Dolphin Pointe Health Care Center

Inspectors wroteBased on observations of kitchen food preparation and storage areas and interviews with staff, the facility failed to adhere to acceptable food storage practices to prevent food contamination or foodborne illness by failing to ensure opened foods were sealed, labeled and dated, and food preparation and storage equipment was clean and sanitary. Food storage and kitchen sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices present a potential source of pathogen exposure and has the potential to affect all residents who consumed foods from the facility, An initial tour of the kitchen was conducted with the Certified Dietary Manager (CDM) on 1/26/26 at 2:15 PM. Inspection of the commercial ice machine's ice chute cover revealed an a 2-inch square area covered with wet, dark matter resembling biological growth such as mildew. [...]

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure residents who were dependent on staff for grooming and personal care received necessary assistance with activities of daily living (ADLs), specifically related to fingernail and toenail trimming and cleaning, for four of six residents reviewed for ADLs (Residents #76, #116, #67, and #45).

Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to ensure residents' rights to self-administer medications was consistently assessed and safely implemented, as evidenced by the failure to complete required self-medication assessments and to ensure medications approved for self-administration were securely stored for three of three residents reviewed (Residents #116, #80, and #37).

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure staff followed policy and procedure for reporting and investigating allegations of abuse for one of one resident sampled for abuse (Resident #38) and failed to ensure staff participated in annual training on abuse, neglect and exploitation for two of 10 staff members reviewed (Staff members J, and the Assistant Director of Nursing).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure accurate medical records were reflective of residents' care for one of one resident (Resident #155) observed with edema and ordered to wear compression stockings (snug knee-high socks that provide pressure to the legs, ankles, and feet to improve circulation, reduce swelling, and prevent blood clots), out of a total of 45 residents in the sample. An observation conducted of Resident #155 on 1/27/26 at 10:29 AM found her barefoot and in bed. During an interview at this time, she was asked if she had any socks available to wear. Resident #155 answered, Yes, but they are over there. (pointing across the room to a pair of slippers) No socks or stockings were observed in the vicinity. Resident #155 was able to provide a detailed medical history leading up to her transfer to this facility. [...]

Inspectors wroteBased on the kitchen food service observations, staff interviews, facility record review, and facility policy and procedure review, the facility failed to document temperatures and sanitation, and clean and maintain kitchen foodservice equipment to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility. The facility failed to maintain temperature logs for the 3-compartment sink and maintain the kitchen oven in a clean and sanitized condition. Food safety and sanitation is important in health care settings serving nursing home residents. Kitchen equipment shall be maintained and kept free of food residue and other debris to avoid a potential source of pathogen exposure.

Inspectors wroteBased on interview and record review, the facility failed to make prompt efforts to resolve a grievance for one (Resident #77) of one resident reviewed for personal property (missing clothing) from a total sample of 53 residents.

Inspectors wroteBased on observation, medical record review, and staff interviews, the facility failed to ensure a new Pre-admission Screening and Resident Review (PASARR) was conducted for one (Resident #38) of two residents reviewed for PASARR completion from 53 residents in the sample. Resident #38 had psychiatric diagnoses that were not documented on the original PASARR and should have been screened for a Level II after admission to the facility. The fndings include: A review of the medical record for Resident #38 revealed an admission date of 12/13/23 and included the following diagnoses: schizophrenia and dementia with mood disorder. The current PASARR received by the facility on 12/12/23 noted no diagnoses checked under Section I, and under Section II, a diagnosis of dementia was checked no. An interview was conducted with the Assistant Administrator on 02/15/24 at 11:38 a.m. [...]

Inspectors wroteBased on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #6) of four residents reviewed for wound care, from a total sample of 53 residents, received wound care according to professional standards of practice to promote healing.

Inspectors wroteBased on observations, interviews, and medical record reviews, the facility failed to ensure that one (Resident #22) of two residents reviewed for pressure ulcers, from a total sample of 53 residents, received pressure ulcer care according to professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing.

Inspectors wroteBased on observations, record review, staff interviews, and a review of the policy and procedure for Oxygen Therapy, the facility failed to ensure oxygen was administered at the physician-ordered flow rate for two (Residents #29 and #129) of six residents reviewed for oxygen use, from a total sample of 53 residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of 5% or less. There were six errors out of 26 opportunities for error, resulting in an error rate of 23% and involving two (Residents #123 and #166) of three residents observed for medication administration. Failure to administer medications appropriately as ordered could result in side effects leading to harm to the residents.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure medications were stored in locked medication carts for three (Residents #16, #22, and #77) of 53 residents in the total sample. Pain creams and other creams were found in residents' rooms, which could lead to overdosing or harm to other residents.

Inspectors wroteBased on record reviews, interviews, and a review of the Medication Pass Guideline Policy and Procedure, the facility failed to ensure to maintain complete, accurately documented medical records for one (Resident #50) of 53 sampled residents for blood pressure medication with parameters. Documenting the blood pressures before administration ensures nurses are following the physician's orders and not administering medication if the resident's blood pressure is too low.

Inspectors wroteBased on observation, dietary staff interview, facility document review, and facility policy and procedure review, the facility failed to store, prepare, and serve food under sanitary conditions when the dietary staff failed to wash hands between glove changes and change gloves when contaminated, as required. Food was stored in the walk-in cooler and walk-in freezer uncovered and not date marked. Food was kept beyond the allowed use by date. Baking sheets were wet nesting. Cutting boards were deeply grooved and in need of replacement. Handwashing sinks had no signage posted to indicate the sink was for handwashing only. The handwashing sink in the dish room was blocked by a mop bucket, broom, and dustpan. Food was observed on the floor of the freezer. Paper products to be used by residents were stored on the floor in the nutrition room. [...]

Inspectors wroteBased on a review of the Facility Assessment, CMS (Centers for Medicare and Medicaid Services) form 672 (Census and Condition of Residents), and interviews with staff, the facility failed to update the Facility Assessment on an annual basis in order to assess the population's acuity level and determine what resources were needed to provide care for its residents during not only day-to-day operations, but during an emergency. The facility also failed to employ the input of facility staff members including the Medical Director, Director of Nursing, any member of the governing body, residents or their representatives. This had the potential to affect all 124 residents in the facility. [...]

Inspectors wroteBased on observations, resident and staff interviews, and a review of resident records, the facility failed to provide medication and treatments as ordered and in accordance with professional standards of practice for one (Resident #121) of one resident who reported problems receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that psychotropic medications were used to treat a specific, diagnosed condition and failed to ensure as-needed (PRN) anti-anxiety medications were limited to a use of 14 days for one (Resident #57) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, resident and staff interviews, and a review of resident records and facility policies, the facility failed to accurately document resident medication and treatment records for one (Resident #121) of one resident who reported problems with receiving treatment and medication, out of six residents whose medication regimens were reviewed, from a total of 42 residents in the sample.