Sabal Palms Health & Rehabilitation

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the identified needs for residents at high risk for fall interventions was effective and prevented falls with major injuries for two vulnerable residents (#7 and #8) out of eight residents sampled.

Inspectors wroteBased on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for one resident (#10) out of three sampled residents.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident representative about a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to immediately notify a resident's primary care provider to receive instructions for a change in condition for one resident (Resident # 2) out of three residents sampled for changes in condition.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the positive end-expiratory pressure (PEEP), a pressure applied by the ventilator at the end of each breath to prevent the collapse of the tiny air sacs in the lung, alarm was audible in accordance with professional standards for four residents (#61, #184, #101, and #130) out of thirteen residents requiring mechanical ventilation support. Findings Included: 1. On 7/22/24 at approximately 9:55 a.m. Resident #61 was observed lying in bed with a tracheostomy tube connected to a LTV 1150 mechanical ventilator. A red-letter sign displaying PEEP OFF was observed on the front panel screen. According to the ventilator manufacturer the PEEP display on the LTV 1150 mechanical ventilator shows the pressure in the airway circuit at the end of expiration. Resident #61 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide physician follow-up for catheter care and recurrent urinary tract infection (UTI) in a timely manner for two residents (#165 and #60) out of three residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess and monitor a dialysis catheter per facility policy for one resident (#191) out of one resident sampled for dialysis.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure clean and sanitary equipment and floors for two of two units and eleven of seventeen rooms where tracheostomy residents reside.

Inspectors wroteBased on interviews and record review, the facility failed to identify, assess, and respond in a timely manner to a resident's change in condition related to a wound for one (Resident #1) of four residents reviewed.

Inspectors wroteBased on observation, resident and staff interview, and record review the facility failed to provide timely care and services for a resident after a reported accident with pain for one resident (#2) out of fourteen sampled residents. Resident #2 reported to nursing staff on 06/24/2022 her right foot had been caught under the wheelchair, while being transported without the foot rests in place, and Resident #2 reported new pain in her right leg. The physician was not notified and no new orders were implemented. On 07/09/2022, Resident #2 was documented to have unrelieved pain in her leg, the physician was notified, an X-ray was ordered which identified an acute fracture of the right proximal tibia. On 07/10/20, Resident #2 was transferred to an acute care facility for treatment of the fracture.

Inspectors wroteBased on observation, interview, record review, and the Plan of Correction (POC) review, the facility failed to ensure it had a functioning Quality Assurance (QA) Committee. The facility was actively involved in the effective creation, implementation, and monitoring of the plan of correction for deficient practice identified during a recertification survey, on [DATE] and was cited at F759. On [DATE] a revisit survey was conducted and the facility was recited at F759. The facility had developed a Plan of Correction with a completion date [DATE]. The facility had not comprehensively implemented the plan of correction for the identified quality deficiencies. Findings Included: A review of the facility's policy and procedure for Quality Assurance & Performance Improvement Program (QAPI), effective [DATE], last reviewed [DATE], revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an allegation of abuse and neglect was reported to the governing agency in accordance with the State law for one resident (#2) out of fourteen residents sampled regarding a resident who reported their foot had been caught under a wheelchair and was reporting new onset of pain in that leg.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to develop care planning problem areas with goals and interventions related to 1. hand covers for one (Resident #58) of three sampled residents related to hand devices; 2. anticoagulant use for one (Resident #107) of five sampled residents; 3. padded side rails for one (Resident #16) of one sampled resident ; and 4. nebulizer medications for one (Resident #175) of three sampled residents for nebulizer use.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to accurately assess and document the presence of one pressure ulcer and two areas of deep tissue injury for one (Resident #1) of sixteen residents with pressure ulcers.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure respiratory equipment was stored in a sanitary manner for three (Residents #194, #175 and #90), and failed to have a physician's order for the use of oxygen for one (Resident #194) of five residents sampled for respiratory care.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure that the medication error rate was less than 5.00%. Thirty-two medication administration opportunities were observed and five errors were identified for one (Resident #110) of six residents observed. These errors constituted a 15.63% medication error rate.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to follow their policy to store medications in a secure manner by leaving six medications unattended, with no facility staff in the vicinity of one room for (Resident #110) of six resident rooms sampled on the 600 Hall.

Inspectors wroteBased on record review and interview the facility failed to designate a healthcare professional with specialized training as the Infection Control Preventionist (ICP) for the facility.

Inspectors wroteBased on observations, interviews and medical record review, the facility failed assure that medications were secure and inaccessible to unauthorized staff and residents for prescribed and discontinued medications and creams for one resident (#36) of thirty-five sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility did not ensure food equipment was stored and handled in a sanitary manner related to cleaning and sanitization of food contact equipment and serving utensils.