Margate Health and Rehabilitation, LLC

Inspectors wroteBased on observations, record reviews and staff, resident, manufacturer customer service representative, Pharmacy Manager and Nurse Practitioner interviews, the facility failed to protect a resident's right to be free from misappropriation of medication. This failure occurred for 1 of 1 resident reviewed for misappropriation.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to implement their abuse policy in the areas of reporting and investigating an allegation of misappropriation. Upon the discovery of misappropriation, the facility did not submit a report to the State Agency or conduct a thorough investigation of the misappropriation. This failure occurred for 1 of 1 resident reviewed for misappropriation (Resident #24).

Inspectors wroteBased on observations, record reviews and staff interviews, the facility failed to follow their Hand Hygiene Policy when the Wound Nurse performed pressure ulcer treatments on Resident #10 and did not wash or sanitize her hands before applying clean gloves. This deficient practice occurred for 1 of 7 staff members observed for infection control practices (Wound Nurse).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code an admission Minimum Data Set (MDS) assessment for the use of oxygen for 1 of 3 residents (Resident #1) reviewed for respiratory care.

Inspectors wroteBased on record reviews, staff, admission Clerk, emergency room (ER) Nurse, ER Physician, and Nurse Practitioner (NP) interviews, the facility failed to implement continuous oxygen as ordered during transport to the ER. This practice affected 1 of 3 residents (Resident #1) reviewed for respiratory care.

Inspectors wroteBased on observations, record review, staff, Nurse Practitioner, Funeral Home Representative and Hospitalist interviews the facility failed to provide care in a safe manner. On [DATE] Nurse Aide (NA) #1 was performing incontinence care for Resident #195 who was resting on an air mattress raised to waist height and rolled Resident #195 on her side away from NA #1 who proceeded to walk around to the other side of the bed at which time the air mattress decompressed. Resident #195 rolled off the side of the bed to the floor and was wedged between the bed and the wall. Resident #195 was transferred to the hospital where she was diagnosed with a right femur fracture, right inferior and superior pubic rami (pelvic) fractures, questionable nondisplaced sacral alar (lower spine) fracture. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to verify that a Nurse Aide (NA) was competent in providing care for a dependent resident. Resident #195 rolled out of bed and sustained a right femur (long bone of the upper leg), right inferior and superior pubic rami (pelvic) fractures and questionable nondisplaced sacral alar (lower spine) fracture during care. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice occurred for 1 of 6 NAs (NA #1) reviewed for competencies. Immediate jeopardy began on [DATE] when NA #1 performed care without competencies being verified Resident #195 rolled off the side of the bed. Immediate jeopardy was removed on [DATE] when the facility implemented an acceptable credible allegation of immediate jeopardy removal. [...]

Inspectors wroteBased on observations, record review, and staff and family interviews, the facility failed to honor a resident's choice to have a communal dining experience for 1 of 1 resident reviewed for choices (Resident #87). This had the potential to affect all residents who wish to have a communal dining experience.

Inspectors wroteBased on record review, resident and staff interviews, the facility failed to communicate the facility's efforts to address concerns voiced by residents during Resident Council meetings for 5 of 8 months reviewed (January 2024, February 2024, May 2024, June 2024, July 2024, August 2024, September 2024, and October 2024).

Inspectors wroteBased on observations, record review, and interviews with staff, the facility failed to follow their infection control policy and procedures regarding Enhanced Barrier Precautions during high-contact care activities for residents with a feeding tube (Resident #126) and wounds (Resident #68 and Resident #49). This failure occurred for 4 of 4 nursing staff observed for infection control practices (Nurse #4, Nurse Aide #1, Nurse Aide #2 and Infection Preventionist).

Inspectors wroteBased on record review and staff interviews the facility failed to follow their infection control policy and procedure to ensure: 1) facility staff received infection control training on Enhanced Barrier Precautions (EBP) to know what required EBP and when to implement EBP and/or 2) failed to communicate to facility staff which residents required the use of EBP for 4 of 4 nursing staff reviewed for infection control (Nurse Aide #9, Nurse #1, Nurse #4, and Nurse #5). This practice had the potential to affect all residents.

Inspectors wroteBased on record review and staff interviews the facility failed to provide required dementia and/or abuse training for 6 of 6 (Nurse Aide #1, #2, #3, #5, #6, and #7) reviewed for training requirements.

Inspectors wroteBased on record review and resident, staff, and pharmacy interviews, the facility failed to obtain additional instructions from the provider when semaglutide (used to control blood sugar for Type 2 diabetics) was not available for 1 of 2 residents reviewed for medical record accuracy (Resident #85).

Inspectors wroteBased on observations, record review, and staff interviews the facility failed to adjust air mattress settings to accommodate residents' weight for 2 of 6 residents (Resident #68 and Resident #20) reviewed for pressure ulcers.

Inspectors wroteBased on observations, record review, and facility staff and resident interviews, the facility failed to keep an oxygen concentrator filter free from dust and debris for 1 of 5 residents reviewed for oxygen (Resident #15).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure accurate medical records when a resident's medication administration was incorrectly documented as administered for 1 of 2 residents (Resident #85) reviewed for medical record accuracy.

Inspectors wroteBased on observation, record review, resident, staff, family, and Medical Director interviews the facility failed to protect Resident #1 from being physically restrained by Nurse Aide (NA) #1. NA #1 grabbed Resident #1's left forearm and held it when the resident became combative during incontinent care and Resident #1 was trying to hit NA #1 and NA #2. Resident #1 received a large purple bruise on her left forearm. This deficient practice affected 1 of 3 residents reviewed for dignity.

Inspectors wroteBased on observation, record review, resident, and staff interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after NA #2 witnessed the NA grab Resident #1's left forearm to prevent her from hitting NA #1 and NA #2 when the resident became combative during incontinent care. In addition, the facility failed to identify, thoroughly investigate, and report the incident to the state agency, Adult Protect Services, and local Law Enforcement for 1 of 3 residents reviewed for dignity.

Inspectors wroteBased on record review and staff interview the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of behaviors, antipsychotic medication use, Pre-admission Screening and Resident Review, diagnoses, and discharge destination for 5 of 29 resident MDS assessments reviewed (Residents #47, #88, #18, #40 and #122).

Inspectors wrote5. Resident #48 was admitted to the facility on [DATE] with a diagnosis of bipolar. Physician orders included an order written on 10/15/2019 for Lithium Carbonate (a medication used to treat manic-depressive disorders, bipolar disorder, to stabilize the mood and reduce extremes in behaviors) 150 milligram (mg) capsule twice a day and Zyprexa (an antipsychotic medication that treats mental health conditions like bipolar disorders) 1 mg at bedtime for bipolar. The annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #48 was moderately cognitively impaired, displayed no behaviors toward others, diagnoses included bipolar disorder and received antipsychotic medications for seven days of the seven-day look back period. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to discard outdated leftover cooked food and failed to label leftover cooked food stored in the main walk-in refrigerator. This practice had the potential to affect food served to the residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to post accurate staffing information for licensed and unlicensed nursing staff for 22 of 43 posted census daily staffing forms reviewed. A review of posted census daily staffing forms from 5/1/2023 to 6/11/2023 indicated the following posted census daily staffing forms contain incomplete and/or inaccurate number of staff working compared to the daily assignment sheets: a. On 5/12/2023, the posted census daily staffing form indicated 7 licensed staff for the 3p.m to 11p.m. shift, and there were 6 licensed staff scheduled on the 3p.m. to 11p.m. daily assignment sheet. On the 11p.m. to 7a.m. shift, the posted census daily staffing form indicated 5 licensed staff and 7.5 unlicensed staff, and there were 4 licensed staff and 6.5 unlicensed staff scheduled on the 11p.m. to 7a.m daily assignment sheet. b. [...]

Inspectors wroteBased on record review, staff interviews and Ombudsman interview, the facility failed to provide written notice of discharge to the ombudsman for 1 of 4 residents reviewed for discharge to the hospital (Resident #73).