursing Assistant) a N95 mask and gloves, but did not wear a gown prior to entering Resident #12's room. Staff C entered the room carrying Resident #12's lunch tray, moved the resident's personal items on the bedside table, and then placed the lunch tray on the bedside table. Interview on 1/14/26 at approximately 11:00 a.m. with Staff E (Infection Preventionist) confirmed that Resident #12 was on droplet precaution for COVID-19. Staff E confirmed it is the facility's policy to wear a N95 mask, gown, gloves, and eye protection when entering a room with a COVID-19 positive resident. Review on 1/14/26 of the CDC's website titled, Infection Control Guidance: SARS-CoV-2 (COVID-19), dated 6/24/24, revealed .2. Recommended infection prevention and control (IPC) practices when caring for a patient with suspected or confirmed SARS-CoV-2 infection .Personal Protective Equipment HCP [Healthcare Personnel] who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face) .

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.

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. 47129 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 . 38218

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 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 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 record review and interview, it was determined that the facility failed to accurately code Minimum Data Set (MDS) assessments for 4 residents in a final sample of 15 residents (Resident Identifiers are #15, #3, #24, #27). Findings Include: Resident #15 Review on 11/5/24 of Resident #15's Preadmission Screening and Resident Review (PASARR) Determination Summary Level II, due to mental illness, dated 5/5/23, revealed that Resident #15 was approved for Nursing Facility Services. Review on 11/5/24 of Resident #15's Annual MDS with an Assessment Reference Date (ARD) of 7/15/24 revealed Section A 1500 was coded as No for Level II PASARR. 47129 Resident #3 Review on 11/5/24 of Resident #3's Significant Change in Status MDS with an ARD of 10/24/24 revealed under section N0415 Medications: High-Risk Drug Classes: Use and Indication E. Anticoagulant was coded indicating that Resident #3 had received an anticoagulant medication during the last 7 days. Review on 11/5/24 of Resident #3's Medication Administration Record for October revealed that no anticoagulant medication was ordered or administered between 10/17/24-10/24/24. Interview on 11/5/24 at 11:15 a.m. with Staff I (Unit Manager) confirmed that Resident #3 was never on an anticoagulant medication. Resident #24 Review on 11/5/24 of Resident #24's medical record revealed that Resident #24 had a PASARR Level II Evaluation and Determination completed on 3/28/24, indicating that Resident #24 had a diagnosis of a serious mental illness and was approved for Nursing Facility Services. Review on 11/5/24 of Resident #24's Admission MDS with an ARD of 5/23/24 revealed that Item A1500, Preadmission screening and Resident Review - Is the resident currently considered by the state level II PASARR process to have a serious mental illness and/or intellectual disability or a related condition? was coded as a 0 or No. Resident #27 Review on 11/5/24 of Resident #27s Annual MDS with an ARD of 9/30/24 revealed that Item P0100 A Restraints and Alarms - Bed Rail was coded as 2 or Used Daily. Review on 11/5/24 of Resident #27's Bed Rail Assessment, dated 7/31/24, revealed that Resident #27 used bed rails to assist with bed mobility. Interview on 11/5/24 at 11:38 a.m. with Staff I confirmed that Resident #27 used bed rails to assist with bed mobility and it was not a restraint. Interview on 11/5/24 at 2:00 p.m. with Staff J (MDS Coordinator) confirmed the above findings that Resident #3, #15, #24, and #27's MDS were not accurately coded.

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 readmitted 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 .

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. 43408 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 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 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 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 send a copy of a written notice of transfer/discharge to the Office of the State Long Term Care Ombudsman (OLTCO) for 1 of 1 residents reviewed for discharge and 1 of 1 residents reviewed for hospitalization s in a final sample of 18 residents (Resident identifiers are #16 and #62). Findings include: Resident #62 Review on 12/15/23 of Resident #62's medical record revealed that Resident #62 was admitted to the facility on [DATE] for skilled nursing services. Further review of Resident #62's medical record revealed that Resident #62 was discharged on [DATE] to the Assisted Living Facility after no longer needing skilled nursing services any longer. Interview on 12/15/23 at 3:30 p.m. with Staff E (Director of Nursing) confirmed that Resident #62 was discharged on [DATE]. Interview on 12/15/23 at 3:34 p.m. with Staff B (Director of Resident Relations) revealed that that no notice was sent to the OLTCO for discharge. 43408 Resident #16 Review on 12/15/23 at approximately 9:15 a.m. of Resident #16's medical record revealed they had been discharged to the hospital on 11/16/23. Interview on 12/15/23 at approximately 3:00 p.m. with Staff B confirmed that Resident #16 had discharged to the hospital on 11/16/23 and no notice was sent to the OLTCO. Review on 12/15/23 of the facility's policy titled, Notice of Transfer/Discharge, revised 2/23, revealed . Golden View Health Care Center shall issue a written notice of transfer/discharge in accordance with RSA 151:26 for facility initiated discharges .

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: ,d+[DATE] 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 .

Based on interview and record review, it was determined that the facility failed to adhere to Center for Disease Control and Prevention (CDC) guidelines for screening residents for signs and symptoms of COVID-19 for 4 out of 5 residents observed out of a final survey sample of 19 residents. (Resident identifiers are #17, #21, #40 and #43.) Findings include: Interview on 10/13/21 at approximately 10:30 a.m. with Staff E (Infection Preventionist) revealed the facility monitors and documents daily the Temperature and Oxygen saturation of all residents for COVID-19 screening. If other symptoms of COVID-19 are present then it would be documented in the resident record. Review on 10/13/21 at approximately 1:00 p.m. of Resident screening for COVID-19, revealed less than daily T (Temperature) and O2 Sat (Oxygen Saturation) was conducted for 4 of 5 residents reviewed from 9/13/21-10/13-21: Resident #17 missing T and O2 Sat monitoring on 9/20/21, 9/28/21, 10/8/21 and 10/9/21. Resident #21 missing T and O2 Sat monitoring on 9/24/21. Resident #40 missing T and O2 Sat monitoring on 9/25/21, 9/28/21, 10/8/21, 10/9/21, 10/12/21 and 10/12/21. Resident #43 missing T and O2 Sat monitoring on 9/13/21, 9/28/21, 10/8/21 and 10/9/21. Interview on 10/14/21 at approximately with 2:00 p.m. with Staff B (Director of Nursing) confirmed there was no other resident screening documentation. Review on 10/14/21 of facility policy titled Resident screening effective 3/16/21, revealed in accordance with CDC guidelines, residents will be screened once a day for signs and symptoms of COVID-19 or a change of condition . Review on 10/14/21 of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on 9/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed, Evaluate Residents at least Daily .Actively monitor all residents upon admission and at least daily for fever (temperature ?100.0°F) and symptoms consistent with COVID-19 . symptoms of COVID-19: Fever, Cough, Shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea.

Based on interview and record review, it was determined that the facility failed to ensure that the facility staff and residents were tested for COVID-19 in response to a positive staff member for 4 out of 4 residents reviewed. (Resident identifiers are #35, #39, #49 and #66.) Findings include: Review on 10/14/21 of CMS guidance titled Interim Final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long-Term Care (LTC) Facility Testing Requirements, revised on 9/10/21, revealed the following: Testing Trigger: Newly identified COVID-19 positive staff or resident in a facility that can identify close contacts. Staff: Test all staff, vaccinated and unvaccinated, that had a higher-risk exposure with a COVID-19 positive individual. Residents: Test all residents, vaccinated and unvaccinated, that had close contact with a COVID-19 positive individual . Close Contact refers to someone who has been within 6 feet of a COVID-19 positive person for a cumulative total of 15 minutes or more over a 24-hour period .Higher-risk exposure refers to exposure of an individual's eyes, nose, or mouth to materials potentially containing [CONDITION(S)]-CoV-2, particularly if present in the room for an aerosol-generating procedure . Review on 10/14/21 of the CDC website titled Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes updated on 9/10/21, retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html revealed, .Testing .Asymptomatic HCP [healthcare personnel] with a higher-risk exposure and residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection,. In these situations testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5-7 days after the exposure . Review on 10/13/21 at approximately 9:50 a.m. of facility staff COVID-19 positive line listing revealed that on 10/8/21 Staff H (occupational therapist) had been experiencing a runny nose and tested positive for COVID-19. Further review revealed that Staff H developed symptoms on 10/7/21 after ending their work shift. Interview on 10/13/21 at approximately 11:00 a.m. with Staff E (Infection Preventionist) revealed that testing was not performed for residents identified as close contact with Staff H, who tested positive for COVID-19 identified on 10/8/21. Review on 10/14/21 at approximately 11:30 a.m. of Staff H's work schedule on 10/7/21 revealed the following treatment sessions with a total of 4 different residents on 10/7/21. Resident # 35 received a 55 minute treatment session from Staff H. Resident # 39 received a 50 minute treatment session from Staff H. Resident # 49 received a 55 minute treatment session from Staff H. Resident # 66 received a 60 minute treatment session from Staff H. Review on 10/14/21 at approximately 1:00 p.m. of Resident # 35's medical record revealed no COVID-19 testing. Review on 10/14/21 at approximately 1:00 p.m. of Resident # 39's medical record revealed the last COVID- 19 test was performed on 8/31/21. Review on 10/14/21 at approximately 1:00 p.m. of Resident # 49's medical record revealed the last COVID-19 test was performed on 9/29/21. Review on 10/14/21 at approximately 1:00 p.m. of Resident #66's medical record revealed the last COVID-19 test was performed on 9/14/21. Review on 10/14/21 of facility policy titled Resident COVID-19 testing reviewed on 10/10/21, revealed Golden View Health Care Center conducts COVID-19 testing for residents in accordance with The CMS Long-Term Care Facility Testing Requirements . Interview on 10/14/21 at approximately 2:00 p.m. with Staff E confirmed the above findings.

Based on record review and interview with staff it was found that the facility failed to provide the care and services for the prevention of pressure sores. One resident failed to receive incontinence care who developed a pressure sore that became unstageable with slough, another failed to receive a scheduled turning program. Both residents developed pressure sores and the facility failed to ensure that residents who enters the facility without pressure sores do not develop pressure sores for 2 of 10 residents with pressure sores in a standard survey sample of 20. (Resident identifiers are, #2 and #8). Findings include: Resident #8. On 2/2/11 Resident #8 was admitted to the facility with a right [MEDICAL CONDITION]. On review of the medical record both bowel and bladder assessment sheets were started but not fully completed and failed to have a three day voiding record. Review of the admission MDS dated [DATE] codes Section H (Bladder and Bowel) H 0200 and H 0500 for toileting program as having no program in place. Also review of the care plan for Resident #8 reveals it fails to have a toileting plan in place. Also on review of the Resident Profile report (which is a report that the LNA's use to provide care to resident) which was provided by Staff B (Director of Nurses) it failed to shows any type of toileting program for Resident #8. On review of the facility's tracking sheets (Matrix Report) it shows Resident #8 incontinent of bowel and bladder daily from 2/2/11 until 3/1/11, on 2/9/11 Resident #8 developed a stage 2 pressure ulcer on the coccyx measuring 1.4cm x .7cm. that progressed to a unstageable pressure ulcer on 2/28/11 with 100 % slough measuring 1.8 x 1.2. Resident #2. Record review for Resident #2 was conducted 3/1/11 - 3/3/11. Review of the Impaired Skin Integrity care plan dated 1/31/11 revealed that this resident had a Stage II pressure ulcer develop on the left buttocks. Review of the medical record revealed that this pressure ulcer was unavoidable secondary to illness, decline in heath and medical condition. Review of the above care plan revealed that this resident was to be turned and repositioned "...every 2 hours and PRN." Review of the Point of Care History Computer form dated 2/1/11-2/28/11 revealed that Resident #2 was totally dependent for bed mobility. There was no documentation that the resident was turned every 2 hours. There was documentation that this resident was moved in bed on 2/1/11 once at 12:49 p.m. and once at 12:39 a.m., a space of almost 12 hours with no documentation of turning during that 12 hour period, on 2/8/11 this resident was moved in bed once at 7:48 p.m. and once at 8:32 a.m., a space of more than 11 hours with no documentation of turning during that 11 hour period, and on 2/11/11 this resident was moved in bed once at 3:06 p.m. and once at 3:54 a.m., a space of more than 12 hours with no documentation of turning during that greater than 12 hour period. In an interview with Staff H (Unit Manager) on 3/2/11 in the afternoon Staff H stated that the Point of Care computer signatures and the skin sheet signatures indicated that the resident was turned every 2 hours. Staff H confirmed that these sheets were their only "turning program" and that no other documentation existed for monitoring the turning and repositioning of Resident #2.