Garden Isle Healthcare and Rehabilitation Center

Inspectors wroteBased on record reviews and interview, the facility failed to provide proper notification of transfer/discharge to four of four residents sampled for Hospitalization (Resident (R)26, R42, R62, and R65). The facility did not send written notification to the Office of the State LTC [long-term care] Ombudsman (LTCO) for four of the four residents that were transferred/discharged . This deficient practice has the potential to affect all residents at the facility who are discharged or transferred to the hospital. Findings Include: 1) R26 was first admitted to the facility on [DATE] for long-term placement. Review of R26's Electronic Health Record (EHR) revealed that on 09/05/24, R26 was transferred to an acute care facility for a higher level of care. Documentation of facility sending a written notification of discharge to the LTCO was not found in the EHR. [...]

Inspectors wroteBased on observation and staff interview the facility failed to promote the dignity and self-esteem for one of nine residents sampled for dining observation. During lunch observation, Resident (R)57 was seen with staff who stood over him as they assisted him to eat. The deficient practice does not promote the resident's self-esteem and put him at risk for weight loss.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to accommodate one of one Resident (R)12 in the sample with the assistance needed to put her hearing aids on during personal care. The deficient practice caused discomfort and frustration for the resident who had to wait for a trained staff that was available to assist her. This deficient practice has the potential to affect all residents that use a hearing aid.

Inspectors wroteBased on observations, record reviews and interviews, the facility did not ensure that a comprehensive person-centered care plan was developed and/or implemented for four of 21 residents (Resident (R)14, R43, R4 and R27) in the active patient sample. The facility failed to develop a comprehensive care plan for the use of bedrails and special mattress for R27, R43 and R14, and emergency care for a tracheostomy (surgically crated opening through the neck into the windpipe) for R4. As a result of this deficient practice, the residents were placed at risk for unmet care needs, decline in their quality of life, and were prevented from attaining their highest practicable physical, mental, and psychosocial well-being. Findings Include: 1) R14 is a [AGE] year-old resident admitted to the facility on [DATE] for long-term placement. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide services to ensure one of two residents (R)52 sampled for ADL (activities of daily living) decline, maintained a level of function and the range of motion of his upper and lower extremities. The deficient practice resulted in the resident's lack of movement to get out of bed. Findings Include: Cross reference to F697 - Pain Management. On 02/18/25 at 11:10 AM, observed R52 in his bed with his eyes closed. Noted he was wearing a knee brace on his right leg. R52 is an [AGE] year-old male admitted to the facility on [DATE] for skilled nursing following a stroke. Diagnosis includes Parkinson's disease, Type two diabetes, Lewy body dementia (a vascular disease in the brain) and communication deficit. Telephone interview waS conducted with R52s family member (FM)10 on 02/19/25 at 09:10 AM. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to assure one of one resident (R)4 sampled for respiratory/tracheostomy (surgically created opening through the neck into the windpipe) care had a care plan with interventions for an unplanned extubation and failed to assure the new tracheostomy tube was placed at bedside for such an emergency situation. The deficient practice could put R4 in a situation that could impede his breathing, causing a preventable life threatening situation. Findings Include: Cross reference to F656 Develop/Implement Comprehensive Care Plan for R4. Despite identifying R4's need for tracheostomy care and need to have a new replacement tracheostomy at his bedside the facility failed to include life saving emergency interventions in R4's care plan for an unplanned extubation. On 02/19/25 at 12:33 PM observed R4 in his room lying in his bed. [...]

Inspectors wroteBased on interviews and record review, the facility failed to identify, anticipate and effectively manage pain for one of two residents (R)52 sampled for pain. The deficient practice resulted in the resident's intolerance to attend activities and participate in exercises to prevent a decline in his Activities of Daily Living (ADLs). Findings Include: Cross reference to F676. Telephone interview with R52s family member (FM)10 on 02/19/25 at 09:10 AM. F10 stated that R52 isn't participating in therapy or exercises because he has pain. He used to get up and go to activities, but now he stays in bed. When they try to move his legs and get him up, he goes ow, ow, ow. His legs are really stiff. Record review of the face sheet on 02/19/25. R52 is an [AGE] year-old male who was admitted to the facility on [DATE] for skilled nursing services. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure assessment for the use of bed rails was completed and alternative interventions were attempted prior to their use for two of three residents (R)4 and R27 sampled for bed rails. This deficient practice puts R4, R27 and any resident who has bed or side rails installed at risk for harm such as entrapment. Findings Include: 1) On 02/19/25 at 01:39 PM observed R4 in his room in his bed which appeared to be like a crib, it was incased in bed rails. Review of R4's Electronic Health Record (EHR) revealed he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, cerebral palsy, unspecified (Primary, Admission), tracheostomy status, unspecified intellectual disabilities, functional quadriplegia, and unspecified lack of coordination, abnormal posture. [...]

Inspectors wroteBased on observation and interview the facility failed to assure the controlled drugs were accounted for each shift by having licensed staff document a count each shift. The deficient practice puts the facility at risk for diversion of narcotic medications which could make medications unavailable for residents who might need it. Findings Include: On 02/20/25 at 08:30 AM after observing medication pass with RN10, reviewed narcotics log and narcotic count. Review of the narcotic log form found missing nurses signatures. Review of the narcotic log dated 02/09/25-02/16/25 found four entries out of the 48 entries missing nurses' signatures. Inquired of RN10 if this should have been filled out and RN10 confirmed narcotic count sheet had some blanks and confirmed this is supposed to be signed at the time of the count by the nurses. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to assure medication errors with residents receiving medications, during medication pass observation, were less than five percent (%). One of five residents (R)29 sampled for medication pass, received medication in an altered form that was not ordered by the physician. The deficient practice has the potential to put all residents who receive medications at risk for a medication error when given their medication. Findings Include: On 02/20/25 at 08:13 AM, observed Registered Nurse (RN)10 prepare medications for R29. RN10 crushed R29's acetaminophen 325 mg (milligrams) tablet two tablets which is given BID (twice a day) for pain and RN10 opened R29's omeprazole DR (delayed release) 20 mg capsule which is given by mouth twice a day. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to provide routine dental services for one of one resident (R)4 sampled for dental care. The deficient practice puts R4 at risk for developing cavities and other mouth infections. Findings Include: On 02/19/25 at 11:49 AM observed R4 in his bed. R4 had his mouth open and surveyor noted R4 had a thick orange-colored build up on his front teeth. Review of R4's Electronic Health Record (EHR) found he was admitted to the facility on [DATE] and his diagnoses include, but are not limited to, cerebral palsy (disorder that affects ability to move, balance and maintain posture), tracheostomy status, unspecified intellectual disabilities, functional quadriplegia, and unspecified lack of coordination, abnormal posture. [...]

Inspectors wroteBased on observation, staff interview and policy review, the facility failed to ensure the resident's right to a dignified existence and treat each resident with respect and dignity for (4) residents. Resident (R)35, R67, R30, R60 residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for one of three (Resident (R)71) sampled for closed records. R71 was coded on the discharge Minimum Data Set (MDS) as discharged to a short-term general hospital. Staff confirmed R71 was discharged home on [DATE].

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there was an ongoing resident-centered activities program that met the resident's needs, for 1 of 3 residents (Resident 4) sampled for activities. Specifically, the facility failed to consistently act on the resident's need for social contact and sensory stimulation and failed to develop and/or implement a person-centered activities program that the resident found meaningful. As a result of this deficient practice, Resident (R)4 was placed at risk of experiencing a decline in his psychosocial well-being and comfort. This deficient practice has the potential to affect all residents at the facility.

Inspectors wroteBased on record review, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide timely psychiatric assessment for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization.

Inspectors wroteBased on record review, review of Facility Reported Incidents (ACTS #10723, 10743), review of Complaint (ACTS #10735), complainant interview, staff interview, and review of policy, the facility did not provide enough supervision for one Resident (R)46, out of three residents sampled, to reduce the risk through multiple falls. R46 had an increasing number of falls with recent fracture needing surgery and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to identify triggers which may cause re-traumatization, and consistently use trauma-informed approaches when caring for, and planning the care for, 1 of 1 resident (Resident (R)274) sampled for Trauma-Informed Care. As a result of this deficient practice, R274 did not have his needs met, was placed at risk of re-traumatization, and was hindered from attaining his highest practicable mental and psychosocial well-being. This deficient practice has the potential to affect all the residents at the facility with a history of trauma, post-traumatic stress disorder, and/or psychosocial adjustment difficulties.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain from an outside resource, routine dental services to meet the needs of 1 of 1 resident sampled for dental concerns. This deficient practice has the potential to affect all residents currently residing in the facility.

Inspectors wroteBased on an interview and record review, the facility failed to maintain an accurate medical record for two residents (Resident (R)24 and R225). An interview with the Director of Nursing (DON) confirmed a document for R225 was uploaded in R24's Electronic Health Record (EHR) erroneously and should not have been.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure that staff followed hand hygiene and contact precautions practices consistent with accepted standards of practice. Registered Nurses (RN)60 did not complete hand hygiene between glove changes during a dressing change for a Pressure Ulcer (PU) on R70's coccyx. Staff Member (SM)15 did not wear personal protective equipment while delivering lunch to R11's room, who was on contact precautions. This deficient practice places the residents in the facility at an increased risk for communicable disease.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, label, monitor, and discard food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure all perishable or refrigerated food items were labeled, dated, and monitored. Residents (R) risk serious complications from foodborne illness as a result of their compromised health status. Unsafe and/or unsanitary food handling practices represent a potential source of pathogen exposure for all residents at the facility.

Inspectors wroteBased on interview and record review, the facility failed to provide proper notification of discharge for three of the sample residents (Resident (R)169, R12 and R66) who were discharged home. The facility failed to provide written notification of the discharge to the resident or her representative, and/or failed to send notification of the discharge to the Office of the State LTC [long-term care] Ombudsman (LTCO). This deficient practice has the potential to affect all residents at the facility who are discharged or transferred.

Inspectors wroteBased on observation and interview, the facility failed to assure a dignified existence for one of three sampled residents (R)56.

Inspectors wroteBased on interview and record review (RR), the facility failed to ensure an Advance Directive and/or discussions regarding Advance Directives was documented in one resident's (Resident 16) medical record. As a result of this deficient practice, Resident (R)16 was placed at risk of not having her wishes honored for future health care decisions, should she become incapacitated. This deficient practice has the potential to affect all residents who wish to have end of life plans at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement a process to address grievances for one resident (R) as evidenced by the facility failing to acknowledge, document, investigate, and resolve verbal complaints filed by a resident's family representative as grievances. This deficient practice has the potential to affect all residents/representatives verbalizing complaints.

Inspectors wroteBased on record review and interview with staff members, the facility failed to report an allegation of physical abuse to Adult Protective Services.

Inspectors wroteBased on record review and interview with staff members, the facility failed to complete a thorough investigation and maintain documentation that an allegation of physical abuse was thoroughly investigated. There was no documentation of the resident interviews that were reportedly conducted. The facility did not thoroughly investigate the allegation, the facility failed to investigate the root cause of the bruises on the resident's arms (injuries of unknown origin) which was not documented in their report, the private caregiver was not interviewed, and the facility did not follow up on staff member's witness of certified nurse aides asking resident about the resident about the allegation.

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for a facility-initiated discharge for one resident (R) in the sample (R169) as evidenced by the lack of provider orders for discharge, a medical clearance for discharge, and/or a discharge summary completed by the provider documenting the reason(s) for discharge. As a result of this deficient practice, R169 was placed at an increased risk of injury and/or readmission to an acute care facility. This deficient practice has the potential to affect all facility-initiated discharges.

Inspectors wroteBased on record review, staff interview and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to accurately record the discharge home status in the RAI, Minimum Data Set (MDS) for one Resident (R)66 of three residents sampled. As a result of this deficiency, the facility put R66 at risk for further RAI, MDS inaccuracy.

Inspectors wroteBased on observation, record review, and interview with staff member, the facility failed to develop a baseline care plan which included minimum information necessary to properly care for the immediate needs of a resident admitted with a Foley catheter.

Inspectors wroteBased on observation and interview, the facility failed to facilitate the ongoing program of activities designed to meet the resident's psychosocial and physical needs. Activities were not carried out for one of four sampled residents (R)4. R4 was not observed out of room and up in wheelchair for stimulation to maintain R4's physical and psychosocial well-being and independence.

Inspectors wroteBased on interview, and record review, the facility failed to manage critical lab [laboratory] values for one Resident (R) in the sample (R169), and failed to identify, care plan, and manage constipation for another resident (R16) in the sample. As a result of this deficient practice, R169 was discharged with an increased risk of injury and/or readmission to an acute care facility, and R16 developed potentially avoidable hemorrhoids. This deficient practice has the potential to affect all the residents at the facility admitted from an acute care facility or at risk of constipation.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure for three of six sampled residents (R)4, R16 and R169 received range of motion (ROM) exercises to prevent decline and reduction in mobility.

Inspectors wroteBased on observation, record review and interview with staff member, the facility failed to assure drug records are in order and that an account of all controlled drugs are maintained to ensure no diversion.

Inspectors wroteBased on observation and interview with staff member, the facility did not assure medications were stored under proper temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate protective and preventive measures for COVID-19 and other communicable diseases and infections for three of six sampled residents (Resident (R)35, R45 and R33). This is evidenced by the facility failing to ensure staff followed transmission-based precautions (TBP) by wearing the proper personal protective equipment (PPE) and facility failing to follow their Mitigation Plan and isolating (R)45. These deficient practices have the potential to affect all residents in the facility, as well as all healthcare personnel, and visitors at the facility.

Inspectors wroteBased on observations, staff interview and review of policy, the facility failed to properly transport two oxygen cylinders (O2 tanks) in a safe manner. As a result of this deficient practice, the facility put the safety and well-being of the residents, staff, as well as the public at risk for accident hazards.