Royal Care of Avon Park

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide supervision to prevent resident to resident abuse for two (#2 and #3) of eight sampled residents.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to identify a new area of skin impairment, until it was an advanced stage pressure ulcer for one resident (#58) of two residents reviewed for pressure ulcers. This failure resulted in actual harm because a facility-acquired unstageable pressure ulcer, which is an advanced stage of skin breakdown that is full-thickness tissue loss is difficult to heal, at increased risk for infection, and disfiguring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to ensure a medication administration error rate of less than 5%. A total of forty-three medication administration opportunities were observed with twenty-two errors for three (#5, #10, and #12) of five residents observed (F759). This resulted in a medication administration error rate of 51.16% during the revisit survey conducted 7/17/2024.

Inspectors wroteBased on observation and interview, the facility failed to provide a clean and homelike environment, in that the facility was not free from offensive odors. This involved the front lobby area, the area in front of the [NAME] nurses' station, and four resident rooms (Rm103, Rm107, Rm109 and Rm110) out of 18 resident rooms on the [NAME] unit.

Inspectors wroteBased on record review, interview, and review of the facility's policy the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents (#15, #26, #28, #38) of 17 residents sampled for PASARR review.

Inspectors wroteBased observations, interviews, and record reviews, the facility failed to provide wound care and treatment in accordance with professional standards of practice for four (#67, #328, #177, and #36) of five residents sampled for skin conditions, and failed to ensure physician's orders were obtained for application of splints for one (#41) of one resident sampled for range of motion.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper storage of drugs and biologicals related to 1.) failing to ensure treatment carts remained locked and secured when not in use on one (South) of three units of the facility on two of four days during the survey and 2.) failing to ensure medications were stored in facility medication carts and not inside of resident rooms for one (#26) of five residents observed during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain food safety standards, such as maintaining clean floors and walls; not store ready-to-eat refrigerated Time/Temperature Control for Safety (TCS) food too long; thawing frozen TCS food (meat) properly under cold running water; and maintaining equipment in good condition. These findings have the potential to cause foodborne illness for 74 out of 76 residents who consume the facility's food.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and maintain an effective infection prevention and control program to control the spread of infection by 1.) failing to ensure staff donned appropriate personal protective equipment (PPE) before entering the rooms of residents under transmission based precautions for four residents (#326, #64, #328, and #67) of seven residents with COVID-19 infection in the facility, 2.) failed to ensure staff doffed PPE before exiting the rooms of residents under transmission based precautions for two residents (#328 and #67) of seven residents with COVID-19 infection in the facility, 3.) failed to ensure residents were assisted with hand hygiene before meals during observation of meal service, and 4.) failed to ensure urinary catheters were stored in a sanitary manner for one resident (#30) of one resident sampled for [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to equip corridors with securely affixed handrails on 2 of 3 units of the facility (West and South).

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain dignity and a homelike dining experience in one (West) of two dining/common areas related to staff not removing dinnerware from trays when serving residents.

Inspectors wroteBased on observation, interview and record review, including resident assessments, the facility failed to accurately reflect the resident's dental status for one of one resident (#17) reviewed for dental status and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide administration of intravenous medication in accordance with professional standards of practice for one (#54) of one resident sampled for intravenous medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure respiratory care was provided in accordance with professional standards related to 1.) failed to ensure proper storage of respiratory equipment for one (#54) of two residents sampled for oxygen therapy, 2.) failed to ensure physician's orders for oxygen therapy were obtained for one (#54) of two residents sampled for oxygen therapy, 3.) failed to ensure oxygen tubing was changed in accordance with physician's orders for one (#126) of two residents sampled for oxygen therapy, and 4.) failed to ensure signage indicating oxygen was in use outside of resident rooms for one (#126) of two residents sampled for oxygen therapy.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide medications for one (#178) out of five residents sampled for unnecessary medications related to antihypertensive medications.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-eight medication administration opportunities were observed and six (6) errors were identified for two (#8 and #126) of five residents observed. These errors constituted a 21.43% medication error rate.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure one (#54) of one resident sampled for intravenous medication administration was free from significant medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist one (Resident #17) of one resident in obtaining routine dental care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the splinting program was clarified and implemented as physician ordered for one (Resident #61)) of six residents on the restorative nursing splinting program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure breakfast was delivered to one (Resident #25) of one hemodialysis resident within a timely manner prior to leaving to the dialysis center on one of one observable survey days.

Inspectors wroteBased on interview and record review, the facility failed to ensure one dialysis resident (#10), of three sampled dialysis residents, was free from a significant medication error by failing to obtain and dispense a dialysis medication from January 17, 2020 to March 13, 2020.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and treat skin conditions for two residents (#72 and #39) of three sampled residents.

Inspectors wroteBased on record review, observations, interviews, policy review, and the State Agency Surveyor Guidance for Hot Water Temperatures related to the Federal regulations, the facility did not ensure water temperatures were maintained at a safe level for four resident bathrooms of twelve resident bathrooms sampled, and for one nursing unit (300 hallway) of two nursing units, with the potential to affect six residents (#56, #47, #139, #50, #140, #65) of eight residents who were capable of using the bathroom.

Inspectors wroteBased on interview and record review, the facility failed to effectively monitor bowel elimination and patterns for one resident (#35) of three sampled residents.

Inspectors wroteBased on observation and interview the facility failed to ensure safe and secure storage and labeling of medications related to 1. high-risk medications were stored at the resident bedside for one resident (#192) of a total sample of 31 residents, 2. one medication cart (Northwest) and one treatment cart (300-hall) were unlocked while unattended, 3. eye drops were stored with oral medications in two medication carts(Southwest and Northwest) of four medication carts, and 4. high risk medications stored in an unlabeled bag in one medication room of two medication rooms.

Inspectors wroteBased on observations, interviews, and record review the facility did not ensure appropriate infection prevention measures were maintained related to maintaining a nasal cannula, oxygen tubing, a wound vacuum and wound vacuum tubing off the floor for one resident (#140) of two residents reviewed for infections.