Darcy Hall Of Life Care

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to maintain an effective infection prevention and control program during a scabies outbreak. One resident had weekly skin assessments documenting a rash over several months, and physician orders were written for ivermectin on two specific dates to treat scabies. A nursing progress note indicated the pharmacy was contacted and would send the medication, but the medical record contained no documentation that the ivermectin was ever administered. The same resident was to be added to a dermatology consult list and later had a physician order for a dermatology consultation for a rash on the back and upper arms, yet there was no evidence in the record that the dermatology consultation occurred. During a side‑by‑side record review, the Infection Control Preventionist (ICP) agreed with these findings. The facility also failed to implement timely and consistent contact precautions for multiple residents treated for scabies, contrary to its policy requiring contact precautions prior to and during treatment. One resident received multiple courses of permethrin cream and ivermectin over several months; contact precautions were documented only for an initial period and then were absent for an extended interval despite ongoing treatment. Another resident received permethrin cream and ivermectin with no documented contact precautions at any time during treatment. A third resident, who reported having a rash that began at the facility and being treated on and off for a few months, had intermittent contact precautions that were delayed several days after initiation of treatment on more than one occasion. The ICP stated that contact precautions should begin with suspicion or treatment of scabies and noted that the onsite dermatologist sometimes ordered permethrin directly from the pharmacy without prior notification to the ICP. The infection surveillance and environmental control components of the program were also deficient. The facility reported a rash/scabies outbreak to the State Agency and maintained a log of residents with itchy rashes, but the corresponding Infection Surveillance Line Listing Report omitted most of those residents, including several identified in October and two in November, even though the ICP acknowledged the log was used to track and trend infections. Environmental services policies required bagging linens, towels, washcloths, lift slings, and clothing from the preceding three days, specific laundering or maintenance procedures, and thorough vacuuming of mattresses for residents treated for scabies. However, documentation provided for the affected unit during the outbreak showed only routine cleaning schedules and terminal cleaning checklists that lacked room numbers and did not reference bagging of linens or personal items or mattress vacuuming, and the Director of Environmental Services agreed with these findings. Additionally, although the ICP stated that staff education on scabies was ongoing and had been provided during the outbreak, the only documented trainings related to scabies were dated in December and January, with no evidence of staff education in October or November during the period of the outbreak.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to provide ordered pressure ulcer care and promote healing of a facility-acquired sacral pressure ulcer for one resident with severe cognitive impairment, dementia, total dependence for ADLs, weight loss, two stage 3 pressure ulcers, and continuous bowel and bladder incontinence. The resident was care planned as at risk for skin breakdown with interventions including frequent turning and repositioning, keeping the skin clean and dry after each incontinent episode, and use of a low air loss mattress. The resident was also care planned for left buttock and sacral pressure ulcers with interventions to administer treatments as ordered and provide frequent incontinent care. Wounds to the left buttock and sacrum were first identified by a CNA and documented as stage 3 pressure ulcers by wound care on 01/13/26. Physician orders dated 01/15/26 required daily wound care and as-needed dressing changes if soiled, wet, or dislodged, but the MAR showed wound care was not completed on 01/16/26 with no documented reason. On 01/21/26, wound care documentation showed the left buttock wound had resolved while the sacral wound had deteriorated, and wound care orders were increased to twice daily. The MAR then showed that the ordered evening wound care on 01/22/26 was not done, again without explanation. Subsequent wound care notes documented that the sacral wound further deteriorated to a stage 4 pressure ulcer, with a wound culture later positive for three different bacteria and an x-ray confirming osteomyelitis. The wound care nurse confirmed that the left buttock wound resolved but the sacral wound deteriorated after initially being identified as a stage 3 pressure ulcer.

Penalty

Inspection fine: $30,924

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to protect a resident from neglect by not providing necessary supervision to prevent elopement. The resident, who had a history of Parkinson's Disease, cognitive impairment, and other significant medical conditions, was identified as being at risk for elopement and resided in a secured unit. Despite this, the resident was able to exit the facility undetected through the main entrance while the receptionist was distracted by visitors. The main entrance required manual unlocking after a buzzer was engaged, and the receptionist, responsible for monitoring the entrance camera, did not notice the resident leaving. There were no additional staff present at the entrance at the time of the incident. The resident's care plan and medical orders clearly indicated an elopement risk, and she was supposed to be provided with safe wandering interventions and supervision. On the day of the incident, the resident was last seen in the dining room and then was not found during medication pass and dinner. Staff initiated a search after realizing the resident was missing, but by that time, the resident had already left the building. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways, and the entrance system allowed visitors to enter without a code, though a code was required to exit. This system was in place at the time of the incident, and staff interviews confirmed that visitors could access the secured unit without a code, potentially allowing residents to leave unnoticed. The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed several doses of her prescribed medications during the period she was missing. Interviews with staff indicated that the resident had not previously exhibited exit-seeking behaviors and that staff were not aware of any immediate risk on the day of the incident. The failure to provide adequate supervision and effective security measures directly led to the resident's elopement and the resulting deficiency.

Removal Plan

• 100% headcount of residents was completed to ensure no other residents were missing. All other residents were accounted for.
• A whole house search of the facility was completed.
• The executive director was notified by the weekend supervisor who in turn notified facility managers to report to work to assist in the search. Regional and divisional staff were also notified and reported to the facility to assist in the search. The medical director and primary physician were notified.
• An external search of the community was initiated.
• Executive Director notified the local Police Department who assisted in the search.
• Upon return, the resident was placed on one-to-one supervision on the secured unit. (1:1 monitoring ordered).
• All facility exit door alarms and screamer devices were inspected by the Maintenance Director.
• Keypad code to secure unit was changed by the Maintenance Director.
• Immediate education on abuse neglect and exploitation and risk of elopement initiated.
• 3-11 shift sign-in sheet reviewed. 11-7 signage sheet reviewed. No concerns.
• The elopement risk assessments of all residents were reviewed for accuracy.
• An elopement drill was performed for the 11-7 shift.
• The resident was assessed by the nurse upon return and by the physician. Skin assessment done.
• An elopement drill was performed for the 7-3 shift.
• The care plans and kardexes of residents at risk for elopement were reviewed for accuracy.
• Visitor lanyards were ordered for identification of visitors/vendors to differentiate visitors from residents. The lanyards were put into use immediately.
• Keypad order to replace push button for entry to units. Keypad was installed.
• Elopement books were reviewed for accuracy.
• An ad hoc QAPI was performed by the facility IDT and reviewed by the Medical Director.
• The Executive Director initiated education related to abuse/neglect reporting.
• The Assistant Executive Director notified the Department of Children and Families of the elopement of Resident #1.
• A Federal Immediate Report was submitted.
• Current facility staff were provided education by the Director of Nursing and Assistant Director of Nursing pertaining to what constitutes resident mistreatment, abuse, neglect, and misappropriation of resident property. Any employees who have not received the training were notified they must receive the training prior to working their next scheduled shift. New employees hired after will receive education during the facility orientation process. Education pertaining to abuse/neglect is provided annually and as needed.
• Facility practices which assist in monitoring/identifying potential abuse and neglect include, but are not limited to: grievance process, complaints resolution process, facility theft and loss reporting, resident council, incident reporting, internal audits of resident trust accounts, daily staffing practices, and regular direct indirect supervision of nursing home employees and resident care by supervisory and administrative staff.
• Root cause analysis was performed by the regional director of clinical services related to the circumstances of the resident elopement. An IDT review and investigation of the residence episode of elopement was completed through the ad hoc copy process. Included in the investigation was reviewed the residence condition preadmission and post admission, resident evaluations including the accuracy of elopement evaluation resident care plan, staffing, facility environments and equipment.
• The residency elopement risk evaluation was completed accurately at the time of admission and a care plan for elopement risk was initiated. The resident was correctly placed on the locked [NAME] wing unit at the time of admission.
• The staffing PPD for licensed nurse assist and for CNA's. On the [NAME] Wing units on the 3:00 PM to 11:00 PM shift, there were two nurses and five CNA's for the 52 residents. 2 weeks staffing calculations (State only Requirement) reviewed with no concerns.
• Staff who predominantly work on the [NAME] Wing were interviewed via a questionnaire and asked if the resident displayed any exit seeking behaviors prior to the incident, verbalizations of wanting to leave, packing belongings, or pushing on exit doors. The staff report no indications of such desire to exit or knowledge of any exit seeking behavior.
• The investigation and root cause analysis revealed potential root cause scenarios (birthday party and push button entrance).
• Elopement risk evaluation facility systems processes in place related to patient identification of potential for elopement/ wandering and safety in place and followed.
• The elopement risk evaluation is completed on admission, quarterly, and after a significant change period the evaluation consists of ambulatory mobility status, wandering behaviors, cognitive status, and exit seeking indicators.
• If a patient is identified as a potential risk, based upon the evaluation, a patient identification form, which will include a current photo, a current description, and personalized care plans, and interventions, and redirection strategies. The patient elopement book contains copy of the patient identification form, a colored photo of the patient and a face sheet. The elopement books are maintained at each nursing station and at the entrance to the reception facility area.
• Facility door prevention maintenance, monitoring and checked for function weekly conducted as scheduled.
• All exit doors are inspected weekly.
• All designated entrance/exit areas have scheduled staff assigned to the receptionist area from 8:00 AM to 8:00 PM seven days a week.
• Staffing schedules are monitored daily by staffing coordinator and reviewed with executive director of nursing and or nursing supervisor on duty to ensure adequate staffing is maintained. Adequate staffing means all minimum PPD, and ratios are met and in addition, staffing is adjusted based on acuity of patient needs.
• All staff are screened prior to hire and a job specific orientation is performed. Receptionist not only receive training but have a completed competency on file.
• A review of five receptionist staff employees' file revealed all had completed training and had a competency on file. The receptionist on duty at the time of the residence elopement was suspended immediately and has subsequently been terminated.
• The maintenance staff performed an inspection of the facility exit doors and screamer devices and all were found to be fully functional.
• Weekly door checks by the Maintenance Director will be performed to ensure proper function. The push button entry system onto the memory care unit was replaced with the keypad the truth device.
• Facility licensed nurses completed a review of the accuracy of 185 current residents elopement risk evaluations. Of the 185 residents, 52 residents resided in the memory care unit and 51 of those who were already assessed to be at risk for elopement. The remaining 1 of 52 residents was originally placed on The [NAME] Wing unit for behavior management but has since become a risk for elopement. The residence assessment was updated to reflect the risk of elopement.
• The care plans and CNA Kardexs' of 52 of 52 residents at risk for elopement were reviewed. All were found to be in compliance with risk for elopement identified.
• Director of Nursing /designee to complete monitoring of new admission evaluations to ensure risk for elopement is accurately identified and care plan and Kardex are reflective of the risk, where appropriate.
• The Medical Director was informed of the citations and is in agreement with the removal plan.

Penalty

Inspection fine: $30,924

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to provide necessary supervision and prevent an elopement for a resident identified as being at risk for elopement. The resident, who had diagnoses including Parkinson's Disease, cognitive impairment, and other significant medical conditions, was admitted to the secured unit due to her risk status. Despite being care planned for elopement risk and having interventions such as placement in a locked unit, the resident was able to exit the facility undetected. On the day of the incident, the resident left the secured unit and exited through the main entrance while the receptionist was distracted by visitors, and no other staff were present at the entrance. The exit door required manual unlocking after a buzzer was engaged, and the receptionist did not notice the resident leaving, as confirmed by surveillance footage. The facility's layout allowed access from the secured unit to the main lobby and entrance through unsecured hallways. Interviews revealed that, prior to the incident, visitors could enter the secured unit without a code but needed a code to exit, and staff did not typically provide codes to visitors. On the day of the incident, a birthday party for another resident in the main dining room resulted in increased visitor traffic, and it was believed that a visitor may have inadvertently allowed the resident to leave the secured unit. Staff did not observe any exit-seeking behaviors from the resident on the day of the incident, and the resident was last seen in the unit's dining room before being discovered missing during a medication pass and dinner. The resident was found by law enforcement several hours later, approximately two miles from the facility, with minor injuries such as abrasions and bruising. She missed multiple scheduled medication doses during her absence. The facility's policy defined elopement as a resident leaving the premises without authorization or necessary supervision, and the resident's care plan specifically identified her as an elopement risk. Despite these measures, the facility failed to ensure effective supervision and security measures to prevent the resident's undetected exit from both the secured unit and the building.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident's choice regarding showering preferences, as evidenced by the case of a resident with moderate cognitive impairment and physical limitations due to a stroke. The resident expressed a desire for showers instead of bed baths, but records showed she received only one shower in the past 30 days, despite being scheduled for showers twice a week. The resident's care plan indicated she required assistance with bathing, yet her preference for showers was not consistently met. Interviews with staff revealed a lack of awareness and adherence to the resident's shower schedule. A CNA working with the resident was unaware of the designated shower days and relied on the resident's requests to determine when to provide a shower. This lack of communication and adherence to the resident's care plan resulted in the resident's preferences not being honored, as she continued to receive sponge baths instead of the showers she requested.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to document an accurate Advance Directive care plan for a resident, leading to a discrepancy in the resident's resuscitation preferences. The resident, who had severe cognitive impairment and was dependent on activities of daily living, was receiving hospice services. The care plan inaccurately documented the resident as having an Advance Directive for CPR and being a full code, despite an existing order for DNR and a State of Florida DNR order form. This error was confirmed during an interview with the Central Unit Manager, who acknowledged that the care plan entry was made in error.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide proper care and treatment to maintain a resident's communication abilities, as evidenced by the absence of a communication board for a resident with a documented communication problem. The resident, who was admitted to hospice services with multiple diagnoses including anxiety disorder, major depressive disorder, persistent mood disorder, panic disorder, and dementia, was dependent on assistance with activities of daily living. The resident's care plan, in place since May 2023, included the intervention of having a communication board at the bedside as needed. However, during observations, the communication board was not present, and the resident struggled to communicate her needs effectively. On two separate occasions, the resident attempted to communicate her needs using non-verbal cues and limited verbal communication. In one instance, the resident motioned for assistance with her incontinence brief, but the CNA misunderstood her request and left to get a drink of water instead. In another instance, the resident indicated she wanted food by touching her fingertips to her mouth, which was eventually understood by the CNA. These interactions highlight the communication challenges faced by the resident due to the absence of the communication board, which was a planned intervention in her care plan.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to address a skin condition in a timely manner for a resident who was admitted with fragile skin and was care planned for potential skin impairment. Despite having orders for Zinc and Hydrocortisone Cream to treat a rash, and a dermatology consult ordered, the resident experienced severe itching for about three weeks without seeing a dermatologist. The Social Service Director acknowledged the delay in arranging the dermatology consultation, which resulted in the resident not being seen until the next scheduled visit. Another resident was prescribed medications for high blood pressure and coronary artery disease, but the facility failed to provide these medications as ordered. Nurses held the medications based on low heart rate without any parameters and did not notify the physician of the held medications. The Director of Nursing agreed with the findings that there were no parameters to hold the medications, indicating a lack of proper communication and adherence to physician orders. Additionally, the facility did not follow physician orders for another resident's blood pressure medications, administering them outside the specified parameters. The Licensed Practical Nurse admitted to not being aware of the PRN medication orders and not following the parameters. Furthermore, a resident with a doctor's order to use a pillow between her legs to prevent knee adduction and lower body contractures was observed without the pillow, and staff were not aware of the requirement. The Director of Rehabilitation acknowledged the need for staff training on proper wheelchair positioning and the use of a pillow between the resident's knees.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to properly manage and document the administration and disposal of controlled medications for several residents. For Resident #64, multiple packs of Lorazepam were found in the medication cart, despite the resident having only two specific orders for the medication, both related to dental procedures. The Director of Nursing (DON) acknowledged that the pharmacy continued to send the medication unnecessarily, and the unused medication should have been returned to the pharmacy. For Resident #124, a medication pack containing 16 pills of Lorazepam was found, although the medication had been discontinued months earlier. The Controlled Medication Utilization Record showed that Lorazepam was removed for administration on two occasions, but there was no documentation of administration on the Medication Administration Record (MAR). Similarly, for Resident #263, Lorazepam was removed multiple times for administration, but there was no evidence of administration documented on the MAR. Staff acknowledged these discrepancies, and the DON confirmed that unused medications should have been returned to the pharmacy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure safe medication storage for one of its medication carts on the D Unit and one treatment cart on the West Unit. On January 27, 2025, a medication cart on the D Unit was found unattended and unlocked, with the lock not fully engaged, allowing easy access to medications for 22 residents. An independently ambulatory resident was observed near the cart, and no staff were present in the hallway. The Assistant Director of Nursing acknowledged the concern when informed. Later, a Licensed Practical Nurse returned to the cart and attempted to open it without a key, indicating a misunderstanding about the lock's engagement. Additionally, on January 27, 2024, a treatment cart on the West Unit was observed unlocked and unattended in a locked memory care unit. The cart contained various wound care supplies and medicated ointments, including sharp instruments. Multiple cognitively impaired residents were seen moving around the area. A Registered Nurse confirmed the findings when notified. The presence of independently ambulatory residents in both units posed a risk due to the unsecured carts.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide food in a pureed form to meet the individual needs of three residents who were on a medically ordered pureed diet. Resident #46, diagnosed with Alzheimer's disease and dementia, was observed receiving a meal that included pureed cabbage and rice, which were lumpy, contrary to the facility's policy that pureed foods should be smooth and free of lumps. Similarly, Resident #48, who has Alzheimer's disease and oropharyngeal dysphagia, was served mashed potatoes that contained a large lump, which the resident struggled to consume. Resident #65, with a history of cerebrovascular accident, dementia, and aphasia, was also served a meal with lumpy pureed cabbage and rice. During an interview, the Food Service Director acknowledged the presence of lumps in the pureed rice and strands in the pureed stir fry vegetables, which were not consistent with the required smooth texture for a pureed diet. The facility's failure to adhere to the pureed diet requirements as per the National Dysphagia Definition and their own policy resulted in the provision of meals that were not suitable for residents with dysphagia, potentially compromising their ability to safely consume their meals.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accommodate a resident's food preferences and offer an alternative food option after the resident refused a meal. The resident, who was unable to communicate effectively due to a low Brief Interview of Mental Status score, had specific dietary dislikes including mayonnaise, rice, and red meat. Despite these documented preferences, the resident was served meals containing these disliked items, such as turkey salad with mayonnaise and ground pepper steak with pureed rice. The resident's care plan indicated increased nutritional needs due to a diagnosis of Malignant Neoplasm of Breast, yet her weight had decreased significantly over a short period. Observations revealed that the resident consumed very little of the meals provided, and when questioned, staff offered a nutritional supplement instead of an alternative meal. The resident's family had previously communicated her food preferences to the Registered Dietitian, but these preferences were not consistently honored. The facility's failure to provide meals in accordance with the resident's documented dislikes and preferences contributed to the resident's inadequate nutritional intake.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adhere to professional standards for food service safety, sanitary conditions, and the prevention of foodborne illnesses, potentially affecting 158 of 165 residents. During an initial tour of the Main Kitchen, a personal backpack was found on a shelf below the food preparation area, resting on dishware. In the dry storage room, a gray plastic bin was observed with dark colored sediment on the handle and inside the bottom of the container, as well as on the handles of at least four scoop serving utensils. Additionally, the Cleveland steamer had brown/red wet residue around the perimeter of the upper steamer and the upper exterior of the lower steamer. These observations were acknowledged by the Food Service Director during the tour. In a separate tour of the nourishment room in the [NAME] Wing, an opened plastic container of Med Plus 2.0 Nutritional Drink was found on a refrigerator shelf without a date indicating when it was opened, contrary to the manufacturer's instructions to refrigerate and consume within four days. An unlabeled styrofoam cup with liquid was also found on a refrigerator shelf, lacking a product name, resident's name, or date. These findings were acknowledged by the Director of Nursing during the tour.