DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:5/14/2018 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105507 NAME OF PROVIDER OF SUPPLIER 04/27/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF NORTH FORT MYERS 991 PONDELLA RD FORT MYERS, FL 33903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0253 Provide housekeeping and maintenance services. Level of harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility failed to ensure resident rooms were maintained in good repair for 9 of approximately 15 rooms reviewed. This was evidenced by air conditioning units and rooms that were dirty and in disrepair including furniture, walls, doors, and windows. This does not afford those residents safe, clean, and comfortable accommodations. The findings included: On 4/25/17 at 8:58 a.m. while on tour with the Maintenance Director Maintenance (DM) and Director of Housekeeping (DHkp). The following was observed: * Room 201 - Air conditioning (AC) unit observed to have an accumulation of dust and dirt. * Room 208 - AC unit an accumulation of dust and dirt. Window observed with an accumulation of dirt and grime. At that time, Resident # 114 complained about Palmetto bugs in room. The DHkp said, well, that is normal; we live in Florida and having bugs should be expected. * Room 207 - AC unit observed with an accumulation of black and brown substance. Observed beige-yellow substance behind bed. Scuff marks and gauges on walls, and black residue on floor. * Room 214 - Footboard of bed located near window with severe damage to the particleboard, and rough plastic edges. Bed siderail on right side of bed rusted and corroded. * Room 215 - Observed Black bio-growth in interior area of AC. Bathroom door interior severely scuffed up. At that time, the DM said that is normal and cannot be prevent due to the wheelchair rubbing up against the door. Noted urine order in bathroom. Wallpaper edging in disrepair throughout the room. * Room 216 - Strong smell of urine in bathroom. At that time, the DHkp said 'this resident's fault he has behaviors and is always peeing on the floor. It is the CNA (certified nursing assistant) job to clean the floor after the resident pees. * Room 219 - Observed nightstand table was scratch up and draw hanging. * Room 107 - AC unit with a large accumulation of dust and dirt. Also observed an accumulation of black and brown substance behind bed located near the window. There were numerous gauges on wall surfaces of the room. * Room 115 - AC unit dusty and dirty. The AC unit not installed correctly on wall exposing the outside environment to the resident's room. Wall surfaces with gauges and scraps. * In all the rooms observed, there was little or no caulking surrounding the AC units. **Photos on file** Residents Affected - Some F 0272 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct initial and periodic assessments of each resident's functional capacity. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to comprehensively assess 2 (Resident #1 and #233) of 29 residents reviewed. Resident assessment guides treatment and progress. The findings included: 1. Observation on 4/24/17 at 1:29 p.m. revealed Resident #1 had a seat belt attached to him in his wheelchair. The seat belt was applied 8 inches from his stomach. A review of his care plan showed he is at risk for falls and uses the pelvic belt for positioning. A review of the nurse's treatment record for April 2017 showed they monitor the pelvic belt for positioning and alignment of pelvis. A review of the occupational therapy notes for the past year revealed no mention of the seat belt and its use. There were no physical therapy notes for 2016 and 2017. In an interview on 4/26/17 at 10:40 a.m., the Director of Rehabilitation (DOR) confirmed occupational and physical therapy did not evaluate Resident #1's seat belt in the past year. The DOR observed Resident #1's seat belt and said Resident #1 had a [DIAGNOSES REDACTED]. In an interview on 4/26/17 at 10:58 a.m., the Buckingham Unit Manager said Resident #1's seat belt is used for safety due to [MEDICAL CONDITION] and falls. She said she did not know how the seat belt was to be applied. She confirmed therapy will have to evaluate the appropriate application of this belt to ensure Resident #1's safety. A review of Resident #1's Kardex revealed no mention of the seat belt. In an interview on 4/26/17 at 12:20 p.m., Certified Nursing Assistant (CNA) Staff A said the seat belt for Resident #1 is in place because he has [MEDICAL CONDITION]. She reviewed the Kardex for Resident #1 and confirmed there was no direction for the use for Resident #1's seat belt. She explained the Kardex is used to give the CNA's direction on how to care for each resident. She did not have any information on how this seat belt was to be applied to him. She also said the seat belt has been loose fitting for the last year and a half. In an interview on 4/26/17 at 1:20 p.m., Occupational Therapist Staff B indicated Resident #1's sitting balance is appropriate and unchanged from last year. He did not evaluate the seat belt and said nursing does that. He confirmed Resident #1 had a [MEDICAL CONDITION] disorder and the seat belt was loose. He tightened the seat belt. He said as loose as the seat belt was, it could be a danger. 2. Record review of the face sheet showed the resident was admitted to the facility on [DATE] from a hospital. In an interview on 4/25/17 at 12:15 p.m., Resident #233 said she developed a pressure ulcer wound while she was in the hospital and stated, Sometimes they have forgotten to do them (the wound treatments) here. Review of the pressure ulcer record dated 4/4/17 showed Resident #233 was admitted with 2 stage-II pressure wounds (1 each to the right and left buttock). The right buttock wound, present on admission, stage II measuring 3 centimeters (cm) long (L) x 3 wide (W) with no depth. Wound bed is pink [MEDICATION NAME] tissue, wound edges are firm. No drainage or odor and peri-wound is intact. The left buttock wound, present on admission, stage II, measuring 9 cm (L) x 3.5 cm (w) with no depth. Wound bed is with pink [MEDICATION NAME] tissue, wound edges firm, no drainage or odor and peri-wound is intact. The pressure ulcer record dated 4/11/17 documented a left buttock/sacral wound, present on admission. Measurements were 6.0 cm (L) x 5.0 cm (W), wound bed was yellow slough, wound edges were firm/no redness. No drainage or odor; periwound area was intact. The pressure ulcer record dated 4/18/17 documented not assessed as resident on LOA (leave of absence). The pressure ulcer record dated 4/25/17 documented this area (left buttock/sacral wound) measuring 5.4 cm (L) x 3.0 cm (W) and no depth. Wound bed with [MEDICATION NAME] tissue and slough, pink and yellow wound bed, wound edges are firm/no redness, moderate amount of serous drainage, peri-wound area intact. In an interview on on 4/25/17 at 9:00 a.m., the Director of Nursing (DON) said Resident #233 was admitted to the facility with pressure injury to her right and left buttock that fused into one which is the left buttock and sacral area. She said this is why there are three wound assessments; they are now assessing the wound as one, not a right and left buttock wound. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105507 If continuation sheet Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:5/14/2018 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105507 NAME OF PROVIDER OF SUPPLIER 04/27/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF NORTH FORT MYERS 991 PONDELLA RD FORT MYERS, FL 33903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0272 (continued... from page 1) On 4/11/17, a pressure ulcer record was completed by the DON. The record showed the wounds deteriorated and had formed together to become 1 unstageable pressure wound. Review of the April 2017 treatment administration record (TAR) showed Resident #233 did not receive wound care as ordered on [DATE] until 4/6/17. The TAR is also blank for 4/8/17. Review of nursing progress notes failed to show why the treatment was not started until 4/6/17 or why treatment was not done on 4/8/17. The TAR showed nurse's circled initials for the date of 4/18/17. In an interview on 4/25/17 at 12:30 p.m., Licensed Practical Nurse (LPN) Manager reported the resident was out on leave of absence with her husband on 4/18/17 and did not return back to the facility until approximately 10:00 p.m. She said the daily dressing was not changed when the resident returned to the facility because they have not had a consistent nurse on the 3-11 shift and have been using a lot of fill-ins. She admitted she could not explain why the dressing wasn't changed. Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0309 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0314 Level of harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567(02-99) Previous Versions Obsolete Provide necessary care and services to maintain the highest well being of each resident **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to fully coordinate care for 1 (Resident #194) of 1 resident reviewed for [MEDICAL CONDITIONS] who receives [MEDICAL TREATMENT] services. The facility failed to follow physician-ordered fluid restriction, causing the resident to be fluid-overloaded on off-scheduled days of [MEDICAL TREATMENT] treatment. The facility also failed to ensure fluids given to the resident were monitored and documented on a routine bases. This can affect the health of a resident with a [DIAGNOSES REDACTED]. The findings included: Resident #194 was admitted to the facility on [DATE] from the hospital for rehabilitation services. The resident had a [DIAGNOSES REDACTED]. The resident was ordered to receive a controlled-carbohydrate diet and with renal restrictions. The physician order [REDACTED].#194's daily diet. Delineation between dietary and nursing was included with the diet order. Nursing and Registered Dietitian (RD) progress notes do not include counseling or instruction on the fluid restrictions for the resident. The physician order [REDACTED]. Delineation between dietary and nursing was included in the fluid restriction order. Nursing and RD progress notes do not include counseling or instruction on the decrease in fluid intake. The physician order [REDACTED]. Nursing and RD progress notes do not include counseling or instruction on the further decrease in fluid intake. Review of the comprehensive care plan for [MEDICAL TREATMENT]/Nutrition under interventions documents a fluid restriction, but does not specify the delineated amount of fluid to be given between nursing and dietary. The care plan does not document the order for the fluid restriction changes on 2/21/17 for 1500 cc per day, on 2/23/17 for decrease to 1200 cc per day, or on 2/28/17 for decrease to 1000 cc per day. The care plan also failed to include that the resident was non-complaint. In an interview on 4/27/17 at 9:30 a.m., Minimum Data Set (MDS) Coordinator Staff L confirmed the fluid restriction and non-compliance should be included in the care plan. On 4/25/17 at 2:22 p.m., observation of Resident #194 room revealed two 16 ounce (about 960 cc) Styrofoam cups sitting on resident's bedside table. Both cups were filled with water and ice. The resident was out of the facility at [MEDICAL TREATMENT] during the time of the observation. On 4/25/17 at 2:24 p.m., Licensed Practical Nurse (LPN) Staff C said Resident #194 is alert oriented and makes her own decisions, I can't force her not to drink the water. I do not encourage or council her not to drink the water. The resident is her own person; she wheels herself around and makes her own decision on what she eats. LPN Staff C said the resident remains on the physician-ordered fluid restriction of 1200 cc per day. Current physicians order of 2/28/17 directed a decrease of fluid restriction to 1000 cc per day. The nursing progress notes did not include any information in reference to the resident being non-complaint with fluids. In an interview on 4/25/17 at 3:05 p.m., the Renal Registered Dietitian (RRD) said Resident #194 was not on a 1200 cc fluid restriction. The resident's fluids were decreased to 1000 cc per day on 2/28/17. The RRD said the resident always complains about being thirsty. The RRD added, I could understand why as she is on an [MEDICATION NAME] 2 times a day and a diuretic 2 times a day. Upon arrival to [MEDICAL TREATMENT] treatment the resident was often very short of breath, but during the treatment the resident says she has relief when the treatment pulls the fluid volume. The RRD said she sent numerous teaching tools to the facility to assist them in instructing the resident on fluid overload, but has gotten no response from them. Information received from the [MEDICAL TREATMENT] center on 4/26/17 at 4:23 p.m. documented the resident's average fluid gain between [MEDICAL TREATMENT] treatments is 3.1 kilograms (about 6.8 pounds). Standard practice for a fluid gain should be maximum 2.0 kilograms (about 4.4 pounds) fluid gain between treatments. Included in the information were the teaching tools originally sent to the facility to assist the nursing home in counseling the resident on non-compliance. The documents sent from the [MEDICAL TREATMENT] center were not included in the facility record except for the most recent labs. In an interview on 4/25/17 at 3:40 p.m., facility RD confirmed she realized the resident would be very thirsty due to the [MEDICATION NAME] and diuretic. The RD said she is not that familiar with the resident as she was hired on 3/8/17. The RD commented the nursing staff need to encourage the resident on following fluid restriction. The RD was thought Resident #194 on 1200 cc per day restriction. On 4/26/17 at 8:00 a.m., Resident #194, said she is receiving [MEDICAL TREATMENT] three times a week. She was concerned about her legs as they were very full of water and difficult to transfer. Her here legs were observed to be very swollen. Resident #194 said the doctor had stopped giving her the [MEDICATION NAME]. She said since I stopped taking the [MEDICATION NAME], I cannot get the mucous up, my chest is very heavy. She said I am always very thirsty, I suck on chips of ice which helps. The resident said she has been on [MEDICAL TREATMENT] for years, has cardiac problems, and has had two stints placed in her heart. In an interview on 4/26/17 at 8:15 a.m., LPN Staff D said she had spoken to the nephrologist (kidney specialist) about Resident #194 being ordered a dialectic since the resident no longer had urine output. The LPN said the nephrologist wrote an order to discontinue the diuretic. LPN Staff D could not recall if she had documented her conversation with the nephrologist. Review of the nurse's progress notes fails to include any documentation of the LPN speaking with the nephrologist about discontinuing the diuretic. Review of the Medication Administration Record [REDACTED]. In an interview on 4/27/17 at 9:04 a.m., LPN Staff D, the Unit Manager, and the Director of Nursing (DON) confirmed although communication does occur between the [MEDICAL TREATMENT] center and facility, many times the communication is not documented. **Photos on file** Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide care and treatment for [REDACTED].#233) of 1 resident reviewed for pressure ulcers. Assessment and treatment of [REDACTED]. The findings included: Review of the face sheet showed Resident #233was admitted to the facility from a hospital on [DATE]. Review of the pressure ulcer record dated 4/4/17 showed Resident #233 was admitted with 2 stage-II pressure wounds (1 each to the right and left buttock). The right buttock wound, present on admission, stage II measuring 3 centimeters (cm) long (L) x 3 wide (W) with no depth. Wound bed is pink [MEDICATION NAME] tissue, wound edges are firm. No drainage or odor and peri-wound is intact. The left buttock wound, present on admission, stage II, measuring 9 cm (L) x 3.5 cm (w) with no depth. Wound bed is with pink [MEDICATION NAME] tissue, wound edges firm, no drainage or odor and peri-wound is intact. The pressure ulcer record dated 4/11/17 documented a left buttock/sacral wound, present on admission. Measurements were 6.0 cm (L) x 5.0 cm (W), wound bed was yellow slough, wound edges were firm/no redness. No drainage or odor; periwound area was Event ID: YL1O11 Facility ID: 105507 If continuation sheet Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION PRINTED:5/14/2018 FORM APPROVED OMB NO. 0938-0391 (X3) DATE SURVEY COMPLETED (X1) PROVIDER / SUPPLIER (X2) MULTIPLE CONSTRUCTION / CLIA A. BUILDING ______ IDENNTIFICATION B. WING _____ NUMBER 105507 NAME OF PROVIDER OF SUPPLIER 04/27/2017 STREET ADDRESS, CITY, STATE, ZIP CONSULATE HEALTH CARE OF NORTH FORT MYERS 991 PONDELLA RD FORT MYERS, FL 33903 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) F 0314 (continued... from page 2) intact. The pressure ulcer record dated 4/18/17 documented not assessed as resident on LOA (leave of absence). The pressure ulcer record dated 4/25/17 documented this area (left buttock/sacral wound) measuring 5.4 cm (L) x 3.0 cm (W) and no depth. Wound bed with [MEDICATION NAME] tissue and slough, pink and yellow wound bed, wound edges are firm/no redness, moderate amount of serous drainage, peri-wound area intact. Review of the April 2017 treatment administration record (TAR) showed Resident #233 did not receive wound care as ordered on [DATE] until 4/6/17. The TAR is also blank for 4/8/17. Review of nursing progress notes failed to show why the treatment was not started until 4/6/17 or why treatment was not done on 4/8/17. The TAR showed nurse's circled initials for the date of 4/18/17. On 4/25/17 at 12:15 p.m., Resident #233 confirmed she developed a pressure sore while she was in the hospital and stated, Sometimes they have forgotten to do them (the treatments) here (at the facility). In an interview on on 4/25/17 at 9:00 a.m., the Director of Nursing (DON) said Resident #233 was admitted to the facility with pressure injury to her right and left buttock that fused into one which is the left buttock and sacral area. She said this is why there are three wound assessments; they are now assessing the wound as one, not a right and left buttock wound. On 4/11/17, a pressure ulcer record was completed by the DON. The record showed the wounds deteriorated and had formed together to become 1 unstageable pressure wound. In an interview on 4/25/17 at 12:30 p.m., Licensed Practical Nurse (LPN) Manager reported the resident was out on leave of absence with her husband on 4/18/17 and did not return back to the facility until approximately 10:00 p.m. She said the daily dressing was not changed when the resident returned to the facility because they have not had a consistent nurse on the 3-11 shift and have been using a lot of fill-ins. She admitted she could not explain why the dressing wasn't changed. Level of harm - Minimal harm or potential for actual harm Residents Affected - Few F 0371 Store, cook, and serve food in a safe and clean way Level of harm - Minimal harm or potential for actual harm Based on observation, staff interview, and record review, the facility failed to ensure food was served in a sanitary manner. The facility also failed to ensure the kitchen environment was in good repair in reference to the ceiling in the main kitchen and dish room area. This can cause the spread of harmful microorganisms that have the potential of causing food borne illness in residents receiving an oral diet. The findings included: Observation of the kitchen on 4/26/17 at 10:30 a.m. revealed areas surrounding the ceiling vents had chipping and peeling paint. The surfaces of the ceiling surrounding the vents was a very rough, bumpy texture with watermarks around the rough, bumpy areas. The areas of concern were located above where food is prepared and served and clean dishes were stored. Observation during tray line on 4/26/17 at 11:00 a.m. revealed Cook Staff E was continually thumbing the rims of plates as she placed portions of foods on the plates. Cook Staff E was pulling apart dinner rolls with her hands and then proceeding to retrieve parsley from a bowl with her right hand, placing it on a plate with food. Cook Staff E then reached over the tray of rolls; as she did so, the sleeve of her shirt brushed over the surface of the rolls. Further observation revealed Cook Staff E's hair was not fully restrained. On 4/27/17 at 9:00 a.m., the Food Service Director (FSD) and Consultant (FSC) were interviewed. The FSD said she was not aware of any repairs done on the ceiling since she had been hired 2 years ago. The FSD said this was a concern, and she would address the concerns with the Director of Maintenance. Regarding handling food with her hands instead of a utensil and not having her hair fully restrained while serving food, the FSD said this was a concern and she would address it with Cook Staff E. **Photos on file** Residents Affected - Many FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: YL1O11 Facility ID: 105507 If continuation sheet Page 3 of 3