Vivo Healthcare Clewiston

Inspectors wroteBased on review of the clinical record, review of facility policy and procedure and staff interview, the facility failed to ensure freedom from significant medication error for 1 (Resident #999) of 3 residents reviewed for accuracy of medications. Failure to administer medications accurately puts residents at risk for adverse health consequences.

Inspectors wroteBased on observation, clinical record review, and staff interviews, the facility failed to provide housekeeping services to maintain a clean and sanitary environment for 1 (Resident #8) of 5 residents reviewed for environment.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to provide routine nail care to meet the needs and preferences of 1 (Resident #144) of 3 residents dependent on staff for Activities of Daily Living (ADL) needs reviewed.

Inspectors wroteBased on observations, record review, resident representative and staff interviews, the facility failed to evaluate and determine whether the use of bed bolsters was an appropriate and effective intervention to minimize the risk of falls for 1 (Resident #5) of 2 residents reviewed for falls.

Inspectors wroteBased on record review and staff interviews the facility failed to protect the residents' right to be free from neglect for 1 (Resident #999) of 4 sampled residents by failing to ensure staff follow safety precautions while providing care to prevent avoidable falls and fall related major injury.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the safety interventions were documented in the care plan and failed to ensure staff used safe repositioning technique to prevent avoidable fall and fall related serious injury for 1 (Resident #999) of 4 dependent residents reviewed.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure completion of the quarterly minimum data set (MDS) within 92 days from the assessment reference date of the last completed assessment for 14 (Resident #7, #17, #41, #45, #62, #66, #67, #72, #73, #79, #82, #84, #88, and #91} of 14 residents sampled. This had the potential to delay assessment and revision of the plan of care. Quarterly assessments are used to track a resident's status between comprehensive assessments to ensure critical indicators of gradual change in a resident's status are monitored.

Inspectors wroteBased on observation, review of the clinical record, and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 2 (Residents #81 and #303) of 3 residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on observation, record review, facility policy review, resident and staff interview, the facility failed to provide an ongoing program of activities to meet the resident's interests and support the resident physical, mental and psychosocial well-being for 4 (Residents #8, #42 #51 and #82) of 4 residents reviewed for involvement in the activity program. The lack of an ongoing activity program could lead to a decline in the residents' self-esteem, physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the comprehensive assessment accurately reflect the dental status of 2 (Residents #39 and #90) of 14 sampled residents.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure completion and transmission of completed resident Quarterly Minimum Data Set (MDS) data to the Center for Medicare and Medicaid Services (CMS) System Within 14 days after a facility completes a resident's assessment for 2 (Resident #17 and 82) of 14 residents reviewed.

Inspectors wroteBased on observation, review of facility policy and procedures, record review and staff interviews, the facility failed to maintain urinary catheters in a safe and sanitary manner for 1(Resident #303) of 3 residents reviewed with an indwelling urinary catheter.

Inspectors wroteBased on observation, review of facility policies and procedures, staff and resident interviews, and record review, the facility failed to ensure 3 (Residents #24, #42 and #100) of 29 residents with bed rails were assessed for alternative interventions prior to the use of bed rails, and failed to ensure residents were assessed for danger of entrapment prior to use of bed rails. In addition, the facility failed to inform the residents and/or their representative of the risks and benefits of bed rails or obtain an informed consent prior to use of the bed rails.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to develop a comprehensive person-centered care plan with goals and individualized interventions to meet the needs of 2 (Resident #22 and #81) of 26 sampled residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain the personal hygiene, grooming for 2 residents (Resident #34 and #53) of 4 residents who require assistance with activities of daily living. Daily grooming contributes to the resident's dignity and the failure of maintaining a resident's personal grooming habits has a potential to affect the psychosocial well-being of the resident.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed provide an ongoing program of activities designed to meet the physical, mental and psychosocial needs of 2 (Resident #12 and #56) of 26 sampled residents. The failure to provide a structured person-centered activities program has the potential to contribute to the decline of the resident's psychosocial wellbeing.

Inspectors wroteBased on administrative and staff interview the facility failed to ensure the activity program was directed by a qualified activities professional who is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body.

Inspectors wroteBased on observation, review of the clinical record, review of facility policy and procedures, staff, and resident interviews the facility failed to provide appropriate services and interventions for the management of contractures for 1 (Resident #34) of 2 residents sampled for positioning devices.

Inspectors wroteBased on observation, review of facility policy, clinical record review, staff and resident interviews, the facility failed to have documentation of coordination to ensure effective interventions to address the needs of 1 (Resident #20) of 6 residents reviewed for impaired nutrition and weight loss.