Florida Presbyterian Homes Inc

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain an accurate, consistent, and complete infection surveillance system as required by its Infection Prevention and Control Program; the facility did not accurately document, track, trend, or map resident infections or antibiotic use; inconsistently recorded infection types and numbers; failed to document organisms, symptoms, and confirmations of infection; and did not ensure both designated Infection Preventionists participated in surveillance processes for three months (April, May and June 2026) of three months reviewed.

Inspectors wroteBased in interview and record review, the facility failed to ensure the accuracy of the Level I Pre-admission Screening and Resident Review (PASSAR) for four (#9, #40, #14 and #198) of five residents reviewed. Findings Included: 1. Record review revealed Resident #9 was admitted to the facility on [DATE] with diagnoses that included but not limited to Unspecified Mental Disorder due to known Physiological Disorder, Anxiety, Schizophrenia and Unspecified Dementia according to the Face Sheet. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed: -Section C: Brief Interview for Mental Status (BIMS) score 00, indicating severe cognitive impairment. -Section I: Active Diagnosis - none checked. -Section N: Medications administered - Antipsychotic and Antianxiety. Review of the Medication Administration Record (MAR) for February 2024 showed: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a baseline and comprehensive care plan was complete for three residents (#148, #150 and #152) related to catheter care (#148), the use of oxygen (#150), and dementia care (#148 and #152) of twenty-five sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5%. A total of 30 medication administration opportunities were observed with 5 medication errors for one (#34) of five residents sampled for medication administration, which resulted in a medication administration error rate of 16.67%.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care and services were provided in a dignified manner to one (Resident #1) of twenty six sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the Resident Assessment Minimum Data Set for one (#9) of five residents reviewed.

Inspectors wroteBased on observations and interviews, the facility failed to ensure respiratory care and services were provided in accordance with professional standards for two (Resident #1 and Resident #150) of three residents sampled for oxygen therapy and failed to ensure oxygen warning signs were posted outside of resident rooms when oxygen was in use for three (Resident #1, Resident #150, and Resident #6) of three residents sampled for oxygen therapy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure recommendations during medication regimen review were addressed and acted upon by the primary care provider for one (Resident #37) of six residents sampled for medication regimen review.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure use of psychotropic meds on an as needed basis was limited to 14 days without rationale for continuation for two (Resident #37 and Resident #152) of six residents sampled for psychotropic medication use.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Infection Control Preventionist (ICP) had specialized training in Infection Control and Prevention.

Inspectors wroteBased on interviews, record reviews, and review of facility policy, the facility failed to provide Pneumococcal vaccinations for three (Resident #26, Resident #23, and Resident #29) of five residents sampled for Pneumococcal vaccinations and failed to provide influenza vaccinations for one (Resident #29) of five residents sampled for influenza vaccinations.

Inspectors wroteBased on interviews and record reviews, the facility failed to conduct ongoing COVID-19 outbreak testing in accordance with testing frequency parameters for five (Resident #26, Resident #29, Resident #9, Resident #23, and Resident #27) of five residents sampled for COVID-19 testing requirements and for five (Staff G, Certified Nurse Aide, Staff H, Registered Nurse, Staff I, Certified Nurse Aide, Staff J, Housekeeper, and Staff K, Maintenance) of five staff members sampled for COVID-19 testing requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor resident rights related to dignity for all residents, by not ensuring a residents quality of life was enhanced for one (Resident #20) of 25 sampled residents related to staff waiting to be invited into a resident's room and staff providing a service without discussing it with the resident.

Inspectors wroteBased on record review and interview, the facility failed to appropriately respond to Consultant Pharmacist recommendations for one (Resident #23) of five residents sampled for gradual dose reduction (GDR) , and the Consultant Pharmacist did not conduct a through review of medication administration for one (Resident #30) of five residents sampled for unnecessary medication

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for one resident (#48) related to an electronic elopement device out of the 11 sampled residents with an electronic elopement device.

Inspectors wroteBased on observation, interview, policy review, and review of the Food and Drug Administration (FDA) food safety guidelines, the facility failed to ensure onsite cooked food for two of two five-gallon containers of soup were cooled to 41 degrees Fahrenheit within food safety time parameters to limit, and prevent, foodborne pathogen growth.

Inspectors wroteBased on observation, interview, record and policy review, the facility failed to create and implement a plan of action to ensure a root-cause analysis, investigation and training were completed, per their quality assurance process, for one resident (#21) of two residents sampled for accidents. In addition, the facility's failure to conduct a root-cause analysis and collect data for Resident #21 revealed current inconsistencies with hot beverage procedures among direct care staff.