Treasure Isle Care Center

Inspectors wroteBased on observations interview and record review, the facility failed to their Quality Assurance Performance Improvement policy and demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area as evidenced by repeated deficient practices for F550-Resident Rights/Exercise of Rights and F761- Labeling of Drugs and Biologicals, F689 Free of Accident Hazards/Supervision/Devices, F880 Infection Prevention and Control and F867 QAPI/QAA Improvement Activities.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure infection control standards were followed as evidenced by nebulizer mask noted uncovered, dirty call light on Resident#15's bed, nebulizer machine on the floor, Resident #5's indwelling urinary catheter drainage bag inside a trash. There were 160 residents residing in the facility at the time of the survey During observation on 09/29/2025 at 09:25 AM, a respiratory mask as noted at Resident # 120's bedside observed without a storage bag. Photographic evidence attached. On 09/30/2025 11:21 AM Resident seated in wheelchair at doorway, alert and watching TV with no distress observed. Liquid within reach. Nebulizer mask not visible at bedside. On 10/01/2025 10:58 AM Resident sleeping in wheelchair near doorway, no distress observed. Liquid at bedside, privacy curtain in place. Empty urinal noted at bedside. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure one resident (Resident #159) out of eight sampled residents was treated with respect and dignity as evidenced by Resident #159 was observed wearing his shirt inside out. 2) During lunch, Resident #159 did not receive his lunch tray in a timely manner while his roommate had already received lunch and finished eating. 3) Facility staff identified residents requiring assistance with meals as feeders.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide an advance directive for one (Resident #151) out of seven residents sampled; as evidence by: Resident #151 did not have an advance directive care plan or acknowledgement form in his chart. There were 160 residents residing in the facility at the time of the survey. During observation and record review on 09/30/2025 1:51 PM the residents advance directives was not located in the electronic chart. On 10/02/2025 03:00 PM, an advance directive care plan was unable to be located electronically. On 10/02/2025 03:20 PM, the facility's Social Services Director presents an advanced directive acknowledgement form with the signature of the resident, dated 10/01/2025. Review of the medical records for Resident #151 revealed the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to provide appropriate notices for one (Resident #175) out of three residents reviewed for beneficiary notices. The resident received the notice after they were discharged from the facility. There were 160 residents residing in the facility at the time of this survey.

Inspectors wroteBased on record reviews and interviews facility failed to submit a [NAME] II Preadmission Screening and Resident Review (PASRR) for a one (Resident #121) out of one sampled resident with a serious mental disorder as evidenced by a record review of a Level I PASRR indicating a Level II to be completed and no Level II was done. There were 161 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper positioning to prevent choking and aspiration for one (Resident #108) out of three sampled residents observed during dining; as evidenced by Resident #108 who has a diagnosis of Dysphagia Oropharyngeal Phase (difficulty swallowing) was noted in bed lying flat eating his lunch meal increasing the risk of food or liquid entering his airway leading to complications that include but not limited to aspiration pneumonia.

Inspectors wroteBased on observation records reviewed and interviews, the facility's staff failed to ensure a safe environment free of potential accidents and hazards for two out of three sampled residents, as evidenced by observation a knife in Resident #15's room on the windowsill and Resident #21 in possession of cigarettes. This deficiency increases the risk of negative outcomes that could affect all occupants in the facility.

Inspectors wroteBased on observations, records reviewed and interviews, the facility staff did not properly position an indwelling urinary tubing to facilitate the flow of urine for one (Resident #21) out of two sampled residents with an indwelling urinary catheter. As evidenced by; Resident #21's indwelling catheter tubing was positioned above the bladder and kinked. This improper practice prevented urine from freely flowing and increasing the risk for catheter-associated urinary tract infections and other serious medical issues. At the time of this survey, eleven residents with indwelling urinary catheters resided in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure their medication error rate were 5% or lower as evidenced by an error rate of 64.29 % out of 28 opportunities. There were 160 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations, record reviews, interviews, the facility failed to ensure medications and biologicals are stored in accordance with professional standards in keep the unit one medication storage room and three medications: as evidence by twelve expired Nutritional Supplement in the medication storage room on unit one and expired insulin on medication cart three. There were 160 residents that resided in the facility at the time of survey.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to ensure privacy of confidential information on three (units three, four and five) out of five nursing stations as evidenced by an unattended unlocked computer screen with information visible and information was on top of a treatment cart.

Inspectors wroteBased on record review and interviews facility failed to protect one (Resident #1) out of three sampled residents' right to be free from abuse and neglect, as evidenced by a staff member witnessed Resident #1 being physically abused (slapped on the buttocks) during hygiene.

Inspectors wroteBased on observations, records reviewed and interviews, the facility failed to properly secure medications on two (Units 1 and 5 out of five Nursing Units as evidenced by an unattended unlocked medication cart on Unit one and medication left on top of an unattended medication cart on Unit five. There were 162 residents residing in the facility at the time of the survey

Inspectors wroteBased on observations records reviewed and interview , used the facility failed to implement infection prevention and control practices; as evidence by several observations revealed residents' rooms were cluttered, had open food items, spoiled food items, linen observed on floor, dirty bathroom and showers, urinal on floor with urine seen from hallway, soiled gauze pads observed on resident's nightstand, used syringe, suction tubing and disposable gown on top of residents' wardrobe, staff failure to wear Personal Protective Equipment (PPE), drainage bag for indwelling catheter on floor, empty food container in residents' room swarmed with flies, soiled floors and trash on floors, increasing the potential for the contracting and spreading of diseases.

Inspectors wroteBased on observations, records reviewed and interviews the facility failed to ensure residents residing in the facility had a safe clean and clutter free environment; as evidenced by observations of several residents that included but not limited to: Resident #6, Resident #7, Resident #8, Resident #11 and Resident #12 call lights were not within the residents reach in the event immediate assistance is needed. (photographic evidence). 2)The facility failed to ensure residents' rooms were organized in a manner that provided a pest free and safe environment. 3} The facility failed to ensure emergency exits were clear and unobstructed. (photographic evidence)

Inspectors wroteBased on observations, records review and interviews, the facility failed to provide adequate respiratory care and services for two residents, (Resident #4 and Resident # 5) as evidenced by failure to ensure oxygen was being administered at the correct flow rate ordered. (Photographic evidence)

Inspectors wroteBased on interview and record review, the facility failed to demonstrate effective plan of actions were implemented to correctly identify quality deficiencies in the problem area related to repeated deficient practices for F880 Infection Prevention & Control. These deficient practices have the potential to affect 168 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure safety for all residents the residents in the facility as evidence by a knife was observed in one (Resident #46) out of eight residents sampled. Staff failed to intervene in a timely manner during an argument between two residents (Resident #128 and Resident #170) that enabled Resident #170 to strike Resident #128, which led to Resident #170 being arrested by local law enforcement. The facility's incidents by incident types report from January 2023 to June 10, 2024 revealed there were six alleged abuse incidents and nine incidents of resident-to-resident altercation. There were 136 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observations interview and record review, the facility failed to their Quality Assurance Performance Improvement policy and demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices for F550-Resident Rights/Exercise of Rights and F725 Sufficient Nursing Staff.

Inspectors wroteBased on observation record review and staff interviews, the facility failed to ensure a splint device was in place for one resident (Resident #131) out of one resident reviewed for splint devices and range of motion. There were nine residents in the facility that required splint devices.

Inspectors wroteBased on observations, interviews and record review facility failed to provide sufficient staffing to provide services to residents. This deficient practice has potential to affect 168 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the pantry refrigerator in Section 1 used exclusively for all resident's food contained foods that were labeled with the resident's name and dated. This has the potential to affect one-hundred and forty-five residents out of one hundred and sixty-nine residents who eat orally residing in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to follow infection control standards and transmission-based precautions to prevent the spread of infections as evidenced by observations of trash in hallways and Staff not donning appropriate Protective Equipment before entering Resident #136's room. There were 136 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure 3 residents (Resident # 131, Resident #27 and Resident #473) out of 33 sampled residents were treated in a dignified manner as evidenced by the facility's staff was observed standing while feeding Resident #131. Furthermore Resident # 27 and Resident #473 were not dressed in their own clothing, rather than hospital gowns, to promote dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a delivered package for one resident (Resident #118) out of one resident reviewed was received by the resident in a timely manner. The delivered package contained frozen foods and they were defrosted and spoiled when delivered to the resident. This has the potential to affect 169 residents residing in the facility at the time of this survey.

Inspectors wroteBased on observation record review and staff interviews, the facility failed to ensure one (Resident #131) out of 33 sampled resident Minimum Data Set (MDS) assessment was accurately coded as evidence by Resident #131 use of a splint device was not accurately coded on the MDS. There were nine residents in the facility that required splint devices.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I PASRR was not completed for residents (Resident # 103, Resident # 108) and Level II PASRR was not requested for Resident # 164, out of five residents investigated. This deficiency had the potential to affect 168 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation record review and interviews, the facility's staff failed to implement the care plan to prevent further decline in the resident's range of motion and maintain skin integrity as evidence by failure to ensure splint devices is in place for one resident (Resident #131) out of one resident reviewed for splint devices and range of motion. There were nine residents in the facility that required splint devices, and failed to reposition Resident #131 at a minimum of two hours.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide the necessary interventions, consistent with professional standards of practice, to promote healing of pressure ulcers for one resident (Resident #146) out of eight sampled residents as evidenced by observations of Resident#146 in supine position for more than 2 hours. There were 27 Residents with wounds residing in the facility.

Inspectors wroteBased on observations record review and interview the facility failed to provide foot care according to professional standard for one (Resident #35) out of eight residents sampled.

Inspectors wroteBased on observations, record review and interviews facility failed to dispose of medication as per policy for one resident (Resident #50) and facility failed to keep an accurate reconciliation of controlled narcotics for two residents (Resident #141 and Resident #99 ) out of eight residents sampled as evidenced by an observation of staff member disposing of a medicated patch into the trash can in a resident's room and review of two narcotic count sheets with totals that did not match amount of pills in the corresponding bingo cards. There were 136 residents residing in the facility at the time of survey.

Inspectors wroteBased on observations and interviews facility failed to properly store drugs and biologics, as evidenced by an observation of unattended normal saline filled syringes in one resident's room (Resident #131) out of one resident observed for Intravenous (IV) medication administration. The facility failed to ensure expired treatment and biological supplies were discarded in one out of one medication storage room. The facility has only one medication storage room.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient staffing for 2 ( unit 2 and unit 3) out of 5 units. This had the potential to affect the 89 residents who resided in those units out of the 169 residents residing in the facility during this survey.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have daily nurse staffing posted prior to the beginning of shifts on 5 of 5 nursing stations. This had the potential to affect the 169 residents who resided in the facility at the time of this survey.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure one ( Resident # 7) out of one resident observed during dining, was treated with respect and dignity, by not serving meals to all residents seated and the same dining table during meals; as evidenced by Resident # 7 meals were not served her meals at the same time as the other resident seated at the same table was served and being assisted with eating by facility staff. This deficient practice has a potential to affect the health and wellbeing of all the residents who eat by mouth and may need assistance with eating.

Inspectors wroteBased on record review and interviews, the facility failed to ensure complete and accurate documentation of resident's Advanced Directives for 2 (Resident #94 and Resident #120) of 34 sampled residents. This had the potential to affect the 169 residents in the facility receiving care and services at the time of this survey.