Abbey Delray South

Inspectors wroteReview of the facility's policy titled, Foods Brought by Family/Visitors with a revised date of March 2022 included in part the following: Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from the facility-prepared food .Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item and the use by date. Record review for Resident #648 revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit and Parkinsonism. The Minimum Data Set for Resident #648 dated 02/04/25 documented in Section C a Brief Interview of Mental Status score of 14 indicating a cognitive response. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain an effective system to obtain and use of feedback and input from (Minimum Data Set (MDS) Department and ensure an effective QAPI/PIP (Quality Assurance Performance Improvement/Performance Improvement Plan) to ensure MDS assessments were completed timely with the potential to affect 70 out of 70 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow the care plan's interventions to prevent falls for 2 of 2 resident reviewed for accidents (Resident #69 and Resident #64).

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide assistance during dining for 1 of 2 residents reviewed for nutrition (Resident #12).

Inspectors wroteBased on observations, interviews and record review, the facility failed to acquire a Physician order for a urinary catheter and failed to initiate a urinary catheter Care Plan for 1 of 2 sampled residents, Resident # 502; and failed to keep the urinary catheter anchored for 1 of the 2 residents, Resident #69.

Inspectors wroteBased on observations, interviews and record review, the facility failed to meet the nutritional needs and provided the correct nutritional supplement for 1 of 2 residents reviewed for nutrition (Resident #47).

Inspectors wroteBased on observations, interview and record review, the facility failed to have an order for oxygen for 1 of 1 sampled residents, Resident #501.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that psychotropic medication PRN (as needed) orders were limited to 14 days for 1 of 5 residents reviewed for Unnecessary Medication (Resident #17).

Inspectors wrote2.) A record review revealed Resident #501 was admitted on [DATE] with diagnoses including Displaced Intertrochanteric Fracture of Right Femur, Type 2 Diabetes Mellitus, and Anxiety Disorder. A record review of the Minimum Data Set (MDS) assessment for Resident #501 dated 02/18/25 revealed it is in progress. Section C for Brief Interview for Mental Status score was blank. Section I revealed, yes responses to anxiety and depression. A record review of Physician Orders dated 02/16/25 revealed Escitalopram Oxalate (Anti-depressant) 10 MG (milligram), to give by mouth one time a day for depression. An additional review of Physician Orders for Resident #501 revealed to monitor for signs and symptoms of depression and to include the following numerical codes : [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure medications were secured at the bedside for 1 of 22 sampled residents (Resident #645).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide water consistent with resident needs for 1 of 3 residents on thickened liquids (Resident #645).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective Infection Prevention and Control Program, for 3 sampled residents, as evidenced by staff failed to wear Personal Protective Equipment (PPE) while providing direct care for residents on Enhanced Barrier Precaution (EBP) for Resident #545 and Resident #38; and failed to have an order and care plan for EBP for Resident #501.

Inspectors wroteBased on observations and interviews the facility failed to ensure a homelike environment with overbed lights having pull cords attached for 2 out of 70 occupied beds.

Inspectors wroteBased on review of policy and procedure, record review and interview, the facility failed to ensure that it followed through in processing a physician's order, in a timely manner for 1 of 5 sampled residents reviewed, Resident #1.

Inspectors wroteBased on interviews and records review, the facility failed to treat in a dignified manner 1 of 3 sampled residents (Resident #110).

Inspectors wroteBased on interviews and records review, it was determined that Residents' rights were not discussed and 3 of 3 sampled Residents (Residents # 4, 14, & 19) were not reminded of their rights during Resident Council meetings.

Inspectors wroteBased on records review and interviews, the facility failed to file a federal report for an allegation of injury of unknown origin immediately to the State Agency for 1 of 1 sampled resident (Resident #108).

Inspectors wroteBased on record review and interview the facility failed to accurately document a resident's discharge status for 1 of 3 residents reviewed for discharges (Resident #56).

Inspectors wroteBased on observation and interview, the facility failed to provide appropriate activities for 1 of 1 resident reviewed for activities (Resident #209).

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to obtain a physician's order for care of nasal steri-stips for 1 of 1 sampled residents observed, Resident #157.

Inspectors wroteBased on record review and interview, the facility failed to monitor and intervene for a resident identified with significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #35); and failed to identify significant weight loss for 1 of 2 residents reviewed for nutrition (Resident #53).

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, it was determined that the facility failed to 1) Follow the physician's order for Oxygen Therapy Administration for 1 of 6 sampled residents observed for Oxygen, Resident #158; and 2) Failed to obtain a physician's order for administration of Oxygen for 1 of 6 sampled residents observed for Oxygen, Resident #109.

Inspectors wroteBased on review of policy and procedure, observation, interview and record review, the facility failed to ensure that it 1) secured prescription insulin medication following a Glucometer Observation for 1 of 1 sampled residents observed during a Medication Administration Observation, Resident #213. And, 2) failed to secure an order for self-medication of a prescription inhaler medication for 1 of 1 residents observed with an inhaler, Resident#158.

Inspectors wroteBased on interview and record review, the facility failed to involve a resident in discharge planning for 1 of 3 residents sampled for discharge (Resident #53).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to address missing personal clothing in a timely manner, for 2 of 2 sampled residents (Residents #514 and #515).

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents will remain free from falls for 3 of 3 sampled residents reviewed for falls (Residents #19, 52, 18).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the correct fluid amount as per the Physician's order for 1 of 1 resident reviewed for Fluid Restriction (Resident #414).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain food safety requirements with storage, preparation, and distribution in accordance with professional standards for food service safety which included: failure to maintain sanitary conditions during lunch observation, and failure to date and label all food items in the central kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the required specialized Rehabilitative Services for 1 of 4 residents reviewed for Rehabilitation Services (Resident #414).