Conway Lakes Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored and/or discarded in the areas of the main reach-in coolers, the pot/pan sink sanitizing solution was at the correct concentration and failed to ensure food preparation surfaces were not cross-contaminated during production in accordance with professional standards for food service safety.

Inspectors wroteBased on interview, and record review, the facility failed to ensure referrals to the appropriate state designated authority for Preadmission Screening and Resident Review (PASARR) Level II evaluation and determination were made for two of three residents reviewed for PASARR, of a total sample of 25 residents, (#11, and #80).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were securely stored in one of two residential halls in the facility, (100s hall, resident #7).

Inspectors wroteBased on observation and interview the facility failed to maintain infection control practices by not keeping the urine collection bag and the tubing off the floor and away from unsanitary surfaces for one of one resident reviewed for urinary catheters, of a total sample of 25 residents, (#7).

Inspectors wroteBased on interview, and record review, the facility failed to thoroughly investigate and report an allegation of neglect and an injury of unknow origin resulting in serious bodily injury to the Agency for Healthcare Administration (AHCA). The facility failed to report the allegation to AHCA within the federally required 2-hour timeframe, and the 5-day investigation report lacked sufficient detail, as required under federal regulation, for 1 of 1 resident reviewed for neglect, of a total sample of 8 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and revise a person-centered, comprehensive care plan to address communication needs for 1 of 4 residents reviewed for care planning, of a total sample of 8 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) followed facility protocol when transferring a physically and cognitively impaired vulnerable resident from bed to wheelchair; and failed to ensure staff transferred residents safely for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7:00 AM to 3:00 PM shift CNA transferred the resident by herself without the use of a gait belt. After CNA A transferred resident #1 from her bed to the wheelchair she transported her to the dayroom. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the appropriate level of transfer assistance for a cognitively and physically impaired vulnerable resident and failed to ensure nursing staff demonstrated competency in all aspects of the transfer process. The facility failed to validate staff retained education provided and monitor Certified Nursing Assistants (CNAs) for adherence to facility transfer processes for 1 of 4 resident reviewed for accidents, of a total sample of 8 residents, (#1). On 6/01/25 at approximately 10:40 AM, resident #1, vulnerable and dependent on staff for all Activities of Daily Living (ADLs), mobility and transfers, sustained a displaced fracture of the right humerus when the 7 AM to 3 PM shift CNA transferred the resident by herself without the use of a gait belt. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure effective implementation of policies, including thorough monitoring of previously identified areas of concern and adequate tracking of performance to verify improvement measures were realized and sustained.

Inspectors wroteBased on interview, and record review, the facility failed to provide appropriate care and services to a long-term resident with a suprapubic catheter (SPC) after hospitalization for 1 of 3 residents reviewed for urinary catheters, of a total sample of 4 residents, (#2).

Inspectors wrote2. Review of the medical record revealed resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE], 12/17/24, and 1/15/25. Her diagnoses included Alzheimer's disease, dementia, falls, muscle weakness and fracture of shafts of humerus on the right and left arms. Review of the admission Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 12/22/24 revealed resident #5's BIMS score of 0 out of 15, which indicated severe cognitive impairment. The assessment indicated resident #5 had no behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The MDS showed she required partial/moderate assistance for eating and upper body dressing, substantial/maximal assistance for oral hygiene, shower/bathe, lower body dressing and personal hygiene and was dependent on staff for toileting hygiene. [...]

Inspectors wrote2. Review of the medical record revealed resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE], [DATE], and [DATE]. Her diagnoses included Alzheimer's disease, dementia, falls, need for assistance with personal care, muscle weakness and fracture of shafts of humerus on the right and left arms. Review of the admission Minimum Data Set (MDS) assessment with dated [DATE] revealed resident #5's BIMS score of 0 out of 15, which indicated severe cognitive impairment. No behavioral symptoms or rejection of care necessary to achieve goals for health and well-being were noted. The Preferences for Customary Routine and Activities section noted it was somewhat important for her to have snacks available between meals and very important for her to choose her own bedtime. [...]

Inspectors wroteBased on interview, and record review, the facility failed to effectively communicate and implement the standards of its compliance and ethics program to promote ethical conduct, and failed to adequately enforce those requirements to deter violations, ensure the provision of quality care and promote the highest practicable well-being for resident #3 and all residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the initial comprehensive assessment was accurately completed and reflective of the resident's mental status for 1 of 2 cognitively impaired residents reviewed for elopement, of total sample of 10 residents, (#3).

Inspectors wrote3. Review of the medical record revealed resident #5 was initially admitted to the facility on [DATE] and readmitted on [DATE], 12/17/24, and 1/15/25. Her diagnoses included Alzheimer's disease, dementia, falls, need for assistance with personal care, muscle weakness and fracture of shafts of humerus on the right and left arms. A discharge MDS assessment dated [DATE] revealed she sustained two falls, one with major injury, since admission. Review of the facility's October 2024 to January 2025 Incident Log revealed resident #5 fell on [DATE], 11/14/24 and 1/11/25. A progress note in the medical record revealed resident #5 also fell on 1/04/25, which was not indicated on the Incident Log. Review of the Progress Notes or Evaluations did not reveal pertinent details of the fall that occurred the morning of 1/04/25. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure necessary care and services were provided to promote healing and prevent infection of a facility acquired pressure ulcer for 1 of 2 cognitively impaired residents reviewed for pressure ulcer management, of a total sample of 20 residents, (#1). The facility's failure to ensure timely and adequate care and treatments for pressure injury and infection resulted in actual harm for a cognitively impaired resident at risk for development of pressure wounds. Resident #1 subsequently was transferred to a higher level of care with an admitting hospital diagnosis of sepsis with hypotension, and sacral wound. Resident #1 was placed on Hospice services on [DATE] and expired four days later on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent the potential of dangerous bacteria from spreading between residents during use of shared vital sign equipment during blood pressure monitoring on 2 of 2 Wings.

Inspectors wroteBased on interview, and record review, the facility failed to obtain admission physician orders for immediate care of a surgical site for 1 of 2 residents reviewed for surgical site admission orders, of a total sample of 20 residents, (#7).

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan to meet the resident's medical, nursing, mental and psychosocial needs for 2 of 3 residents reviewed for comprehensive care plans out of a total sample of 40 residents, (#33 and #99).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice regarding non-pressure related skin wounds, specifically, treating a wound without a physician order, and not documenting treatment for 1 of 1 resident reviewed for non pressure wounds out of a total sample of 40 residents, (#17).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice for 2 of 2 residents reviewed for IV care, out of 40 total sampled residents, (#321, #182).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident was assessed to safely self-administer medications for 1 of 1 resident reviewed for self-administration of medications, from a total sample of 45 residents (#67).

Inspectors wroteBased on interview and record review, the facility failed to ensure showers were provided per schedule/preference for 1 of 12 residents reviewed for choices, of a total of 45 residents (#4).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a clean and homelike environment in 1 of 32 rooms on the [NAME] wing (219A).

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASRR) level 1 screen for newly evident possible Serious Mental Illness (SMI) for 1 of 1 resident reviewed for PASRR from a total sample of 45 residents (#9).

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the use of 4 side rails for 1 resident reviewed for restraint, of a total sample of 45 residents (#10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure follow-up wound care and services were provided to 1 of 3 residents reviewed for non-pressure skin conditions from a total sample of 45 residents (#568).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure specialty respiratory Chest Percussion Therapy (CPT) care and services were provided in accordance with professional standards of practice for 1 of 2 residents reviewed for respiratory care from a total sample of 45 residents (#48).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nursing documented behavior monitoring and side effects for antipsychotic medication for 1 of 5 residents reviewed for unnecessary medication review out of a total sample of 45 resident (#19).

Inspectors wroteBased on interview and record review, the facility failed to promptly inform the physician of a laboratory report for 1 of 3 residents reviewed for hospitalization, of a total sample of 45 residents (#4).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Personal Protective Equipment (PPE) was discarded appropriately to prevent transmission of highly contagious microorganisms for 1 of 1 resident requiring Transmission Based Precaution on the [NAME] Wing (#520).