Tarpon Bayou Center

Inspectors wroteBased on observations, interviews, record review, facility policy review and the Plan of Correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) Program. The facility was actively involved in the creation, implementation and monitoring of the Plan of Correction for deficient practice during a recertification and complaint survey conducted on 04/08/2024 to 04/11/2024 and was cited at F657, F677, F690, F758, F759, F842, and F880. On 06/03/2024 to 06/04/2024 a revisit survey was conducted and the facility was recited at F657, F677, F690, F758, F759, F842, and F880. The facility had developed a Plan of Correction with a completion date of 05/10/2024.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure hand hygiene was provided before and after meal service on four (100, 200, 300 and Melody-secured) of four units, and the facility failed to ensure hand hygiene was available after toileting for one unit (Melody-secured) out of four units observed.

Inspectors wroteBased on observations, staff interviews and facility record review, the facility failed to ensure the kitchen's low temperature dish washing machine was operating effectively to include provision of correct chemical sanitizer during one of four days observed (4/8/2024).

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain a homelike environment on one (300) of four units and failed to ensure one of two resident patios was not used for storage of facility housekeeping equipment, sunshade, rolled up mattresses, and an unused bed frame.

Inspectors wrote3. A review of Resident #25 admission Record shows a primary diagnosis of diffuse traumatic brain injury (TBI) with loss of unconsciousness of unspecified duration subsequent encounter with a secondary diagnosis of unspecified mood [affective] disorder both dated 11/07/2015. A review of the Minimum Data Set for Section I- Active Diagnoses dated February 05, 2024, for Neurological Section, 15500 [Traumatic Brain Injury] has a check mark. A review of the Pre-admission Screening and Annual Resident Review, dated 7/17/2023, revealed TBI or unspecified mood [affective] disorder not checked. 2. [...]

Inspectors wroteBased on observations, resident/staff interviews, and record review, the facility failed to provide Activities of Daily Living (ADL) care, to include feet nail care for one (#163) of thirty-eight sampled residents (#163).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide activities in an appropriate and stimulating manner on one of one (secured memory care) unit.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure 4 residents sitting at one of four tables were treated in manner of dignity and respect related to staff spraying cleaner directly onto the table in front of the residents, and failed to dress one (#107) out of 7 residents sampled on the memory care unit in clothing belonging to them.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assess, obtain physician orders, revise the person-centered comprehensive care plan and educate one resident (#32) out of three sampled residents during medication pass, related to self- administering medications.

Inspectors wroteBased on record review, interview and review of the facility's policy titled physician notification, the facility failed to ensure one Resident (#12) out of five residents reviewed for unnecessary medications had a significant change in condition assessment completed prior to antibiotic use.

Inspectors wroteBased on record review and interview, the facility failed to ensure multiple Minimum Data Set (MDS) assessments accurately reflected diagnoses of one Resident (#85) out of 33 sampled residents.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to revise the care plan for one (#52) of thirty-two initially sampled residents in regards to the Advance Directive of code status, failed to revise the care plan of one (#107) out of twenty-five final sampled residents, and failed to revise the care plan of one (#15) of one resident sampled for the diagnosis of Post-Traumatic Stress Disorder.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the catheter of one (#107) out of one resident sampled with an urinary catheter was stored in a manner that promoted proper infection control.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to document and monitor the behaviors of two (#24 and #83) out of five residents reviewed for unnecessary medications resulting in the physician being notified and orders for additional as needed psychotropic medications were obtained.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure the medication error rate was less than 5.00%. Twenty-seven medication administration opportunities were observed and two errors were identified for two (#31 and #13) of five residents observed. These errors constituted a 7.41% medication error rate.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to maintain two (#107 and #31) out of fifty (50) resident records accurately related to documenting a medication was administered when refused by the resident and to obtain vital signs daily for the skilled notes.

Inspectors wroteBased on record review, interview and review of facility's policies titled, Infection Prevention and Control Program, Tracking: Monitoring, Antibiotic Prescribing, Use and Resistance, Individuals Accountable for Antibiotic Stewardship Activities, and Antibiotic Stewardship, the facility failed to ensure one Resident (#12) out of one Resident reviewed for antibiotics was appropriately assessed for the use of an antibiotic.

Inspectors wroteBased on observation, staff interviews, policy and record review, the facility failed to ensure that a safety device of a protective smoking apron was worn for one (1) resident (Resident #29) of six residents who smoke, failed to ensure the red metal smoking receptacle in the smoking area contained only smoking butts, for two of four days (02/01/2022 and 02/04/2022); and failed to follow their policy related to providing a safe smoking environment by not placing a required smoking fire blanket in the smoking area for three of four days (02/01/2022, 02/02/2022 and 02/03/2022) observed during the survey.

Inspectors wroteBased on observation, interview, facility policy and record review the facility failed to ensure that a resident centered care plan was developed and implemented related to hospice care for one resident (#90) of seven residents receiving hospice care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure therapy devices (splints) were applied to contracted limbs to maintain, and prevent, a decrease in range of motion for two residents (#57 and #45) of thirteen residents sampled as evidenced by: 1) For Resident #57, the facility did not ensure the right-hand splint was available for use by direct care staff and applied per therapy discharge orders to prevent further wrist and hand contracture. Additionally, the facility did not evaluate and update Resident #57's care plan to determine if the ordered ankle foot orthoses was required to prevent decreased mobility in the right lower extremity, and 2) For Resident #45, the facility failed to ensure direct care staff assisted with the application of the left-hand splint to maintain range of motion.

Inspectors wroteBased on observation, interviews, record review, and review of the facility policy and plan of correction, the facility's Quality Assessment and Assurance committee failed to ensure that interventions for the plan of correction for splinting devices were comprehensively implemented by not ensuring the splinting devices were ordered, in place, or care planned for three residents (#1, #3 and #2) out of a total of six sampled residents.