Rockledge Healthcare & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 1 of 1 residents reviewed for self-administration of medications, of a total sample of 51 residents, (#97).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike interior in 1 of 28 rooms, on 1 of 2 units, (East Wing, 103).

Inspectors wroteBased on interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Pre-admission Screening and Resident Review (PASARR) results for 2 of 5 residents reviewed for PASARR, (#6, #8), and use of insulin for 1 of 1 resident (#97) reviewed for insulin, of a total sample of 50 residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents on admission and/or failed to make referrals for newly evident or possible mental disorders/diagnoses to evaluate the need for specialized services or alternative placement for 4 of 5 residents reviewed for PASARRs, of a total sample of 51 residents, (#49,#79, #23, and #34).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order for oxygen (O2) for 1 of 3 residents reviewed for O2 use, of a total sample of 50 residents, (#8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain adequate communication with the dialysis center, follow the comprehensive person-centered care plan and ensure post-dialysis assessments were completed for 1 of 2 residents reviewed for dialysis, of a total sample of 51 residents, (#655).

Inspectors wroteThe facility failed to label drugs and biologicals safely and accurately, in accordance with currently accepted professional principles for 2 of 7 residents observed for medication administration, of a total sample of 51 residents, (#305, and #7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices per infection control standards; and failed to prevent cross contamination when handling trash.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor the right to make choices about significant aspects of activities of daily living related to preferred method of toileting (#250), and frequency and preferred method of bathing, (#9, #28, #307, #308, #252) for 6 of 8 residents reviewed for choices of a total sample of 44 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who smoked did not keep lighters or ignition materials on their person for 6 of 7 residents reviewed for smoking and failed to identify an accident hazard of a wet floor for 1 of 1 residents reviewed for accidents, out of a total sample of 44 residents,(#6, #69, #75, #50, #303, #73, #26).

Inspectors wroteBased on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to implement its smoking policy and procedures to provide adequate oversight of 16 smokers and ensure the safety of all residents in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to demonstrate the effectiveness of the performance improvement plan for education of nursing staff and implementation of following physician orders for oxygen for 1 of 3 residents reviewed for oxygen therapy out of a total sample of 44 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and sanitary environment in the laundry department to prevent cross-contamination of facility equipment and facility linens.

Inspectors wroteBased on interview and record review, the facility failed to promote dignity and positive interactions through courteous behavior and respectful attitude by direct care staff for 1 of 4 residents reviewed for Dignity of a total sample of 44 residents, (#252).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bathroom shared by residents in 1 of 18 bathrooms on the East Wing (room [ROOM NUMBER]) and 2 of 29 rooms on the [NAME] Wing (rooms #154 & #156) were maintained in a clean and homelike condition.

Inspectors wroteBased on interview and record review, the facility failed to appropriately record and investigate a grievance to ensure resolution in a timely manner for 1 of 1 resident reviewed for grievances, of a total sample of 44 residents, (#71).

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures for prohibition of Abuse for 1 of 4 residents reviewed for Abuse, of a total sample of 44 residents, (#252).

Inspectors wroteBased on interview and record review, the facility failed to conduct a Level 1 Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed for PASARRs of a total sample of 44 residents, (#26).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan that reflected person-centered care related to assistance with toileting for 1 of 3 residents reviewed for activities of daily living (ADLs), of a total sample of 44 residents, (#250).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person-centered care plan to address dental care and services required by 1 of 2 residents reviewed for dental services, out of a total sample of 44 residents, (#26).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care related to shaving, bathing, and nail care to maintain good grooming and personal hygiene for 2 of 3 residents reviewed for ADL care, out of a total sample of 44 residents, (#26 & #250).

Inspectors wroteBased on interview, and record review, the facility failed to ensure surgical wound treatments were initiated and provided for 1 of 1 resident reviewed for non-pressure skin out of a total sample of 44 residents, (#298).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders and follow professional standards of practice related to oxygen use, monitoring oxygen levels, and replacing respiratory supplies for 1 of 3 residents reviewed for respiratory care, of a total sample of 44 residents, (#27).

Inspectors wroteBased on interview and record review, the facility failed to administer pain medication in a timely manner for 1 of 3 residents reviewed for pain management, (#92).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to maximize the effectiveness and promote optimal therapeutic effect of medication for 1 of 5 residents reviewed for medication administration, of a total sample of 44 residents, (#248).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent medication errors for 1 of 5 residents reviewed during the Medication Administration task, of a total sample of 44 residents, (#248). There were 2 errors in 25 opportunities for a medication error rate of 5%.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a prescribed ointment was appropriately labeled, and failed to maintain medication and supplies securely to prevent unauthorized access in 1 of 1 treatment cart and 1 of 2 medication carts on the [NAME] Wing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services for 1 of 2 residents reviewed for dental care, (#26).

Inspectors wroteBased on observation, and interview, the facility failed to ensure food was safely stored to prevent foodborne illness for residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain safe and sanitary conditions for food storage in 2 of 2 nutrition rooms (East & [NAME] Wing).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was assessed to self-administer oral pain/sleep medication and topical pain relief cream medications for 1 of 50 total sampled residents (#88).

Inspectors wrote2. Resident #644 was readmitted to the facility on [DATE] with diagnoses that included stroke, dysphagia, protein calorie malnutrition, type 2 diabetes, and adult failure to thrive. Review of the quarterly MDS assessment dated [DATE] revealed resident #644 is rarely/never understood and needed extensive assistance with eating. On 10/31/2021 at 12:15 PM during lunch trays distribution, CNA B took the untouched tray off of resident #644's overbed table. In the resident's room, CNA B said she was taking the tray back to the food cart to stay warm because the resident is a feeder and we do them last. CNA A, who was also in the room, did not try to correct CNA B for calling resident #644 a feeder. [...]