Terrace of Kissimmee, the

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected health conditions for 1 of 3 residents reviewed for falls, of a total sample of 12 residents, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to communicate with the hospice provider when a change in condition was identified to ensure collaboration on the provision of necessary care and services for 1 of 1 resident reviewed for hospice services, of a total sample of 12 residents, (#2).

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for food service safety by failing to label, date, and discard food after an acceptable time period and by failing to air-dry glasses, cups, and trays prior to their use in meal service, in one of one walk-in refrigerator/freezer, one of one dry storage room and one of one kitchen.

Inspectors wroteBased on interview, and review of facility documentation, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained for two of ten concerns identified during the survey, (F554, and F880).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper administration of medications for one of one resident assessed for self administration of medications, of a total sample of 44 residents, (#94).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflected resident's tobacco use for 1 of 1 residents reviewed for smoking (#511); reflected oxygen (O2) therapy for 1 of 1 residents reviewed for respiratory care, (#511); and accurately reflected active diagnoses for 1 of 1 residents reviewed for psychiatric diagnoses, (#93), of a total sample of 44 residents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure individuals with a mental disorder, intellectual disability (ID), or other related disorders had accurate Level I Preadmission Screening and Resident Reviews (PASARR) completed upon admission and/or updated as needed to receive appropriate care and services in the most integrated setting appropriate for 2 of 5 residents reviewed for PASARRs, of a total sample of 44 residents, (#4 and #98).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician's order for the care and treatment of catheter dressings for 1 of 5 residents sampled for skin conditions, of a total sample of 44 residents, (#412).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely assessment and follow-up for removal of an indwelling urinary catheter including a urology referral, for 1 of 2 residents reviewed for urinary catheters, of a total sample of 44 residents, (#95).

Inspectors wroteBased on interview, and record review, the facility failed to follow up on a triggered excessive weight loss for 1 of 13 residents reviewed for food and nutrition, of a total sample of 44 residents, (#26).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a system for preventing and controlling infections and communicable diseases for residents by not offering hand hygiene to residents prior to meals and not maintaining a catheter bag dragging on the floor. This had the potential to affect 43 residents eating meals in the dining room, and one of one resident reviewed for urinary tract infections, (#95) of a total sample of 44 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services according to assessed needs, to promote the highest practicable physical and psychosocial well-being; and failed to follow required processes to prevent neglect by appropriately identifying and communicating care needs and ensuring continuity of care for 1 of 3 residents reviewed for neglect, out of a total sample of 9 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate activities of daily living (ADL) care for a dependent resident related to incontinence care, fingernail care, and shaving facial hair for 1 of 3 residents reviewed for ADL status, out of a total sample of 9 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate pharmaceutical services to prevent administration of a prescription ointment by unlicensed nursing staff, for 1 of 1 resident reviewed for medication administration, out of a total sample of 9 residents, (#2).

Inspectors wroteBased on interviews, and record review, the facility failed to protect the resident's right to be free from neglect by failing to honor the resident's wishes for life saving measures, by failing to follow physician's order for Full Code and failing to initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident with no vital signs. LPN C did not check the resident's code status nor provide CPR but instead informed the Weekend Supervisor Registered Nurse (RN) E of the situation at approximately 10:08 PM. [...]

Inspectors wroteBased on interview, and record review, the facility failed to honor the resident's/family's wishes and failed to follow the physician's order to provide basic life support (BLS) and initiate Cardiopulmonary Resuscitation (CPR) for 1 of 6 residents reviewed for Advanced Directives, of a total sample of 8 residents, (#2). On [DATE] at approximately 10:05 PM, resident #2 was found unresponsive in bed, not breathing by Certified Nursing Assistant (CNA) D. The CNA notified Licensed Practical Nurse (LPN) C who evaluated the resident had no vital signs. LPN C did not verify the resident's code status, or initiate CPR and instead asked Registered Nurse (RN) Supervisor E at approximately 10:08 PM to come to the resident's room. RN E evaluated resident #2 with no vital signs, disregarded the physician order for Full Code or Full Resuscitation status and did not initiate CPR. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure staff reported neglect of a resident related to not performing cardiopulmonary resuscitation (CPR) to the Risk Manager or Administrator which resulted in late reporting to the State Agency and Adult Protective Services for 1 of 2 residents reviewed for neglect, of a total sample of 8 residents, (#2).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure accommodation for residents who needed their call bell within their reach to alert staff to care needs for 2 of 4 sample residents, (#1 and #2).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent resident received the necessary services to maintain activities of daily living (ADL) regarding nail and oral care for 1 of 4 sampled residents, (#1). Resident #1 was admitted on [DATE], with diagnoses to include cerebral infarction (stroke) and hemiplegia and hemiparesis (paralysis and weakness on one side of the body) following cerebral infarction affecting right dominant side. Review of resident #1's Minimum Data Set (MDS) Quarterly assessment dated [DATE] noted in the functional abilities self-care section the resident was dependent, meaning the resident was unable to provide any effort, to complete her oral and personal hygiene. The MDS showed her Brief Interview for Mental Status Summary Score was 7/15 which indicated severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity in dining for 1 of 1 resident reviewed for dignity, of a total sample of 16 residents, (#4).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 5 residents was assessed for self-administration of medications of a total sample of 5 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate hand hygiene practices while administering intravenous (IV) antibiotics for 1 of 5 residents reviewed for medication administration of a total sample of 44 residents, (#260), and the facility failed to follow appropriate hand hygiene practices during meal delivery per infection control standards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was assessed to self-administer antihistamine nasal spray for 1 of 1 resident of a total sample of 45 residents, (#16).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record accurately reflected the resuscitation status of 1 of 1 resident reviewed for Advanced Directives out of 45 total sampled residents, (#9).