Lake Worth Rehabilitation Center

Inspectors wroteBased on record review and interview, the facility failed to collect a urine test to rule out a urinary tract infection (UTI) for 1 of 3 sampled residents (Resident #1).

Inspectors wroteBased on observation, interview, record and policy review; the facility failed to ensure reporting of 2 of 2 incidents involving events with major injuries both affecting 1 of 2 sampled residents (Resident #11) reviewed for accidents.

Inspectors wroteBased on observation, interview, record review and policy review; the facility failed to thoroughly identify and investigate the alleged witnessed fall and unwitnessed fall for 1 of 2 sampled residents reviewed for accidents (Resident #11).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had a current order for a nebulizer treatment medication, failed to secure that medication observed at the bedside for 1 of 16 sampled residents receiving nebulizer treatments (Resident #85), and failed to ensure the resident received a psychotropic medication at the prescribed time for 1 of 4 sampled residents observed for medication administration (Resident #85).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to prevent complications for a resident who received enteral feeding. This affected 1 of 1 sampled resident, (Resident #300), who was reveiwed for enteral feeding (tube feeding). This had the potential to affect 4 residents who were dependent on enteral feeding for nutrition at that time.

Inspectors wroteBased on observation, interview and record review, the Administrator failed to carry out her duties as outlined in her job description which included risk management and overall management of the facility which affected 1 of 2 sampled resisdents reviewed for accidents (Resident #11).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide an environment free of pests in 4 of 15 rooms on the 2 South Unit (room [ROOM NUMBER], #241, #250 and #251).

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable, and homelike environment for residents on 1 of 2 units/floors in the facility (2nd floor secured unit). This affected Residents #67, #24, #85, #51, #79, #57, #58, #68, #40, #31, #59, #32, #91, #28).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to provide an ongoing activity program based upon assessments, care plans, and personal preferences, for 2 of 2 residents who voiced concerns related to the lack of activities (Resident #51 and #9), and for 5 of 5 residents observed only in their rooms, with a lack of sensory stimulation, and or assessed as needing either one-to-one activities or friendly visits (Residents #79, #91, #37, #43, and #40).

Inspectors wroteBased on observation and interview, the facility failed to maintain resident care equipment in a safe and sanitary condition related to specialized mattress and wheelchairs for 7 of 32 sampled residents (#24, #68, #40, #32, #91, #21, #28).

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure showers as per resident preference and schedule for 1 of 2 sampled residents reviewed for choices (Resident #51).

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate Minimum Data Set (MDS) assessments for 2 of 32 sampled residents related to oxygen use for Resident #91 and discharge status for Resident #57.

Inspectors wroteBased on record review and interview, the facility failed to refer 1 of 1 sampled resident for a Level II resident review, as indicated by the pre-admission screening and resident review (PASRR) Level I review completed by hospital staff (Resident #67).

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan for 1 of 5 sampled residents reviewed for unnecessary medications (Resident #33).

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate care between the facility and dialysis for 1 of 2 residents reviewed for dialysis (Resident #29).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices after wound care for 1 of 2 sampled residents observed for wound care (Resident #43); Failed to follow best practice to prevent transmission of blood-borne pathogens using the ultra-mist machine for 1 of 1 sample residents with specialized wound care (Resident #43); and failed to maintain clean oxygen tubing for 1 of 2 residents reviewed for respiratory care (Resident #91).

Inspectors wroteBased on record review and interview, the facility failed to state in their admission Agreement (pg. 15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 100 out of 100 residents.

Inspectors wroteBased on observation and interview, the facility failed to serve food in a sanitary manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure of an accurate Minimum Data Set (MDS) assessment was completed for for 5 of 23 sampled residents, related to Hospice (Resident #31), catheter (Resident #47), nutrition (Resident #79 and Resident #99), and medications (Resident #121).

Inspectors wroteBased on record review and interview, the facility failed to ensure staff recieved training in abuse, neglect, and exploitation upon hire and annually, as per facility policy and facility assessment, for 8 of 14 sampled staff personnel records reviewed for training (Staff I, Staff J, Staff K, Staff L, Staff M, Staff N, Staff O, and Staff P).

Inspectors wroteBased on record review and interview the facility failed to ensure there was a documented thorough investigation for 3 of 4 sampled residents, reviewed for incident investigations (Resident #98, Resident #102 and Resident #172).

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that activities meet the needs for 1 of 3 sampled residents reviewed for Activities (Resident #58).

Inspectors wroteBased on observation, record review, and interview, the facility failed to implement preventative measures of ordered specialty air mattresses, repositioning, offloading, and wound care, to prevent the development or worsening of pressure ulcers for 3 of 4 sampled residents (Resident #84, #109, and #274).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure monitoring of hydration status, provision of recommended extra fluids, and timely provision of IV (intravenous) fluids for 2 of 4 sampled residents (Residents #116 and #172).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately document medicating residents with controlled medications for 2 of 4 sampled residents (Resident #73, and #62).

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure proper storage and labeling of drugs and biologicals. Specifically, 1 of 1 treatment carts was left open and unattended during a wound care observation for Resident #109; a medication was improperly disposed of during the medication pass observation for 1 of 7 residents; and an opened PPD (purified protein derivative) vial in the medication refrigerator was not properly labeled.