Life Care Center of New Port Richey

Inspectors wroteBased on interview and record review, the facility failed to ensure resident council grievances were fully and promptly acted upon, for ten of ten resident council members who regularly attend the resident council meetings.

Inspectors wroteBased on record review and interview, the facility failed to complete/update the Pre-admission Screening and Resident Reviews (PASRRs) for residents with a mental disorder and individuals with intellectual disability following qualifying mental health diagnoses for six (#12, #57, #66, #30, #73, and #84) of 23 residents reviewed for PASRRs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure competent staff were available to provide skilled nursing care and services related to (1.) Failure to monitor resident's access to food allergens for two residents (#163 and #66), 2. Failure to ensure dressings were dated for one resident (#73), 3. Failure to follow up on a physician order with a black box warning for one resident (#264), 4. Failure to provide nutrition services for one resident (#91), and 5. Failure to provide hydration for three residents (#91, #16, and #49) of 58 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessments were accurately coded for two (#108 and #110) of fifty - six sampled residents.

Inspectors wroteBased on observation interview and record review, the facility failed to effectively assess and revise a resident's care plan following a significant weight loss for one resident (#162) of three residents reviewed for comprehensive assessments.

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure activities of daily living (ADLs) were completed and maintained for one (#91) of three residents sampled related to meals/snacks and three (#91, #16 and #49) of 23 residents sampled for hydration.

Inspectors wroteBased on observation, record review, and interview, the facility failed to follow-up on a physician order with a black box warning for one resident (#264) of fifty-one residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the medication error rate was less than 5%. Twenty-nine medication opportunities and 3 errors were identified for two residents (#102 and #361) of four observations, resulting in an error rate of 10.34%

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure medications were inaccessible to unauthorized staff, residents, and visitors for five (#265, #63, #12, #164 and #18) of 58 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure food that accommodates resident allergies, intolerances, and preferences was served for one (#163) of four residents reviewed for nutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change assessment within 14 days of determining a weight loss for one (#162) of four residents reviewed for nutrition.

Inspectors wroteBased on record review and interviews with facility staff and family members, the facility failed to notify the Resident Representative (RR) of a significant change in the resident's health status that resulted in acute care for one (Resident #1) of three residents reviewed.

Inspectors wroteBased on interviews and record review, the facility failed to ensure timely assistance was provided for ADLs (Activities of Daily Living) for one (Resident #2) of two sampled residents reviewed.

Inspectors wroteBased on record review and interview, the facility failed to ensure an advance directive was accurate in the medical record for one (Resident #257) of thirty-two sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) form to two (Residents #94 and #49) that were terminated from Medicare Part A Services that included physical therapy, occupational therapy, speech therapy, and nursing services, but would remain living in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident assessments accurately reflected the resident's status for one (Resident #39) of 32 sampled residents related to assessments.

Inspectors wroteBased on record review and interview, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a qualifying mental health diagnosis for five (Residents #257, #25, #24, #82, and #4) of thirty-two residents sampled for PASARR Level II.

Inspectors wroteBased on observation, record review, and interview, the facility failed to revise the care plan for one (Resident #24) of thirty-five sampled residents related to code status.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure the medication error rate was below 5.00%. A total of twenty-seven medications were observed, and two errors were identified for two (Residents #8, #78) of four residents observed. These errors constituted a medication error rate of 7.41 percent.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure new and adequate interventions and supervision measures were in place following repeated falls with injury for one (Resident #14) of three sampled residents. Findings Included: Review of the facility matrix report (resident data report) revealed that Resident #14 had a fall with injury in the past 90 days. The facility's incident log for the date range of 04/12/21-07/12/21 revealed the resident had five unwitnessed falls: 05/01/21; 06/15/21; 06/18/21; 07/03/21; 07/06/21. Observation was conducted in Resident #14's room on 07/13/21 at 12:25 p.m. She was observed lying on her back in bed with the head of bed raised, the bed was not in a lowered position, there were no mats on the floor. The call light was observed in reach. The resident engaged freely with some confusion noted. [...]

Inspectors wroteBased on record review and interviews, the facility failed to prescribe when necessary (PRN) psychotropic medication within the acceptable duration of use for one (Resident # 17) of five sampled residents who were reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that the medication error rate was below 5.00%. A total of twenty-five medications were observed administered and three errors were identified for three (Residents #72, #91, and #99) of three residents observed. These errors constituted a medication error rate of 12 percent.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to appropriately secure medications in five (100, 200, and 300 Halls) of five medication carts.

Inspectors wroteBased on observation of medication administration and of medication storage carts, both with facility nurses, review of facility documents and interview with facility staff including the Director of Nursing and the Administrator, it was determined the quality assessment and assurance committee failed to implement appropriate plans of action related to the facility's plan of correction for education and competency not being fully implemented and their auditing tools, even with identification of the continued concern of expired medications, were not changed to ensure compliance.