Gulf Coast Village

Inspectors wroteBased on observation, record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to investigate a fall and implement individualized interventions to minimize the risk of further falls and fall related injuries for 1 (Resident #1) of 3 residents reviewed.

Inspectors wroteBased on record review, residents and staff interviews, the facility failed to ensure that the arbitration agreement signed by 3 (Residents #111, #115 and #107) of 3 residents reviewed provided the selection of a neutral arbitrator agreed upon by both parties and provided for the selection of a venue that is convenient to both parties when there is a dispute. This has the potential to affect all residents residing in the facility.

Inspectors wroteBased on record review, review of facility policy and procedure, and staff interviews, the facility failed to develop and implement an individualized care plan to meet the needs of 1 (Resident #104) of 5 residents reviewed for care plan.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the safe transfer with a mechanical lift of 1 (Resident #14) of 3 residents by failing to ensure the sling was properly placed and secured, resulting in a bruise to the resident's left upper extremity.

Inspectors wroteBased on observation, review of facility policy and staff interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on record review, review of facility's policy and procedure and staff interview the facility failed implement their policy and procedure and notify the office of the Long-Term Care Ombudsman of residents' discharges. The notification to the Ombudsman's office is to protect residents' rights to prevent unwarranted or unnecessary transfers or discharges and to prevent facilities from refusing to allow the residents return to the facility.

Inspectors wroteBased on record review, review of facility's Policy and Procedure, and staff interview the facility failed to ensure the clinical records were completely and accurately documented for 3 (Residents #115, #34 and #109) of 3 residents reviewed.

Inspectors wroteBased on record review, review of policy and procedure and staff interviews the facility failed to develop and implement systemic appropriate corrective actions related to identified quality of care deficiencies related to falls and failed to identify and address unresolved quality deficiency related to food safety and sanitation in the kitchen.

Inspectors wroteBased on observation, review of facility policy and staff interview, the facility failed to maintain an effective pest control program to ensure a sanitary environment free from pests for residents.

Inspectors wroteBased on clinical record review, review of facility's Policy and Procedure, resident representative and staff interview the facility failed to notify the resident's representative of a change in condition requiring treatment with a new medication for 1 (Resident # 115) of 3 residents reviewed for change in condition.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to ensure the Advanced Beneficiary Notice of Non-Coverage issued to 2 (Residents #66 and #92) of 3 residents was complete and accurately reflect the residents' decision to stop or continue skilled services and the financial liability.

Inspectors wroteBased on observation, clinical record review, review of facility's policy and procedure, resident and staff interviews, the facility failed to provide activities that meets the interests and accommodate the needs of 1 (Resident #7) of 3 residents reviewed for involvement in activities.

Inspectors wroteBased on observations and interviews, the facility failed to properly store medications in a safe manner. Throughout the survey, medications were observed unattended at bedside, unsupervised on medication carts and medication carts left unlocked leaving these medications to be easily accessible to residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure physician's orders received via text for 1 (Resident #92) of 3 residents reviewed for change in condition were immediately documented, signed, dated, and implemented, creating the potential for a negative outcome.

Inspectors wroteBased on observations, facility policy, and staff interviews, the facility failed to maintain sanitary conditions during food service, including a visibly soiled ice machine, inadequate sanitizer levels in the three-compartment sink, and kitchen staff without proper hair restraints, posing a risk of food contamination and potential foodborne illness.

Inspectors wroteBased on observation, record review, review of facility's policies and procedures, resident and staff interviews the facility failed to protect the residents' right to be free from verbal and mental abuse resulting in feeling of humiliation for 1 (Resident #35) of 3 residents reviewed.

Inspectors wroteBased on observation, interviews and records review, the facility failed to provide the necessary service to maintain grooming for 1 (Resident 12) of 3 sampled residents dependent on staff for Activities of Daily Living.

Inspectors wroteBased on record review, facility's policies and procedures review and staff interviews, the facility failed to ensure staff followed established policies and procedures to honor the advance directives for full code status for 1 (Resident #1) of 3 residents reviewed. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, without a pulse or respiration. Clinical staff failed to ensure timely confirmation of code status and immediately initiate cardiopulmonary resuscitation (CPR) for Resident #1 who had a full code status. Three Licensed Nurses on duty did not call Emergency Medical Services (EMS) or initiate CPR for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced dead by EMS. [...]

Inspectors wroteBased on record review, facility's policies and procedure reviews and staff interviews the facility staff failed to immediately initiate cardiopulmonary resuscitation (CPR) in the absence of a Do Not Resuscitate (DNR) Order for 1 (Resident #1) of 4 residents reviewed who was found without a pulse or respirations. On [DATE] at 5:19 a.m., Resident #1 was found unresponsive, had no pulse, and no respirations. Clinical staff delayed calling Emergency Medical Services (EMS) and did not initiate CPR for 51 minutes while attempting to locate a non-existent DNR order. CPR is a crucial life-saving technique that aims to sustain blood circulation and oxygenation in individuals experiencing cardiac arrest. Resident #1 was pronounced dead by EMS. [...]

Inspectors wroteBased on observation, record review, facility's policies and procedures review, and staff interview, the facility failed to ensure nursing staff had the appropriate competencies to immediately initiate lifesaving measures, including cardiopulmonary resuscitation (CPR) when residents with full code status experience cardiac or respiratory arrest. On [DATE] at 5:19 a.m., clinical staff found Resident #1 in cardiac and respiratory arrest. Three nursing staff on duty (two Registered Nurses and one Licensed Practical Nurse) delayed the initiation of CPR and the calling for Emergency Medical Services (EMS) for 51 minutes while they attempted to locate a non-existent Do Not Resuscitate Order. Resident #1 was pronounced deceased by EMS. [...]

Inspectors wroteBased on observation, record review and staff interview, the facility's Administration failed to utilize its resources effectively by failing to ensure staff was adequately trained and knowledgeable in policies and procedures to honor residents' rights to advance directives, including the right to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. On [DATE] at 5:19 a.m., Resident #1 was found without pulse or respiration. The clinical staff on duty did not initiate CPR until 6:10 a.m., 51 minutes after Resident #1 was found unresponsive. Resident #1's wishes to be a full code and receive CPR was not documented in the baseline care plan, despite the Social Services Department being aware of the resident's full code status on [DATE]. Resident #1 was pronounced dead by Emergency Medical Services. [...]