Friendly Village Nursing and Rehab Center

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure unlicensed staff would not administer medications to 1 resident (R27) for 5 residents reviewed for medication administration in a sample of 23 residents. Certified Nursing Assistant (CNA) D was observed by Surveyor applying a Lidocaine external patch 4% to R27's back.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure standard and transmission-based precautions are followed to prevent spread of infections for 2 residents (R27, R25) of 23 residents reviewed for infection control precautions in a sample of 23 residents. The facility failed to prevent possible transmission of infection/disease to R25 and R27 as follows: Staff did not wear personal protective equipment (PPE) during cares performed for R27 who is on enhanced barrier precautions (EBP). Staff did not perform hand hygiene before and after cares performed for R27. Staff used contaminated gloves during application of topical cream to buttock and applying a new dressing to suprapubic catheter site for R27. Urinary catheter drainage bag lying on floor at foot of R25's bed without a protective barrier between drainage bag and floor.

Inspectors wroteBased on observation, record review and interview, the facility did not store resident foods brought in by visitors in a manner to prevent food-borne illness. The facility practice had the potential to affect 59 of 76 residents who reside on the main level of the facility on the 100, 200, 300 and 400 wings. The facility did not ensure the low temperature dishwasher chemical sanitizer maintained the correct concentration per manufacturer's guidelines. The facility practice had the potential to affect all 76 residents who are served foods from the facility's kitchen. Surveyor observed foods and beverages brought in for residents by visitors in 2 refrigerators/freezers in the nurses' station that were not labeled by resident or dated with received by and use by dates. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure the mandatory staffing data that had been submitted from 7/1/24-9/30/24 was complete, accurate, and auditable. This has the potential to affect all 76 residents that reside in the facility. This is evidenced by: The facility policy titled Payroll Based Journal dated as revised on 2/26/22 in part read: Policy: Long-term facilities must electronically submit to CMS (Centers for Medicare and Medicaid Services) complete and accurate direct care staffing information, including information for agency and contracted staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. Procedure: ~The facility must submit to CMS complete and accurate direct care staffing information, including: [...]

Inspectors wroteBased on interview and record review, the facility did not provide a notice of transfer to residents or resident representatives. This affected 4 of 4 sampled residents (R8, R9, R20, and R73). -A notice of transfer was not provided prior to a facility-initiated discharge for R8, R9, R20, and R73. -The facility did not inform the residents or their representatives, prior to a transfer, of appeal rights, including the name, address, and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request.

Inspectors wroteBased on record review and interview, the facility did not accurately code the Minimum Data Set (MDS) for 2 of 2 residents (R) reviewed for Preadmission Screening and Resident Review (PASARR) screen. (R18 and R48) -The MDS assessments are coded in error stating that a PASARR level 2 screen had not been completed when it was completed at the time of assessment for R18. -The MDS assessments are coded in error stating R48 had a serious mental illness when, in fact, the mental illness was a result of progressive dementia.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure the resident (R) maintained acceptable parameters of nutritional status for 1 out of 3 residents reviewed for nutrition. R5 did not receive the assistance R5 required with eating. Weights were not obtained in over 60 days when R5 had been identified for high risk for altered nutrition. R5 had a recorded significant weight loss, and the facility did not reassess significant weight loss or her ability to feed herself.

Inspectors wroteBased on meal observations, interviews and record review, the facility failed to distribute food under sanitary conditions, improper glove use, and food handling without proper hand hygiene. This has the potential to affect all 78 residents who reside in the facility. This is evidenced by: The facility policy and procedure entitled: Sanitization and Cleaning Schedule, states in part . 2. All foodservice employees must use one of two acceptable sanitary procedures when handling foods: a. Hands are washed using appropriate procedure and food is handled with tongs, deli paper or other utensils. b. Disposable gloves are used and changed when soiled, torn, or switching tasks. 3. Bare hand contact with ready to eat food is not permitted by dietary staff preparing or serving the food. On 01/08/24 at 7:48 AM, Surveyor observed Dietary Aide (DA) G dishing food onto plates to all residents. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility did not maintain an infection prevention and control program according to professional standards of practice when droplet precautions of appropriate Personal Protective Equipment (PPE) were not followed, and improper hand hygiene was performed during cares. This affected 4 of 4 residents (R49, R72, R16, R71) observed for infection control. This is evidenced by: The facility policy entitled: Isolation Precautions under the category Droplet Precautions, states in part .3. Prior to entering the isolation room, the following steps are required: a. Perform hand-hygiene and apply gloves, gown, and mask prior to entering room. The facility policy entitled: Hand Hygiene, states in part, staff are to wash hands with soap or water or use alcohol-based hand gel .Before applying and after removing gloves . [...]

Inspectors wroteBased on interview and record review, the facility did not ensure care plans were reviewed and revised based on changed needs and goals for antidepressant medications for 1 of 18 residents (R48) reviewed. This is evidenced by: R48 was admitted to the facility on [DATE]. R48's diagnoses include dementia with behaviors, anxiety disorder, and depression. R48's Minimum Data Set (MDS) dated [DATE] indicates Brief Interview for Mental Status (BIMS) of 10, which means R48 has a moderate cognitive impairment. R48's physician orders dated 01/25/23, includes in part, Citalopram 10mg by mouth once a day until 02/15/23, then give Citalopram 20mg once a day for severe depression. Surveyor reviewed R48's care plan with a target date of 01/09/24 where there is no mention of the antidepressant medication Citalopram which R48 is currently receiving. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene following urinary incontinence for 1 of 4 residents reviewed (R16) for toileting and hygiene assistance. This is evidenced by: The National Association for Incontinence ([NAME]) states in part, .Urinary incontinence leaves the aging population at risk for impaired skin integrity. Exposure to urine and feces is one of the most common causes of skin breakdown . The [NAME] goes on to state that urinary incontinence makes the skin more susceptible to maceration, incontinent dermatitis, bacterial infections, fungal infections, and exposure to caustic agents, such as ammonia, a prime caustic agent in urine. [NAME] goes on to state, . [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that a resident with a pressure injury (PI) received correct treatment and services, consistent with professional standards of practice, to promote healing for 1 of 1 resident (R) reviewed for PIs. (R4)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide pharmaceutical services related to the accurate administration of steroid inhaler to meet the needs for 1 of 1 resident reviewed (R20). This is evidenced by: Surveyor reviewed manufacturer's instructions for Symbicort on My Symbicort.com, which states, Symbicort may cause serious side effects, including . fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using Symbicort to help reduce your chance of getting thrush . On 01/09/24 at 3:09 PM, Surveyor observed Licensed Practical Nurse (LPN) N enter R20's room with eye medication and an inhaler. LPN N educated R20 to take a deep breath in and to exhale and then administered one puff of Symbicort Aerosol 160 MCG/4.5 with a spacer or aero-holding device. LPN N administered a second puff at 3:11 PM. [...]