Blue Palms Health and Rehabilitation Center at Fle

Inspectors wroteBased on observations, interviews and record review, the facility failed to respond to grievances appropriately for two residents (#12 and #13) out of three residents reviewed for grievances.

Inspectors wroteBased on record review and interview, the facility failed to implement their current written policy on resident abuse as it related to annual abuse, neglect, and exploitation training for 2 (Staff B and Staff C) of 6 staff members reviewed.

Inspectors wroteBased on observation, interview, record review and policy review, the facility failed to ensure adequate supervision and assistive devices to prevent an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) as a result of an over inflated air mattress that was not monitored by staff for one dependent resident (#44) out of the sampled two residents.

Inspectors wroteBased on observations, interviews with residents and facility staff, and review of the facility's records and policies, the facility failed to provide sufficient staff to provide meal assistance on one floor (second floor) of two floors for six (#32, #15, #30, #3, #18 and #54) of 17 dependent residents, and failed to respond to a call light for Resident #20 for two days (04/09/2024 and 04/10/2024) of a three day survey.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement an effective infection prevention and control program related to: 1) failing to ensure a contact precautions sign was displayed timely for one resident (#24) diagnosed with Clostridioides difficile (C-Diff), 2) failing to ensure proper usage of personal protective equipment (PPE) by staff and volunteers (I, Q, R, V, and Dog Handler), 3) failing to ensure four staff members (Staff Q, B, C, Director of Nursing) performed hand hygiene, and 4) failing to ensure staff provided hand hygiene for 14 residents (#54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33) prior to dining for three days of a three day survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure a change in condition was addressed for one resident (#51) of a total sample of 46 residents.

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to ensure four resident rooms (212, 216, 217 and 218) were maintained in a clean and sanitary for one of two floors.

Inspectors wroteBased on observation, record review, interview, and review of the policy and procedure, the facility failed to ensure an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) was reported to the appropriate agencies for one resident (#44) out of the sampled two residents.

Inspectors wroteBased on observations, interview, and record review the facility failed to develop and implement care plan for two residents (#23 and #670) out of 25 sampled residents.

Inspectors wroteBased on observations, record review and interview the facility failed to provide Activities Of Daily Living (ADLs) for two residents (#122 and #123) of five residents sampled for ADL care related to personal hygiene.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure failed to ensure an order was in place for pressure relieving boots being utilized for one resident (#670) of three residents reviewed for post fall intervention and 2) failed to follow-up on an order for a swallow test for one resident (#43) of a total sample of 46 residents.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide care consistent with professional standards of practice related to oxygen therapy for one resident (#21) of two residents reviewed for oxygen therapy.

Inspectors wroteBased on observation, record review and interview the facility failed to appropriately store and secure medications related to one (1st floor) of two units for medication at the bedside and one (200 hall, cart 1) of four medication carts left unlocked.

Inspectors wroteBased on record review and interview, the facility failed to ensure the binding arbitration agreement explicitly informed the resident or their representative of the right to not sign it for three residents (#6, #120, and #122) of three residents sampled.

Inspectors wroteBased on observations, interviews and review of facility policy, the facility failed to maintain an effective pest control program related to small flying insects observed in three resident rooms (212, 216, and 218) on one of two floors.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure, six residents (#25, #34, #69, #75, #87 and #99) and a representative for one resident (#40) were invited and/or participated in their plan of care meetings out a total of 43 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and homelike environment related to wall baseboard bumpers, handrails, and a resident wall being in disrepair were reported to maintenance staff within a timely manner for repair on one floor (first floor) of two floors .

Inspectors wroteBased on interview and record review the facility failed to adhere to their grievance policy for one resident (#26) of 43 sampled residents.

Inspectors wroteBased on observations, record review and interview the facility failed to provide for dependent residents appropriate nail care for one resident (#13) of 43 sampled residents.

Inspectors wroteBased on record review, and interview, the facility did not ensure that pharmacy recommendations were followed for one resident (#41) out of 5 residents sampled for unnecessary medications, related to the change in dosage for Aspirin from 325 mg (milligrams) to 81 mg recommended by the consultant pharmacist on 08/03/21.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed and six errors were identified for five (#21, #20, #85, #25, and #37) of five residents observed. These errors constituted a 20.69% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to store, prepare, and distribute, serve food in accordance with professional standards for food service safety and failed to maintain the kitchen in a sanitary condition.

Inspectors wroteBased on observation and resident and staff interviews it was determined that the facility did not ensure that twelve (#56, #73, #104, #130, #140, #148, #208, #211, #212, #213, #406, and #407) of 58 residents were treated with respect and dignity related to lack of clothing for two residents (#208 and #213); reused non- skid socks for two residents (# 211 and # 212); identifying information in ID bands for two residents (#148 and #56); timely assistance with meals for one resident (#104); providing care and speaking to residents in a rushed manner for five residents (#130, #140, #407, #406, and #73), and staff talking on phones and to each other in patient care areas in a foreign language and during patient care.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure sufficient staffing was maintained to provide necessary care and services to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication regimen was free from unnecessary psychotropic medications for five of six sampled residents. Three residents (#118, #130 and #36) lacked behavior monitoring and two residents (#104 and #50) lacked the rationale for the use of as needed psychotropic medications for over 14 days.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were stored in an orderly manner in one medication cart (2nd floor #1), and medications with a shortened open life were dated as opened in two medication carts (West 2 and [NAME] 3) out of three medication carts reviewed, and two of two refrigerated narcotic storage boxes were permanently affixed to the refrigerator.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to use appropriate hand hygiene while assisting two residents (Resident #85 and #12) with their meals, left nebulizer tubing unbagged for one resident (Resident #2), a catheter bag was stored inappropriately for one resident (Resident #127), and failed to ensure two glucometers were cleaned and disinfected in between residents appropriately and according to manufacturer's recommendation.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to assess two residents (Resident #34 and #73) out of the sampled 58 residents for the self-administration of medications.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the accuracy of the code status for one resident (Resident #26) out of the sampled 58 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to perform an Comprehensive Resident Centered Care Plans including a baseline care plan on admission for one of 58 sampled residents (#256).

Inspectors wroteBased on observation and resident and staff interview, it was determined the facility did not ensure that a care plan was developed related to communication for 1 of 58 residents reviewed (#139). Findings Included: Review of the record for Resident #139 revealed that she was admitted to the facility on [DATE] from the hospital. Diagnoses on the face sheet revealed Displaced fracture of base of neck of left femur, subsequent encounter for closed fracture with routine healing, History of falling, Other specialized disorders of muscle, Other abnormalities of gait and mobility, Muscle wasting and atrophy, Dysphasia following cerebral infarction, pain, Hyperlipidemia, Anxiety disorder, Age related osteoporosis, Hypertension, Embolism and thrombosis of unspecified artery, Unspecified dementia without behavioral disturbance, Major depressive disorder. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that one resident (Resident #26) out of the sampled 58 residents who was identified as a risk for elopement was assessed appropriately.

Inspectors wroteBased on resident interview, staff interview, resident record review and review of policy and procedure, it was determined that the facility did not ensure that a resident who was admitted as continent of bladder and bowel received services and assistance to maintain continence for one (#210) of 58 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the pharmacy recommendations were acted upon for three of six sampled residents (#36, #50 and #118).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three (#155, #103, and #130) of seven residents observed. These errors constituted a 14.29% medication error rate.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 58 sampled residents was free from a significant medication error related to one resident receiving an incorrect dosage of Zoloft (#36) and one resident not receiving all their medications on dialysis days (#151).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was accurate and complete for one (#138) of 58 sampled records related to falls.