Courtyards of Orlando Care Center and Rehab

Inspectors wroteBased on interview, and record review, the facility failed to follow physician orders for medication administration for 5 of 5 residents reviewed for medication administration, of a total sample of 45 residents, (#112, #3, #94, #5, and #67).

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure proper handling and food safety practices when staff failed to sanitize a food thermometer between checking food items, and ice bath calibration. The deficient practice had the potential to affect all residents who received a regular or puree diet by increasing the risk of cross-contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop an individualized care plan with interventions to address the resident's preference and needs for administration of oxygen for a resident who smokes, for 1 of 1 resident reviewed for respiratory care, of a total sample of 45 residents, (#40).

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) for one of three residents reviewed for ADL care, of a total sample of 45 residents, (#75). This failure resulted in resident #75 not receiving timely and adequate support for personal grooming and hygiene, which could contribute to a decline in the resident's physical and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to assist in making transportation arrangements to diagnostic and physician's appointments for 1 out of 1 resident reviewed for choices, of a total sample of 45 residents, (#97).

Inspectors wroteBased on interview and record review, the facility failed to provide a refund, and a final accounting of the resident's funds deposited with the facility within 30 days of the resident's discharge, for 1 of 3 residents sampled for personal funds, (#1). Resident #1 was admitted to the facility on [DATE] and discharged from the facility to the community on 6/27/24. Review of the facility's admission Agreement signed by resident #1's financial power of attorney on 1/13/22 revealed the facility would refund any deposits held by them within thirty days from the resident's date of discharge. Review of the facility's Policy and Procedure Manual in the section regarding Resident Personal Funds, issued 4/01/22 and revised 1/01/24, under the Procedure section item 6. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the Ombudsman for 4 of 6 residents reviewed for hospitalizations, out of a total sample of 45 residents, (#42, #79, #18, and #21).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 1 resident was evaluated for safe self-administration of medications and failed to obtain a physician order for self-administration of medication for 1 of 1 resident reviewed for choices, of a total sample of 45 residents, (#47).

Inspectors wroteBased on interview and record review, the facility failed to send quarterly personal fund account balance statements to resident's responsible party for 1 of 7 sampled residents reviewed for personal funds, out of a total sample of 45 residents, (#71).

Inspectors wroteBased on interview, and record review, the facility failed to ensure documentation for code status Do Not Resuscitate (DNR) matched the clinical records for 1 of 1 resident reviewed for Advance Directives, of a total sample of 45 residents, (#47).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected vision and edentulous (without teeth) status for 1 of 3 residents reviewed for vision and dental services, of a total sample of 45 residents, (#69).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a midline dressing was changed as per professional guidelines to prevent the potential for infection, and failed to obtain physician's order for a midline dressing for 1 of 1 resident of a total sample of 45 residents, (#107). A midline catheter is a small tube used to give treatments and to take blood samples. The catheter is inserted into a vein in your arm .can stay in place for up to 30 days. (Retrieved on 3/22/24 from drugs.com)

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for Oxygen (O2) therapy for 1 of 1 resident reviewed for respiratory care, of a total sample of 45 residents, (#47).

Inspectors wroteBased on interview, and record review, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for 1 of 5 residents reviewed for unnecessary medications, of a total sample of 45 residents, (#47). Findings Resident #47 was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, diabetes type II, atrial fibrillation, acute on chronic diastolic (congestive) heart failure, hypertension, and major depressive disorder. Pharmacy recommendations for resident #47 on 9/18/23 indicated the resident was currently taking Digoxin and recommended that an apical pulse be obtained prior to administration of the medication. The physician/prescriber agreed to the recommendation on 10/16/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 2 of 2 residents reviewed for IV care out of 50 total sampled residents, (#103 and #109).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not crushed prior to administration according to manufacturers' and pharmacy instructions for 1 of 9 residents reviewed for medication administration, (#76); and failed to obtain appropriate dosage orders for medications for 2 of 5 residents reviewed for unnecessary medications, (#96 & #38) of a total sample of 50 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected health conditions for 1 of 3 residents reviewed for falls (#314), use of a monitoring device for 1 of 2 residents reviewed for mood and behaviors (#94), and edentulous status for 1 of 2 residents reviewed for dental services (#7), out of a total sample of 50 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a resident-centered care plan for use of a right hand palm guard by a dependent resident and personal hygiene and bathing needs for the right hand for 1 of 7 residents reviewed for activities of daily living (ADL) care out of a total sample of 50 residents, (#106).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide personal hygiene care for 1 of 7 dependent residents reviewed for activities of daily living (ADL) care of a total of 50 sampled residents, (#106) .

Inspectors wroteBased on observation, interview, and record review, the facility failed to address the wheelchair positioning needs of a resident with limited range of motion for 1 of 2 residents reviewed for positioning of a total of sample of 50 residents, (#22).

Inspectors wroteBased on observation, interview, and record review, the facility failed to refer a resident with lost upper and lower dentures for dental services in a timely manner, and failed to conduct a reassessment for appropriate diet texture for 1 of 2 residents reviewed for dental services of a total sample of 50 residents, (#7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete for 1 of 1 resident reviewed for edema, of a total sample of 50 residents, (#32).