Pinellas Point Nursing and Rehab Center

Inspectors wroteBased on observations, interview and record review the facility failed to maintain the dish machine in a clean manner.

Inspectors wroteBased on record review and interview the facility failed to ensure that three residents (#29, #33, #41) of three residents sampled for binding arbitration agreements acknowledged that they understood the agreement prior to signing the document.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe and sanitary environment for one of one resident laundry room and one of one resident adaptive equipment storage room.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain an effective pest control program for two residents (#7 and #44) and two facility wings (East and West) of three facility wings and one of one emergency supply shed.

Inspectors wroteBased on record reviews, and interview the facility failed to confirm the accuracy of the Pre-admission Screening and Resident Review (PASRR) Level I and failed to complete a PASRR Level II for three residents (#4, #13, and #29) out of sixteen residents sampled.

Inspectors wroteBased on record review and interview the facility failed to ensure baseline care plans were developed and accurate for two residents (#105, #205) of 28 sampled residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility did not ensure side effect monitoring of psychotropic medications was in place for two residents (#33 and #39) of seven sampled residents reviewed for unnecessary medication.

Inspectors wroteBased on interviews, record review, and policy review the facility failed to protect the residents' right to be free from neglect related to neglecting to complete ordered laboratory tests for one resident (#3), not noticing a change of condition and notifying the physician and for two residents (#3 and #1) out of three reviewed for change of condition, and not performing cardiopulmonary resuscitation (CPR) according to policy for one resident (#1) out of three reviewed for the CPR process. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Residents #3 and #1 and resulted in the determination of Immediate Jeopardy which began on 2/3/24. [...]

Inspectors wroteBased on record review, interviews, facility documentation, and policy review, the facility failed to ensure the nursing staff was competent to recognize and respond to a change in condition for two (#3 and #1), out of three residents reviewed for change in condition, failed to ensure nursing staff were competent to process labs and x-rays appropriately for one (#3) out of three residents reviewed for change in condition and failed to ensure nursing staff were competent to initiate Cardiopulmonary Resuscitation (CPR) according to policy for one (#3) out of three residents reviewed for CPR administration. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #3 and Resident #1 and resulted in the determination of Immediate Jeopardy which began on 2/3/24 with a scope and severity of K. [...]

Inspectors wroteBased on record review, interviews, and review of the facility policy and procedure the facility failed to implement policies and procedures to honor the resident's right to choose an advance directive for one resident (#1) out of three reviewed for Advance Directives. Resident #1 was found not breathing with no pulse. The nursing staff did not honor the resident's wish to have all resuscitative efforts made until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. These failures created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy which began on [DATE] with a scope and severity of J. [...]

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure cardiopulmonary resuscitation (CPR) was performed according to professional standards for one resident (#1) out of three reviewed for CPR. Resident #1 was found not breathing with no pulse. Nursing staff did not initiate CPR until approximately 2 hours after the resident was discovered. Resident #1 expired in the facility. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #1 and resulted in the determination of Immediate Jeopardy starting on [DATE]/24. The findings of Immediate Jeopardy were determined to be Past noncompliance with a compliance date of [DATE] after surveyor verification of actions implemented removed and corrected the noncompliance.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure adequate supervision with assistance devices to prevent accidents for two residents (#5 and #6) out of three residents reviewed for use of mechanical and sit to stand lifts.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure one resident (#43) received adequate supervision and assistance to prevent at least four falls over twenty-two days resulting in transfer to a higher level of care and diagnoses of fracture of humerus to the right arm out of 21 sampled residents. Findings Included: An observation of Resident #43 on 3/02/22 at 2:07 p.m. while wheeling herself to the bathroom wearing a splint and sling on her right arm revealed Resident #43 sliding her arm out of the sling to wash her hands in the doorway of the bathroom. Then she backed her wheelchair up for an interview and stated she used to go to the bathroom all the time but fell and hurt herself. Resident #43 stated she would use her call light, and no one would come so she would go on her own. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (#52) had orders for the use of oxygen continuously for three (2/28, 3/1, and 3/2) of three days observed for three residents on continuous oxygen. Findings Included: Observation and interview with Resident #52 on 2/28/22 at 10:16 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula. The resident stated she never wore oxygen at home unless she was in bed. During the day at the facility if she takes it off the staff say to put it back on. Observation of Resident #52 on 3/1/22 at 8:15 a.m. revealed the resident was wearing oxygen at 2 liters via nasal cannula sitting up in bed. Observation of Resident #52 on 3/2/22 at 9:50 a.m. was wearing oxygen at 2 liters while sitting in her wheel chair. [...]

Inspectors wroteBased on record review, observations, interviews, and policy review the facility did not ensure the care plan was implemented for one resident (#17) of 25 residents reviewed for personal hygiene.

Inspectors wroteBased on observation, medical record review and staff interviews the facility failed to assist one Resident #(17) with necessary services to maintain good grooming and personal hygiene of 25 sampled residents who were in need of assistance to carry out activities of daily living .

Inspectors wroteBased on record reviews, observations, interviews, policy review, review of the Consumer Product Safety Commission website, and surveyor guidance found at the Agency for Health Care Administration's website, the facility did not ensure safe water temperatures were maintained in one resident bathroom of twenty resident bathrooms and for four residents (#9, #14, #24, and #29) of 25 residents in the facility with the potential to be affected.