Regents Park Of Winter Park

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's QAPI program failed to identify a repeated deficiency and systemic non-compliance with IV catheter care. Survey history showed repeat concerns for IV catheter care, including a CMS enforcement citation for F694 Parenteral/IV Fluids during the 10/23/24 recertification survey and again during the current recertification survey conducted from 6/01/26 to 6/04/26. The deficient practice had the potential to affect more than a limited number of residents because the facility did not ensure consistent monitoring and follow-up of identified problems. On 6/04/26 at 5:45 PM, the Administrator discussed the facility's QAPI program and was unable to show evidence of a Process Improvement Plan or current audits in effect for parenteral/IV fluids. The Administrator acknowledged the prior citation for parenteral/IV fluids during the last recertification survey but could not explain the repeat concerns with IVs. Review of the undated 2026 Quality Assurance & Performance Improvement Plan showed it was intended to be a facility-wide, data-driven program, with objectives that included addressing gaps in systems or processes and a goal of having no previously cited tags in the past three years.

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 implement and maintain an effective infection prevention and control program in the laundry room. During a tour, surveyors observed wet floors with standing water between two large washers, broken tiles on the floor, and an uncovered AC vent above the clean linen area with visible dust blowing through it. The Housekeeping Manager said the floor had been wet for a few days, was unsure whether the leak was from the washer, and noted there may have been an issue with bleach dispensing into the wash. He also stated there was no alarm or alert on the washer screen to indicate a problem with bleach or detergent, and the Infection Preventionist acknowledged the laundry room conditions could cause cross contamination. Surveyors also observed Laundry Attendant E folding clean linen and shaking a bed sheet without wearing a gown or gloves. The sheet touched her chin, clothing, and upper chest. The Infection Preventionist acknowledged this could lead to cross contamination and stated staff should hold linen away from their face and avoid shaking linens. The facility’s undated Infection Control-Linen Management policy stated linens are to be handled to prevent cross contamination, clean linens are to be kept covered and protected from dust, and laundry equipment should be properly maintained according to the manufacturer’s instructions. The facility also failed to follow infection prevention practices for residents with IV access and transmission-based precautions. Resident #128 was admitted with acute pyelonephritis, bacteremia, UTI, ESBL resistance, and dementia, and hospital paperwork showed ESBL Klebsiella bacteremia from a urinary source treated with ertapenem. The resident had a midline catheter and was on contact isolation, yet a Social Service Assistant entered the room without PPE despite contact isolation signage and PPE being available outside the room. For Resident #127, who had a single lumen midline IV in the left upper arm, there were no orders or signage for transmission-based precautions or enhanced barrier precautions, and the Infection Preventionist stated the resident should have been on enhanced barrier precautions because of the midline IV.

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 inform residents and/or their representatives about the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive (AD), and failed to obtain complete AD acknowledgment documentation for multiple residents. The report identified 20 residents in the sample whose records showed incomplete AD acknowledgment forms, including residents who were able to make their own healthcare decisions and residents whose representatives should have been involved because the residents were dependent or unable to decide for themselves. Resident #1 had diagnoses including malignant neoplasm of the lung, secondary malignant neoplasm of bone, pneumonia, and COPD with exacerbation, and an MDS assessment showed a BIMS of 12/15, indicating moderately impaired cognition. Resident #15 had diagnoses including Alzheimer’s disease, schizoaffective disorder bipolar, and COPD, and her MDS showed a BIMS of 2/15, indicating severe impairment. Resident #116 had metabolic encephalopathy, hemiplegia and hemiparesis, type 2 diabetes mellitus, major depressive disorder, and dysphagia, and her MDS showed a BIMS of 3/15; her care plan referenced AD education and materials, but the form in the chart was incomplete with no date or signatures. Resident #11’s admission MDS showed she was unable to complete the BIMS and was severely impaired in daily decision making, yet the AD acknowledgment form had no resident or representative signature. Resident #12 had stroke, metabolic encephalopathy, contracted hands, aphasia, and a BIMS of 6/15, indicating impaired cognition and inability to make her own healthcare decisions; her chart contained a blank AD form with no date, signatures, or code status. For residents #4, #5, #6, #7, #8, #10, #13, #16, #57, and #108, the AD acknowledgment forms were also incomplete, with questions and checkboxes left blank regarding whether an AD had been chosen or issued. Staff interviews described attempts to contact families or guardians for code status decisions when residents were confused or unable to communicate, but the facility was unable to provide progress notes showing further attempts for resident #12, and the facility’s policy stated the admitting nurse should verify code status upon admission with the resident or representative.

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 completion and accuracy of Level I PASARR screens on admission and failed to update PASARR information for residents with newly evident or documented mental disorders or intellectual disabilities. Survey review identified 7 of 7 residents reviewed for PASARR had incomplete or inaccurate screens, including residents with diagnoses such as bipolar disorder, schizophrenia, depression, anxiety, PTSD, brief psychotic disorder, and autistic disorder. The facility’s PASARR policy stated residents admitted to the facility were to receive PASARR screening and that Level I and II PASARRs were to be coordinated into the care plan. Resident #4 was admitted with diagnoses including bipolar disorder, anxiety, major depressive disorder, OCD, and paranoid schizophrenia, and the PASARR Level I screen listed mental illness as bipolar disorder and schizoaffective disorder, but the record showed no updates to include the resident’s documented mental illnesses. Resident #6 was admitted with dementia with agitation and brief psychotic disorder, yet the PASARR form incorrectly indicated no mental illness under Section IA, and no update was made after psychiatry documented brief psychotic disorder and psychotic symptoms. Resident #8 was re-admitted with bipolar disorder, major depressive disorder, GAD, and PTSD, but the PASARR screen completed by the facility did not include depression or PTSD; resident #62 had diagnoses including paranoid schizophrenia, bipolar disorder, anxiety disorder, autistic disorder, major depressive disorder, and PTSD, but the PASARR screen did not include PTSD. Resident #66 was re-admitted with major depressive disorder, but the hospital PASARR screen did not check that diagnosis and left sections blank. Resident #7 had bipolar disorder, and although one PASARR screen identified bipolar disorder, a later facility-completed screen included anxiety and depression but omitted bipolar disorder; the MDS also listed depression and bipolar disorder, and physician orders included Depakote used to treat bipolar disorder. Resident #10 had stroke, depression, and bipolar disorder, but the PASARR Level I screen left all diagnoses blank even though the MDS listed bipolar disorder and anxiety and physician orders included medications for depression and anxiety. The MDS Coordinator stated the facility had not yet submitted the PASARR screens for residents #4, #6, #8, #62, #7, and #10 because they were being reviewed for accuracy, and the DON stated she and the MDS Coordinator were responsible for PASARR screens.

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 safe, appropriate administration of IV fluids for a resident receiving IV antibiotics through a midline catheter. Resident #128 was admitted with acute pyelonephritis, bacteremia, UTI, ESBL resistance, and dementia. Hospital paperwork documented an Infectious Disease consult for ESBL Klebsiella bacteremia from a urinary source, with left-sided pyelonephritis and ertapenem ordered because the organism was susceptible to that antibiotic. Physician orders directed ertapenem sodium 1 gram IV daily for seven days. Surveyors found that the resident had a midline IV catheter but no physician orders for midline monitoring or dressing changes at the time of the survey. An LPN prepared and administered ertapenem but set the dial flow rate at 100 ml/hour instead of the pharmacy instruction of 200 ml/hour, which would have caused the antibiotic to run over an hour rather than the intended 30 minutes. The LPN acknowledged the error and stated she should have verified the pharmacy instructions and physician's order before setting the flow rate. The DON acknowledged the resident did not have the midline-related orders until after the start of survey and confirmed the nurse administered the IV antibiotic at the incorrect rate.

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 trauma-informed and culturally competent care for 2 residents diagnosed with PTSD by not ensuring their identified trauma triggers were incorporated into their care plans and communicated to direct care staff. The report states that the facility’s Trauma-Informed Care policy required care that respected culture and preferences and avoided triggers or re-traumatization, and that even if a trauma survivor did not want to share their history, the facility should still try to identify triggers and create care plan steps to reduce or remove them. Resident #8 was admitted with multiple diagnoses including bipolar disorder, major depression, anxiety, PTSD, and alcoholic liver cirrhosis. Her psychiatric notes documented a history of significant trauma with nightmares, flashbacks, and hypervigilance, and her PTSD care plan identified childhood emotional, physical, and sexual abuse by family members, with triggers including a male resident resembling her father and trauma-related nightmares. However, her comprehensive care plan only included a general focus for risk for trauma related to medical settings and did not list her specific trauma triggers. During interviews, her assigned CNA and RN stated they were not aware of any special care instructions or precautions for her, despite special instructions being present in the Kardex. Resident #62 was admitted with diagnoses including paranoid schizophrenia, bipolar disorder, anxiety disorder, autistic disorder, major depression, and PTSD. Her psychiatric note documented trauma from being stabbed by her niece, with triggers including discussing past trauma, and the care plan noted a need to monitor for nightmares or emotional triggers and maintain a supportive environment. Her comprehensive care plan identified a risk for emotional distress related to abuse, PTSD, and trauma, but did not include her triggers or reflect the psychiatrist’s suggestions. The resident was observed upset about remaining in her room during deep cleaning and uncomfortable sitting near another resident who coughed a lot, while her assigned CNA and RN both stated they were not aware of any special instructions or precautions. The DON and other leaders acknowledged that the care plans were not resident centered and that communication between the psychiatrist and the team had broken down.

Penalty

Inspection fine: $153,225

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 protect residents from neglect, resulting in a fall with major injury for one resident and a near-miss incident for another. Resident #3, a vulnerable and physically impaired individual, required assistance from two staff members for transfers using a full body mechanical lift. However, on 11/22/24, a CNA attempted to transfer the resident single-handedly, leading to a fall when one of the sling's loops detached from the lift. The resident suffered blunt head trauma and a sacral fracture, and later developed a left hip fracture, which significantly impacted her quality of life. In another incident, the facility failed to ensure staff accessed and implemented the care plan for resident #2, who required a full body mechanical lift for transfers. A CNA neglected to review the care plan and attempted to transfer the resident using a sit-to-stand lift, which was inappropriate given the resident's weakness and poor balance. Although the transfer was averted due to a dead battery in the lift, the CNA's actions placed the resident at high risk for an adverse outcome. These failures in providing appropriate care and services for mechanical lift transfers not only resulted in a serious injury for resident #3 but also placed resident #2 and other residents requiring mechanical lifts at risk for serious injury or death. The facility's neglect in following established care directives and ensuring staff compliance with safety protocols led to these deficiencies.

Removal Plan

• The evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service.
• The CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended.
• The Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility's Administrator, Director of Nursing, and Medical Director to review the initial incident.
• The Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans.
• The MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents.
• The MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified.
• The Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified.
• Current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.
• Current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet.
• An Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation.
• The Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers.
• Nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
• Nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey that started and additional steps the facility is taking to re-educate staff.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns.

Penalty

Inspection fine: $153,225

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 prevent an avoidable fall from a full body mechanical lift for a vulnerable, physically impaired resident. The resident's care plan required assistance from two staff members for transfers with a full body mechanical lift, but a CNA attempted the task single-handedly. During the transfer, one of the sling's loops detached from the lift, causing the resident to fall to the floor, resulting in blunt head trauma and a fracture of the sacrum. The resident developed a fear of using the mechanical lift, which affected her quality of life by limiting her participation in usual activities. Another incident involved the facility's failure to ensure the use of the appropriate type of mechanical lift for a physically impaired resident. The resident's assigned CNA neglected to review the care plan or kardex and attempted to transfer him with a sit-to-stand lift instead of the required full body lift. The resident exhibited noticeable weakness and poor balance, placing him at high risk for an adverse outcome as he was unable to stand. This oversight demonstrated a lack of adherence to the resident's care plan, which required two staff members to perform transfers with a full body mechanical lift. These failures in adhering to care plans and using the appropriate equipment placed residents at risk for serious injury. The incidents highlighted the facility's inability to follow its policies and procedures, contributing to a fall and fracture for one resident and potential harm for another. The deficiencies were identified during a survey, and the facility was notified of the Immediate Jeopardy status due to these failures.

Removal Plan

• The evening shift Nursing Supervisor immediately placed the mechanical lift and sling out of service.
• The CNA who failed to follow correct procedure for use of mechanical lift using two staff members was immediately suspended.
• The Weekend Nursing Supervisor began education and skills validation with 13 of 24 CNAs duty on the day, evening and night shifts.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with the facility Administrator, Director of Nursing, and Medical Director to review the initial incident.
• The Therapy Director completed resident transfer status evaluations on current residents. Any updates were placed in the kardex and care plans.
• The MDS coordinator completed care plan/kardex reviews to ensure appropriate transfer status was on care plan/kardex for current residents.
• The MDS Coordinators completed a quality review of current residents for MDS accuracy related to transfer status. Corrections were made as identified. Quality reviews were then completed on current resident care plans and kardexes to ensure accurate transfer status were listed. Corrections were made when identified.
• The Maintenance Director inspected all mechanical lifts and slings for any malfunctions and no concerns were identified.
• Current nursing staff were educated on mechanical lift usage and competencies were performed by the Director of Nursing, Staff Development Coordinator, and Nurse Managers. Occupational and Physical Therapy staff were educated on mechanical lift usage. Of 91 total nursing staff, 80 total current nursing staff received education, and 11 total nursing staff members were to receive education prior to next shift worked. Of 27 total Occupational and Physical Therapy staff, 26 total current therapy staff received education, and 1 total therapy staff member was to receive education prior to next shift worked. There are no contracted licensed nurses or CNAs currently on staff. Any contracted nurses or CNAs who are placed at the facility on assignment will receive the above education prior to starting their shift through an agency orientation packet.
• Current facility staff were educated on abuse, neglect and exploitation by the Administrator, Director of Nursing, Staff Development Coordinator, and Nurse Managers. Of 171 total staff, 171 current staff received education. There are no staff members who require education prior to next shift worked, and no contracted licensed nurses or CNAs on staff. Any contracted nurses or CNAs who are placed at the facility on assignment in the future will receive the above education prior to starting their shift through an agency orientation packet.
• An Ad Hoc QAPI meeting was completed with the Medical Director, Administrator, and DON. The topics of the incident, abuse and neglect, use of mechanical lifts, mechanical lift competencies, updating care plans/kardex, and following care plans/kardex were discussed.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, Staff Development Coordinator, IDT members, and Nurse Managers to review the 4-Point Plan and Investigation.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT members to include the Director of Rehabilitation, to review the 4-Point Plan, Root Cause Analysis, and progression of investigation.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON and IDT team to include the Director of Rehabilitation, to review the 4-Point Plan progress, quality reviews, and conclusion of investigation.
• The Unit Manager corrected the assigned CNA on the proper way to transfer resident #2 and showed her the transfer status on the kardex. The CNA was suspended pending investigation and re-educated on checking the kardex prior to transfers.
• Nursing staff re-education on how to view kardex for transfer status was initiated with return demonstration required. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
• Nursing staff competencies were initiated by the Director of Nursing or designees. Of 92 nursing staff members, 43 total nursing staff were re-educated. Other staff will be educated prior to the beginning of their next shift, by the Director of Nursing or designee, and 49 nursing staff members will be educated prior to the beginning of their next shift.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to discuss areas of concern that were identified during the complaint survey and additional steps the facility is taking to re-educate staff.
• An Ad Hoc QAPI meeting was held with the Medical Director, Administrator, DON, and IDT team to include Director of Rehabilitation, to go over Kardex education, discuss quality monitoring tools, root cause of concerns, and clarify areas of concerns.

Penalty

Inspection fine: $153,225

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 that Certified Nursing Assistants (CNAs) possessed and demonstrated the appropriate competencies and skills to meet the needs of residents requiring mechanical lift transfers. This deficiency was identified through the cases of two residents who were not transferred according to their care plans. Resident #3, a female with multiple sclerosis and other significant health issues, fell during a mechanical lift transfer when only one CNA was present, contrary to the care plan that required two staff members. The CNA involved admitted to performing the transfer alone, despite recent training that emphasized the need for two staff members for such transfers. In another incident, Resident #2, a male with a history of seizures and muscle atrophy, was nearly transferred using an incorrect lift method. The CNA involved did not verify the resident's transfer instructions in the kardex and attempted to use a sit-to-stand lift instead of the required full body mechanical lift. This misunderstanding occurred despite the CNA having access to the correct transfer instructions in the kardex, which she failed to review properly. The facility's management acknowledged that CNAs had access to both the detailed nursing care plan and the simplified kardex, but there was a lack of clarity and training on how to use these resources effectively. The Director of Nursing admitted that staff were not required to demonstrate their understanding of the care instructions, and there was no checklist to ensure CNAs followed all necessary steps during transfers. This lack of proper validation and oversight contributed to the incidents involving both residents.

Penalty

Inspection fine: $153,225

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 immediately notify the physician and resident representative of a change in condition regarding a fracture for a resident reviewed for falls. The resident, an elderly female with multiple health conditions including multiple sclerosis and bone cancer, was found to have a fracture at the upper end of her left femur following x-rays conducted on the evening of December 11th. However, the results were not communicated to the physician until the following morning, approximately 12 hours later, which delayed the resident's transfer to the hospital for evaluation. The delay in notification was attributed to the assigned nurse, RN G, who did not check the electronic medical record for the x-ray results during his 16-hour shift. The Director of Nursing discovered the oversight while reviewing test results and orders the next morning. The facility's policy requires immediate notification of the physician and resident representative in the event of a significant change in condition, which was not adhered to in this case. The Medical Director and Unit Manager confirmed the expectation for immediate notification of abnormal findings, which was not met, leading to the deficiency.

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 right to choose their preferred bathing method, which was a shower on scheduled days. The resident, who was admitted with diagnoses including cellulitis, gangrene, dementia, and diabetes, expressed a preference for showers on Mondays and Thursdays during the evening. Despite this preference being documented in the resident's medical records and CNA Kardex, the resident received only five showers over a 67-day period, with the majority of bathing instances being bed baths instead. Interviews with the resident and her daughter confirmed that the resident had communicated her preference for showers, but the staff continued to provide bed baths. The Bristol Unit Manager and the Director of Nursing acknowledged the discrepancy between the resident's documented preferences and the care provided. The Director of Nursing confirmed that the resident's choices were not honored, as evidenced by the bathing task report and lack of proper documentation for refusals or deviations from the resident's preferences.

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 appropriate care and services for the monitoring and management of an intravenous (IV) therapy site for a resident with a PICC line. The resident, who was admitted with multiple diagnoses including a displaced closed fracture of the left femur and sepsis, had a PICC line inserted in her left arm. However, there were no physician orders documented for the insertion, monitoring, or flushing of the PICC line on the Medication Administration Record (MAR) or the Treatment Administration Record (TAR) for several days following the insertion. Additionally, the resident's baseline care plan did not include any information regarding the PICC line or IV therapy site. The Unit Manager and Director of Nursing acknowledged that the resident did not receive the proper monitoring or sufficient care for IV therapy. The facility's policy and procedure for intravenous therapy required that IV sites be checked every four hours or as per facility protocol, and that nurses confirm the patency of the IV site per flushing protocols. Despite these requirements, the resident's PICC line was not properly monitored or flushed, and the necessary physician orders were not entered into the system by the admission nurse. The oversight was attributed to a failure in the check system for new physician orders, which was supposed to be reviewed by the clinical team daily.

Penalty

Inspection fine: $10,845

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 adequate supervision to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. On the morning of 7/25/24, a resident with a history of exit-seeking behavior and severe cognitive impairment managed to leave the facility without staff knowledge. The resident was not discovered missing until staff found him outside the facility, approximately 0.2 miles away, near an assisted living facility. This incident highlighted a lapse in monitoring and supervision, particularly concerning the front lobby door, which allowed the resident to exit unnoticed. The resident, who had been admitted with diagnoses including encephalopathy, unspecified dementia, and heart failure, was previously identified as at risk for elopement. Despite this, his elopement risk was reassessed in May 2024, and it was determined that he was no longer at risk, leading to the removal of his electronic wander bracelet. However, staff continued to document the placement and function of the bracelet even after its removal, indicating a lack of accurate record-keeping and communication among staff regarding the resident's status. On the day of the incident, multiple staff members interacted with the resident but failed to maintain adequate supervision. The resident was last seen at the nurse's station before he went missing. An alarm was triggered at the front door, but the staff member who responded did not investigate further or notify others, allowing the resident to remain unsupervised outside the facility. This series of oversights and miscommunications among staff members contributed to the resident's elopement and placed him at risk for potential harm.