Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Life Care Center Of New Port Richey during CMS and state inspections, most recent first.
The facility failed to maintain emergency exit doors according to NFPA 101 standards. During a facility tour, it was observed that the exit door by Room 114 did not latch when closed. This was confirmed by the maintenance director, indicating a lapse in the facility's maintenance protocols for door inspections and testing.
The facility failed to address grievances raised by the resident council, including delayed call light responses, staff not wearing name tags, and insufficient staffing. Despite discussions in meetings, these issues were not logged or documented as resolved, contrary to facility policies. Interviews revealed a lack of understanding and execution of the grievance process by the Activities Director and Nursing Home Administrator.
The facility failed to complete or update PASRRs for several residents with mental illness and intellectual disabilities. This oversight affected six residents, whose PASRR documentation was either incomplete or outdated, failing to include necessary diagnoses and evaluations. The facility's policy mandates thorough screening and evaluation, but these procedures were not followed, leading to the identified deficiencies.
The facility failed to ensure competent nursing staff, resulting in multiple deficiencies. A resident with documented allergies was served inappropriate food items, and another had undated bandages. There was also a failure to follow up on a medication order with a black box warning. Additionally, residents were not provided adequate nutrition and hydration, with one resident missing lunch before a medical appointment and others not being offered hydration in the activities room.
A resident experienced a significant weight loss, which was not addressed in their care plan. Despite documented weight loss and meal refusals, the care plan was not updated with new interventions. Staff interviews revealed a lack of communication and coordination, as the resident consistently ate less than 25% of meals, yet this was not effectively communicated or reflected in the care plan.
A facility failed to follow up on a medication order with a black box warning for a resident, resulting in the resident not receiving the medication since admission. Additionally, another resident missed a meal due to an outing, and staff did not provide a meal or snack upon return. Furthermore, a resident was observed without hydration in the activities room, contrary to facility expectations.
A resident experienced a significant weight loss of 10.53%, but the facility failed to complete a timely assessment or update the care plan. Despite the resident's nutritional risk due to advanced age, there was no documented assessment or physician notification. Staff noted the resident's poor meal intake, and the RD confirmed the lack of an updated assessment and interdisciplinary team meeting.
The facility failed to accurately code the MDS assessments for two residents. One resident was incorrectly coded as discharged to home/community instead of the hospital, while another was coded as discharged to a hospital instead of home. The inaccuracies were confirmed by the MDS Coordinator and DON, and the facility lacked a specific policy to address this issue.
A resident experienced a significant weight loss of 10.53%, which was not addressed in their care plan. The facility staff, including a CNA and Diet Technician, were unaware of the weight loss, and the Registered Dietician confirmed that the care plan was not updated with new interventions. The interdisciplinary team did not meet to address the resident's weight loss, and the focus was on the resident's ability to eat independently rather than meal consumption.
The facility failed to maintain adequate hydration and meal provision for residents, as observed in several cases. A resident missed lunch due to a medical appointment and was not provided with food upon return, while two other residents were observed without hydration. Staff interviews revealed a lack of communication and adherence to facility policies on hydration and nutrition, contributing to these deficiencies.
A resident did not receive a prescribed medication with a black box warning due to a lack of follow-up by the facility. The medication was not sent by the pharmacy, and the issue persisted since the resident's admission. The DON contacted the PCP and ARNP, who advised discontinuing the medication. The facility's policy on medication shortages was not adhered to, as the nurses failed to collaborate with the pharmacy and physician for an alternative.
The facility exceeded the acceptable medication error rate, reaching 10.34% due to staff failing to administer the 81 mg Delayed Release medication as ordered to two residents. Despite the facility's policy requiring adherence to the 10 rights of medication administration, errors occurred during observations involving an LPN and an RN, which were later confirmed by the Unit Manager and reported to the DON.
The facility failed to securely store medications, leaving them accessible to unauthorized individuals. Medications, including a custom medication bottle, an inhaler, and creams, were found in residents' rooms without corresponding physician orders for administration or self-administration. The Director of Nursing confirmed that medications should be stored in locked compartments and administered by nursing staff unless a self-administration order is present, which was not the case for the involved residents.
A resident with documented intolerances to milk and wheat was repeatedly served these items, despite requests for alternatives like almond milk. The facility's dietary staff failed to ensure meal tickets reflected the resident's preferences, leading to inappropriate food being served.
Failure to Maintain Emergency Exit Doors
Penalty
Summary
The facility failed to maintain emergency exit doors in accordance with NFPA 101 standards. During a facility tour conducted on March 6, 2025, between 11:30 a.m. and 2:00 p.m., it was observed that the exit door by Room 114 did not latch when in the closed position. This observation was made in the presence of the maintenance director, who confirmed the findings during an interview conducted concurrently with the observations. The deficiency highlights a failure in the facility's maintenance, inspection, and testing of doors, as required by NFPA 101 and NFPA 80 standards. The report indicates that fire door assemblies are to be inspected and tested annually, and non-rated doors should be routinely inspected as part of the facility's maintenance program. However, the failure of the exit door to latch properly suggests a lapse in these maintenance protocols, as the individuals responsible for door inspections and testing are expected to possess the necessary knowledge, training, or experience to ensure compliance.
Plan Of Correction
4/5/25 On March 6, 2025, a security and fire protection company repaired the latch on the exit door by room 114. A facility-wide audit on exit doors was performed by a security and fire protection company on March 6, 2025, with no variances noted. Education was provided to the Maintenance Staff by the Executive Director on March 27, 2025, about NFPA 101 Inspection & Testing Doors per (2012 and 2021 Editions). Monthly audits will be completed by the Maintenance Director or Designee to ensure the exit doors are maintained. These audits will be reviewed in the Quality Assurance Performance Improvement meeting for three months until substantial compliance is met.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to ensure that grievances raised by the resident council were fully and promptly addressed. During a resident council meeting, ten participants confirmed ongoing complaints about delayed responses to call lights, particularly during the third shift, and the lack of staff wearing name tags. Residents also expressed concerns about insufficient staffing, which affected the availability of restorative care, and issues with the facility's cable TV service. Despite these grievances being discussed in meetings, they were not logged in the grievance log or documented as addressed. The resident council meeting minutes revealed several unresolved issues, including the need for staff to wear name tags, education on diets, and the installation of a second rod in closets for wheelchair users. Additionally, residents requested Spanish language lessons due to language barriers with staff. Other concerns included the need for department heads to be identified, visitors not signing in and out, and the absence of garbage bags in restrooms. These grievances were not documented or followed up on, as required by the facility's policies. Interviews with the Activities Director (AD) and the Nursing Home Administrator (NHA) highlighted a lack of understanding and execution of the grievance process. The AD was unaware of the need to initiate grievances from council meetings, while the NHA believed that grievances were addressed promptly and documented. However, the facility's policies on resident council and grievance programs were not adhered to, as grievances were not logged, and resolutions were not communicated effectively to the residents.
Plan Of Correction
On , the Executive Director reviewed the last 3 months of resident council meeting minutes with the Resident Council President and wrote a grievance for the identified concerns. All residents have the potential to be affected. Appropriate notice and invitations were provided for a Resident Council meeting. The Resident Council meeting was held on with, Long Term Care Certified Ombudsman present and residents report satisfaction with facility response to the previously cited grievances. On , the facility Executive Director/Nursing Home Administrator educated the Activities Director on the Resident Council policy and procedures as well as the facility Grievance policy and procedures. A Resident Council concern/grievance follow up form was created and incorporated to ensure that the Executive Director and Resident Council President confirm each month that follow up to grievances brought forth in the Resident Council meeting is appropriate. Results of the Resident Council concern/grievance follow up forms will be tracked and trended and reported monthly to the Quality Assurance Performance Improvement Committee until sustained compliance achieved.
Failure to Complete PASRRs for Residents with Mental and Intellectual Disabilities
Penalty
Summary
The facility failed to complete or update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with mental illness and intellectual disabilities. This deficiency was identified for six residents out of 23 reviewed. The PASRR process is crucial for determining whether individuals with mental or intellectual disabilities require the level of services provided by a nursing facility and if they need specialized services. The facility's oversight in this process led to incomplete or outdated PASRR documentation for these residents. For Resident #12, the Level I PASRR was not revised to include diagnoses of major mental health conditions. Similarly, Resident #57's PASRR was left blank, and qualifying diagnoses were not submitted for consideration. Resident #66's PASRR was incomplete, and a Level II evaluation was not conducted despite qualifying diagnoses. Resident #30's PASRR was also incomplete, with no Level II evaluation submitted. Resident #73's PASRR did not document a qualifying diagnosis, and Resident #84's PASRR was incomplete, lacking a Level II evaluation for consideration of their diagnoses. The facility's policy requires that potential admissions are screened for serious mental or intellectual conditions through a Level I PASRR before admission. A positive Level I screen necessitates a Level II evaluation by the state-designated authority. The facility is responsible for ensuring these screenings are completed and updated as necessary, and for notifying the appropriate state authority when a resident experiences a significant change in their condition. However, the facility failed to adhere to these procedures, resulting in the identified deficiencies.
Plan Of Correction
A new screening was completed on or before for Resident #12, #57, #66, #30, #73, and #84 to accurately capture applicable diagnoses. For any that resulted in Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor, requested documentation has been submitted and is pending third party vendor review. Current residents have the potential to be affected. Current resident Preadmission Screening and Resident Review Forms will be reviewed by to ensure accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. The facility process will be to review new admission Preadmission Screening and Resident Review Forms in the facility clinical meeting and submit revisions or requests for Resident Review Evaluation if applicable. Director of Nursing / Nursing Home Administrator/or Designee will educate Social Services Department staff, Nursing Administration staff, and Admissions Department Staff on Preadmission Screening and Resident Review Form accuracy, specific to ensuring that the Preadmission Screening and Resident Review Form captures applicable diagnoses referenced on the Preadmission Screening and Resident Review Form screening form. Director of Nursing / Nursing Home Administrator/ or Designee will audit 8 Preadmission Screening and Resident Review Forms per week for accuracy. For any inaccurate Preadmission Screening and Resident Review Form identified, a new screening will be completed and Resident Review Evaluation Requests through the Preadmission Screening and Resident Review Form third party vendor if applicable. Results of the audits will be tracked and trended and reported to the monthly QAPI meeting until sustained compliance achieved.
Deficiencies in Nursing Competency and Resident Care
Penalty
Summary
The facility failed to ensure competent staff were available to provide skilled nursing care and services, resulting in multiple deficiencies. One significant issue involved a resident who was served food items containing allergens, specifically wheat and milk, despite having documented allergies to these substances. The dietary staff, including the Certified Dietary Manager and Dietary Aides, acknowledged the error, stating that the resident's meal ticket was not properly reviewed, leading to the resident being served inappropriate food items. The facility was also out of almond milk, which was the resident's preferred alternative, and the family was expected to supply it. Another deficiency was observed with a resident who had undated bandages on their left side, contrary to the facility's policy requiring bandages to be dated and initialed by the nursing staff. This oversight was confirmed by the Director of Nursing and other nursing staff, who acknowledged the importance of dating bandages to track when they were last changed. Additionally, there was a failure to follow up on a physician's order for a medication with a black box warning for another resident. The medication was not administered since admission due to a lack of communication between the facility and the pharmacy, and the nursing staff did not notify the resident's physician to seek further instructions. The facility also failed to provide adequate nutrition and hydration services. One resident was not given lunch before a medical appointment and was not offered any food upon returning to the facility. Furthermore, several residents were observed in the activities room without being offered hydration, and staff were not aware of the residents' hydration needs. The Director of Nursing stated that residents should be offered hydration at least once an hour, and dietary staff should be notified to provide meals or snacks for residents who miss mealtime due to appointments.
Plan Of Correction
Resident # 163 was discharged from the facility. Resident # 66 was assessed with no negative outcome. Resident #73 was changed by our Nurse with no negative outcome. Resident # 91, 16, and 49 were assessed with no negative outcomes. Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with food have the potential to be affected. Residents with food will be reviewed to ensure no related consequences. Residents with have the potential to be affected by not being dated. Residents with will be reviewed to ensure are dated. Residents with medications with black box warnings have the potential to be affected. They will be reviewed to ensure no black box medication related negative effects. Current residents with since will be evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. Residents' whose Activities of Daily Living are dependent on staff that spend time in the activity day rooms for hydration were reviewed to ensure the necessary assistance and fluids are being provided according to the resident needs and plan of care. The Director of Nursing / Staff Development Coordinator will complete training to the Licensed nurses and Certified Nursing Assistants on the process for ensuring food items that residents are to are not accessible, the facilities hydration policy and process with a focus on the residents that are dependent upon staff to meet their hydration needs. The training will also review the process for communicating resident to the kitchen and ensuring residents receive a snack or meal according to resident preferences. The Director of Nursing/ Staff Development Coordinator will educate licensed nurses on the need to ensure are dated and follow up on physician ordered black box warnings is completed timely. The Director of Nursing / Designee will complete 5 random weekly audits of day rooms to ensure residents do not have access to food to verify staff understanding of the education provided. The Director of Nursing/Designee will complete 5 random observations of to ensure they are labeled and 5 random audits of residents with black box warning to ensure physician orders are followed up on. In addition, the Director of Nursing/ Designee will interview 3 residents per week to determine if residents who have have been offered and/or provided a meal or snack and complete 5 random observations of dependent residents in the activity day rooms to ensure they are being provided and assisted with hydration. These audits, interviews and observations will validate staff competency and knowledge of the facility processes. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance improvement meeting until sustained compliance achieved.
Failure to Update Care Plan After Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident had a history of variable intake and meal refusals, which were not adequately addressed. The resident's family noted a significant decrease in the resident's eating habits. Staff interviews indicated that the resident consistently ate less than 25% of meals, yet this was not communicated effectively to the nursing staff or reflected in the care plan. The facility's Registered Dietician confirmed that the resident's significant weight loss was documented but not followed up with appropriate care plan updates or interdisciplinary team meetings. The dietician had recommended supplements, but there was no evidence of a revised care plan or additional interventions to address the resident's nutritional decline. The lack of communication and coordination among staff contributed to the failure to update the resident's care plan appropriately.
Plan Of Correction
The facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing / Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication and ADL Deficiencies in Resident Care
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for one resident. The Director of Nurses (DON) discovered that the resident had not received the medication since admission due to the pharmacy withholding it because of the black box warning. The pharmacy was waiting for a response from the facility, which had not been provided. The DON contacted the Primary Care Provider (PCP), who was uncomfortable making a decision about the medication and advised consulting a specialist. Another deficiency involved the failure to ensure that a resident's activities of daily living (ADLs) were completed and maintained. A Certified Nurses Assistant (CNA) was unsure about the resident's meal schedule and did not provide a snack or meal when the resident missed lunch due to an outing. The resident returned to the facility without having eaten, and staff failed to offer a meal or snack upon her return. The Certified Dietary Manager was not informed of the resident's outing, which would have allowed for meal arrangements to be made. Additionally, a resident was observed in the activities room without hydration for an extended period. Staff interviews revealed that residents should have water available at all times, and hydration should be offered at least once an hour. However, this was not the case for the resident observed. The Director of Nursing expected staff to ensure hydration was available, especially during activities, but this expectation was not met, leading to the deficiency.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide and complete alternative options for meals and/or snacks to accommodate the outing. Current residents with since were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy including offering and providing assist with fluids, meals and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings including communicating to the kitchen for timely tray delivery to accommodate the resident needs and preferences with meals, hydration and snacks with the residents on outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents with. The Director of Nursing / Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assist and hydration is being offered to meet the resident's hydration needs.
Failure to Conduct Timely Assessment for Significant Weight Loss
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days for a resident who experienced a notable weight loss. The resident, who was at risk for nutritional decline due to advanced age and other health conditions, showed a 10.53% weight loss. Despite this significant change, there were no documented assessments related to the change in status, and the care plan was not updated accordingly. Observations and interviews revealed that the resident was not eating much, with staff noting that the resident consumed less than 25% of meals. The resident was on a mechanically altered diet with supplements, but there was no evidence of a change in condition being submitted or the physician being notified of the significant weight loss. The Registered Dietician (RD) confirmed that the resident's assessment had not been updated and that the interdisciplinary team had not met to address the resident's significant weight loss. The facility's policy required immediate notification of significant changes in a resident's condition, but this was not followed. The Director of Nursing acknowledged that the physician should have been contacted, and the care plan updated. The failure to conduct a timely assessment and update the care plan represents a deficiency in the facility's compliance with regulatory requirements.
Plan Of Correction
Resident #162 was discharged from the facility. Facility residents with a significant loss are at risk of being affected by not having a significant change assessment. Residents with significant loss were reviewed by the interdisciplinary team to determine if a significant change was indicated. A significant change assessment will be completed if needed. The Director of Nursing/Designee will educate the Minimum Data Set Coordinators, Registered Dietitian, and Dietary Tech on the criteria for determining a significant change with loss and the need to complete a significant change assessment if the criteria is met. The Director of Nursing/Designee will complete 3 random weekly audits on residents with significant loss to determine if a significant change Minimum Data Set assessment was completed. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Inaccurate MDS Coding for Resident Discharges
Penalty
Summary
The facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two residents. Resident #108 was admitted with diagnoses including Type 2 diabetes without complications and acute failure with major recurrent, moderate. The MDS for Resident #108 inaccurately indicated a discharge to home/community, while the resident was actually transferred to the hospital for further evaluation and treatment due to increased no output. This discrepancy was identified through a review of the resident's records. Similarly, Resident #110, who was admitted with acute failure and Type 2 diabetes without complications, was inaccurately coded in the MDS as being discharged to a short-term general hospital. However, the discharge summary revealed that Resident #110 was discharged home in stable condition with his daughter. Interviews with the MDS Coordinator and the Director of Nurses confirmed the inaccuracies in the MDS coding for both residents. The facility did not have a specific policy to address this issue, relying instead on the Resident Assessment Instrument (RAI) to ensure accurate MDS coding.
Plan Of Correction
Resident (#108) and Resident (#110) Minimum Data Sets were modified to reflect the accurate discharge status. Residents that were discharged from the facility have the potential to be affected. Residents discharged from the facility in the last 30 days were reviewed by the Minimum Data Set coordinator/ designee to ensure accurate coding of the discharge on the minimum data set. Those found to be inaccurate will be modified to accurately reflect the residents discharge location. The Director of Nursing/Designee provided education to the Minimum Data Set coordinators, Case Manager and Social Service Director on the process for identifying the discharge location and accurate coding of the Minimum Data Set. The Director of Nursing/Designee will complete 3 random weekly audits on discharged residents to ensure residents discharged status was coded accurately. Results of the audits will be tracked and trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Failure to Update Care Plan for Significant Weight Loss
Penalty
Summary
The facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident. The resident, identified as Resident #162, experienced a 10.53% weight loss, which was not addressed in the care plan. The care plan, last updated prior to the weight loss, included interventions such as dietician evaluations and medication administration but did not reflect the recent significant weight change. Observations and interviews revealed that the resident was not eating much, and family members confirmed the resident's decreased appetite. The facility's staff, including a Certified Nursing Assistant (CNA) and the Diet Technician (DT), were unaware of the resident's significant weight loss. The DT stated that she was responsible for nutritional assessments upon admission but did not know about the resident's weight loss. The Registered Dietician (RD) confirmed that she had documented the weight loss but had not seen the resident in person. The RD acknowledged that the care plan should have been updated with new interventions and that the interdisciplinary team had not met to address the resident's weight loss. Interviews with the Occupational Therapist (OT) revealed that the focus was on the resident's ability to eat independently rather than meal consumption. The OT stated that the dietician would typically communicate with the Director of Rehab (DOR) if there were concerns about weight loss. The facility's policy on comprehensive care plans emphasized the need for timely updates and revisions by an interdisciplinary team, but this was not followed in the case of Resident #162.
Plan Of Correction
Resident # 162 was discharged from the facility. Facility residents with significant loss have the potential to be affected by not revising the care plan with changes and new interventions. Residents with a significant loss will be reviewed by the Registered Dietitian/Designee to determine if a significant change assessment and or care plan revision is needed. Revisions and updates will be completed as indicated. The Director of Nursing/Designee will educate the Registered Dietitian, Dietary Tech, Minimum Data Set Coordinators on the need to complete an assessment, and revise the care plan with new interventions for residents with a significant change in status in loss so that the care plan accurately reflects the resident. The Director of Nursing/Designee will complete 3 random weekly audits on residents with a significant loss to determine if the care plan accurately reflects the residents significant loss and/or if revisions are needed. The results of the audits will be tracked, trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Deficiencies in Resident Hydration and Meal Provision
Penalty
Summary
The facility failed to ensure that activities of daily living (ADLs) were adequately maintained for several residents, particularly concerning meals, snacks, and hydration. Resident #91 was observed in various locations without access to hydration and reported not having eaten lunch before a medical appointment. The resident was not provided with food during the appointment or upon returning to the facility, despite staff being aware of the situation. Interviews with staff revealed a lack of communication and coordination regarding the resident's meal arrangements, with the Certified Dietary Manager and nursing staff unaware of the resident's missed meal. Additionally, Resident #16 was observed without hydration while sitting in the activities room. The resident's medical records indicated a need for substantial assistance with eating, and the CNA responsible for the resident was unsure about the frequency of providing hydration. Similarly, Resident #49 was also observed without hydration in the activities room, with medical records showing a need for maximal assistance with eating. Staff interviews highlighted a lack of consistent hydration monitoring, with expectations for hourly checks not being met. The facility's policy on hydration and nutrition requires that residents receive sufficient food and fluids, with hydration always available. However, observations and staff interviews indicated that these procedures were not consistently followed, leading to deficiencies in resident care. The Director of Nursing and Regional Director of Clinical Services acknowledged the lack of monitoring and communication regarding resident hydration and meal arrangements, contributing to the identified deficiencies.
Plan Of Correction
Resident #91 was discharged from the facility. Resident #16 and 49 were assessed with no negative outcomes. Residents that are dependent on staff for hydration that spend time in the activity day rooms are at risk of not being offered and assisted hydration. Residents whose Activities of Daily Living are dependent on staff for hydration that spend time in the activity rooms were reviewed to ensure the necessary assistance and fluids are being provided while in the activity day rooms. Residents who have scheduled outings have the potential to be affected by not having staff arrange, provide, and complete alternative options for meals and/or snacks to accommodate the outing. Current residents were evaluated for negative consequences from not being provided a meal or snack with a scheduled outing. The Director of Nursing/Designee in-serviced the licensed and certified nursing staff on the hydration policy, including offering and providing assistance with fluids, meals, and snacks based on the residents' needs and plan of care. This training includes the facility process for residents who have scheduled outings, including communicating to the kitchen for timely tray delivery to accommodate the residents' needs and preferences with meals, hydration, and snacks during outings as needed. The Dietary Director will educate kitchen staff on the facility process for communicating and accommodating meal or snack delivery for residents. The Director of Nursing/Designee will complete 5 weekly activity day room observations of residents dependent on staff for hydration to ensure appropriate assistance and hydration is being offered to meet the residents' hydration needs. The Director of Nursing/Designee will also complete 3 random weekly interviews and/or observations to ensure residents are being provided an earlier meal/snack or meal/snack upon return based on resident need or preference. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Follow Up on Medication with Black Box Warning
Penalty
Summary
The facility failed to follow up on a physician's order for a medication with a black box warning for a resident. The resident was admitted with a prescription for a medication that was not sent by the pharmacy due to the black box warning. The Licensed Practical Nurse (LPN) noticed the medication was out and placed a STAT order, but the issue had been ongoing since the resident's admission. The Director of Nursing (DON) was informed and contacted the pharmacy, which revealed they were waiting for a response from the facility regarding the black box warning. The DON then reached out to the Primary Care Provider (PCP), who deferred the decision to discontinue the medication to the resident's Advanced Registered Nurse Practitioner (ARNP). The ARNP stated that if contacted earlier, she would have recommended discontinuing the medication upon admission. The facility's policy on medication shortages was not followed, as the nurses did not collaborate with the pharmacy and physician to determine a suitable therapeutic alternative. The pharmacist confirmed that the facility should have contacted them to understand why the medication order was not completed.
Plan Of Correction
Resident #264 had his medication, (HCI) discontinued by order from the Advanced Registered Nurse Practitioner. Residents with black box medication warnings have the potential to be affected by not following up on a physician order. Residents with black box sever interactions were reviewed for any missing, late, ordered or not available medications. Physicians will be notified if indicated. Director of Nursing/Designee will in-service the licensed staff on the facility process if a medication is unavailable from Pharmacy due to formulary coverage, contraindications, drug-drug interactions, drug interaction, black-box warnings or other clinical reason. The facility will collaborate with the Pharmacy and physician/prescriber to determine a suitable therapeutic alternative if needed. This in-service will also have a focus on reporting medications not available in Grand Rounds and in the morning clinical meeting. The Unit Managers/Designee will complete 5 random weekly audits on residents with black box sever interactions to ensure follow up with the physician has been completed and the medication is available if medication is approved for the resident. Results of the audits will be tracked trended and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance achieved.
Medication Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 10.34% during the survey. This deficiency was identified through observations, record reviews, and interviews involving two residents. Specifically, during a medication administration observation, a Licensed Practical Nurse (LPN) administered several medications to a resident but failed to provide the 81 mg Delayed Release medication as ordered. Similarly, a Registered Nurse (RN) administered medications to another resident but also omitted the 81 mg Delayed Release medication as per the physician's order. The Director of Nursing (DON) was informed of these medication administration concerns by the Unit Manager, who verified the omissions. The facility's policy on medication administration emphasizes adherence to the 10 rights of medication administration, including ensuring the right drug is administered as per the physician's order. However, the staff failed to comply with this policy, leading to the identified medication errors.
Plan Of Correction
Residents #102 and #361 were evaluated for any negative consequences with none noted. The physicians and resident representatives were notified with no new orders received. Facility residents that receive medications have the potential to be affected. The Director of Nursing/Staff Development Coordinator will complete medication administration competencies on each licensed nurse to validate staff competency related to medication administration with focus on preventing medication errors. The Director of Nursing/Staff Development Coordinator will educate licensed nurses on the policy and procedure for medication administration including following physician orders and preventing medical errors. The Director of Nursing/Staff Development Coordinator will complete 5 random weekly medication administration observations to ensure medications are provided as ordered. Observations will be completed on each shift and weekends. Results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely and were inaccessible to unauthorized staff, residents, and visitors. During observations, medications were found in the rooms of five residents, including a custom medication bottle, an inhaler, and various creams, none of which had corresponding physician orders for administration or self-administration. These medications were left on bedside tables or in accessible areas, contrary to the facility's policy that requires medications to be stored in locked compartments or administered by nursing staff unless a self-administration assessment is completed. The Director of Nursing confirmed that medications should be stored in treatment or medication carts and administered by nursing staff unless there is a self-administration order, which was not present for any of the residents involved. The facility's policy also mandates that medications should not be left at the bedside and should be securely stored to prevent unauthorized access. The failure to adhere to these protocols resulted in medications being accessible to residents and potentially unauthorized individuals, posing a risk to resident safety.
Plan Of Correction
Residents #265, #63, #12, #164 and #18 medications were removed and properly stored with the permission of the resident or resident representative. Facility residents have the potential to be affected by medications being accessible to unauthorized staff, residents, and visitors. The Director of Nursing and Unit Managers completed 100% observation of each resident's room to ensure medications are not accessible to unauthorized staff, residents, and visitors. Residents that had medications not stored appropriately were removed and stored in the medication carts or residents' locked drawer, if a physician order is in place for self-administration, with the resident or resident representative's permission. The Director of Nursing/Designee will complete 5 random weekly observations of resident rooms to ensure there are no medications that are accessible to unauthorized staff, residents, and visitors. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
Failure to Accommodate Resident's Food Intolerances
Penalty
Summary
The facility failed to provide food that accommodates a resident's intolerances and preferences, as evidenced by the case of a resident who was served wheat and milk despite having documented intolerances to these items. The resident, who was observed eating breakfast in her room, reported that she had been served wheat and milk on multiple occasions, despite her requests for alternatives such as almond milk. The resident's care plan and physician orders indicated that she should not be served milk or wheat, and that almond milk should be used instead. However, the facility did not have almond milk available at the time, and the resident's meal ticket incorrectly included items she was intolerant to. Interviews with the facility's dietary staff, including the cook, dietary aides, Certified Dietary Manager (CDM), and Diet Technician (DT), revealed a breakdown in communication and responsibility. The dietary aides admitted to errors in reviewing meal tickets, and the CDM acknowledged that the resident was served items she was intolerant to, despite having documented these preferences. The DT confirmed her role in updating meal tickets and expressed confusion over the oversight. The facility's policy on food preferences and intolerances was not effectively implemented, leading to the resident being served inappropriate food items.
Plan Of Correction
Resident #163 was discharged from the facility. Residents with food intolerances and preferences have the potential to be affected by not honoring intolerances and preferences. The Registered Dietician/diet tech will review residents with food intolerances to ensure the residents' tray ticket and care plan are accurate. The diet tech/food service director will interview residents to ensure their food preferences are accurate and are correct on residents' tray tickets. The facility added a food tray checker at the end of the tray line to verify the tray is accurate, honoring the resident's intolerances and food preferences. The Registered Dietitian/Designee will in-service the food and nutrition staff on the process for ensuring residents with intolerances are not served those food items and that food preferences are honored. This training will include the process for checking the tray prior to serving. The Director of Nursing/Designee will in-service licensed nurses, certified nursing assistants, and activity staff on the need to ensure that the items on the tray match the tray ticket and that food items that the residents are to avoid or have intolerances to are not served, and that food preferences are provided. The Registered Dietitian/Designee will complete 5 random weekly meal observations to ensure that residents are not served items they are to avoid or have intolerances to and are provided their food preferences. The results of the audits will be tracked, trended, and reported to the monthly Quality Assurance Performance Improvement meeting until sustained compliance is achieved.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire At Ridge Haven | 0.5 mi | ★★★★★ | 0 | 0 |
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| Heather Hill Healthcare Center | 2.1 mi | ★★★★★ | 1 | 0 |
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