Space Coast Healthcare and Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility neglected to ensure necessary care and services were provided by ensuring nurses coordinated with physicians to provide proper provision of care for 1 of 1 resident reviewed for insulin-dependent Diabetes Mellitus with an insulin pump, of a total sample of 5 residents, (#1). The facility failed to recognize the critical need for insulin orders and blood glucose finger sticks upon admission and failed to implement physician ordered finger stick blood glucose monitoring after it was prescribed. These combined failures in care coordination resulted in a lack of proper blood glucose monitoring and treatment for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement and review physician's admission orders for 1 of 3 residents reviewed for admission orders, of a total sample of 5 residents, (#1). The facility did not verify, implement, or initiate expected treatments and prescribed medications consistent with the resident's medical status and as listed in the hospital discharge summary. The Interdisciplinary Team (IDT) failed to recognize that essential components of the admission orders to maintain a chronic condition, including critical medications were missing or not transcribed into the Electronic Medical Record (EMR). This failure resulted in a lack of proper blood glucose monitoring and insulin medication for eight days, during which the resident developed Diabetic Ketoacidosis (DKA), a life-threatening condition. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skills to obtain and implement critical physician medication admission orders for the care of a resident admitted from the hospital with a diagnosis of Type 1 Diabetes Mellitus for 1 of 3 residents, reviewed for admission orders, of a total sample of 5 residents, (#1). For eight consecutive days following admission, for all three nursing shifts and involving nine different licensed nurses, the facility did not obtain or implement physician orders for routine blood glucose monitoring (finger sticks) or insulin administration. [...]

Inspectors wroteBased on interview, and record review, the facility failed to report an incident involving possible neglect to the State Agency (SA) within the required timeframes for 1 of 3 residents reviewed for neglect, of a total sample of 5 residents, (#1). The facility did not report possible neglect regarding a rehospitalization involving a resident with type 1 diabetes and an insulin pump who had not received physician's ordered finger stick blood glucose monitoring or insulin and was subsequently re-hospitalized for Diabetic Ketoacidosis (DKA). The deficient practice had the potential to place residents at risk for unreported neglect and delayed investigation. DKA is a life-threatening complication that affects people with diabetes which requires immediate medical attention. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a thorough investigation was conducted for a rehospitalization involving possible neglect when a resident with type 1 diabetes did not receive physician's ordered blood glucose monitoring or insulin resulting in rehospitalization for Diabetic Ketoacidosis (DKA) for 1 of 5 residents reviewed for neglect, of a total sample of 5 residents, (#1). DKA is a life-threatening complication which requires immediate medical attention which can affect people with diabetes. DKA happens when your body doesn't have enough insulin (an essential hormone that helps your cells use sugar for energy). Lack of insulin causes your liver to break down body fat for energy causing your blood to become acidic, which creates a medical emergency. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program effectively identified and addressed a systemic process failure related to physician's admission orders for immediate care. Following a resident's rehospitalization for Diabetic Ketoacidosis (DKA) due to not receiving physician's ordered blood glucose monitoring or insulin, the facility did not identify an underlying electronic order error until approximately three weeks later. Approximately one month later, the QAPI committee initiated only an Ad hoc review, and a limited Performance Improvement Plan (PIP) focused solely on the electronic order error, without evaluating broader systemic factors. This narrow scope delayed the implementation of broader corrective actions and placed residents at risk of harm due to unaddressed deficiencies.

Inspectors wroteBased on interview, and record review, the facility failed to follow generally accepted accounting principles to handle residents' funds for 2 of 2 residents reviewed for personal funds, of a total sample of 59 residents, (#32, and #47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for residents who ate their meals in the B Wing dining room to ensure resident dining did not resemble an instutional experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure waste was disposed of in a sanitary manner.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure correct signage was posted for Enhance Barrier Precaution (EBP), failed to ensure Personal Protective equipment (PPE) was readily available for residents on EBP, and failed to ensure proper infection control measures were practiced, by failing to store residents' equipment in a sanitary manner on 1 of 2 Wings, (A wing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that dignity was maintained for 2 of 2 residents reviewed for dining, of a total sample of 59 residents, (#13, and #88).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 2 of 2 residents were evaluated for safe self-administration of medications and failed to obtain a physician order for self-administration of medication for 2 of 9 residents reviewed for choices, of a total sample of 59 residents, (#37, #95).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the privacy, and confidentiality of resident records was maintained for 1 resident, of a total sample of 59 residents, (#519).

Inspectors wroteBased on interview, and record review, the facility failed to follow the grievance process to make a prompt effort to resolve the grievance and keep the resident apprised of the progress toward resolution for 1 of 5 residents reviewed for personal property, of a total sample of 59 residents, (#56).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care and removal of chin hair for 3 of 3 residents observed for Activities of Daily Living (ADL) care of a total sample of 59 residents, (#13, #87, and #88).

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an on-going program of activities to meet the needs and preferences for 3 of 4 residents reviewed for activities, of a total sample of 59 residents, (#13, #40, and #88).

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident received proper and timely treatment to maintain his vision for 1 of 3 residents reviewed for vision and hearing, of a total sample of 59 residents, (#32).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an intravenous (IV) dressing was changed as ordered for 1 of 2 residents reviewed for IV therapy, of a total sample of 59 residents, (#513).

Inspectors wroteBased on interview, and record review, the facility failed to implement pharmacy recommendations and physician orders and failed to document a physician rationale for not following pharmacy recommendations for 3 of 5 residents reviewed for Medication Regimen Review (MRR), of a total sample of 59 residents, (#61, #11, and #34).

Inspectors wroteBased on interview, and record review, the facility failed to ensure an as needed (PRN) order for a psychotropic drug was limited to fourteen (14) days for 1 of a total sample of 59 residents reviewed, (#30).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a mentally impaired resident from exiting the facility unsupervised and failed to provide adequate supervision and a secure environment for 1 of 4 residents reviewed for elopement, out of a total sample of 12 residents, (#2).

Inspectors wroteBased on observation, interview and record review, the facility failed to report suspected staff abuse of a resident to the state licensing authority for 1 of 4 residents reviewed for Abuse, of a total sample of 12 residents, (#5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure scheduled medications were administered as ordered and according to professional standards of practice for 17 of 18 residents reviewed for medication administration out of a total sample of 19 residents, (#1, 4, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 & 19).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was free from accident hazards and each resident received adequate supervision to prevent accidents for 4 of 4 residents reviewed for smoking out of a total sample of 42 residents, (#17, #29, #42, and #74).

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

Inspectors wroteBased on observation, and interview, the facility failed to maintain the area surrounding the dumpster in a clean and sanitary manner.

Inspectors wroteBased on observation, and interview, the facility's Governing Body failed to implement policies regarding the management and operation of the facility to ensure the building's hot water was maintained to ensure residents comfort for bathing and hygiene in 32 resident bathrooms on 1 of 2 units, (Unit B). During a complaint, and recertification and relicensure survey that began on 5/15/2023, it was identified that 32 resident room bathrooms on 1 of 2 units were not supplied with hot water. Facility staff stated the problem started in late January 2023 due to plumbing damage that caused an outage to the entire B unit. The facility's governing body approved funding that allowed the facility to partially complete repairs in March 2023 which provided hot water to the Unit B shower room only.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain the walk-in refrigerator in a safe and clean operating condition.

Inspectors wroteBased on interview and record review, the facility failed to follow the grievance process related to missing personal items for 1 of 3 residents reviewed for personal property in a total sample of 42 residents, (#35).

Inspectors wrote2. Review of the medical record revealed resident #17 was admitted to the facility on [DATE] from an inpatient psychiatric hospital with schizoaffective disorder, bipolar type, other schizophrenia, and mild cognitive impairment. The Minimum Data Set quarterly assessment with Assessment Reference Date 2/22/2023 showed the resident scored 10 out of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively impaired. The assessment noted the resident had received antipsychotic medications for 7 out of 7 days during the look back period. The comprehensive care plan included focuses for potential ADL self-performance deficits related to schizophrenia and anxiety, refusals of medications, mild cognitive impairment, and monitoring for adverse effects of antipsychotic medication use. [...]

Inspectors wroteBased on interview, and record review, the facility failed to refer 1 resident for a level 2 Preadmission Screening and Resident Review (PASARR), (#4), and failed to submit a level 1 PASARR in accordance with the state process for 1 resident, (#77) out of 4 residents reviewed for PASARR from a total sample of 42 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide intravenous (IV) care and services according to standards of practice and plan of care for 1 of 1 resident reviewed for IV care out of 42 total sampled residents, (#68).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was assessed to be safe and clinically appropriate to self-administer an Albuterol inhaler for 1 of 1 resident reviewed for self-admisnitration (#192).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 32 rooms on 1 of 2 units (B-Wing, B23).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the grievance process related to missing personal items for 2 of 2 residents reviewed for personal property in a total sample of 52 residents (#26 & #49).

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman of a transfer to the hospital for 1 of 2 residents reviewed for hospitalization, of a total sample of 52 residents (#36).

Inspectors wroteBased on interview and record review, the facility failed to initiate baseline care plans and/or provide copies of baseline care plans to 4 of 4 residents or their representatives, of a total sample of 52 residents (#32, 43, 72 & 82).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment to promote healing of a left heel pressure ulcer for 1 of 1 resident reviewed for pressure ulcers in a total sample of 52 residents (#23).