Debary Health And Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility's bowel management process, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (Resident #1, #2, and Resident #4) of three residents reviewed for management of constipation, by failing to implement medical director's directive/order to administer stool softeners/laxatives. The findings include:1.Review of Resident #1's medical record revealed an admission date of 9/7/23, and a discharge date of 2/2/26. Her diagnoses included unspecified Sequelae of Cerebral Infarction, Cerebral Palsy, generalized anxiety disorder, and constipation, unspecified. Review of Resident #1's quarterly minimum data set assessment dated [DATE], noted the resident had a brief interview for mental status (BIMS) score of 0 out of 15, indicating severe cognitive impairment. The resident was noted as always being incontinent of bowel and bladder.Review of the task for bowel movements for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide one dependent resident (#8) from a total sample of 35 residents, with services to carry out activities of daily living necessary to maintain appropriate grooming and personal hygiene. Resident #8 was not provided adequate fingernail care. The findings include: On 01/16/24 at 11:56 AM, Resident #8's hands were observed and his fingernails on both hands had jagged edges and brown matter underneath the fingernails. He was asked if staff provided his nailcare and he answered yes. (Photographic evidence obtained) On 01/17/24 at 9:06 AM, Resident #8 was observed in bed. His fingernails remained the same as observed on 01/16/24 at 11:56 AM, with jagged edges and some evidence of deterioration of the nailbeds on the 2nd and 3rd digits of the right hand. Resident #8 stated, I had fungus a long time ago. On 01/19/24 at 10:34 AM, an interview was conducted with Licensed Practical Nurse (LPN) C. The nurse was asked who was responsible for providing the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that one (Resident #96) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and resident choices, based on the resident's and resident representative's desire to have bilateral compression stockings placed on lower extremities daily as ordered. The findings include: On 1/16/24 at 12:18 PM, Resident #96 was observed seated in his wheelchair. He was dressed in a long-sleeved shirt, long dark pants, and dark-colored crew socks. When greeted, he smiled and said hello. He was accompanied by his niece, who reported that she visited every day. When asked how the care at the facility had been, she stated He's ordered to wear compression stockings daily, but they never place them on him. I even purchased multiple pairs. The resident's niece pulled up Resident #96's pant legs to expose his lower extremities showing that he was not wearing bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record review, interviews, and review of the policy and procedure for Following Physicians' Orders (revised 1/2024), the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote healing for one (Resident #111) of two residents selected for pressure ulcer review, from a total sample of 35 residents. Resident #111 suffered deterioration of a sacral pressure wound which was facility-acquired. The findings include: An interview was conducted with Resident #111 and her son on 1/16/24 at 11:53 a.m. in her room. The resident was speaking with her son and was observed on a low air loss mattress with pillows on the bed and booties on both her feet. She reported having wounds on her sacrum and lower legs. The son reported the wound care nurse was great, but when she was off on weekends, no one completed the wound care. Both reported that the wound care physician was overseeing and caring for the wounds. On 1/17/24 at 9:00 a.m., Resident #111 was observed lying in bed and stated the wound care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff and resident interviews, medical record review, and a review of facility policy, the facility failed to ensure that two (Resident #56 and #94) of 35 residents in the total sample, were provided an environment as free of accident hazards as was possible. The findings include: On 01/16/24 at 11:44 AM, razors were observed at the sink in Resident #56's room. On 01/17/24 at 9:12 AM, four razors were observed rubberbanded together in a cup on the sink in Resident #56's room. (Photographic Evidence Obtained) On 01/19/24 at 8:57 AM, three razors were observed in an open cabinet at the sink in Resident #94's room. (Photographic Evidence Obtained) Resident #94 was asked if the razors belonged to him and he stated, yes. He was asked if the razors were usually stored in the cabinet at the sink and he replied, Yes. On 01/19/24 at 9:12 AM, an interview was conducted with Registered Nurse (RN) J. She was asked how sharps were managed at this facility and she replied, We dispose of sharps in the sharps container after use. She was asked to describe some examples of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure a medication error rate of less than 5 percent. Three errors were identified out of 26 opportunities for error, resulting in a medication error rate of 11%, involving two (Residents #50 and #99) of four residents observed during medication administration, from a total of 35 residents in the sample. The findings include: On 1/17/24 at 8:00 a.m., Nurse A was observed preparing medications for Resident #50. She pulled each medication according to the electronic Medication Administration Record (eMAR) and signed off each as she prepared the medications. She administered the medications, which were being given by mouth, to the resident. Upon returning to the medication cart, Nurse A was asked if she had completed this medication pass for Resident #50. She stated yes. She was asked if she had signed off all the medications on the eMAR for this resident. She stated yes. She was asked if she was going to prepare medications for the next resident at this time. She stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Specifically, the facility failed to ensure that the dietary staff were trained and knowledgeable about proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents, due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. This failure potentially impacted every resident consuming food from the facility's kitchen. The findings include: A tour of the kitchen with the Certified Dietary Manager (CDM) on 02/07/22 at 2:13 PM revealed: -On the refrigerator across from the tray line, the door handles were soiled and sticky with food debris, and the inner door of the refrigerator had dried…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to thoroughly investigate an allegation of sexual abuse by failing to promptly identify one (Resident #35) of nine hospice residents as a potential victim of an alleged perpetrator's actions. The findings include: A review of Resident #35's medical record revealed an admission date of 4/17/20. Her medical diagnoses included dementia, heart failure, and respiratory failure. A Significant Change Minimum Data Set (MDS) assessment, dated 11/30/2021, revealed a Brief Interview for Mental Status (BIMS) score of 12 out of a total 15 points possible, indicating moderately impaired cognition. Resident #35 required extensive to total assistance from staff with activities of daily living (ADLs) and was receiving hospice care. A psychiatric evaluation, dated 12/30/2021, indicated Resident #35 was alert and oriented to person, place and time. Her thought processes were documented as organized and she was noted with fluent speech. A review of facility documentation indicated that Resident #35 was not interviewed on 12/15/2021, the date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record reviews, the facility failed to effectively manage a resident's pain, by failing to identify and respond to non-verbal indicators of pain for one resident (Resident #7) reviewed for pain management from a total sample of 35 residents. The findings include: A review of Resident #7's medical record, revealed an admission date of 6/6/2014. Her medical diagnoses included vascular dementia and cerebral infarction (stroke). Resident #7 also had a contracture of her left arm. A quarterly Minimum Data Set (MDS) assessment, dated 2/1/2022, revealed a Brief Interview for Mental Status (BIMS) score of 02 from a total 15 possible points, indicating severely impaired cognition. Resident #7 required extensive to total assistance with activities of daily living (ADLs) and received hospice services for end-of-life care. On 2/7/2022 at 12:13 p.m., Resident #7 was observed sitting in a reclining geri-chair in her room. The chair was reclined. She was grimacing, her brow was furrowed, and she was repeatedly whimpering. Resident #7 was not able to answer…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.