Terraces Of Lake Worth Care Center And Rehab

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, interview, and record review, the facility failed to initiate and act on grievances regarding dialysis chairs, affecting 2 of 2 sampled residents, Residents #31 and #344. The findings included: Review of the policy titled grievances/complaints, filling, dated April 2017, indicated the following: residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the state ombudsman). The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the residents and/or representatives. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. Grievances also may be voiced or filed regarding care that has not been furnished. All grievances,…

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 observations, interviews and record reviews, the facility failed to accurately document the status of upper and lower extremity impairment for 1 of 19 sampled residents, Resident #52. The findings included: Record review revealed Resident # 52 was admitted on [DATE] with diagnoses that included Quadriplegia, Paraplegia, Neuromuscular Dysfunction of Bladder, Gastroesophageal Reflux Disease without Esophagitis, and Anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating Resident #52 had intact cognitive function. Section GG-A of the upper extremity including shoulder, elbow, wrist and hand revealed 0 or no impairment. Further review of Section GG-B of the lower extremity including the hip, ankle, knee and foot revealed 0 or no impairment. Section GG-C for toileting hygiene, including the ability to maintain perineal hygiene, adjusting clothes before and after voiding or having a bowel movement…

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 3. Record review revealed Resident #9 was admitted to the facility on [DATE], with a diagnosis of Hypertension. The admission MDS assessment, reference date 03/31/25, recorded a BIMS score of 15, indicating the resident was cognitively intact. Review of the physician orders dated 03/25/25, prescribed Hydralazine oral tablets at a dosage of 50 mg to be taken by mouth twice a day for Hypertension. The order specified holding the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. The baseline care plan dated 03/26/25 noted that Resident #31 had the potential for complications related to altered cardiac function due to diagnoses of hypertension and atrial fibrillation. The interventions included administering medications as ordered and observing for effectiveness and side effects. Review of the medication and treatment administration records (MARs and TARs) for May 2025 indicated that Hydralazine 50 mg was administered on May 2 at 5 PM, with a blood pressure reading 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews and facility policy review, the facility failed to ensure a safe smoking environment by not providing safety devices and supervision per the residents' care plans and assessments for 6 of 10 sampled residents that smoke, Residents #6, #30, #36, #77, #86 and #399. The facility failed to assess residents for safe smoking at least quarterly and as needed for 4 of 10 sampled residents, Residents #6, #36, #77, and #86. The findings included: Review of the facility's Smoking Policy, with a revision date of 04/26/25, documented: Procedures: Residents will be assessed upon admission, quarterly and on an as needed basis as to their need for required assistance or special safety devices. All residents determined to need supervision according to safe smoking evaluation: 1. Will be observed when smoking by a staff member during designated supervised times. 2. All smoking materials of residents who require supervision will be kept at the Division 1 Nursing Office. 3. All…

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 observations, interviews and record reviews, the facility failed to obtain a urology consultation timely for 1 of 3 sampled residents reviewed for urinary care, Resident #52. The findings included: Record review revealed Resident # 52 was admitted on [DATE] with diagnoses that included Quadriplegia, Paraplegia, Neuromuscular Dysfunction of Bladder, Gastroesophageal Reflux Disease without Esophagitis, and Anemia. Review of the Minimum Data Set (MDS) assessment dated [DATE] under Section C of the Brief Interview for Mental Status (BIMS) revealed a score of 15 indicating Resident #52 had intact cognitive function. Section H dated 03/05/25 revealed the resident had an indwelling catheter (Foley). Review of the physician orders dated 02/27/25 revealed an order to monitor the urinary catheter for impairment of drainage every shift. Review of the urine culture dated 04/18/25 revealed the resident had acquired Extended Spectrum Beta-Lactamase (ESBL) (a type of enzyme produced by certain bacteria that makes them…

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 observations, interviews and record reviews, the facility failed to follow physician ordered fluid restrictions for 1 of 1 sampled resident reviewed who had physician ordered fluid restrictions, Resident #38. The findings included: Record review revealed Resident #38 was admitted to the facility on [DATE]. According to the resident's most recent complete assessment, an Annual Minimum Date Set MDS) assessment, with a reference date of 05/14/25, Resident #38 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Resident #38's diagnoses at the time of the assessment included: Post polio syndrome, Anemia, Coronary Artery Disease, Hypertension, Gastro Esophageal Reflux Disease, Benign Prostatic Hyperplasia, Renal Insufficiency, Neurogenic Bladder, Obstructive Uropathy, Urinary Tract Infection (in the previous 30 days), Arthritis, Seizure disorder, Depression, and Muscle Weakness. Review of the physician orders for Resident #38's included the following:…

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 2. Record review revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis of Hypertension. The admission Minimum Data Set (MDS) assessment, conducted on 03/31/25, included a BIMS score of 15, which indicated the resident was cognitively intact. On 03/26/25, the physician orders for medication management were documented. The following rating scale was used to assess behavior related to antidepressant medication: - 0 = No behavior - 1 = Combativeness - 2 = Verbally inappropriate - 3 = Sexually inappropriate - 4 = Disrobing - 5 = Crying excessively - 6 = Calling out constantly - 7 = Screaming excessively - 8 = Auditory hallucinations - 9 = Delusional - 10 = Resists care - 11 = Socially inappropriate - 12 = Extreme pacing - 13 = Restlessness - 14 = Other The following medications were prescribed: - On 04/01/25, Mirtazapine oral tablet 7.5 mg, to be taken one tablet by mouth at bedtime for major depressive disorder. - On 04/01/25, Nortriptyline oral capsule 75 mg to be taken one capsule by mouth…

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 observations, interviews, and record reviews, the facility failed to ensure the medication error rate was not 5% or greater. The medication error rate was 18.75% with 6 medication errors identified while observing a total of 32 opportunities, affecting Resident #43 and Resident #86. The findings included: Review of the facility's policy, titled, Adverse Consequences and Medication Errors, with a revised date of April 2014, included in part the following: A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacture specifications, or accepted professional standards and principles of the professional(s) providing services. Examples of medication errors include omission - a drug is ordered but not administered, unauthorized drug - a drug is ordered but not administered, wrong time. 1. Record review for Resident #43 revealed the resident was originally admitted to the facility on [DATE] with most recent readmission…

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, interview, and record review, the facility failed to ensure that physician visit notes were made part of the residents' records for 1 of 1 sampled resident who voiced concerns regarding physician services, Resident #9. The findings included: Record review revealed Resident #9 was admitted to the facility on [DATE] with a diagnosis of Hypertension. The admission Minimum Data Set (MDS) assessment, conducted on 03/31/25, included a Brief Interview for Mental Status (BIMS) score of 15, which indicated that the resident was cognitively intact. Clinical record review indicated that the Advanced Practitioner Registered Nurse (APRN) visited Resident #9 on the following dates: 03/26/25; 03/27/25; 04/02/25; 05/09/25; 05/19/25; and 05/29/25. There was no documented evidence of the attending physician visiting Resident #9 at the facility. On 06/03/25 at 10:55 AM, an interview was initiated with Resident #9. She said that she had been at the facility for approximately three months and had not seen 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 4. Record review for Resident #72 revealed the resident was originally admitted to the facility on [DATE] with a readmission on [DATE] with diagnoses that included in part the following: Neuromuscular Dysfunction of Bladder Unspecified. Review of the MDS assessment dated [DATE] documented in Section C a BIMS score of 15 indicating an intact cognitive response. Review of the Physician's Orders for Resident #72 revealed in part the following: An order dated 05/22/25 to Monitor urinary catheter for impairment of drainage flow every shift for prophylaxis. An order dated 05/22/25 for Catheter care with soap and water every shift and as needed. Review of the care plans for Resident #72 with an initiated date of 04/12/25 and the most recent revised date of 05/23/25 with a focus on the resident has a urinary device in place revealed: Foley catheter for diagnosis of Neurogenic Bladder. At risk for UTI (Urinary Tract Infection). The goal was for the resident to maintain adequate urinary elimination via urinary device and…

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 observations, interviews and record reviews, the facility failed to provide enteral feeding as ordered by physicians; and failed to monitor weights per protocol for 1 of 2 sampled residents reviewed for tube feeding, Resident #42. The findings included: 1. Review of the facility's policy, titled, Enteral Nutrition, revised November 2018, documented, in part: Adequate nutrition support through enteral nutrition is provided to residents as ordered. Review of the facility's policy, titled, Enteral Tube Feeding via Continuous Pump, revised November 2018, documented, in part: General Guidelines 3. Check the enteral nutrition label against the order before administration. Check the following information: a. Resident name, ID and room number b. type of formula c. Date and time formula was prepared d. Route of deliver e. Access site f. Method (pump, gravity, syringe); and g. Rate of administration (ml/hr.) Initiate feeding: 5. On the formula label document initials, date and time the formula was…

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 observations, interviews, and record review, the facility failed to secure medications at the bedside for 1 of 21 sampled residents, Resident #73. The findings included: Review of the facility's policy, titled, Storage of Medications, with a revised date of November 2020, included: The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Record review for Resident #73 revealed the resident was originally admitted to the facility on [DATE] with a readmission date of 05/13/23 and with diagnoses that included: Paroxysmal Atrial Fibrillation, Need for Assistance with Personal Care, Unspecified Severe Protein-Calorie Malnutrition, Pressure Ulcer of Sacral Region Stage IV, and Spinal Stenosis Cervical Region. Review of the Minimum Data Set (MDS) assessment for Resident #73 dated 01/27/24 revealed in Section C, a Brief Interview for Mental Status (BIMS) score of 5, indicating severe cognitive impairment. Review of the Physician's Orders for Resident #73 revealed an order dated…

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 interview, observation, and record review, the facility failed to provide timely dental services for 1 of 1 sampled resident, reviewed for dental services, Resident #78. The findings included: The facility's policy, titled, Dental Consultant, revised April 2007, had a section, titled, Policy Interpretation and Implementation. Item #2 describes the services provided by the Consultant Dentist. Letter b documented the following: b. Providing a dental assessment of each resident within ninety (90) days of admission. Record review revealed Resident #78 was admitted to the facility on [DATE]. On 02/19/24 at 3:10 PM, an interview was conducted with Resident #78 during the Initial Pool process. At the time of the interview, the surveyor observed that Resident #78 had missing teeth in his right lower jaw, at the front of his mouth. Resident #78 was asked if he was okay with the missing teeth, and indicated he was not. When Resident #78 was asked if he wanted to see the dentist about the missing teeth, he replied…

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, record review, interview, and policy review, the facility failed to ensure an accurate count and reconciliation of controlled drugs (narcotics) for 1 of 4 sampled residents (Resident #290). The facility also failed to follow their own policy and process for disposition of controlled drugs for 2 of 2 sampled discharged residents (Residents #342 and #65). The findings included: Review of the policy Discontinued Medications revised April 2007 documented, Staff shall destroy discontinued medications or shall return them to the dispensing pharmacy in accordance with facility policy. 3. Discontinued medications must be destroyed or returned to the issuing pharmacy in accordance with established policies. On 10/20/22 at 2:57 PM, the Director of Nursing (DON) provided the above policy as had been requested earlier that day. When asked if there was an established policy as noted in the above Discontinued Medication policy, that further instructed the process for discontinued controlled medications,…

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.