The Terrace of Delray Beach Nursing and Rehabilita

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent for residents prescribed psychotropic medications for 4 of 5 sampled residents reviewed for unnecessary medication review affecting Residents #4, #14, #87, #129.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to allow residents to have consistent access to a functional telephone for communication with family members or an accessible television remote control to support personal choice and self-directed activities, for 1of 2 sampled residents, Resident #12.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide showers per resident request for 1of 5 sampled residents reviewed for choices, Resident #87.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow resident's preferences for incontinence care for 1 of 1 sampled resident reviewed for Activities of Daily Living (ADLs), Resident #73.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to coordinate and implement structured activities for 1 of 2 sampled residents reviewed for activities, Resident #13.

Inspectors wroteBased on observation and interview, the facility failed to provide privacy curtains for residents in 14 resident rooms (Rooms 121-133) for Bed A, which is closest to the door, and affecting 2 of 2 sampled Residents #40 and #77.

Inspectors wroteBased on interview and record review, the facility failed to ensure the provision of showers as per facility schedule for 1 of 4 sampled residents, Resident #48.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff awareness and implementation of DNR (Do Not Resuscitate) status for 1 of 1 sampled resident, Resident #70.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safe and comfortable environment for the residents as evidenced by the environment not being homelike, carts broken and wheelchairs in disrepair, on the 100 and 200 units.

Inspectors wroteBased on policy review, interview, and record review, the facility failed to ensure restorative services were provided for 1 of 1 sampled resident, Resident #54.

Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure timely and ongoing nail care for 1 of 2 sampled residents reviewed for Activities of Daily Living (ADLs), Resident #22.

Inspectors wroteBased on observation, interviews, record and policy review, the facility failed to provide timely care and treatment for a skin tear for 1 of 1 sampled resident reviewed for skin conditions, Resident #1.

Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure appropriate indwelling urinary catheter care and maintenance for 2 of 2 sampled residents, as evidenced by staff failed to provide appropriate urinary catheter care for Resident #22 and failed to ensure an anchoring device for the urinary catheter of Resident #77. Both residents had a history of urinary tract infections (UTIs).

Inspectors wroteBased on observation, interviews, record and policy review; the facility failed to provide pain management for 1 of 1 resident reviewed for pain management (Resident #294); and and failed to provide medications as per physician order for 2 of 5 sampled residents reviewed for unnecessary medications, Resident #4 and #28.

Inspectors wrote4. Review of the policy, titled, Nail Care, implemented 05/01/24, documented, in part, Policy Explanation and Compliance Guidelines: . 3. Routine cleaning and inspection of nails will be provided during ADL care on an ongoing basis. 5. The resident's plan of care will identify: a. The frequency of nail care to be provided. b. The type of nail care to be provided. C. The persons responsible for providing nail care (e.g., licensed nurse, nurse aide, podiatrist, activity professional). 7. Procedure: . i. Document completion of task, any complications, or if resident refuses. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the current Minimum Data Set (MDS) assessment dated [DATE] documented Resident #22 had a Brief Interview for Mental Status (BIMS) score of 14, on a 0 to 15 scale, indicating the resident was cognitively intact. [...]

Inspectors wrote4. Review of the record revealed Resident #22 was admitted to the facility on [DATE]. Review of the record revealed Resident #22 had a Urinary Tract Infection (UTI) as per the laboratory results reported on 02/09/24. This urinalysis and culture reported the organism was ESBL (extended-spectrum beta-lactamase), classified as an organism resistant to antibiotic, necessitating the use of contact precautions with PPE (personal protective equipment). This infection was treated with an antibiotic for seven days. Further review of the orders and corresponding Medication Administration Record (MAR) revealed contact precautions for just three days as of the evening shift on 02/09/24. [...]

Inspectors wroteBased on record review and interview, the facility failed to state in their admission Agreement (page15, Item #26) that Arbitration is not a requirement for admission or a requirement to continue to receive care at the facility. This affects all current residents who have signed the admission agreement, 88 of 88 residents at the time of survey.

Inspectors wroteBased on record review and interview, the facility failured to provide the appropriate Beneficiary Notification Form (CMS Form 10055/SNF ABN) to 2 of 3 sampled residents, Resident #22 and #70.

Inspectors wroteBased on record review and interview, the facility failed to have adequate discharge documenation to ensure the facility followed physician orders to provide Home Health Services set up and that services were provided to residents on discharge home for 1 of 3 sampled residents reviewed for discharge, Resident #92.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide foods that were prepared in a sanitary manner in accordance with professional standards.

Inspectors wroteBased on observation, interview, policy and record review, the facility failed to notify a resident and/or resident representative of a room change prior to the room change for 1 of 1 sampled resident reviewed for room changes, Resident #60.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow tube feeding physician orders for 2 of 2 sampled residents reviewed for tube feedings (Percutaneous Endoscopic Gastrostomy / PEG), Residents #48 and #62.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to administer timely and to monitor effectiveness of pain medications for 2 of 2 sampled residents reviewed for pain, Residents #313 and #314.

Inspectors wroteBased on observation, interview, and record review; it was determined that the facility failed to ensure pharmacitical services were provided that ensured the accurate administration of medications per the physician orders, for 1 of 29 opporunities observed duringa medication observation, affecting Resident #86.