Coral Reef Subacute Care Center LLC

Inspectors wroteBased on record review, observation, and interview, the facility's staff failed to answer incoming calls after 8:00 PM. Six documented calls to the facility were not answered by the staff. This deficient practice had the potential to affect all 159 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide necessary housekeeping and maintenance services to maintain a sanitary, clean homelike environment with a comfortable interior free of disrepair for 11 out of 32 resident rooms on the East Unit. (Photographic evidence available). There were 156 residents residing at the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (Resident #131) out of eight residents sampled was treated with respect and dignity during dining, as evidenced by Staff B, Certified Nursing Assistant observed standing while feeding Resident #131. This deficient practice has the potential to affect any residents residing in the facility requiring assistance from staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment that is free from potential hazards for one (Resident #54) out of eight vulnerable residents sampled. As evidenced by the electrical cord for an Intravenous (IV) infusion pump attached to a pole at the right side of the resident's bed observed extended across bed connected to an electrical outlet on the left side of the resident's bed. There were 156 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications and treatment ointments were stored in accordance with facility policy. As evidenced by ointments and medication were found in the residents' rooms unsecured. There were 156 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review, the facility's Quality Assurance and Performance Improvement (QAPI)/ Quality Assessment and Assurance (QAA) committee failed to demonstrate effective action plans were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F641- Accuracy of assessment and F761- Label/Store drugs and biologicals. Facility's failure to accurately code the Minimum Data Set (MDS). Facility's failure to store medications appropriately. There were 156 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations record reviews and interviews, the facility's staff failed to supervise and implement adequate measures to prevent the elopement for one (Resident #1) out of three residents sampled. The facility's system failure, lack of adequate supervision and a failure in ensuring an adequate alert monitoring system were in place enabled Resident #1 who had risk factors that include visual impairment and seizure disorder, exited the facility undetected on 09/01/2024 shortly after lunchtime. Resident #1 who had displayed and voiced his intent to leave the day prior ambulated 3.2 miles from the facility in areas that has high traffic volume, intersections and cross streets; these factors increased the likelihood of an adverse outcomes, serious injury and serious harm or death. [...]

Inspectors wroteBased on observations record review and interviews, the facility's staff failed to ensure accuracy of controlled medication and failed to ensure drugs and biologicals used in the facility are stored and disposed in accordance with professional standards; as evidenced by three out of eight medication carts were observed unattended and unlocked, inaccurate narcotic accounting, medications observed in drawers at the north wing nurses' station and medications incorrectly disposed. On 12/02/2024 at 4:55 AM during the initial tour, the west wing's medication cart # 3 assigned to Staff N, RN was observed unlocked and unattended. On 12/02/2024 at 5:04 AM, Staff A, Registered Nurse (RN) observed tossing medications in the trash can attached to the medication cart. Staff A revealed the resident refused the medications, so she had to toss them. [...]

Inspectors wroteBased on observations, record review and interview, the facility's staff failed to implement infection prevention control policies and procedures as evidenced by failure to handle soiled linen and garbage to ensure a sanitary environment to help prevent the development and transmission of communicable diseases and infections. This deficient practice has the potential to affect all residents residing in the facility. Observation on 12/02/2024 at 4:55 AM, several clear plastic bags containing trash and soiled linen were observed on the floor in the facility's hallways and resident's doorways. On 12/02/2024 at 4:57 AM during an observation on the east wing Certified Nursing Staff (CNA) Staff H was observed placing soiled linen in a bin and then returned few minutes later to remove clean linen from the clean linen cart that was noted beside two bins (a gray bin and a white bin). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store food under sanitary condition as evidence by: 1) failure to ensure reach-in freezer and the reach-in refrigerators in the kitchen contained thermometers on the inside and 2) failure to ensure the resident's foods were labeled and dated. 3)The refrigerators were not working properly, and the refrigerator contained opened milk cartons in the snack/nourishment refrigerators on the resident's units. This has the potential to affect 163 out of 171 residents who eat orally residing in the facility at the time of the survey and potential to affect 55 out of 56 residents who eat orally residing on the East Wing.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the refrigerator in the East Wing Nourishment Pantry used to store resident's food was working properly. This has the potential to affect 55 out of 56 residents who eat orally residing in the East Wing at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to treat residents with respect and dignity by the right to be free from any physical restraints for one (Resident number 27) out of two residents who triggered for physical restraints.

Inspectors wroteBased on record review and interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) for hospice for one Resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: On 01/17/24 at 02:49 PM, review of Resident #307's MDS revealed no Significant Change MDS was completed for the resident's status change to hospice effective 12/11/23. Review of the Physician's Orders Sheet for January 2024 revealed Resident #307 had orders that included but not limited to: admitted to Hospice effective (12/11/23) for diagnoses late effect Cerebral Vascular accident (CVA). Prognosis is for a life expectancy of 6 months or less if terminal illness runs its normal course, and Start continuous care 1/15/24 due to uncontrollable vomiting/ Intravenous hydration. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to accurately code the Minimum Data Set (MDS) for one Resident (#100) out of 34 sampled residents. As evidenced by inaccurate coding of MDS section B for Corrective lenses. There were 171 residents residing in the facility at the time of the survey.

Inspectors wroteBased on record review and interview the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was revised following admission for one resident (#107) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The findings Included: During observation on 01/16/24 at 09:57 AM, Resident #107 was in bed well-groomed and had a cell phone in her hand. On 01/19/24 at 08:45 AM, Resident #107 was observed on a medical stretcher and leaving the facility, accompanied by two attendants. Record review of Resident #107's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: MI or suspected MI (check all that apply) - no mental Disorders checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: [...]

Inspectors wroteBased on record review and interview, the facility failed to develop and implement a hospice care plan in a timely manner for one resident (#307) out of 34 sampled residents. There were 171 residents residing in the facility at the time of the survey. The Findings Included: Review of the care plans with reference date 9/29/23 for Resident #307 revealed the hospice care plans created, were completed on 1/16/24, the first day of initial observation of the resident by the surveyor. The care Plans documented: Resident is at end of life, diagnosis of terminal illness and have chosen Hospice care. Date Initiated: 01/16/2024, Revision on: 01/16/2024. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure oxygen therapy was administered accurately as ordered for one out of two sampled residents (Resident #105) who were investigated for oxygen administration. This deficient practice has the potential to affect all residents who are on oxygen therapy.

Inspectors wroteBased on observation, record review and interviews. The facility failed to ensure medications were securely stored as evidenced by four broken and three loose pills found on two out of four carts checked. There were 71 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that menus are developed and prepared to meet residents' choices including their cultural and ethnic needs for one (Resident number 207) out of three residents who triggered for food.

Inspectors wroteBased on observations, interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F645 PASRR (Preadmission Screening and Resident Review) for Individuals with a serious mental illness (SMI), intellectual disability(ID), F695 Respiratory/Tracheotomy Care and Suctioning, and F812 Food Procurement, Store/Prepare/Serve-Sanitary. This deficiency has the potential to affect 171 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner and in accordance with professional standards

Inspectors wroteBased on observations, interviews and record review, the facility failed to honor residents' rights to reasonable accommodation of needs as evidenced by failure to ensure call lights can be used by one (Resident #447) out of three residents investigated out of 32 sampled residents. Facility had a census of 160 residents at the time of this survey.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASSAR) Level I for Serious Mental Illness (SMI) or intellectual disability (ID) was completed at the time of admission for one (Resident # 19) out of two residents investigated. This deficiency had the potential to affect 160 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide oxygen per physician's orders for two (Resident #104, Resident #447) of two residents reviewed for respiratory treatment out of 17 residents receiving oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to have nurse staffing information posted prior to the beginning of shifts on 2 of 3 nurse's stations.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration for two ( Resident #342, Resident # 446) out of six residents sampled, as evidenced by License Practical Nurse and Registered Nurse observed crushing extended release and enteric coating medications for administration to residents. This had the potential to affect the 160 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to ensure a medication error rate below five percent as evidence by licensed nurses observed crushing extended release and enteric coating medications during medication observation for Resident # 342 and Resident # 446 resulting in a 9.09 percent error rate out of 33 opportunities. There were 160 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain communication with Hospice to ensure continuity of care for 1 of 2 residents reviewed for Hospice, Resident #104.

Inspectors wroteBased on interview and record review, the facility's quality assurance and assessment committee failed to identify quality concerns as evidenced by not implementing an effective plan of action for correcting repeated deficiencies related to reasonable accommodation of needs, respiratory treatment, pharmacy services, medication errors, food services, quality assurance and performance improvement activities resulting in repeated deficient practice. Cross reference of F 558 for Accommodation of Needs, F 695 for Oxygen Treatment, F 755 for Pharmacy Services, F 759 for Medication Error 5% of more, F 812 for Sanitary Food Handling, and F867 for QAPI/QAA Improvement activities. The facility had deficiency practice during the last recertification survey conducted in 2020. The facility had a census of 160 residents at the time of the survey.