Every finding on record at Friendship Health and Rehab

Based on observations, staff interviews, and review of the facility's policies Handwashing/Hand Hygiene, and Medication Administration-General Guidelines, the facility failed to perform proper hand hygiene practices while observing two out of two Licensed Practical Nurses (LPN) (LPN AA and LPN BB) during medication administration. This deficient practices had the potential to increase the risk of infection transmission and compromise the health and safety of residents. The facility census was 55 residents. Findings include: Review of the facility's policy Handwashing/Hand Hygiene, dated February 2021 under the Policy Statement revealed, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to the personnel, residents, and visitors .7. Use an alcohol-based hand rub .for the following situations: .(b.) Before and after direct contact with residents;( c.) Before preparing or handling medications; (d.) Before performing any non-surgical invasive procedures .(i.) After contact with a resident's intact skin; .(l.) After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. (m.) After removing gloves .9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare associated infections .Procedure. Applying and Removing Gloves. 1. Perform hand hygiene before applying non-sterile gloves .4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. Perform hand hygiene. Review of the facility's policy Medication Administration-General Guidelines, dated April 4, 2016, revealed, 2) Handwashing and Hand Sanitation: The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly before beginning a medication pass, prior to handling any medication, after coming into direct contact with a resident .(c.) Sanitization is not a substitute for proper handwashing, and washing should be done if there is any question. 1. Observation on 4/23/2025 at 8:40 am, during a medication pass revealed, LPN AA entered the Resident (R) 37 (R37), room without performing hand hygiene and waited several minutes while the R37 remained in the bathroom. During this time, she repositioned R37's roommate in bed but failed to perform hand hygiene afterward. LPN AA then proceeded to check R37's oximetry (measuring the oxygen saturation level using a device placed on the finger) and, after completing the check, placed the pulse oximeter in her pocket and administered R37's medications. After completing medication administration, LPN AA sanitized her hands, exited the room, and returned to her medication cart. Upon returning to the cart, she began preparing medications for the next resident without re-sanitizing her hands. In an interview that was conducted during this time with LPN AA revealed, when asked whether she should have sanitized her hands between residents or prior to preparing medications for the next resident, she acknowledged that she should have but did not. 2. Observation on 4/23/2025 at 9:04 am during a medication pass revealed, LPN BB prepared medications for R8 and entered the resident's room without performing hand hygiene. In an interview immediately following medication administration for R8, the surveyor asked LPN BB whether hand hygiene should have been performed prior to starting the task. LPN BB acknowledged that she should have performed hand hygiene but, stated that she was nervous and forgot. In an interview conducted on 4/23/2025 at 2:10 pm with the Infection Control (IC) Licensed Practical Nurse revealed that she expects staff to perform hand hygiene consistently before and after providing care to residents. When presented with a scenario in which a nurse, while assisting one resident, needs to provide care to the roommate, she confirmed that hand hygiene must be performed between interactions with each resident. 3. Observation on 4/23/2025 at 4:00 pm of LPN AA performing a blood glucose check on R19 revealed, LPN AA did not perform hand hygiene upon entering the resident's room or prior to performing the procedure or applying gloves. Upon completion, LPN AA removed the gloves and washed her hands. In an interview immediately after the procedure, the surveyor asked LPN AA whether hand hygiene should have been performed before starting the task and LPN AA responded that it was not necessary because she had worn gloves. In an interview with the Director of Nursing (DON) on 4/23/2025 at 4:05 pm, she revealed that staff are expected to perform hand hygiene before and after providing care to residents, including if a nurse pauses one task to complete another and then returns to the original task. DON confirmed that wearing gloves was not a substitute for handwashing.

Based on observations, staff interviews, and review of facility policies titled, Pot and Pan Washing and Sanitation, Dishwashing, Food storage and Inventory, Food temperatures, and Personal Hygiene, the facility failed to ensure pans were stored dry to prevent bacterial growth; failed to store food items off the floor in the dry storage area and walk-in refrigerator; failed to ensure resident nourishment refrigerator food items were properly labeled and dated; failed to ensure all food items served on the steam table were held above 135 degrees Fahrenheit; and failed to ensure male dietary staff completely covered facial hair. These deficient practices affected all 39 residents consuming an oral diet. Findings include: 1. Review of the facility's policy titled, Pot and Pan Washing and Sanitation revealed after pots and pans are dry, they must be inspected and stored inverted in a clean dry protected area. Review of the facility's policy titled, Dishwashing revealed allow all items to thoroughly dry before unloading racks or storing items. Observation on 4/14/2023 at 8:27 a.m. of stored steam table pans reveal a stack of five square pans. When the top pan was pulled from the stack, the inside had moisture that covered the bottom and sides. Interview on 4/14/2023 at 8:30 a.m. with Dietary Cook CC confirmed that the square steam table pan was wet and stated that dietary staff know not to stack pans when wet. Additional kitchen observation on 4/16/2023 at 9:05 a.m. of a stack of five square steam table pans, the pan second from the top was pulled to reveal the inside the bottom of the pan had moisture. Interview on 4/16/2023 at 9:05 a.m. with the Certified Dietary Manager (CDM) confirmed that the square pan had moisture inside and staff should have let it dry completely before stacking. 2. Review of the facility's policy titled, Food Storage and Inventory revealed food to be stored a minimum of 6 inches above the floor and 18 inches from the ceiling and sprinkler heads. Observation on 4/14/2023 at 8:34 a.m. of the walk-in refrigerator revealed a black colored milk crate on the floor near the door. The crate contained cans of carbonated beverage. Observation on 4/15/2023 at 8:18 a.m. of one of two emergency supply storage closets revealed a stack of beverages directly on the floor. The stacked beverages were two cases of electrolyte beverage bottles and four cases canned ginger ale. Interview on 4/15/2023 at 8:18 a.m. the CDM confirmed that the stack of beverages in the emergency storage closet were sitting on the floor and not stored off the floor. The CDM stated that all food items should be stored off the floor. Observation on 4/16/2023 at 9:03 a.m. of the walk-in refrigerator revealed the black colored milk crate containing canned beverages remained on the floor. Interview on 4/16/2023 at 9:03 a.m. the CDM confirmed that the crate with canned beverages was on the floor of the walk-in refrigerator. The CDM stated that the crate should not be directly on the floor. 3. Review of the facility's policy titled, Food Storage and Inventory revealed leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Observation on 4/15/2023 at 8:25 a.m. of the resident nourishment room refrigerator revealed on the middle shelf four sandwiches in individual plastic bags with no label or date. Continued observation revealed a small square plastic container on the bottom shelf that contained an orange colored food item which had no label or date. Further observation revealed the top freezer contained two frozen meals with no label or date and one frozen Salisbury steak meal with no label or date. The freezer also contained a half gallon container of rocky road ice cream with no label or date. Interview on 4/15/2023 at 8:25 a.m. the CDM stated that dietary staff is only responsible for stocking the refrigerator and freezer with food items for the residents. The CDM stated that housekeeping is responsible for cleanliness, temperature taking, and ensuring all food items are properly labeled and dated. The CDM confirmed that the four sandwiches in the refrigerator had no label and dated and stated that the sandwiches likely came from the dietary department. The CDM stated that dietary staff should have labeled/dated the sandwiches before they left the kitchen and before being stored in the resident refrigerator. Interview on 4/15/2023 at 8:33 a.m. with Housekeeper DD confirmed that housekeeping staff is responsible for ensuring food items in the refrigerator are labeled and dated. Housekeeper DD stated that if food items are not labeled and dated, they are to be discarded. 4. Review of the facility's policy titled, Food Temperatures revealed to keep the temperature of hot foods no less than 140 degrees during tray assembly. Review of the Resident Count by Diet Order report revealed that the facility has 10 residents receiving a puree consistency diet. Steam table temperatures were completed on 4/15/2023 at 12:30 p.m. The CDM assisted with taking the temperatures of food items using the facility's calibrated thermometer. Continued observation revealed that not all hot food items could fit into the steam table and several small steam table pans were kept on top of lids which were on top of hot food items in the steam table. The pureed Creole sauce had a temperature of 122 degrees. Interview on 4/15/2023 at 12:30 p.m. with the CDM confirmed that the puree Creole sauce only had a temperature of 122 degrees and stated that it needed to be re-heated. The CDM revealed that hot food should be held on the steam table at least 135 degrees. Interview on 4/15/2023 at 12:30 p.m. with Dietary Cook BB revealed that seven residents receiving puree consistency diets remained to be served a lunch meal. Dietary Cook BB stated there are 10 residents total receiving a puree diet. Dietary cook BB revealed there was not enough room directly in the steam table for the pureed Creole sauce. 5. Review of the facility's policy titled, Personal Hygiene revealed head covering to be worn, hair must be completely covered with a hair net at all times. Observation on 4/16/2023 at 9:07 a.m. of Dietary Cook BB revealed he was in the kitchen preparing resident's lunch meals. Dietary Cook BB had facial hair and only wore a paper surgical mask which allowed the sides of his beard to be exposed. Interview on 4/16/2023 at 9:07 a.m. with Dietary Cook BB revealed that he typically wears a hair net over his facial hair and thought wearing the mask was enough. Interview on 4/16/2023 at 9:07 a.m. the CDM confirmed that Dietary Cook BB's facial hair was not completely covered with sides exposed. The CDM stated that she expected all facial hair to be covered. The CDM confirmed that the policy regarding dietary staff personal hygiene did not include anything regarding facial hair.

Based on record review, staff interview, and review of the facility's policies titled, Automatic Stop Orders, and Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of four residents (R) (R#13, R#9, R#14, R#21) reviewed for unnecessary medications. This failure had the potential for medication interaction, adverse reactions, respiratory depression, falls, constipation, and increased anxiety. Findings include: Review of the facility's policy titled, Automatic Stop Orders, number IB3, effective date 4/1/2016, revealed the policy did not address a 14-day stop date for psychotropic medications. Review of the facility's policy titled, Medication Orders dated 4/1/2016 revealed the policy of new medication orders are subject to automatic stop orders unless the medication orders specify the number of doses or duration of medication. A time limit is included in recapped orders. The procedures sections D: revealed: all medication orders that do not specify duration or number of doses are automatically discontinued in accordance with the Stop Order policy; section G: when entering medications covered by the Stop Order policy on the Medication Administration Record (MAR), the automatic stop date is recorded in the appropriate area on the MAR. 1. Review of the Medical Doctor (MD) orders for R#13, dated 1/1/2023, revealed the MD ordered Ativan (for treatment of anxiety) 0.5 milligrams (mg), one tablet by mouth every six hours, as needed (PRN) for agitation. The order had no stop date. Review of the monthly MAR's for February 2023, March 2023, and April 2023 revealed R#13 received lorazepam (generic for Ativan) 0.5 mg by mouth on the following dates and times: February 3, 2023, at 8:30 p.m., February 6, 2023, at 8:56 p.m., February 8, 2023, at 3:53 a.m., February 9, 2023, at 8:34 p.m., February 10, 2023, at 9:52 p.m., and February 11, 2023, at 11:14 p.m. March 1, 2023, at 9:12 a.m., March 3, 2023, at 9:22 a.m., March 11, 2023, at 10:34 a.m., March 15, 2023, at 10:02 a.m., March 17, 2023, at 8:44 a.m., March 18, 2023, at 7:37 p.m., March 19, 2023, at 1:30 a.m., March 22, 2023, at 8:40 a.m., March 28, 2023, at 8:45 p.m., March 29, 2023, at 8:28 a.m., and March 30, 2023, at 8:46 a.m. and 9:30 p.m. April 1, 2023, at 9:30 p.m., April 2, 2023, at 9:49 p.m., April 11, 2023, at 9:15 p.m., and April 14, 2023, at 9:40 p.m. Interview on 4/15/2023 at 9:55 a.m. with the Assistant Director of Nursing (ADON) revealed that she was aware that antipsychotic medications required a stop date. She stated she believed antipsychotic and psychotropic medications had a 30-day mandatory stop date. She acknowledged R#13 had a PRN order for lorazepam 0.5 mg every 6 hours PRN, which the physician ordered on 1/1/2023. The ADON stated it was the pharmacist's responsibility to ensure medications had stop dates if a medication required one and to inform the physician. The ADON said the facility did not have a process to ensure the pharmacist monitored the medications for stop dates. 2. Review of the Medical Doctor (MD) orders for R#9, dated 9/14/2022, revealed the MD ordered Ativan 0.5 mg, one tablet by mouth every four hours, PRN for agitation. The order had no stop date. Review of the MAR's for October 2022 through April 2023 revealed a nurse administered R#9 lorazepam (generic for Ativan), 0.5 mg by mouth, on the following dates and times: October 4, 2022, at 11:40 p.m., October 17, 2022, at 1:55 p.m., and October 24, 2022, at 8:12 p.m. November 3, 2022, at 7:44 p.m., November 2022 at 7:55 p.m., and November 13, 2022, at 8:15 p.m. January 17, 2023, at 8:53 a.m. and 9:05 p.m. February 2, 2023, at 12:09 a.m., February 6, 2023, at 10:50 a.m. and 9:01 p.m., February 11, 2023, at 11:13 p.m., February 15, 2023, at 10:58 p.m., February 16, 2023, at 11:42 p.m., February 17, 2023, at 9:03 p.m., February 20, 2023, at 8:09 p.m., February 21, 2023, at 8:51 a.m., February 22, 2023, at 9:20 p.m., and February 25, 2023, at 9:41 a.m. March 11, 2023, at 10:35 a.m., March 16, 2023, at 9:11 p.m., March 18, 2023, at 7:37 p.m., March 28, 2023, at 4:22 p.m. and 9:00 p.m., March 29, 2023, at 8:30 p.m., and March 31, 2023, at 8:42 a.m. and 9:20 p.m. April 1, 2023, at 9:30 p.m., April 2, 2023, at 8:52 p.m., April 11, 2023, at 9:17 p.m., and April 14, 2023, at 9:33 p.m. 3. Review of the medical record for R#14 revealed diagnoses including but not limited to Alzheimer's disease, dementia, delusional disorders, anxiety disorder, depression, muscle weakness, dysphagia, hallucinations, and protein calorie malnutrition. Review of the quarterly Minimum Data Set (MDS) dated [DATE] for R#14 indicated Section C-Cognitive Patterns revealed a Brief Interview for Mental Status (BIMS) was coded as 2, which indicated severe cognitive impairment. Section G-Activities of Daily Living (ADL's) revealed R#14 required extensive assistance of two or more persons for bed mobility, transfers, dressing, toileting, and personal hygiene. Section N-Drug Regimen Review revealed R#14 received an antipsychotic medication seven days a week, an antianxiety medication seven days a week, and an antidepressant medication seven days a week during the look back period. Review of the physician orders for R#14 revealed an order dated 12/15/2022 for lorazepam 0.5 mg one tablet daily two times day and PRN, every six hours PRN for agitation. The physician order did not have a stop or end date. There is no evidence of a rationale from the physician for the extension past 14 days. Interview on 4/16/2023 at 10:10 a.m. with the ADON confirmed that R#14 had an order for PRN lorazepam with no stop/end date. The ADON revealed that the consult pharmacist should have alerted them to the issue of PRN lorazepam needing a 14 day stop date. 4. Review of the medical record for R#21 revealed diagnoses including vascular dementia, unspecific psychosis, generalized anxiety disorder, and major depressive disorder. Review of the significant change MDS dated [DATE] revealed sections C revealed BIMS was not documented, section D-Mood Disorders was not documented, section E-Behavior revealed physical behaviors directed toward others one to three days, rejection of care or evaluation one to three days; section N revealed antianxiety medication was received seven days a week. Review of the physician's orders for R#21 revealed an order dated 12/15/2022 for lorazepam 0.5 mg one tablet by mouth every six hours PRN for agitation. Review of the physician's orders did not indicate that the use of PRN medications had been evaluated by the physician for continued use beyond 14 days. There was no stop date for the order. Review of the care plan for R#21 revealed a focus area of using anti-anxiety medications related to anxiety disorder with a goal that resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions included medications as per physician's orders including Ativan (lorazepam) tablet PRN. Review of the MARS dated January 2023, February 2023, March 2023, and April 2023 revealed R#21 received lorazepam 0.5 mg thirteen times. Review of the Gradual Dose Reduction (GDR) document dated 3/8/2023 for R#21 revealed the medication lorazepam 0.5 mg was documented as being reviewed with no recommended changes. Review of the last six months of the Monthly Medication Review (MMR) for R#21 revealed there were no changes recommended for the medication lorazepam 0.5mg. Interview on 4/15/2023 at 1:37 p.m. with Licensed Practical Nurse (LPN) EE revealed she had worked at the facility for two years. She revealed nurses transcribe physician orders into the Electronic Medical Records (EMR) system. She revealed nurses follow a template within the EMR system when transcribing and the order is transmitted to the pharmacy. She revealed the pharmacist reviewed all medications every month and recommended changes go to the ADON and Director of Nursing (DON). She revealed she would notify the physician if she questioned a medication order and was unsure if a psychotropic medication should have a stop date. Interview on 4/15/2023 at 2:00 pm with LPN AA revealed nurses transcribe physician orders into the EMR as written by the physician. She revealed she would consult with the physician if she questioned an order. She went on to revealed she was not aware if lorazepam should be ordered as a prn medication for more than fourteen days. Interview on 4/15/2023 at 2:20 pm with the Director of Nursing (DON) revealed PRN psychotropic medication orders should be discontinued after 14 days and a new physician's order obtained. She revealed when nurses transcribe medications into the EMR, an end date of 14 days should be placed in the system. She verified that R#21 had an order dated 12/15/2022 for lorazepam tablet 0.5 mg give one tablet by mouth every six hours PRN for agitation. She verified the facility did not have a process to ensure the pharmacist monitored the medications for stop dates. 35180 46691

Based on observation, staff interviews, record review, and review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure the filter on an oxygen concentrator for one of four residents (R) (R#20) receiving oxygen therapy was changed per physician's order. This failure had the potential to compromise R#20's access to the required level of oxygen. Findings include: Review of the facility's policy titled, Sanitation and Infection Control Oxygen Concentrator and Humidifier, revised September 2020, revealed oxygen filters were to be cleaned weekly and as needed and recorded on the Treatment Administration Record (TAR). Review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed the following: Section C-Cognition revealed that R#20 had a documented Brief Interview for Mental Status (BIMS) score of 14, indicating R#20 was cognitively intact. Section O-Special Treatments & Programs revealed that R#20 received oxygen therapy. Review of the care plan for R#20 revealed the nurse would clean the oxygen concentrator filter weekly if the filter was visibly dirty. Additionally, the filter would be changed on Fridays during the evening shift. Review of the Medical Doctor (MD) orders dated 12/30/2022 revealed the following: Clean the oxygen concentrator filter weekly if the filter is visibly dirty, every night shift, and every Friday when oxygen is in use. Review of the TAR for R#20 dated 4/1/2023 through 4/30/2023 revealed a facility nurse documented R#20's oxygen concentrator filter was changed on 4/7/2023 at 7:00 p.m. Observation on 4/14/2023 at 8:45 a.m. of R#20's oxygen concentrator revealed the filter had apparent signs of dust and debris noted on the entire filter. The oxygen tubing had a change date of 4/12/2023. Interview on 4/14/2023 at 8:47 a.m. with the Licensed Practical Nurse (LPN) AA revealed that R#20's oxygen concentrator filter was supposed to be changed every week. LPN AA acknowledged R#20's oxygen concentrator filter was dirty and appeared it had not been changed in a long time. However, LPN AA stated it was the night nurse's responsibility to change the filters weekly, and the date of change was indicated weekly on the TAR. Per LPN AA, the TAR showed the filter had been changed on 4/7/2023, but she went on to state it did not look like it had been changed. LPN AA added that the filters do not look that dirty after one week. LPN AA said she would generally back-check to ensure the filter was changed, even though the task fell to the night shift on Friday nights. Interview on 4/15/2023 at 1:12 p.m. with the Administrator revealed that they acknowledged R#20's oxygen concentrator filter was dirty. The Administrator stated it was their expectation for staff to follow MD orders and change the filter weekly and as needed. Interview on 4/15/2023 at 1:18 p.m. with the Assistant Director of Nursing (ADON) revealed they expected staff to change the oxygen concentrator filters per MD orders, which was weekly and as needed.

Based on observations, record review, staff interviews and review of the policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier, the facility failed to ensure humidification was provided for one resident (R#10) receiving two liters of Oxygen therapy. The sample size was 27 residents. Findings include: Review of the facility policy titled Sanitation and Infection Control Oxygen Concentrator and Humidifier revealed the purpose is to ensure that oxygen concentrators, humidifier bottles, and nebulizer setups remain clean, revised 9/2020. General information is to follow the schedule and intervals specified in this procedure unless State specific requirements specify more frequent time frames. Procedure number two (2) revealed Changing Schedule- oxygen mask, oxygen tubing, and nebulizer tubing are to be changed weekly. Humidifier bottles are to be changed when empty and as needed. Review of the clinical record for R#10 revealed the resident was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was assessed as three, which indicated severe cognitive impairment, and was assessed for oxygen use. Observation on 1/4/22 at 12:34 p.m. revealed the resident was receiving oxygen with the concentrator set on two liters being delivered via nasal cannula (N/C). The water humidification bottle on the concentrator was empty. Observation on 1/5/22 at 8:30 a.m. revealed the oxygen was in use at two (2) liters via concentrator, and the water humiliation bottle is dry although the R#10 was not using oxygen at this time. Observation on 1/5/22 at 8:45 a.m. revealed R#10 was using oxygen set at two liters via N/C and the water humidification bottle remains dry. An interview on 1/5/22 at 8:50 a.m., with Licensed Practical Nurse (LPN) AA revealed that oxygen supplies are changed on Fridays and as needed, along with the humidification bottles. She stated that the nurse is supposed to date the tubing and the water bottles each time they are changed. She further stated that the humidification bottles can be changed more often if they become empty. She stated that she assesses each resident, verifies the flow rate, looks at the dated tubing and the humidification bottles. She stated she did not check the oxygen tubing and humidification for R#10 this day and confirmed that the humidification bottle was dry. An interview on 1/5/22 at 8:56 a.m. with the Director of Nursing (DON) revealed that oxygen supplies are changed weekly on Friday and as needed if the humidification bottle is empty or other supplies are damaged or dirty and that the nursing staff is responsible for this task.

Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to oral care every shift, showers per facility policy, and clean nails as necessary for one resident (R) (R#61). In addition, the facility failed to implement the care plan related to monitoring for behaviors and side effects for one resident (R#48), who was routinely receiving an antipsychotic medication. The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition). Review of R#61's care plan for oral/dental health problems including several carious teeth dated 9/11/18, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revised on 9/17/18 revealed interventions for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care A.M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath, nor had mouth care, since he was admitted to the facility (on 9/11/18). Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails. Observation on 10/2/18 at 1:26 p.m. revealed that R#61's fingers appeared dirty, and had dark debris underneath the fingernails. R#61 denied receiving a bath, shower, or mouth care during interview at this time. During interview with CNA FF on 10/4/18 at 11:48 a.m., she stated that R#61 was scheduled for a shower on Mondays and Thursdays, was due for a shower that day, and that there was no documentation that he had received a shower in October. During continued interview, CNA FF stated that mouth care could be done by anyone in the morning, after lunch and at bedtime, and that she did nail care for residents on their shower day. During interview with the Assistant DON (ADON) on 10/4/18 at 2:10 p.m., she stated that the only documentation she found that R#61 received a shower since admission was on 9/11/18 and 9/25/18. Review of a Bathing: Self Performance report dated 10/4/18 revealed that R#61 received a shower on 9/11/18 at 4:08 p.m. (the day of admission), and 9/25/18 at 2:15 p.m. Cross-refer to F 677 2. Record review for R#48 revealed he was admitted with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] assessed that R#48 exhibited behaviors not directed towards others and received antidepressant and antianxiety medications. The Care Area Assessment (CAA) triggered Behavioral Symptoms and [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the Care Plans for R#48 identified: * The resident has depression. Goal- the resident will remain free of signs and symptoms (s/s) of distress, symptoms of depression, anxiety or sad mood by/through review date of 9/10/18. Interventions included, but not limited to; Administer medications as ordered. Monitor for side effects and effectiveness. Monitor/report PRN (as needed) any s/s of depression, including hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, negative statements, repetitive anxious or health- related complaints, tearfulness, harm to self and harm to others. * The resident has a mood problem related to (r/t) depression anxiety. Goal- The resident will have improved mood state, happier, calmer appearance, no s/s of depression, anxiety or sadness through review date of 9/10/18. Interventions included, but not limited to; Administer medications as ordered. Monitor for side effects and effectiveness. Monitor any risk of harm to self or harm to others. Monitor/report to MD PRN acute episode feelings of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/ eating habits, change in sleep patterns, diminished ability to concentrate, change in psycho motor skills, impaired judgment or safety awareness. * The resident uses [MEDICAL CONDITION] medications r/t anxiety, dementia, depression. Interventions included, but not limited to; Administer [MEDICAL CONDITION] medications as ordered by physician. Discuss with MD, family ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Monitor/Record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility policy. * The resident is receiving antipsychotic medication for management of dementia/depression. Goal: Resident will be managed/treated with the lowest possible antipsychotic dose and will not develop a movement disorder through the next review date of 9/10/18. Interventions included, but not limited to; Administer medication as ordered per physician. Document behaviors in MAR tracking form. Monitor for adverse medication reactions and report any to physician. Review of the Physician orders [REDACTED]. Review of the EMAR (Electronic Medication Administration Record) from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no documentation of evidence of behavior or medication side effect monitoring. R#48 was observed with anxious pacing, wandering, sleepiness r/t [MEDICAL CONDITION], verbal growling and outburst, and overall flat affect all four days of the survey from 10/1/18 through 10/4/18. During interview on 10/4/18 at 10:40 a.m. with Certified Nursing Assistant (CNA) BB, she reported behaviors of constant pacing, excessive drinking coffee and disrobing in the halls. During interview on 10/4/18 at 10:50 a.m. with the Licensed Practical Nurse (LPN) AA, she reported behaviors of [MEDICAL CONDITION], daytime sleepiness, food seeking, excessive drinking of coffee and fluids, exit seeking, wandering, pacing, and verbal growling/grunting. Further LPN AA confirmed that behavior monitoring and medication side effect monitoring had not been conducted since the resident was admitted in March, (YEAR). LPN AA further stated that she never questioned why behavior monitoring and medication side effect monitoring was not on the residents EMAR but stated it should be. Interview on 10/4/18 at 11:10 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed R#48 had been receiving antipsychotic, antianxiety, antidepressants and mood stabilizers and that no monitoring for behaviors or medication side effects had been conducted since the resident's admission to the facility in (MONTH) (YEAR). had been conducted. The DON and the ADON stated that they do not follow up to ensure behavior and side effect monitoring was entered into the EMAR and being conducted. (Cross Refer F758)

Based on record review, resident and staff interview, the facility failed to notify two residents (R) (R#69 and R#171) of the dates of their scheduled care planning conferences, to enable these residents to participate in the development and/or revision of their care plans and allow them to make decisions about their care and treatment options. The sample size was 34 residents. Findings include: Review of the facility policy Care Planning-Interdisciplinary Team revised (MONTH) 2013 revealed: Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 1. During interview with R#69 on 10/1/18 at 4:03 p.m., she stated that she had never been invited to a care plan meeting, and that this was something she would be interested in. Review of R#69's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 (a BIMS score of 13 to 15 indicates that a resident is cognitively intact). Further review of her MDS revealed that she had MDS assessments completed on 12/28/17, 3/29/18, 5/30/18, 6/25/18, and 9/24/18. Review of R#69's Invitation to attend Resident Care Plan Meeting forms revealed that on 12/27/18 (sic), 3/22/18, 5/9/18, and 8/14/18, the invitations with dates of the scheduled care plan meetings were sent to the resident's responsible party (RP) listed on her admissions packet face sheet, but no evidence that R#69 was notified or invited to her meetings. Review of Plan of Care/MDS Notes dated 1/9/18, 4/3/18, 6/26/18, and 9/25/18 revealed: Note Text: Care plan reviewed with IDT (interdisciplinary team). Family did not attend. Continue with plan of care. Review of Care Plan Session forms revealed that the IDT met to discuss R#69's care planning on 1/9/18, 4/3/18, 6/26/18, and 9/25/18. Further review of these forms revealed that the section Resident Invited to Care Plan Conference was not checked for any of these meetings, and there were notations that the family was invited but did not attend. During interview with Registered Nurse (RN) MDS Coordinator CC on 10/4/18 at 9:50 a.m., she stated that she invited residents who were cognitively intact, and able to understand what was being discussed, to their care plan meetings, and that she also sent invitations to the RP. She verified during further interview that R#69 was cognitively able to attend her care plan meetings, but that she did not invite her. 2. Record review for R#171 revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 11, indicating the resident had moderate cognitive impairment. During an interview on 10/02/18 at 8:38 a.m., R#171 stated he had never attended a care plan meeting with staff and had never been invited to attend a meeting to discuss his treatment, goals or plan of care. R#171 expressed that he would like to participate in the care plan meetings and it is important to him to be involved in the decisions of his care. He stated it is his goal to be discharged back to the community. R#171 stated he is unsure if his cousin, who is helping him, attends the meetings. Review Patient Care Conference form dated 8/14/18 documented in handwriting Family requested phone review of care plan. A check mark indicated Letter sent to family member/responsible party to attend conference. There was no check mark to indicate Resident invited to care plan conference. Interview on 10/2/18 at 2:04 p.m. with the MDS/LPN CC revealed she did not invite R#171 to his Care Plan Conference meeting. She stated the resident is forgetful but he is cognitive and she should have invited him. MDS/LPN CC stated she is relatively new to MDS and she would make sure the residents are invited to their care plan meetings moving forward.

Based on observation, record review, resident and staff interview, the facility failed to consistently provide showers, nail, and mouth care for one resident (R) (R#61). The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition); had no behaviors including rejection of care; needed supervision for personal hygiene; and extensive assistance for bathing. Review of R#61's care plan for oral/dental health problems including several carious teeth, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revealed an intervention for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care A.M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath since he had been admitted to the facility (21 days ago on 9/11/18), and that staff will tell him that they were going to come and get him, but never do. He stated during further interview that he would like a shower every day, and had never refused one. Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails, and stated during interview that he did not remember the last time they were cleaned. R#61 stated during continued interview that he had not had his teeth brushed since he had been there, and would like to have them brushed daily. Observation on 10/2/18 at 1:26 p.m. revealed that R#61's fingers appeared dirty, and had dark debris underneath the fingernails. R#61 denied receiving a bath, shower, or mouth care during interview at this time. Review of an admission Skin/Wound Note dated 9/11/18 revealed that R#61 was alert and oriented, was clean but unshaven, and had his own teeth in poor shape. Review of all of the Nurse's Notes since admission revealed that nothing was seen related to R#61 refusing care. During interview with Certified Nursing Assistant (CNA) DD on 10/3/18 at 2:58 p.m., she stated that the facility had a shower team, who worked every day but Sunday. She further stated that if other CNA staff called out, the shower team CNAs were pulled to take their place, and that this happened a lot but they still seemed to get the showers done. During interview with Licensed Practical Nurse (LPN) EE on 10/4/18 at 10:42 a.m., she stated that the shower team CNAs had been pulled to work the floor quite a bit in the past three weeks, because of a lot of call-outs and resignations recently. During interview with the Director of Nursing (DON) on 10/4/18 at 11:08 a.m., she stated that if a CNA called out for their shift, that they had to pull the shower team staff to take their place, and tried to make up the missed showers on the weekends. During interview with R#61 on 10/4/18 at 11:31 a.m., he stated that he did not believe that he had gotten a shower. During interview with CNA FF on 10/4/18 at 11:48 a.m., she stated that there were three CNAs scheduled to work the shower team, and they did an average of nine to ten showers each per day. She further stated that just about every other day at least one of the shower team staff was pulled to work the floor. She stated during further interview that if a shower team CNA got pulled, the residents assigned to them did not get a shower that day unless they had extra time at the end of the day. She stated during continued interview that showers were given sometimes on the weekend for the residents that missed their shower during the week. CNA FF further stated that R#61 was scheduled for a shower on Mondays and Thursdays, was due for a shower that day, and that there was no documentation that he had received a shower in October. During continued interview, CNA FF stated that mouth care could be done by anyone in the morning, after lunch and at bedtime, and that she did nail care for residents on their shower day. She further stated that she had never known R#61 to refuse care, and thought she may have bathed him one time but could not remember when. During interview with the Assistant DON (ADON) on 10/4/18 at 2:10 p.m., she stated that R#61's shower schedule had not been entered into the CNA's computerized system to be done routinely, but he had been scheduled for showers PRN only. She further stated that the only documentation she found that R#61 received a shower since admission was on 9/11/18 and 9/25/18. Review of a Bathing: Self Performance report dated 10/4/18 revealed that R#61 received a shower on 9/11/18 at 4:08 p.m. (the day of admission), and 9/25/18 at 2:15 p.m. During interview with the Administrator on 10/4/18 at 4:37 p.m., she stated that she had some residents recently tell her that they had not gotten their showers, and that she met with the nursing management team last Thursday to address the concern. Review of a document entitled Shower Meeting 9/27/2018 revealed that the Administrator and five nurses discussed a plan to ensure that residents received their scheduled shower if a shower team CNA got pulled.

Based on observations, record review, review of the policy titled Documentation- Behavior Monitoring and staff interviews, the facility failed to ensure that behavior and medication side effect monitoring was conducted for one resident (R) (#48) that exhibited behaviors of verbal outburst, pacing/wandering, exit seeking and obsessive drinking and received [MEDICATION NAME], an antipsychotic medication. The sample was 34 residents. Findings include: Review of the facility policy titled Documentation- Behavior Monitoring dated 3/10/16 documented When a resident receives and antipsychotic medication that is medically indicated and may help promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the resident will be placed on behavior or monitoring. 1- All residents receiving antipsychotic medications will have Behavior Monitoring to include side effects monitoring in place. 2- Nursing Management will review all medication orders daily. 3- If there is a new order for antipsychotic medication, the nurse manager reviewing will verify that the resident has also been placed on Behavior Monitoring with side effects monitoring. 6- Behavior Monitoring will be initiated on all residents with Behavior incident, and the resident will remain on Behavior Monitoring until the Behavior has resolved or stabilized and Behavior Par is discontinued. 7- Behavior Monitoring will be documented each shift on the EMAR by the Charge Nurse. R#48 was admitted to the facility with [DIAGNOSES REDACTED]. Record review for R#48 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which demented a Brief Interview for Mental Status summary score of 99 indicating the resident was unable to complete the interview. Staff assessed that the resident was fidgety or restless and moved around more than usual. R#48 exhibited behavioral symptoms not directed towards others and received antianxiety and antidepressant medications all seven days of the look back period. The Care Area Assessment (CAA) triggered Behavioral Symptoms with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS of 99. Staff assessed that the resident was fidgety or restless and moved around more than usual. R#48 exhibited behavioral symptoms not directed towards others and the presence of wandering 1-3 days of the look back period. The resident received antipsychotic, antianxiety and antidepressant medications all seven days of the look back period. Further record review for R#48 revealed a Wandering PAR tracking which documented two elopements in which the resident was found in the parking lot on 5/9/18 and 7/24/18. No further attempts to exit facility had been made by the resident. Review of the Medication Review Report revealed the following [MEDICAL CONDITION] medications: [REDACTED] 3/2/18- [MEDICATION NAME] 15 MG (milligrams) three times a day (TID) for Anxiety Disorder 3/15/18- [MEDICATION NAME] 10 MG one time a day for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 3/5/18- [MEDICATION NAME] Sprinkles 125 MG delayed release twice daily (BID) for Dementia with Mood Behaviors 3/14/18- [MEDICATION NAME] 0.25 MG once daily for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 3/16/18- [MEDICATION NAME] 1 MG once daily for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 9/28/18- Trazadone 150 MG once at bedtime for [MEDICAL CONDITION] Review of the Medication Administration Records (MAR) for R#48 from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the medications were administered as ordered. Further review of the MARs revealed no evidence or documentation of target behavioral symptoms and no evidence or documentation of medication side effect monitoring of the [MEDICAL CONDITION] medications. Observation on 10/1/18 at 12:36 p.m. revealed the resident at the dining room table, waiting for lunch. The resident was noted to make verbal growling noise throughout the dining observation. Resident also noted to walk up and down the halls and in the dining room throughout the day. Observation on 10/3/18 at 8:13 a.m. revealed R#48 at the dining room table leaning over his breakfast tray sleeping. Staff observed waking the resident up to eat. The resident did wake up to eat would then fall back asleep. Interview attempted with R#48 but the resident just makes verbal growling noises and was not a candidate for interview. Interview on 10/3/18 at 8:20 a.m. with Licensed Practical Nurse (LPN) AA revealed R#48 often stays up late and paces the halls and will not lay down. She stated the resident always fights sleep. LPN AA stated R#48 did not receive any sedation last night but received his regular scheduled 150 MG (milligrams) of Trazadone for [MEDICAL CONDITION]. She stated some mornings he is like this and if they try to lay him down, he just gets back up, will go sit in a chair on the dining/day room and fall asleep in the chair. She stated the resident gets ups and lays down as he wants to. LPN stated he probably was up a lot last night. Observation on 10/3/18 at 12:30 p.m. revealed R#48 sleeping in his bed. At 1:28 p.m. the resident was observed in his bed and had not been to the dining room. Interview on 10/3/18 at 1:30 p.m. with the Certified Nursing Assistant (CNA) BB revealed R#48 was up and awake all night and was now sleeping. She stated the kitchen staff put his lunch away and they will heat his lunch up when he wakes up. Observation on 10/4/18 at 8:24 a.m. revealed R#48 in the dining room eating his breakfast. The resident was awake and alert and occasionally grunting and making growling noises. Interview on 10/4/18 at 8:30 a.m. with LPN AA revealed it was reported to her by the nightshift LPN that R#48 was up much of the night again last night. Nightshift reported that they put him to bed and he would get back up, come into the dayroom and fall asleep in the chair. Interview on 10/4/18 at 10:40 a.m. with CNA BB revealed she is very familiar with R#48. She stated that the resident does not have any physical aggression and rarely resist care but he paces the halls a lot. She further stated the resident drinks a lot of coffee and will just keep drinking it all day. Stated he also loves food and loves to eat a lot. Interview on 10/4/18 at 10:50 a.m. with the LPN AA revealed the R#48 does not have any physically aggressive behaviors, or verbal aggression. She stated he does make a growling nose that has seemed to improve some. She stated the resident was drinking so much coffee that his sodium was low and the Physician put him on fluid restrictions. She stated R#48 does not like that and he is not compliant with this. She stated he has a gastric bypass in the past and he is food seeking. LPN AA stated she can't leave anything out like a cup of pudding or applesauce for meds or he will take it. She stated he loves to eat. LPN AA stated R#48 was exit seeking but does not exhibit this behavior anymore. She stated he paces the halls, fights sleep and walks constantly. She stated the resident goes around touching things and messing with things. Further, LPN AA confirmed that since the resident' admission in March, (YEAR), there had been no behavior monitoring or monitoring of side effects of antipsychotic medications for R#48. LPN AA stated that as a nurse, any resident receiving an antipsychotic medication is supposed to monitor and document behaviors and medication side effects each shift daily. LPN AA was asked had she ever questioned why behavior monitoring or medication side effects was not on the MARS, she stated No. Interview on 10/4/18/at 11:43 a.m. with the Attending Physician for R#48 revealed the R#48 gets extremely agitated at times. He stated the resident has a behavior where he bellows out super loud and it can go on for hours at a time. He stated he has witnessed this behavior himself. He stated the resident was exit seeking although this has improved some but he still paces or walk around constantly and at night time. He stated the resident has exhibited obsessive behaviors and would drink 20-30 cups of coffee a day. He stated his sodium was low and he ordered fluid restriction for the resident although the resident is rarely compliant. He stated the resident touches everything and is food seeking and it's disconcerting to the resident and he is generally unsettled and miserable. The Attending Physician stated R#48 is not aggressive and very pleasant but dementia medications or that family of medications will not help with these types of behaviors. He stated he is trying the [MEDICATION NAME] for now and he has seen a little improvement. He stated he may try other medications down the road but this is currently what they are doing to try and address his behaviors. Interview on 10/4/18 at 11:10 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed the ADON typically enters the new admission orders [REDACTED]. The ADON stated new medication orders after admission are entered by the nurse receiving the orders and that nurse would be responsible for entering the behavior and medication side effect monitoring. The DON stated they discuss all new medications every morning in meeting. The DON and the ADON stated that they do not follow up to ensure the medication was entered in the Electronic Medical Record (EMER) or that behavior and side effect monitoring was entered on the MAR. The DON and ADON confirmed R#48 had been receiving antipsychotic, antianxiety, antidepressants and mood stabilizers and that no monitoring had been conducted.

Based on record review and staff interview, the facility failed to ensure that Liability and Appeal Notices for three (3) of three (3) resident's reviewed (#35, #45, and #49), were given timely following discharged from Medicare Part A Skilled services. Findings include: Record review for resident #35 revealed the resident received Medicare services from 10/25/14 until 11/14/14. There was no evidence that any Liability notice was given to the resident that Medicare covered days were ending. Record review for resident #49 revealed that resident received Medicare services from 11/16/13 until 2/23/14. Notification that Medicare covered services were ending was issued on 2/13/14. Record review for resident # 45 revealed the resident received Medicare services from 12/1/14 until 12/18/14. There was no evidence that any Liability Notice was given to resident that Medicare covered services were ending. Interview with the Financial Services Coordinator "AA" on 3/12/15 at 10:37 AM revealed that the former office manager had resigned and she was not able to provide Liability notices for these resident.

Based on record review, observation and staff interview, the facility failed to ensure a resident with visual impairment had glasses available for one (1) resident ("A") from a sample of twenty-three (23) residents. Findings include: Review of the clinical record revealed resident "A" was admitted on [DATE] with [DIAGNOSES REDACTED]. Loss, Hypertension, Alcohol withdrawal and Unsafe home environment. Review of the current admission Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed that the resident as having visual impairment and no corrective lenses. Review of the resident care plan revealed that the resident was care planned for vision with appropriate interventions but did not include eye examination. Interview on 08/15/13 at 8:25 a.m. with resident "A" revealed his glasses were left at home and he was not allowed to go back to get them. The resident was not wearing eyeglasses. Interview with the MDS Coordinator on 8/11/13, at 10:50 a.m.revealed that she assessed the resident as having visual impairment but did not know if the resident had been placed on the list to be seen by the eye doctor. Continued interview revealed that the list is done by the Social Worker. Interview on 08/15/13 at 11:35 a.m. with the Social Worker revealed this was the first time she had heard anything about the resident needing glasses but would put the resident on the list for a visit with the Eye doctor when he comes to the facility again. Continued interview revealed that his last visit was in June and he visits about every 3 months. Resident "A" was admitted in May and the Eye doctor's last visit was in June.

Based on observation and record review, the facility failed to provide appropriate supervision for one (1) resident (#40) from a sample of twenty three (23) residents. Findings include: Review of the clinical record for resident #40 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Observation of resident #40 on 8/14/13 at 7:57 a.m. revealed resident sitting in a Broda Chair in the dining room. Resident had a large bruised area around the left eye. Review of the nurses notes dated 5/17/13 revealed that at 5:40 p.m. the resident had a fall in the South dining room. Continued review revealed that the resident fell from the geri chair biting her tongue,no other injuries were assessed. Neuro checks were initiated and vital signs were recorded as within normal limits. Further review revealed that the resident was seated upright in the geri chair without supervision at the time of the fall. Spot education regarding supervision at meal times and geri chair positioning was provided to the staff. Review of the nurses notes dated 8/8/13 revealed that at 11:45 a.m. was transferred to the Broda chair by two (2) Certified Nursing Assistants (CNAs). One CNA left the room after resident was in the chair. The Broda chair was at its highest upright position-Another resident in the room began to yell out and the CNA, attending resident #40, turned to check on the resident that was yelling, and the resident in the Broda chair leaned forward and fell head first to the floor receiving a hematoma to forehead. Ice was applied, neuro checks begun, and the physician and family notified. Vital signs remained stable as did neuro checks. Review of the facility falls risk assessment for resident #40 revealed that the resident was assessed at high risk for falls with total score between 12 and 14. Ten (10) or above indicated high risk. Review of the Minimum Data Set (MDS) assessment of 5/13 revealed that the resident was assessed as at risk for falls. Review of the resident care plan revealed that the resident was care planned at risk for falls with appropriate interventions. Physical Therapy evaluated the resident quarterly and continued to evaluate the resident as no candidate for therapy.

Based on record review, family interview, and staff interview, it was determined that the facility failed to provide appropriate toenail care for one (1) resident ("A") in a survey sample of five (5) residents. Findings include: Record review for Resident "A" revealed the Minimum Data Set (MDS) assessment of August 2010 indicated that the resident had required the assistance of staff with activities of daily living, including personal hygiene, and that the resident had [DIAGNOSES REDACTED]. A podiatry progress note signed by the podiatrist and dated 08/06/2009 documented that the resident's ten nails had been debrided on 08/06/2009, and that the resident was to be seen again in three months or sooner if needed. This note also documented that the resident complained of long, painful toenails, which had been present for years and were increasing in severity. However, further record review revealed no evidence to indicate that the resident was seen again by the podiatrist. During an interview with the Administrator conducted on 12/01/2010 at 3:40 p.m., the Administrator acknowledged that the resident had not been placed on the podiatrist's list to have the toenails cut during 2010, and acknowledged that the last documented time the resident was seen by a podiatrist was 08/06/2010. During an interview with the family of Resident "A" conducted on 12/01/2010 at 12:00 p.m., the family stated that prior to the resident's November 2010 death, the resident's toenails were overgrown and curved under the toes.

Based on staff interviews and record review, it was determined that the facility failed to obtain the laboratory test results in a timely manner for one resident (#11) which resulted in a delay of effective treatment in a total sample of 16 residents. Findings include: Resident #11 had a 10/13/10 physician's orders [REDACTED]. The physician ordered licensed nursing staff to give the resident 100 milligrams of [MEDICATION NAME] two times a day for 10 days after receiving the urinalysis report on 10/14/10. The urine culture report that was obtained from the hospital included a notation that the final report was completed on 10/17/10. However, the facility did not obtain the urine culture and sensitivity report until 10/20/10 (three days later). It revealed that the resident had Proteus Mirabilis bacteria in his/her urine that was resistant to [MEDICATION NAME], the current antibiotic therapy. During an interview on 10/19/10 at 11:00 a.m., the Director of Nurses (DON) stated that the facility had a tickler system to track all of the laboratory reports. She explained that the reports were obtained timely by the facility from a computer web site and that the Assistant Director of Nurses (ADON) was responsible for obtaining them daily. She stated that there had been occasions where the facility obtained the report directly from the hospital. During an interview on 10/20/10 at 8:45 a.m., the DON stated that an inservice had been held with the licensed nursing staff on 10/6/10 that included problems that had been identified in the facility regarding the delay time of obtaining urine culture and sensitivity reports. On 10/20/10 at 10:30 a.m., the ADON reviewed the computer web site with the surveyor. She stated that, at times, residents' names were entered incorrectly when the request for laboratory test results was entered into the computer. On 10/20/10 at 11:50 a.m., the ADON confirmed that she had started a tickler system for the laboratory test results when she took the position in July of 2010 after a problem was identified through their QA (Quality Assurance) program. She explained that the reports of the laboratory tests were not obtained directly from the hospital but, the facility obtained those reports from a web site that had been set up by the hospital. She stated that she checked that web site and printed the reports. However, resident #11's name was correctly listed on the web site which confirmed that the urine culture and sensitivity test results were available on 10/17/10 (Sunday). However, the ADON was not sure why the report was not printed by the facility. Therefore, there was a delay in the physician determining the most effective treatment modality for the resident's urinary tract infection.