Rehabilitation Center Of Winter Park

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to treat residents who required assistance with meals in a dignified and respectful manner for 1 of 1 residents reviewed for dignity, of a total sample of 49 residents, (#42). Findings: Review of resident #42's medical record documented she was readmitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia (comprehension and communication disorder), stroke, and contracture of right hand. Review of the Quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date of 6/02/24 revealed resident #42's Brief Interview for Mental Status was not obtained because she was rarely or never understood. The MDS showed she was dependent of staff for most Activities of Daily Living. Review of the Follow Up Question Report for August 2024 revealed resident #42 was dependent for eating. On 8/26/24 at 8:43 AM, Certified Nursing Assistant (CNA) K stated resident #42 was not interviewable and she was, a feeder. On…

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 and interview the facility failed to provide a sanitary, comfortable and homelike interior for one out of 10 residents reviewed for environment, of a total sample of 42, (#126). Findings: Resident #126 was admitted to the facility on [DATE] with diagnoses which included left leg above the knee amputation, other abnormalities of gait and mobility and the need for assistance with personal care. On 8/26/24 at 8:53 AM, resident #126 was observed in his room, alert and oriented, sitting up in his wheelchair eating breakfast. He indicated the bedside commode next to his table had not been emptied for two days. When he lifted the lid of the commode, there was a foul odor and a large amount of feces and urine were observed. He explained he asked the staff that morning during breakfast service to empty it but was told it was not their job. On 8/26/24 at 1:30 PM, observation of the bedside commode in resident #126's room revealed it remained dirty with a foul odor in the room and still had not been…

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, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate for eating assistance for 1 of 3 residents reviewed for nutrition, of a total sample of 49 residents, (#42). Findings: Cross Reference F550 Review of resident #42's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing), aphasia (comprehension and communication disorder), stroke, and contracture of right hand. On 8/27/24 at 5:26 PM, resident #42 was observed in bed, wearing a splint on her right arm and her both of her hands were contracted. Review of the Quarterly MDS assessment with Assessment Reference Date (ARD) of 6/02/24 revealed resident #42's Brief Interview for Mental Status was not obtained because she was rarely or never understood. The MDS incorrectly showed she needed partial/moderate assistance for eating. Review of the previous Quarterly MDS assessment with ARD dated 3/02/24 also showed resident #42 needed…

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 and record review, the facility failed to request a Preadmission Screening and Resident Review (PASARR) level I and level II evaluations for 2 of 6 residents reviewed for PASARR,of a total sample of 49 residents, (#100, and #93). Findings: 1. Review of the medical record revealed resident #100 was admitted to the facility on [DATE] from the hospital. Her diagnoses included psychosis and major depressive disorder. Resident #100's Quarterly Minimum Data Set (MDS) with an assessment reference date of 8/02/24 revealed the resident had diagnoses of depression and psychotic disorder. The Quarterly assessment also noted the resident had severely impaired cognitive skills for daily decision making. Review of resident #100's medical record revealed her care plan noted the resident had alteration in thought processes related to psychosis and major depressive disorder. On 8/28/24 at 11:13 AM, the Social Service Director accessed resident #100's Level I PASARR dated 7/30/21, (prior to admission), in 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 interview and record review, the facility failed to develop a comprehensive person-centered care plan for a resident with diabetes for 1 of 5 residents reviewed for high-risk medications, of a total of 49 residents, (#571). Findings: Review of resident #571's medical record revealed she was readmitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus, lupus, and congestive heart failure. Review of resident #571's admission Minimum Data Set (MDS) assessment with Assessment Reference Date of 8/04/24 revealed a Brief Interview for Mental Status score of 15 out of 15, which indicated intact cognition. The assessment showed resident #571 received insulin injections. Review of resident #571's physician orders dated 8/20/24 showed medication orders dated the same day for Steglatro 5 milligrams (mg) daily, 24 units of Insulin Glargine two times a day and 10 units of Insulin Lispro with meals for diabetes. Review of resident #571's medical record revealed a comprehensive care plan for diabetes…

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 provide appropriate care consistent with professional standards of practice, and treatment to promote healing of a sacral pressure ulcer (PU) for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 42 residents, (#42). Findings: Resident #42 was readmitted to the facility on [DATE] with a diagnosis of dysphagia (trouble swallowing) following unspecified cerebrovascular disease, end stage renal disease, need for assistance with personal care, aphasia (difficulty speaking), and unspecified protein-calorie malnutrition. Review of the Minimum Data Set quarterly assessment, with Assessment Reference Date 6/02/24 revealed resident # 42's Brief Mental Status score was 3 out of 15 which indicated severe cognitive impairment. The assessment indicated she had no behaviors or refusal of care and was dependent on staff to roll from left to right. Further review of the assessment showed resident #42 required substantial assistance 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate care for a resident on tube feedings in relation to feeding rate and time for 1 of 1 resident reviewed for tube feedings, of a total sample of 49, (#48). Findings: Resident #48 was re-admitted to the facility on [DATE] from an acute care hospital with diagnoses that included metabolic encephalopathy, diabetes mellitus type II, moderate protein-calorie malnutrition, anemia in chronic kidney disease, dysphagia, and vascular dementia. The quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed resident #48 was severely cognitively impaired and was dependent on staff for all care. Resident #48 had diagnoses listed for aphasia (lost or impaired speech), malnutrition, and gastrostomy status. Services received included feeding tube care and wound care for a stage 3 pressure ulcer. The assessment also indicated he received hospice services. Review of resident #48's order summary report dated 8/28/24 revealed an…

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, and record review, the facility failed to ensure the manufacturer's specifications regarding the preparation and administration of an over-the-counter medication was followed to ensure accurate and safe administration of medication for 1 of 1 residents reviewed for dialysis, of a total sample of 49 residents, (#18). Findings: Resident #18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included pulmonary edema, acute and chronic respiratory failure, lupus, end stage renal disease, congestive heart failure, hypertension, dependence on renal dialysis. Review of resident #18's physician orders revealed an order for Diclofenac Sodium External Gel 1 % (Topical) dated 7/26/24. The order indicated the nurse was to apply to neck topically four times a day for pain. Diclofenac is a Nonsteroidal anti-inflammatory drug (NSAID), people who use NSAIDS such as topical Diclofenac may have a higher risk of having a heart attack or stroke than people who do not use these…

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 residents were able to call for staff assistance through a call bell system for 2 of 2 residents reviewed for call bells, of a total sample of 49 residents, (#71 and #95). On 8/26/24 at 8:59 AM, residents #71 and #95 were observed in their shared room, each lying in their own bed, each, awake and alert. Resident #71 was asked if staff responded in a timely manner when he activated his call bell, and the resident responded, I don't even have a call bell. At that moment, resident #71's roommate, resident #95 stated, Neither do I. Upon observation, both residents' call bells were noted to be attached by a hook to the wall behind the head of their beds, which was out of reach for both residents. Resident #71 was asked what would he do if he needed help, he replied, Yell, I guess. A few minutes later assigned Registered Nurse (RN) E was asked to come to the room. She confirmed the call bells were attached to the walls out of reach 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 observation, interview and record review the facility failed to ensure the availability of routine medications to enable continuity of care for a newly admitted resident (#4), resulting in resident leaving the facility Against Medical Advice (AMA). The facility also failed to administer medications as ordered, resulting in resident (#12) receiving incorrect medication, for 2 of 2 residents reviewed for medication administration, of a total sample of 12 residents. Findings: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses that included cellulitis of the right lower limb, acute respiratory failure with hypoxia, pneumonia, chronic lung disease, and tobacco use. She was promptly discharged , Against Medical Advice (AMA), the next day on 4/10/24 at 2:00 PM. Review of the medical record for resident #4 revealed she had a Brief Interview for Mental Status Score (BIMS) of 15/15 which meant she was cognitively intact. Review of the Order Summary Report revealed resident #4 had 12 routine…

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 implement components of the abuse prohibition policy and failed to ensure two ineligible employees did not work with vulnerable residents of a total sample of 16 employees reviewed for background screening, (Certified Nursing Assistant C, Licensed Practical Nurse D). Findings: 1. Review of employee records revealed Certified Nursing Assistant (CNA) C was hired by the facility on [DATE]. Review of the Agency for Health Care Administration (AHCA) Level 2 Background Screening Result revealed the status was Screening in Process with no Eligibility Determination Date. The employment record included a copy of an AHCA Level 2 Background Screening Result printed [DATE] which noted CNA C was eligible as of [DATE] and the Retained Print Expiration Date was on [DATE]. Review of the facility's nursing assignment sheet and Keys CNA Assignment sheet for Monday, [DATE] revealed CNA C worked from 7 AM to 3 PM. On [DATE] at 5:25 PM, the Administrator…

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, Administration failed to effectively oversee and monitor the eligibility status of active employees working with residents in the facility. Findings: 1. Review of employee records revealed Certified Nursing Assistant (CNA) C was hired by the facility on [DATE]. Review of the Agency for Health Care Administration (AHCA) Level 2 Background Screening Result revealed the status was Screening in Process with no Eligibility Determination Date. The employment record included a copy of an AHCA Level 2 Background Screening Result printed on [DATE] which revealed CNA C was eligible as of [DATE] and the Retained Print Expiration Date was [DATE]. Review of the facility's nursing assignment sheet and Keys CNA assignment for Monday, [DATE] revealed CNA C worked the 7 AM to 3 PM shift. On [DATE] at 7:15 PM, the Director of Nursing (DON) stated she noticed fingerprints had expired for CNA C during a facility wide audit conducted on [DATE]. She stated she informed the employee,…

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, and record review, the facility failed to report an allegation of neglect to the Agency for Health Care Administration (AHCA) for one resident (#1) and failed to report an allegation of neglect timely to AHCA for one of three residents reviewed for abuse/neglect of a total sample of 9 residents, (#2) . Findings: 1. Review of resident #1's medical record revealed he was readmitted to the facility on [DATE] with diagnoses including injury of urethra, quadriplegia, muscle wasting and atrophy. Review of the Minimum Data Set (MDS) 5-day assessment with Assessment Reference Date of 12/26/23 revealed resident #1's Brief Interview for Mental Status (BIMS) score was 15 out of 15 which indicated intact cognition. Review of resident #1's care plan for Activities of Daily Living (ADL) self-care performance deficit was initiated on 11/14/23. The care plan revealed resident #1 required substantial/maximal assist of one staff member for toileting, bed mobility, bathing, personal hygiene and dressing 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 interview and record review, the facility failed to ensure a Licensed Practical Nurse (LPN) with an expired license did not provide care to residents, for 1 out of 5 nurses selected for employee record review, (LPN A). Findings: Review of employee records revealed LPN A was hired by the facility on [DATE]. Review of the Nursing Homes Federal Reporting revealed the Immediate Report was submitted to the Agency for Health Care Administration (AHCA) on [DATE] and listed the event occurred on [DATE] at 10:00 AM. The AHCA report was completed by the Director of Nursing (DON). The Background Information section included the facility had self-reported from an audit conducted on [DATE] to [DATE] where it was discovered LPN A's nursing license status was delinquent. On [DATE] at 8:23 AM, LPN A stated she worked at the facility for two years and was the Unit Manager (UM) for the Palms unit for approximately a year. She explained she had been a nurse for 7 years. She indicated her nursing license was good until…

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 record review and interview, the facility failed to ensure residents were not asked to waive facility's liability for losses of personal property as a condition for admission for 122 residents currently residing in the facility. Findings: Review of the facility's admission agreement/contract revealed the facility required residents to waive facility's liability for losses of personal property. Section 9a of the contract read, .The Facility will also offer the Resident with a private closet and a locked storage space in his/her room. The facility will only be responsible for failing to take reasonable care in protecting residents' personal property including to protect personal property specifically placed into safekeeping at the facility, with the Facility's consent and in accordance with the Facility established policies or in the Resident's locked storage space. Facility shall insure against loss of valuable items (such as money or jewelry) only if such items are deposited with the management or placed in locked storage provided to the Resident by the facility. 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.

Based on interview and record review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) CMS [Center for Medicare &Medicaid Services]-10055 form was provided to inform beneficiaries of potential liability for payment and related standard claim appeal rights for 3 of 3 residents reviewed for Beneficiary Protection Notification of a total sample of 64 residents, (#94, #129, #180). Findings: Review of the SNF Beneficiary Protection Notification Review forms revealed the question Was an SNFABN, Form CMS-10055 provided to the resident? was answered yes for residents #94, #129, and #180. The CMS form-10055 was not provided, instead CMS-R-131 form with missing date, and residents' names was given to the residents. On 10/19/22 at 11:58 AM, the Case Manager stated the SNF Beneficiary Protection Notification Review forms were completed by her, and the CMS -R-131 forms were provided by the previous Social Services Director. The CMS-R-131 forms were reviewed with the Case Manager and revealed the residents' names were not on the forms, and the forms…

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 sections C, D and E of the Minimum Data Set (MDS) assessments were accurately completed for 3 of 8 residents reviewed, (#17, #23 and #117), failed to accurately complete the MDS assessment pertaining to oxygen use for 2 of 3 residents reviewed for oxygen therapy (#94 and #108), and failed to ensure accurate assessment for 1 of 5 residents reviewed for comprehensive assessment accuracy, (#123), of a total sample of 64 residents. Findings: 1. Review of resident #17's medical record revealed he was admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, major depressive disorder, B-cell lymphoma, and polyarthritis. Review of the quarterly MDS assessment with Assessment Reference Date (ARD) of 7/17/22 revealed resident #17 was not interviewed for the Brief Interview for Mental Status (BIMS) in Section C or the Mood assessment in Section D. The MDS showed both sections were completed by interviewing staff…

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 observation, record review, and interview, the facility failed to follow the menus to meet the residents needs and choices for 4 of 64 sampled residents, (#113, #127, #432, and #433). Finding On 10/17/22 at 9:28 AM, resident #113 was reclining in bed, listening to music. He stated he did not get the meal that was noted on his meal tray ticket. The tray ticket indicated he would receive French Toast. The resident stated he did not get any French Toast and he had to go to the kitchen to get the French Toast himself. He explained he did not eat pork and staff were aware, but they had sent him pork sandwiches in the past. He stated he had a problem with his meals daily as they were never correct. On 10/17/22 at 10:31 AM, Certified Nursing Assistant, (CNA) E stated resident #113 often went to the kitchen himself when his meal tray did not have the right food. Review of the lunch menu for 10/17/22 revealed the residents would receive Swedish meatballs with gravy, egg noodles, cauliflower with pimento, dinner roll with margarine, chilled peaches and beverage of choice. On 10/17/22…

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 observation, interview and record review, the facility failed to follow physician ordered tube feedings for 1 of 2 residents receiving tube feeds, in a total sample of 64 residents, (#119). Findings: Review of resident #119's medical record revealed his diagnoses included intracerebral hemorrhage, and dysphagia. A physician's order dated 10/5/22 read, Osmolite 1.5 at 60 milliliters (ml) per hour for 20 hours to start at 2 PM and turned off at 10 AM, the next morning. On 10/17/22 at 11:12 AM, resident #119 was observed in bed and his tube feeding pump was noted to be off. On 10/19/22 a new physician order for tube feedings read, Osmolite 1.5 at 80 ml for 12 hours. The tube feed pump was to be turned on at 7 PM and turned off at 7 AM, the next morning. On 10/19/22 at 5:38 PM, the resident was observed sitting up in bed. The tube feeding pump was on and the formula was infusing at a rate of 60 ml per hour. At 5:41 PM, the resident's direct care Licensed Practical Nurse, (LPN) C observed the tube feeding pump and acknowledged the tube feed formula infused at a rate of 60 ml per…

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 oxygen [O2] therapy was administered per physician's order for 1 of 4 residents reviewed for O2 therapy of a total sample of 64 residents, (#94). Findings: Review of resident #94's clinical records noted he was admitted to the facility on [DATE], with his most recent readmission on [DATE]. His diagnoses included acute respiratory failure with hypoxia, bipolar disorder, Parkinson's Disease, dementia, psychotic disorder, and schizoaffective disorder. A physician's order dated 6/06/22 read, oxygen [O2] 2 Liters/per minute [LPM] via nasal cannula [NC] continuously. A progress note dated 6/07/22 read, on oxygen 2 L continuously. On 10/18/22 at 9:55 AM, resident #94's oxygen was noted at 3 LPM. On 10/18/22 at 10:09 AM, Licensed Practical Nurse [LPN] D stated resident #94 had physician orders for O2 at 2 LPM. LPN D observed the resident's oxygen setting and acknowledged it was set at 3 LPM, and not 2 LPM as ordered. LPN D verbalized that…

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 observation, interview, and record review, the facility failed to ensure medications were accurately labeled on the South/Keys unit medication cart for 1 of 6 residents reviewed for medication administration of a total sample of 64 residents, (#53). Findings: Medication administration pass was observed on South/Keys unit on 10/17/22 at 12:10 PM, with Licensed Practical Nurse (LPN) A. LPN A confirmed she administered Levetiracetam 250 milligrams (mg) tablet by mouth to resident #53. Observation of the medication label listed on blistex package revealed label instructions for Levetiracetam 250 mg tab give 1 tab via gastrostomy (G)-tube twice a day. Review of resident #53's physician orders with LPN A revealed order dated 8/8/22 that read, may crush meds all crushable meds and put in applesauce, pudding, or yogurt every shift. Observation of blister card packs located in the medication cart with LPN A for resident #53 showed medication labels for Clopidogrel Bisulfate Tablet 75 mg give 1 tablet via G-Tube in the evening, and Escitalopram Oxalate tablet 10 mg give 1 tablet via…

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 and record review, the facility failed to obtain consent for administration of a Coronavirus Disease 2019 (COVID-19) vaccine for 1 of 5 residents reviewed for immunization out of a total sample of 64 residents, (#106). Findings: Review of resident #106's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease and dementia. The record showed resident #106's spouse was the responsible party. Review of the Minimum Data Set (MDS) quarterly assessment with Assessment Reference Date of 9/15/22 revealed the facility did not attempt to complete a Brief Interview for Mental Status for resident #106 due to severely impaired cognition. Review of resident #106's immunization record revealed the facility administered a booster for COVID-19 on her left deltoid on 12/16/21. No evidence of education or consent from resident #106's responsible party was found in the medical record. On 10/20/22 at 6:05 PM, the Staff Development nurse stated the resident or…

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 observation, interview and record review, the facility failed to revise the plan of care related to passive range of motion (ROM) exercises for 1 of 5 residents reviewed for positioning/mobility out of a total sample of 62 residents (#32). Findings: Resident #32 was admitted to the facility in 2017 with diagnoses that included multiple sclerosis, muscle weakness, cramps/spasms and paraplegia. On 2/15/21 at 10:27 AM, resident #32 was noted laying in bed. His legs were extended and resting on a positioning device. He said that he had therapy a few months ago. He stated that since therapy was completed, no one has come in to move or exercise my arms. A review of the current physician orders noted restorative nursing program for passive ROM to both arms to reduce the risk of contractures. The order was last revised on 9/09/20. Interviews on 02/18/21 from 10:07 AM to 11:26 AM revealed that Certified Nursing Assistant (CNA) Q was trained by the Restorative Program Nurse (RPN) on passive ROM exercises. CNA Q explained the lower extremity passive ROM program. CNA Q said he did not…

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 observation and interview the facility failed to ensure the lint traps were cleaned as recommended for 3/3 dryers in the laundry. Findings: On 2/18/21 at 10:16 AM during a tour of the facility's laundry, there was lint build- up in three of three dryers. This was confirmed by the Environmental Supervisor. A review of the Lint Trap Checksheet revealed no documentation to indicate the lint trap was cleaned as required on the following days: Sunday 2/08/21 at 9 AM, 11 AM, 1 PM, 2:50 PM, 5 PM, 7 PM, 9 PM, 11 PM, 12:50 AM. Wednesday 2/10/21 at 9 AM, 11 AM, 1 PM, and at 2:50 PM. Thursday 2/11/21 at 5 PM, 7 PM, 9 PM, 11 PM, and 12:50 AM. Tuesday 2/16/21 at 5 PM, 7 PM, 9 PM, 11 PM, 12:50 AM. Wednesday 2/17/21 at 9 AM, 11 AM, 1 PM, and 2:50 PM . The Lint Trap Checklist was reviewed with the Environmental Supervisor. She confirmed the findings, and stated that lint should be removed from the lint trap every two hours as required. The supervisor said the lint build-up was a potential for fire. The facility's policy Procedure for dryer cleaning read, Clean filter area and filter after…

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 and record review, the facility failed to accurately complete the Minimum Data Set (MDS) assessment for skin integrity for 1 of 4 residents reviewed for pressure ulcers, of a total sample of 62 residents, (#234). Findings: Resident #234 was admitted to the facility on [DATE]. Her diagnoses included left femur fracture, end stage renal disease (ESRD), diabetes type II, age related osteoporosis, and pleural effusion. The resident's admission Nursing Data dated 1/27/21 at 8:45 PM, indicated the resident had an .open area to sacrum with discoloration, scant bleed, Tx (treatment) initiated. The resident's physician orders dated 1/27/21 included skin prep to bilateral heels every shift, cleanse sacrum with normal saline, pat dry, apply foam dressing daily. On 2/03/21 the physician orders were changed to clean sacrum with normal saline, pat dry, apply Santyl, Calcium Alginate and secure with foam dressing every day. Santyl is used to help the healing of burns and skin ulcers .an enzyme. It works by…

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 record review and interview, the facility failed to develop a comprehensive care plan to reflect the goals of treatment and necessary care and services for pain management, for 1 of 6 residents reviewed for pain, of a total sample of 62 residents, (#3). Findings: Resident #3 was admitted to the facility on [DATE] with diagnoses including left shoulder pain, osteoarthritis and difficulty walking. The Minimum Data Set (MDS) admission assessment with assessment reference date of 11/08/20 revealed resident #3 did not receive scheduled or as needed (PRN) pain medication during the lookback period. She denied experiencing pain in the previous 5 days. Resident #3's medical record revealed an Order Summary Report and Medication Record for February 2021 with the following physician's orders: 10/27/20 Check for pain every shift 11/12/20 Acetaminophen 325 milligrams (mg), 2 tablets every 6 hours PRN for pain 11/16/20 Gabapentin 100 mg twice daily for pain 11/16/20 Tramadol 50 mg every 6 hours PRN for pain 11/30/20…

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 follow accepted professional nursing standards of clinical practice for obtaining medication, following a physician's order and maintaining an accurate medical record for 1 of 62 sampled residents, (#3). Findings: Florida Board of Nursing, Nurse Practice Act, 464.003 (3)(a)(1)(2), states that the practice of professional nursing means the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: (1) the observation, assessment, nursing diagnosis, planning, intervention, and evaluation of care; health teaching and counseling of the ill, injured, or informed; and the promotion of wellness, maintenance of health, and prevention of illness of others, (2) the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner authorized…

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 (1) provide podiatry care to 1 of 6 dependent residents reviewed for activities of daily living (ADL), (#124), (2) ensure that a dependent resident was assisted with eating in a timely manner for 1 of 6 residents, (#17), and (3) provide assistance with ADLs related to removal of facial hair for dependent female residents (#6 & #31), of a total sample of 62 residents. Findings: 1) Resident #124 was admitted on [DATE] with diagnoses of dementia, cerebral infarction, and collapsed vertebra. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #124 required extensive assistance of 1 person with dressing, toilet use, personal hygiene and bathing. On 02/15/21 at 10:05 AM, resident #124 was resting in bed. Her feet were swollen and her toenails to both feet were long and jagged, measuring about 1 centimeter from the skin. On 02/16/21 at 11:06 AM, the resident was sitting in her wheelchair. Her toenails remained long…

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 identify new skin impairment under the right breast for 1 of 3 residents reviewed for skin conditions, (#86). Findings: Resident #86 was admitted to the facility on [DATE] with diagnoses that included morbid obesity and generalized weakness. A review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] noted the resident had moisture associated skin damage. On 2/15/21 at 9:38 AM, resident #86 was observed resting in bed. She stated that she had soreness under her right breast. She pulled up her clothing and exposed reddened sore area under the breast. She stated that she the area was sore and painful and she had told the Certified Nursing Assistant (CNA) earlier this morning when she gave her a bed bath. A nursing weekly skin observation note dated 2/15/21 at 11:51 PM revealed redness to buttock treatment continue. There was no documentation of the reddened area under the right breast. On 2/17/21 at 5:18 PM, the Wound Nurse 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to follow the physician's order for oxygen (O2) for 1 of 6 residents reviewed for O2 use in a total sample of 62 residents, (#66). Findings: Resident #66 was readmitted from an acute care hospital on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), asthma, coronary artery disease, and pneumonia. Resident #66's most recent 5 day Minimum Data Set assessment dated [DATE] revealed her Brief Interview for Mental Status score was 4 out of 15, which indicated severely impaired cognition. The hospital transfer form dated 12/30/20 specified resident #66 was in the hospital due to tachycardia. The transfer form noted continuous O2 at 2 liters (L) via nasal canula (NC). Tachycardia is a condition that makes the heart beat more than 100 times per minute (Retrieved from www.webmd.com on 2/19/21). O2 is a drug and should always be prescribed (retrieved from www.oxfordmedicaleducation.com on 2/19/21). A review of 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, interview and record review the facility failed to adequately manage pain for 2 of 6 residents reviewed for pain management of a total sample of 62 residents, (#234, #3). Findings: 1) Resident #234 was admitted to the facility on [DATE]. Her diagnoses included, left femur intertrochanteric fracture, end stage renal disease (ESRD), diabetes type II, age related osteoporosis, and pleural effusion. The resident's history and physical revealed the resident was admitted to the hospital on [DATE], and read, Present to the ED (Emergency Department) with left hip pain after fall .she was unable to bear any weight on her left leg. She reports increased pain with movement and decreased pain with narcotics. The resident's admission Minimum Data Set (MDS) assessment with assessment reference date (ARD) 2/03/21, revealed the resident's cognition was intact, with a Brief Interview of Mental Status (BIMS) score of 14/15. Section J, Health Conditions, indicated the resident received as needed pain…

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 medications were appropriately given for 1 of 62 sampled residents, (#21) Findings: Resident #21 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes, heart failure, hypertension, unspecified psychosis and depression. The resident's morning medications included Carvedilol 12.5 milligrams (MG), Clonidine HCl 0.1 MG, Cyanocobalamin tablet 500 micrograms (MCG) Docusate Sodium Capsule 100 MG, Escitalopram table 10 MG, Gabapentin capsule 100 MG, Hydralazine HCL tablet 25 MG, Hydrochlorothiazide tablet 25 MG, Lisinopril tablet 40 MG, Metformin HCl tablet 1000 MG, Multivitamin with Iron tablet, Tylenol 325 MG 2 tablets, Vitamin A 3000 units 1 tablet, Vitamin D3 1000 International Units 1 tablet. On 2/16/21 at 10:28 AM, resident #21 was sitting near her window with bedside tablet to her side. There were two medication cups on the table. One cup had one pill in it and the other cup had 5 pills. The resident…

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 observation, interview and record review, the facility failed to ensure medications that required refrigeration were stored at an appropriate temperature in 1 of 3 medication rooms, (Palms Unit). Findings: On 2/16/21 at 10:49 AM, during an inspection of the Palms Unit medication room, a thermometer in the refrigerator read 60 degrees Fahrenheit (F). Another thermometer in the freezer read -2 degrees F. The temperature log posted on the appliance read, Temperature range must be between: Refrigerator: 36-46 [and] Freezer: 0 degrees or below. The temperature log indicated on 2/16/21, a nurse noted the freezer temperature was 0 degrees F and the refrigerator was 40 degrees F. The Palms Unit Manager (UM) validated the thermometer in the refrigerator read 60 degrees. She confirmed the refrigerator was stocked with medications including insulin, that required a specific temperature range per manufacturers' directions. She explained night shift nurses were responsible for checking refrigerator and freezer temperatures, then recording them on the log. The Palms UM stated she would…

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.