Luxe at Lutz Rehabilitation Center (the)

Inspectors wroteBased on interviews and record review, the facility failed to ensure urinary catheter care was provided in accordance with standards of care for one resident (#1) out of 3 residents sampled for catheter care.

Inspectors wroteBased on interviews and record review, the facility failed to ensure continuous oxygen therapy was provided in consistent with professional standards of practice, related to failure to ensure the resident's record included accurate and active physician orders and on-going assessment of the resident's respiratory status and response to oxygen therapy, for two (#18 and #12) of two residents reviewed, resulting in Resident #18 experiencing respiratory distress requiring emergency hospitalization.

Inspectors wroteBased on observation, staff interview and policy and procedure review, the facility did not ensure resident medical records and confidential medical information were safeguarded in a confidential manner that would prevent unauthorized access on two (100 and 200) of two halls toured.

Inspectors wroteBased on observations interviews and policy review, the facility failed to ensure proper infection control practices were in place for two (100 and 200) out of two halls related to use and availability of personal protective equipment (PPE) and performing hand hygiene.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure a post fall care plan was updated and interventions were implemented in a timely manner for one (#21) of two residents reviewed for falls.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure wound care orders were put in place and completed timely for one resident (#1) and did not ensure medications were administered appropriately for two residents (#10 and #22) out of twenty-two sampled residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure it had an effective infection control program related to hand hygiene on 2 of 4 units (TCU, Lakeview) , sharps containers, and use of Personal Protective Equipment (PPE) for one of one residents on Transmission Based Precautions (room [ROOM NUMBER]).

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure the resident's right to privacy was upheld related to staff and visitors knocking at resident doors prior to entering for 3 of 36 (#51, #38 #55) sampled residents and 6 of 12 (Rooms 122, 123, 124, 127, 129, 130) random resident rooms on TCU unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician and resident representative was informed of medications not given as well as weights not performed for one of 40 sampled residents (#56).

Inspectors wrote2. A review of the admission Record showed Resident #2 was initially admitted to the facility on [DATE] with diagnoses of anxiety disorder and bipolar disorder. The admission Record revealed a new diagnoses of adjustment disorder with anxiety on 06/22/20, major depressive disorder on 01/04/21, and persistent mood disorder on 06/01/21. Review of Resident #2's PASRR Level I Screen dated 04/03/24 and completed by the Assistant Director of Nursing (ADON) only showed a qualifying diagnosis of anxiety disorder and indicated no PASRR Level II was required. On 04/18/24 at 11:42 a.m., the ADON reported they started doing audits on PASRRs because there were a lot of diagnoses not listed on the PASRRs. She confirmed she completed the PASRR for Resident #2 during the audit. She confirmed that all her current diagnoses were not listed on the PASRR. [...]

Inspectors wroteBased on observations, record review and interview, the facility failed to provide Activities Of Daily Living (ADL) for 2 of 3 (#10, #55) residents sampled for ADL care related to personal hygiene.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure 2 of 39 (#340, #389) sampled residents received treatment and care in accordance with professional standards of practice related to unlabeled dressings.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Forty-four medication administration opportunities were observed and fourteen errors were identified for three residents (#42, #241, #24) of eight residents observed. These errors constituted a 25% medication error rate.

Inspectors wroteBased on interview and record review, the facility failed to implement the Comprehensive Resident-Centered Care Plan related to administering medications and performing weights for one of 40 sampled residents (#56).

Inspectors wroteBased on interviews, and record reviews the facility failed to implement policies and procedures for ensuring the reporting of resident neglect related to an elopement for one resident (#4) out of three residents sampled for elopement risk.

Inspectors wroteBased on interviews and record review the facility failed to implement an effective discharge planning process by not ensuring medical follow-up related to home health care was initiated for one resident (#1) of two residents sampled for discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen in a safe and sanitary manner related to ensuring equipment is maintained in a clean manner and free from debris, related to 3 of 4 (Kitchen, Fern Unit, TCU Unit) ice machines, dish machine, and kitchen walls.

Inspectors wroteBased on observations, record reviews, interviews and review of the Center for Disease Control and Prevention (CDC) guidelines, the facility failed to implement and maintain an infection prevention and control program to mitigate the spread of COVID-19 related to: 1) not ensuring 2 staff members (K and P) disposed of Personal Protective Equipment (PPE) in the recommended manner when exiting one of nine rooms on the COVID positive unit and one (#179) of rooms where two resident (#282 and #289) were under Enhanced Barrier Precautions for COVID-19 and 2) not ensuring one staff members (N) complied with the wearing of required PPE when entering one (#177) out of thirteen rooms posted for Enhanced Barrier precautions.

Inspectors wroteBased on record reviews and interviews, the facility failed to notify residents, resident representatives, and staff members of the positive COVID-19 test results in a timely manner.

Inspectors wroteBased on observations, record review and interview the facility failed to maintain its kitchen equipment in a safe operating condition, related to a 6 burner stove.

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure skin conditions were addressed and assessed for 3 (Resident #69, #294 and #27) of three sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure weight variances were addressed for two (#4 and #40) out of thirty-eight sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-nine medication administration opportunities were observed, and three errors were identified for three (#296, #295 and #69) of five residents observed. These errors constituted a 10.34% medication error rate.

Inspectors wroteBased on observations, staff interviews and record review, the facility did not ensure the kitchen and cooking equipment were maintained in a clean and sanitary manner related to the dishwashing machine not reaching the required hot water temperature which had the potential to negatively impact 75 of the 77 residents in the facility.

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-seven medications were observed administered and two errors were identified for one (Resident #356) of four residents observed. These errors constituted a medication error rate of 7.41 percent.