Life Care Center of Winter Haven

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents were provided dining services and resident care with dignity for four residents (#63, #2, #26, and #72 ) out of eight sampled residents. Findings Include: 1. During an observation made on 02/17/25 at 1:03 pm., Resident #63 was sitting up in bed with her lunch tray placed in front of her. She was observed having a hard time picking up her food using a specialized spoon. At 1:42 p.m., Staff D, Certified Nursing Assistance, CNA was observed standing over Resident #63 assisting her with her meal. During an observation made on 02/19/2025 at 1:29 pm, Resident #63 was observed sitting up in her bed with her lunch tray in front of her. Staff D, CNA was observed standing over her assisting Resident #63 with her meal. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide proper foot care and treatment to maintain good foot health according to professional standards of practice for three residents ( #134, #141, and #140) out of fifty-three residents sampled. Findings Include: 1. During an observation on 02/17/2025 at 9:20 a.m., Resident #134 was observed lying down in bed dressed in his night clothes. Resident #134's great toe was observed with the toe nail sticking out of a hole on his left sock. Resident #134 stated he really needed his toenails cut because they were causing his feet to hurt. He stated he had asked staff repeatedly to cut his toenails, but no one would listen to him. Resident # 134 gave consent to take a picture of his toenails. Photographic evidence obtained. [...]

Inspectors wroteBased on observation, review, and interview, the facility failed to ensure the medication error rate was less than 5.00%. Thirty-three medication administration opportunities were observed, and fourteen errors were identified for six (#143, #37, #218, #117, #120, and #106) of eight residents observed. These errors constituted a 42.42% medication error rate.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two (#49 and #141) of fifty- four sampled residents were assessed for self-administration of medications and failed to ensure physician orders had been obtained for medications observed on over-bed table of one (#141) of two residents observed.

Inspectors wroteBased on observation, record review and interview, the facility failed to file a grievance related to missing clothes for one resident (#57) out of eight residents sampled.

Inspectors wroteBased on record review and interview the facility failed to provide written notification to the resident and resident representative prior to an emergency transfer for one (#49) of two residents sampled for transfer and discharge rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure Preadmission Screening and Record Review (PASSR) was completed accurately for eleven residents (#112, #144, #21, #12, #126, #140, #130, #23, #54, #18, and #49) out of 33 residents sampled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound care in accordance with professional standards of practice and as ordered by the physician for one resident (#54) of two residents reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain physician ordered laboratory testing for one (#141) of fifty-four sampled residents.

Inspectors wroteBased on observation, and interview, the facility failed to ensure direct care equipment was cleaned in between two (#149 and #218) of eight residents observed during the administration of medications.

Inspectors wroteBased on record review, staff interviews, and review of the facility's policy, the facility failed to complete the Preadmission Screening and Resident Review (PASARR) Level II upon a new qualifying mental health diagnosis for six (Residents #40, #78, #95, #55, #63 and #94) of seven residents sampled for PASARR Level II.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure respiratory equipment was stored in a sanitary manner for six (Resident #40, #118, #14, #51, #49 and #103) of eight residents reviewed for respiratory care.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure dignity was maintained for two (Residents # 103 and #133) of two residents related to catheter exposure to the public during 3 of 4 days of survey.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure assessments and treatments were provided for two (Residents #49 and #94) of three residents reviewed for skin conditions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure behavioral and side effect monitoring related to the use of psychotropic medication was completed for one (Resident #32) of five residents sampled for unnecessary medication use.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5%. Twenty nine medication opportunities were observed and two errors were identified for Resident #107 resulting in an error rate of 6.9%

Inspectors wroteBased on observations, record review, photographic evidence and staff interviews, the facility failed to implement a care planned intervention related to the use of heel protectors for one resident (#15) of 47 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility did not monitor specific behaviors for one resident (#84) and did not monitor the side effects of psychotropic medications for one resident (#115) out of five residents sampled for unnecessary medications.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed, and four errors were identified for three residents (#3, #44, and #37) of five residents observed. These errors constituted a 14.29% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to maintain drugs and biologicals used in the facility in accordance with currently accepted professional principles by not ensuring: 1. one treatment cart (Oasis Suites) was locked while unattended, 2. one comfort kit was discarded timely for a deceased resident in one medication room (Oasis Suites), 3. eye drops with an expiration date was dated when opened on one medication cart (Golden Hall), 4. insulin pens were dated when opened and refrigerated when unopened, and ProSource Plus undated in two medication carts (Oasis Suites Hall and Cypress Hall), and a Victoza pen was stored in the original pharmacy packaging in one medication cart (Oasis Hall) of a total of five treatment carts, seven medication carts and five medication rooms.

Inspectors wroteBased on observation, interview and record review the facility failed to store food in accordance with professional standards for food service safety by not ensuring pre-prepped desserts, a peanut butter and jelly sandwich, and a fruit plate with cut melon and grapes were dated, and not ensuring two personal water bottles were not stored in a cooler in the prep area of the kitchen, and that two measuring scoops were not stored in dry good containers.

Inspectors wroteBased on observations, record reviews, and interviews the facility's Quality Assurance Committee failed to implement an effective plan of action related to behavior monitoring associated with the use of psychotropic medications for three residents (#6, #5, and #4 ) of three residents sampled.