Clearwater Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide respiratory care and services for tracheostomy dependent residents according to professional standards of practice for four residents (#14, #15, #16, and #19) out of five residents with a tracheostomy. On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested his tracheostomy to be suctioned. The certified nursing assistant (CNA) notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, Cardiopulmonary Resuscitation (CPR) was initiated with no evidence the airway was cleared prior to providing breaths, the resident was transported to the hospital where he expired. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the nursing staff was competent to provide appropriate tracheostomy care, respond to resident's request for tracheostomy suctioning, and document tracheostomy care for four residents (#14, #15, #16, and #19) out of five residents reviewed for tracheostomy care. On 3/22/24 a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. On 3/24/24 Resident #15 requested his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. A code was called, CPR initiated with no evidence the airway was cleared prior to providing breathes, the resident was transported to the hospital where he expired. [...]

Inspectors wroteBased on observations, interviews, and record review the facility administration failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident related to residents with a tracheostomy not being cared for in a safe and sanitary manner for four residents (#14, #15, #16, and #19) out of five residents sampled. On [DATE] a grievance was filed by Resident #16's family related to tracheostomy care and suctioning. The grievance process was not followed through by the facility to a resolution for the resident. On [DATE] Resident #15 requested for his tracheostomy to be suctioned. The CNA notified the nurse. By the time the nurse got to the room, Resident #15 was unresponsive. [...]

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for three of four shifts reviewed.

Inspectors wroteBased on record reviews, staff interviews and observations, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for the year 2023 for 99 of 99 residents in the facility during survey, and failed to ensure hand sanitizing was performed by two staff (N and M) during medication pass observation

Inspectors wroteBased on record reviews, staff interviews and observations, the facility failed to establish and maintain an infection prevention and control program that included an antibiotic stewardship program which includes antibiotic use protocols and a system to monitor antibiotic use for 2023 for 99 of 99 residents in the facility during survey. Findings revealed: Review of the Facility Policy and Procedure for the Infection Control Program, effective October 2021 from the Infection Control Manual revealed: Policy: The infection prevention and control program is comprehensive program that addresses detection, prevention and control of infections and communicable disease among residents, visitors, those individuals providing services under contractual agreement, and personnel. [...]

Inspectors wroteBased on medical record review, facility file review and staff interviews, the facility failed to ensure Level I Pre admission Screen and Record Reviews (PASRR) were complete and accurate prior to resident admission and failed to ensure Level II PASRRs were completed as required, for fourteen (Residents #5, #49, #10, #35, #64, #67, #75, #13, #92, #69, #48, #54, #83, and #51) of thirty-four sampled residents who were reviewed for PASRR assessments, .

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess and develop care plan interventions related to communication for Non-English speaking residents for three residents (#16, #17 and #20) out of four residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide sufficient staff to meet the needs for five residents (#72, #80, #44, and #210) on three of four units.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed, and nineteen errors were identified for four residents (#72, #80, #44, #10) out of four residents observed. These errors constituted a 63.33% medication error rate.

Inspectors wroteBased on observations and interviews, the facility failed to accommodate one resident (# 77) to ensure that the resident has access to an appropriate wheelchair for locomotion out of eight residents sampled. Findings Included: During an observation on 02/18/2024 at 9:00 AM., Resident observed laying down in bed with her call light within reach. Resident was very talkative and happy. Resident said that she has not been able to get out of bed for a month, and she had not been able to get her hair cut because she can't sit up in her wheelchair due to it being so uncomfortable for her. She said she voiced her concerns to the facility, but nobody has done anything about it. During an observation on 02/21/24 at 10:00 AM., Resident observed laying down in bed with her call light within reach. The resident was fully dressed well-groomed with no odors. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to act upon a resident grievance related to tracheostomy (trach) care for one resident (#16) out of two residents sampled for grievances.

Inspectors wroteBased on record review and interview, the facility failed to complete and to accurately assess a discharge Minimum Data Set (MDS) on two residents (# 87, 106) out of five residents sampled. Finding Included: 1. Review of an admission Record dated 02/21/2024 showed Resident # 87 was admitted on [DATE] with diagnoses to include but not limited to Type 2 Diabetes Mellitus with Unspecified Complications, Acquired Absence of left Above Knee, Major Depressive Disorder, Recurrent Unspecified, Adult Failure to Thrive, Cannabis Abuse, Uncomplicated Review of the admission Minimum Data Set, dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 15 indicated cognitively intact. Review of the medical record profiled showed Resident # 87 was discharged on 9/5/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide care and services related to performing weekly skin checks for 2 of 2 sampled residents (#75 and #39).

Inspectors wroteBased on interview and record review, the facility failed to show evidence the facility provided required discharge support including documentation for 2 of 4 sampled residents (#87 and #110) related to transfer to the hospital and discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 sampled residents (#110) was made aware of the facility's bed-hold policy upon transfer to a hospital.

Inspectors wroteBased on observations, a resident council meeting and interviews, the facility failed to maintain the dignity of seven residents (#66, #22, #82, #55, #17, #19 and #9) while dining due to the use of disposable dishware for meals of a total sample of 31 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two residents (#2 and #1) were assessed to safely self-administer medications related to nebulizer treatments and failed to ensure one resident (#2) did not self-administer medications that were not prescribed at the time of observation for two residents observed of a total sample of 31 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure care was consistent with professional standards of practice related to the care and lack of a physician order for care of an ileostomy at the time of admission for one resident (#2) of three residents with ostomy care.

Inspectors wroteBased on interview, record and policy review, the facility did not ensure grievance documentation, reporting, and resolution for one (Resident #100) of three residents sampled.

Inspectors wroteBased on observations, records review, and interviews, the facility did not ensure that care plans were developed and implemented for 2 (Resident #94 and Resident #100) out of 33 residents sampled related to refusing to let staff weigh them, and for the application of an electronic wander bracelet for Resident #100.

Inspectors wroteBased on observation, interview, record and facility policy review, the facility failed to follow their policy for supervision of elopement/wandering behaviors and an electronic wander bracelet for one (Resident #100) of six residents in the sample group.