Health inspection·February 16, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, record review, and interview, the facility failed to treat residents with respect and dignity related to one (Resident #230) of six residents with an indwelling catheter who did not have a privacy cover on the urine drainage bag, on two (02/13/2022 and 02/15/2022) of four survey days. Findings included: On 02/13/2022 at 10:49 a.m., an observation of Resident #230 revealed the resident had an indwelling urine catheter, with the drainage bag not covered by a privacy cover, and the bag was visible from the room door and hallway. On 02/15/2022 at 9:49 a.m., an observation of Resident #230 revealed the resident had an indwelling urine catheter, with the drainage bag not covered by a privacy cover, and the bag was visible from the room door and hallway. During an interview on 02/15/2022 at 9:54 a.m. with Staff A, Certified Nursing Assistant (CNA), she confirmed the drainage bag did not have a privacy cover. In an interview with Staff B, Registered Nurse (RN) on 02/15/2022 at 10:05 a.m., he said it was the facility's policy to ensure a urine catheter drain bag was covered. Review of the clinical record for Resident #230 showed an admission date of 01/31/2022 and diagnoses that included, Urinary Tract Infection (UTI) and Benign Prostatic Hyperplasia (BPH) as per the admission face sheet. Review of the Care Plan, dated 01/31/2022, did not reveal an intervention related to the preservation of the resident's dignity and placement of a privacy cover on the catheter drain bag. On 02/15/2022 at 1:02 p.m. during an interview with the Director of Nursing (DON), she stated it was her expectation the indwelling catheter drain bag was covered with a vanity cover to preserve the resident's dignity. A facility-provided policy titled 'Catheter Care' and dated '7/20' was reviewed; it did not address the use of a privacy cover for the catheter drain bag. A facility-provided policy titled 'Resident Rights' and dated '7/20' was reviewed; it revealed, the resident has the right to be treated with respect and dignity. It did not address the use of a privacy cover for the catheter drain bag. Page 1 of 12 105926 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility did not ensure the advance directive wishes were implemented for one resident (#35) of eighty-three residents reviewed for advance directives. Findings included: A review of the face sheet in the admission record for Resident #35 revealed he was admitted with a diagnosis of hemiplegia following cerebral infarction affecting the left non dominant side. Review of the MDS (minimum data set) assessment dated [DATE] reflected a BIMS (brief interview for mental status) score of thirteen, indicating his cognition was relatively intact. A review of the physician's orders in the electronic medical record dated 1/25/21, revealed an advance directive of Full Code. Further review of the physician's orders reflected an order dated 2/8/22 indicating patient wishes to sign DNR (do not resuscitate) DC (discontinue) when done. Review of the medical record located at the nurses' station on the unit where Resident #35 resided on 2/14/22, revealed a laminated bright green paper in the front of the record with FULL CODE marked on it. On 2/14/22 at 10:11 a.m., an interview was conducted with Resident #35's nurse, Staff K, LPN (licensed practical nurse). Staff K, LPN said you could locate the residents' code status on the computer or in the chart. It says code status and it will tell you if they are a DNR or full code. Staff K, LPN checked Resident #35's electronic medical record and said he was a full code. Staff K also checked the paper record located at the nurses' station and presented the laminated bright green sheet of paper in the front of the chart indicating full code. During the interview the electronic medical record was reviewed with Staff K, LPN who confirmed there was an order dated 2/8/22, which read patient wishes to sign DNR. Staff K, LPN said on paper he is a full code. Technically he is a full code. She said she would do full resuscitation. On 2/14/22 at 10:26 a.m., an interview was conducted with Staff F, ADON (assistant director of nursing), unit manager. Staff F said he probably put the order in the computer. The nurse practitioner was in and ordered the DNR. She had the resident sign the form. She had a conversation with him and had him sign. The resident signed it on 2/8 and the doctor signed it on 2/11. Staff F presented the State of Florida Do Not Resuscitate Order form with Resident #34's signature on it, dated 2/8/22. Further review of the document reflected the physician had signed the form on 2/11/22. Staff F, ADON unit manager said until it was approved by the physician it was not in effect. We have to have the completed form. Staff F said he spoke to the nurse practitioner. She told him about it on 2/8. We have folders here for physician communication with anything the physician needs to sign. Staff F, ADON unit manager confirmed there was an order in the medical record located at the nurses' station that indicated patient wishes to sign DNR. The order was signed by a PA (physician's assistant). Staff F said the order should be followed pretty quick. It should be faxed to notify the physician it was here and that he needed to sign it. The order was the eighth, and the physician signed it on the eleventh. Staff F said he was not sure what the delay was. The order would have been faxed. He did not know 105926 Page 2 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0578 if the physician got it on the eighth. He may have come in on the eleventh and signed it. Level of Harm - Minimal harm or potential for actual harm On 2/14/22 at 10:30 a.m., an interview was conducted with Staff L, case manager RN (registered nurse). Staff L said if there was a result or anything the doctor needed to know, telephone orders, or anything that needed a physician signature, it went in their folder for a signature. The nurse notified them if there was an abnormal lab or X-ray finding. The nurse wrote on the result that the doctor was notified, with the date, time, and what the doctor said. The DNR's were faxed immediately if there was a need. Residents Affected - Few At 10:45 a.m. on 2/14/22 an interview was conducted with the DON (director of nursing). She said, We should notify the doctor we have a resident that wishes to have a DNR so that they can also sign it, which I believe the ADON did. I think they faxed it to him. The resident's physician was the medical director. He signed the DNR on the eleventh when he was here. He might have wanted to have a discussion with the resident first before he signed it. I would hope that they would call him. The DON said she was not sure if the nurse practitioner for [Insurance Company Name] would have called his doctor. The resident's doctor was here every week. On 2/14/22 at 12:41 p.m., a telephone interview was conducted with Resident #35's attending physician. He explained that the process was to handle those requests the same day. He said he did not recall if the facility reached out to him. He assumed they did. He believed they faxed it to him. He said he should have signed it that day. He believed the policy was to sign it that same day. He heard about this this morning. He said he should have signed it. On 2/14/22 at 12:54 p.m. a follow up interview was conducted with the DON. The DON said she wrote down a note that Resident #35's physician was going to sign it on Thursday. That was 2/9. She said she always wrote notes on things to follow up on. Resident #35's physician usually came in on Thursdays. He did not come to sign it until Friday. The DON said she would assume the ADON would follow up on it. He sent the fax and he was the nurse manager. That DNR snuck in Friday, most likely after we left. A review of the policy, Residents' Rights Regarding Treatment and Advance Directives, dated 7/20, reflected the following: Policy It is the policy of this facility to support and facilitate a resident's right to request, refuse and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Guidelines: 6. The facility will define and clarify medical issues and present them to the resident or legal representative as appropriate. 7. During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes related to advance directives. 8. Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions. 105926 Page 3 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0578 Level of Harm - Minimal harm or potential for actual harm 9. Any decision making regarding the resident's choices will be documented in the resident's medical record ands communicated to the interdisciplinary team and staff responsible for the resident's care. 11. Should the resident refuse treatment of any kind, the facility will document the following in the resident's chart: Residents Affected - Few a. what the resident refused. b. The reason for the refusal. c. The advice given to the resident about the consequences of refusing. d. the offering of alternative treatments. e. The continuation of providing all other services. 105926 Page 4 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based observation, interview, and record review, the facility failed to implement the care plan for one (Resident #34) of two residents sampled for vision and hearing. The facility staff failed to offer Resident #34 their eyeglasses on three of three observed days. The failure of the staff to offer Resident #34 their eyeglasses per the care plan, resulted in a failure to identify Resident #34's eyeglasses were missing. Findings included: On 02/13/22 at 12:45 p.m., Resident #34 was observed lying in bed under the covers saying help . is someone going to help? Upon interviewing the resident, Resident #34 stated her stomach hurt and assistance was needed. The resident's call light was within reach, however, Resident #34 said I can't see [it] . The location of the call light for the resident was explained and the resident pressed the call light button for assistance from staff. Resident #34 said, I hate this thing [referring to the call light button], I can't hear it. Further observation of the resident revealed her without eyeglasses. An observation of the resident's direct vicinity revealed no eyeglasses within the resident's reach. A review of Resident #34's Facesheet revealed current medical diagnoses of glaucoma and cataracts. A review of Resident #34's minimum data set (MDS), dated [DATE], revealed the resident had a brief interview for mental status score of 8, indicating moderate cognitive impairment without behaviors of inattention or disorganized thinking. Resident #34 had moderately impaired vision and used corrective lenses. A review of Resident #34's Care Plan, revealed a problem onset date of 07/22/2020 with a goal and target date of 03/16/2022 for Decreased vision related to cataracts, glaucoma and vision loss to left eye. Approaches for this problem area included ensuring that eyeglasses are in place/being worn by the resident during waking hours and ensuring that eyeglasses are appropriate strength/type for resident's needs. A follow-up interview on 02/14/2022 at 10:13 a.m. with Resident #34 revealed she had eyeglasses but had not worn them in a while, stating that . things go missing for me a lot. Resident #34 stated she had notified someone a while ago that her eyeglasses were missing. An observation of Resident #34 on 02/15/2022 at 10:00 a.m. revealed the resident not wearing eyeglasses. An interview on 02/15/2022 at 10:26 a.m. with Staff C, Registered Nurse (RN) revealed the certified nursing assistants (CNAs) were responsible for offering and putting a resident's glasses on if they had them. An interview on 02/15/2022 at 10:44 a.m. with Staff D, CNA revealed she had worked with Resident #34 before but was unsure if the resident had glasses or not. Staff D, CNA stated if the resident did have glasses, they would be inside the nightstand drawers. Staff D, CNA looked inside the resident nightstand drawers and was unable to find eyeglasses. During this observation Resident #34 said, my glasses have been missing for a while. Staff D, CNA stated she was unsure where the eyeglasses would 105926 Page 5 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0656 be. Level of Harm - Minimal harm or potential for actual harm An interview on 02/15/2022 at 10:52 a.m. with Staff E, CNA revealed she had worked with Resident #34 for a while, and had not seen the resident wearing eyeglasses. Residents Affected - Few An interview on 02/15/2022 at 1:15 p.m. with the Nursing Home Administer (NHA) and the Director of Nursing (DON) confirmed the plan of care should be implemented and followed. Both the NHA and DON stated they were unaware the resident was missing her eyeglasses. The NHA and DON confirmed that if the plan of care had been followed, facility staff would have identified the resident's eyeglasses were missing. A policy review of Hearing and Vision Services, dated 07/2020, revealed It is the policy of this facility to ensure that residents have access to and received proper treatment and assistive devices to maintain vision and hearing abilities . 1. the facility will utilize the comprehensive assessment process for identifying and assisting a resident's vision and hearing abilities in order to provide person-centered care. This process includes: resident's vision and hearing abilities in order to provide person-centered care. This process includes: a. Obtaining history from medical records, the family, and the resident regarding hearing and vision abilities; b. MDS and care assessments; c. Ongoing monitoring of sensor problems; d. Care plan development and implementation, and e. Evaluation . 5. Employees will assist the resident with the use of any devices or adaptive equipment needed to maintain vision or hearing. A policy review of Comprehensive Care Plans, revised 07/2020, revealed It is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a residence medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . 1. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma-informed . 3. The comprehensive care plan will describe, at a minimum, the following a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . 105926 Page 6 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 5. the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the residents needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. 105926 Page 7 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and eighteen errors were identified for three residents (#130, #79, #131) observed. These errors constituted a 66.67% medication error rate. Residents Affected - Some Findings included: 1. On 2/14/22 at 10:28 a.m., an observation of medication administration with Staff J, Registered Nurse (RN), was conducted with Resident #79. Staff J. was observed dispensing the following medications: -Loratadine 10 milligrams (MG) tablet orally -Fluticasone Prop 50 micrograms (MCG) Spray 1 spray each nostril -Lisinopril 20 mg. 1 tablet orally -Tumeric 1 capsule orally -Amlodipine Besylate 2.5 MG 1 tablet orally During the dispensing of the medications for Resident #79, Staff J said the Cyanocobalamin 1,000 microgram (MCG)/milliliter (ML) was not in the medication cart. Staff J confirmed the medication was not administered. She confirmed the medication pass was late and not within the 6-10 a.m. window. She stated, I am not sure of the policy. Review of Resident #79's February 2022 Medication Administration Record (MAR) indicated the following: -Cyanocobalamin 1,000 MCG/ML VL inject 1ML intramuscular (IM) Every 14 days marked 'N' indicating Not Given -Loratadine 10 MG tablet give 1 tablet by mouth for allergies AM -Lisinopril 20 MG tablet 1 tablet by mouth daily for Hypertension AM, -Amlodipine Besylate 2.5 MG Tab 1 Tablet by mouth Twice a Day for Hypertension -Fluticasone Prop 50 MCG Spray 1 Spray each nostril Twice Daily -Tumeric give 1 capsule by mouth daily for deficiency AM A review of Nurses Notes dated 2/14/22 at 1:09 p.m. entered by Staff J for Resident #79 identified the following, Resident medication were late this morning, MD [physician] and resident aware. 2. On 2/14/22 at 10:43 a.m., an observation of medication administration with Staff J (RN) was conducted with Resident #131. Staff J was observed dispensing the following medications: 105926 Page 8 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0759 -Triamterene-HCTZ 37 5-25 MG 1 tablet orally Level of Harm - Minimal harm or potential for actual harm -Probiotic 10 billion cell cap 1 capsule orally -Atenolol 50 MG tablet 1 tablet orally Residents Affected - Some On 2/14/22 at 10:50 a.m., during an interview Staff Member J stated, Medications were late for 6-10 AM window for Resident #131. The medication pass is completed for hallway 300. A review of Resident #131 February Medication Administration Record indicated the following: -Triamterene-HCTZ 37.5-25 MG 1 tablet by mouth daily in AM for Hypertension -Probiotic 10 billion cell cap 1 capsule by mouth daily in AM for colon health -Atenolol 50 MG tablet 1 tablet by mouth every morning DX Hypertension AM 3. On 2/14/22 at 10:50 a.m. during an interview, Staff J requested to review and confirm medication administration for Resident #130. Staff J stated, I missed Resident #130 and did not see she did not receive her medications for 6:00 AM-10:00 AM. On 2/14/22 at 10:53 a.m., an observation of medication administration with Staff J (RN) was conducted with Resident #130. Staff J was observed dispensing the following medications: -Myrbetriq ER 50 MG 1 orally -Lisinopril 20 mg 1 tablet orally -Metoprolol Tartrate 50 MG tab 1&1/2 tablets (75mg) orally -Eliquis 2.5 MG tablet 1 tablet orally -Amiodarone HCL 200 mg 1 tablet orally -Acyclovir 400 MG tablet 1 tablet orally -Vitamin D3 400 unit tablet 1 tablet orally -Ocular Vitamin 1 tablet orally -Dorzolamide-Timolol 2%-0.5% instill 1 drop Right Eye On 2/14/22 at 11:00 a.m. following dispensing of medication to Resident #130, Staff J stated, Since I am new I do not know the policy for here. I should have shared with the residents they received the medication late today and I will need to check the policy to contact the Physician's for the residents. A review of Resident #130 February 2022 Medication Administration Record indicated the following: 105926 Page 9 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0759 -Myrbetriq ER 50 MG tablet Give 1 tablet by mouth one daily AM Level of Harm - Minimal harm or potential for actual harm -Acyclovir 400 MG tablet 1 tablet by mouth daily for infection AM -Amiodarone HCL 200 MG tablet 1 tablet by mouth daily for atrial fibrillation Residents Affected - Some -Dorzolamide-Timolol 2%-0.5% Instill 1 drop in Right Eye twice daily for glaucoma AM, HS -Eliquis 2.5 MG tablet give 1 tablet by mouth twice daily for A Fib AM, HS -Lisinopril 20 MG tablet give 1 tablet by mouth twice daily for HTN -Calcium Carb 500 MG tab Chew 1 tablet by mouth twice a day for vitamin deficiency AM, HS -Vitamin D3 400 Unit Tablet 1 tablet (400 Units) by mouth twice a day for risk for malnutrition -Preservision Areds Tablet 1 tablet by mouth twice a day for risk for malnutrition AM, HS -Metoprolol Tartrate 50 MG tab 1 & ½ tablets (75 MG) by mouth twice a day for hypertension Review of a facility provided policy titled Medication Errors Policy and dated 7/20 identified: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by ensuring residents receive care and services safely in an environment free of significant medication errors. 2. The facility must ensure that it is free of medication error rates of 5% or greater as well as significant medication error events. 5. Medication timing errors will be determined by utilizing the facility's policy relating to dosing schedules. Review of The Facility's Medication-time guidelines document, undated, indicated: #a. medication time for AM medication administration as 06h00-10h00 (6-10am), #d. identifying AM for BID30, (twice a day) medication times as 6AM-10AM for medication schedules. In an interview conducted on 2/14/22 at 3:28 p.m. with Staff J, she confirmed the medications were administered outside the facility's identified range for morning medications and would be considered administered late. An interview with the Director of Nursing (DON) was conducted on 2/15/22 at 1:10 p.m. She stated, Medication schedule for AM order at this facility is currently 6:00-10:00 AM window, if medications are administered outside that timeframe for AM medications they would be untimely. On 02/16/22 10:13 AM an interview was attempted with the facility's Consultant Pharmacist via phone. A voicemail was left; however, a return call was not received by completion of the survey. 105926 Page 10 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0770 Provide timely, quality laboratory services/tests to meet the needs of residents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to obtain and verify laboratory results for a physician ordered urinalysis (U/A) for one (Resident #6) of two residents sampled for urinary tract infections. Residents Affected - Few Findings included: Resident #6's minimum data set (MDS), dated [DATE], revealed the resident was severely cognitively impaired, required extensive assistance for toilet use, and had occasional urinary incontinence. A review of Resident #6's Department Notes, dated 01/19/2022 at 12:36 p.m. revealed CNA [certified nursing assistant] reports resident weeps upon urination. ARNP [advanced registered nurse practitioner] visited and order received for UA, C&S [urinalysis culture and sensitivity]; straight cath [catheter] if needed. A review of Resident #6's electronic Medication Administration Record (e-MAR), dated January 2022, revealed under description, an order for UA C&S MAY STRAIGHT CATH IF NEEDED. Further review revealed on 01/19/2022 at 10:00 p.m. a check mark; which indicated the urinary sample was collected to complete the physician order. In an interview on 02/14/2022 at 11:07 a.m., with Staff C, Registered Nurse (RN), she stated once a laboratory (lab) service was ordered, and the results were received, it was uploaded into the online medical chart. If the lab result was not in the online medical chart, it could also be found in the resident's hard paper chart, the physician folder awaiting review, or in the online lab result file. A review of the online lab result system revealed the last lab result for Resident #6 was on 01/04/2022. Staff C, RN stated there were no other lab results available after 01/04/2022 for Resident #6 related to a urinalysis. On 02/14/2022 at 2:26 p.m., Staff F, Assistant Director of Nursing (ADON) stated during an interview that laboratory services were ordered by the physician, a nurse would input the order into the online system, and the laboratory sample was obtained and sent to a lab by a nurse. The results of the labs were reviewed by the physician for further guidance. The ADON reviewed Resident #6's online medical chart and hard paper chart. The ADON confirmed a lack of lab results related to Resident #6's physician ordered urinalysis. On 02/14/2022 at 2:55 p.m., an interview with both Staff F, ADON and Staff C, RN confirmed Resident #6's online medical chart indicated a urinalysis sample was collected on 01/19/2022, however, there was no indication within the resident's medical files that the lab was completed, nor the results obtained and reviewed. On 02/14/2022 at 2:56 p.m. the Director of Nursing (DON) confirmed the facility process for ordering, obtaining, and reviewing a physician ordered laboratory service. The DON stated even if a resident's lab result did not indicate abnormal findings, the results should still be confirmed and filed into the resident's medical chart. A follow-up interview on 02/14/2022 at 4:22 p.m. with the DON confirmed Resident #6's urinalysis lab was not completed. The facility was unable to verify if the urinalysis lab sample was . even 105926 Page 11 of 12 105926 02/16/2022 Westminster Suncoast 1095 Pinellas Point Dr S Saint Petersburg, FL 33705

F 0770 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few collected and done. The DON spoke with the nurse who signed off on collecting the urinalysis lab sample and the nurse was unable to verify if the lab was collected. A policy review of Provision of Physician Ordered Services, dated 07/2020, revealed The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . 1. Facility will maintain a schedule of diagnostic tests (laboratory and radiology) in accordance with the physician's orders. No diagnostic test or consultation request will be performed without specific physician, physician assistant, nurse practitioner or clinical nurse specialist's orders in accordance with state law, including scope of practice laws . 3. Qualified nursing personnel will receive and review the diagnostic test reports or consults and communicate the results to the ordering Physician, physician assistant, nurse practitioner or clinical nurse specialist within 24 hours of receipt unless they report fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders. Ordering provider will be notified of results upon receipt if deemed critical and or require immediate attention. 4. Documentation of consultations, diagnostic tests, the results, and date/time of Physician notification will be maintained in the residence clinical record. A policy review of Laboratory Services and Reporting, dated 07/2020, revealed the facility must provide or obtain laboratory services when ordered by a physician, physician assistant, nurse practitioner, or clinical nurse specialists in accordance with state law . 1. The facility must provide or obtain laboratory services to meet the needs of its residents. 2. The facility is responsible for the timeliness of the services . 6. All laboratory reports will be dated and contain the name and address of the testing laboratory and will be filed in the resident's clinical record. 7. Promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside the clinical reference range. 105926 Page 12 of 12