Regents Park of Winter Park

Inspectors wroteBased on observation, interview, and record review, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to identify a repeated deficiency and area of systemic non-compliance with Intravenous (IV) catheter care. The deficient practice had the potential to affect more than a limited number of residents by not ensuring consistent monitoring and follow-up of identified problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection and prevention control program to provide a sanitary environment to prevent the development and transmission of communicable diseases and infections related to laundry services in one of one laundry room of the facility. Additionally, the facility failed to ensure staff implemented and adhered to infection prevention and control practices for transmission based, and enhanced barrier precautions for a midline intravenous (IV) catheter for one of two residents reviewed for IV antibiotics, of a total sample of 38 residents, (#128, and #127).

Inspectors wroteBased on interview, and record review, the facility failed to inform and provide written information to residents and/or their representatives about their right to accept or refuse medical or surgical treatment and to formulate an Advance Directive (AD) for five dependent residents' representatives, (# 1, # 11, #12, #15, and #116) and 15 residents able to make their own decisions for healthcare, (#1, #4, #5, #6, #7, #8, #10, #11, #12, #13, #15, #16, #57, #108, and #116), of a total sample of 38 residents. Specifically, the facility failed to ensure residents or their representative acknowledged receipt of verbal and written information about AD and failed to ensure AD acknowledgment forms were complete.

Inspectors wroteBased on interview, and record review, the facility failed to ensure completion and accuracy of Level I Preadmission Screening and Resident Reviews (PASARRs) on admission, and/or failed to make referrals for newly evident or possible mental disorders, to evaluate the need for specialized mental health services or alternate placement for 7 of 7 residents reviewed for PASARR, of a total sample of 38 residents, (#4, #6, #7, #8, #10, #62, and #66).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to accepted standards of practice for intravenous (IV) catheters, including midlines for 1 of 2 residents reviewed for IV antibiotics, of a total sample of 38 residents, (#128).

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice that accounted for residents' experiences and preferences to mitigate triggers to avoid re-traumatization of the resident, for 2 of 2 residents diagnosed with Post Traumatic Stress Disorder (PTSD), of a total sample of 38 residents, (#8, and #62).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from neglect to prevent a fall with major injury (#3); and neglected to implement care directives to promote safety during a transfer procedure, (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policies and procedures and accepted standards of practice to prevent an avoidable fall from a full body mechanical lift (#3); and ensure use of the appropriate type of mechanical lift to meet assessed needs (#2), for 2 of 7 residents reviewed for mechanical lift use, out of a total sample of 8 residents. On 11/22/24 at approximately 5:00 PM, the facility failed to prevent resident #3, a vulnerable, physically impaired resident, from suffering a fall and fracture. The resident's plan of care indicated she required assistance from two staff members for transfers with a full body mechanical lift, but her assigned Certified Nursing Assistant (CNA) attempted the task single-handedly. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to validate that Certified Nursing Assistants (CNAs) possessed and demonstrated appropriate competencies and skills to meet identified needs based on assessments, and followed directives in the plans of care for 2 of 7 residents reviewed for mechanical lift transfers, out of a total sample of 8 residents, (#2 and #3), and for all residents who required assistance with transfers.

Inspectors wroteBased on interview, and record review, the facility failed to immediately notify the physician and resident representative of a change in condition regarding a fracture for 1 of 2 residents reviewed for falls, out of a total sample of 8 residents, (#3).

Inspectors wroteBased on interview, and record review, the facility failed to honor resident's right to choose their preferred bathing preferences for 1 of 4 residents reviewed for choices, of a total sample of 41 residents, (#78).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services according to professional standards for monitoring and management of an intravenous (IV) therapy site for 1 of 1 residents reviewed for IV access, of a total sample of 41 residents, (#168).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to maintain a secure environment to ensure vulnerable residents did not exit the facility without supervision and failed to respond appropriately to a door alarm for 1 of 15 residents reviewed for elopement, of a total sample of 15 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. While resident #1 was out of the facility unsupervised, there was reasonable likelihood he could have fallen, become lost, been accosted/harmed by a stranger or been hit by a car. On 7/25/24 at approximately 5:15 AM, the facility failed to prevent a resident with severe cognitive impairment from exiting the facility unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to identify, monitor and treat pressure injuries for 2 of 3 residents reviewed for pressure ulcers, of a total sample of 45 residents, (#214 and #17). The facility's failure to evaluate alterations in skin integrity and implement appropriate treatments timely resulted in actual harm. Resident #214 was identified to have 2 new facility acquired pressure ulcers/injury identified 15 days after being admitted to the facility. The resident had one stage II pressure wound on her left buttock and an unstageable pressure wound on her sacrum. The facility failed to identify the wounds at an early stage and failed to implement timely treatment and preventable measures.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with newly evident mental illness diagnoses for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 1 of 1 resident reviewed for PASARR, out of a total sample of 45 residents, (#27).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the plan of care and follow physician orders for 1 of 2 residents reviewed for tube feeding management out of a total sample of 45 residents, (#2).

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide podiatry services for 1 of 3 residents reviewed for Activities of Daily Living (ADLs), out of a total sample of 45 residents, (#44).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received appropriate services to prevent further decrease in range of motion related to application of hand splints for 2 of 2 residents reviewed for limited range of motion, out of a total sample of 45 residents, (#53 and #83).

Inspectors wroteBased on observation, and interview, the facility failed to provide services to prevent complications from a gastronomy tube for 1 of 2 residents observed for enteral feeds, out of a total sample of 45 residents, (#214).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure intravenous (IV) dressing was changed as ordered for 1 of 1 resident reviewed for IV therapy, of a total sample of 45 residents, (#269).

Inspectors wroteBased on interview, and record review, the facility failed act timely on pharmacy Monthly Regimen Review (MRR) recommendations for 2 of 5 residents reviewed for unnecessary medications from a total sample of 45 residents, (#29, #3)

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication error rate of 5 per cent or greater for 1 of 6 residents sampled for medication administration, (#67). There were 3 errors in 25 opportunities on 1 of 2 units by 1 of 3 nurses observed, for a medication error rate of 12%.

Inspectors wroteBased on observation, and interview, the facility failed to repair a stand lift used for physical therapy in a timely manner for 1 of 1 lift.