West Volusia Healthcare and Rehabilitation Center

Inspectors wroteBased on observations and staff interviews, the facility failed to follow proper sanitation and food handling practices to prevent foodborne illness by failing to ensure: (1) Opened refrigerated foods were labeled and dated; (2) Canned goods received from the vendor and intended for resident consumption were within the manufacturer's expiration date; and (3) Food was prepared and served from a clean, sanitary kitchen. Unsafe food handling and sanitation practices present a potential source of pathogen exposure which could result in foodborne illness. This had the potential to affect all residents who consumed foods from the facility's kitchen.

Inspectors wroteBased on facility record review, staff interview, and facility policy and procedure review, the facility failed to develop and implement a comprehensive water management program for the purpose of reducing the risk of growth and spread of Legionella and other opportunistic pathogens in the facility water system. Residents of nursing homes who may suffer from a weakened immune system, chronic lung disease, or other underlying medical conditions such as immunosuppression, are at risk for Legionnaires' Disease (type of pneumonia) if exposed to Legionella bacteria. This had the potential to affect all residents residing in the facility. Facilities must be able to demonstrate their measures to minimize the risk of Legionella and other opportunistic pathogens in building water systems such as by having a documented water management program that must be based on nationally accepted standards. [...]

Inspectors wroteBased on a review of resident records, resident and resident room observations, and resident and staff interviews, the facility failed to maintain accurate resident records reflective of the care provided for one (Resident #17) of two residents reviewed for wounds, from a total of 34 sampled residents whose records were reviewed.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to protect the residents' right to be free from physical and verbal abuse for two (Residents #2 and #4) of four residents reviewed for abuse, out of a total sample of 7 residents. Resident #2 was physically hit by a staff member after the staff member reacted to being hit by the resident in the shower. Resident #4 was verbally abused by a staff member while the resident was in the process of taking a shower.

Inspectors wroteBased on observations, interviews, medical record review, and facility policy review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Residents #3, #2, and #4) of 5 residents on various precautions, from a total sample of 9 residents. Failure to follow proper infection control standards increases the risk of adverse health outcomes for facility residents, staff, and other facility occupants.

Inspectors wroteBased on observations and interview, the facility failed to post the nurse staffing data specified in paragraph (g)(1) of this section [ (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (as defined under State law). (C) Certified nurse aides. (iv) Resident census.] on a daily basis at the beginning of each shift for 2 of 2 days observed.

Inspectors wroteBased on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility's kitchen, by failing to date mark numerous open food packages in the refrigerator and the freezer. Food handling and sanitation is important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate staffing to respond timely to call lights for 2 (Residents #103 and #262) of 2 residents requiring assistance with activities of daily living. The facility also failed to ensure sufficient nursing staff to provide a timely medication pass for 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication.

Inspectors wroteBased on observations, record reviews, staff interviews, and facility policy and procedure review, the facility failed to ensure a medication error rate of less than 5%, based on 14 errors with 33 opportunities for errors, resulting in an error rate of 42.42%.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to 1) ensure that 7 (Residents #102, #215, #214, #71, #31, #14, and #212) of 12 residents observed for medication administration, remained free of significant medications errors, by failing to administer their 9:00 am medications within one (1) hour of prescribed time and failing to notify the physician of the medication errors, and 2) failed to administer blood pressure medication as ordered, following parameters set by the physician for 1 (Resident #41) of 12 residents reviewed for medication administration, by failing to obtain blood pressure readings prior to giving the medication.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to revise the comprehensive care plan to reflect the current level of care for one (Resident #42) of 3 residents sampled for falls, and failed to include one (Resident #54) of 2 residents sampled for care planning, out of a total of 63 sampled residents, the opportunity to participate in the development of the care plan. Failure to update the care plan puts the resident at risk of not receiving appropriate care interventions. Failure to include the resident or their representative in care planning ensures the resident lacks information that will assist the resident in making informed decisions about her health care.

Inspectors wroteBased on observation, interviews, record review, and facility policy and procedure review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #6) out of 63 sampled residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to ensure that one (Resident #21) of 10 residents receiving respiratory care, received oxygen as ordered, from a total sample of 63 residents.

Inspectors wroteBased on observations and an interview with the Director of Dietary Services (DDS), the facility failed to store ice in a clean and sanitary manner, and refrigerated food and nutritional supplements at safe and proper temperatures and in accordance with professional standards in one (East Wing pantry) of two pantries in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory care as needed and ordered for four (Residents #38, #57, #65 and #29) of 13 residents receiving oxygen therapy, from a total of 33 residents in the sample. Three residents (#38, #57, #29) were receiving oxygen without physician's orders, and one resident (#65) was receiving the wrong amount of oxygen.

Inspectors wroteBased on observations and staff interviews, the facility failed to provide the necessary care and services for one resident (#28), dependent for all activities of daily living, from a sample of 33 residents.

Inspectors wroteBased on observations, staff and resident interviews, admission packet review and medical record review, the facility failed to ensure one resident (Resident #70), from a sample of 33 residents, received assistance with making appointments to receive proper treatment and an assistive device to maintain hearing ability.

Inspectors wroteBased on record review, staff interview and observations, the facility failed to ensure behavior monitoring was conducted for one (Resident #77) of five residents receiving psychotropic medications from a total sample of 33 residents.

Inspectors wroteBased on a review of resident and facility records, and interviews with residents and staff, the facility failed to maintain complete medical records in accordance with professional standards of practice and the facility's policies and procedures for one (Resident #18) of one resident who received hemodialysis treatments, out of a total of 33 residents in the sample.