89:39 s4137?1454 JAN 2.4 2012 141253/Nu. 7333351 104 2 DEPARTMENT OF HEALTH AND HUMAN SERVICES 01124/2012 FORM APPROVED CENTERS FOR MEDICARE S. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES out PROVIDERISUPPLIERICLIA MULTIPLE consreucrron (X3) oars suever AND emu OF CORRECTION IDENTIFICATION uumese; COMPLETED A. BUILDING 105983 3' Wm 01l12l2D112 NAME OF PROVIDER OR SUPPLIER STATE CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 pan Io SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN or CORRECTION ore; PREFIX (EACH DEFICIENCY MUST EE FRECEDED BY FULL I CORRECTIVE ACTION SHOULD BE rec; REGULATORY OR LSC IDENTIFYING The TO THE APPROPRIATE I ll 000 I INITIAL COMMENTS i 000 Preparation an.d submission of this plan I I This is annual receriifioafion survey conducted . 1/9l12 through 1!12l12 at Consulate of Sarasota, or agreement by the provider of the truth ofthe er skilled nursing facility (SNF). of correction does not constitute an admission facts alleged or correctness of the conc.Ius:ions I The facility was not in compliance with 42 CFR . 483. subpart requirements for Long Term Care. - forth the "f 156 -- (10), NOTICE OF RIGHTS RULES SERVHCES CHARGES 156i the plan ofcorrection is prepared and submitted s= 1 . . I I solely because of the under The facility must inform the resident both orally i 3 and in writing In a language that the resident Sta"? arid I understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay In the facility. 'The i 5 I) facility must also provide the resident with the notice (it any) of the State developed under . ?1919(e)(6) of the Act. Such notification must be made prior to or upon admission and during the I residents stay. Receipt of such information. and _i any amendments to it, must be acknowledged in writing. The facility must inform each resident who is 5 entitled to Medicaid benefits, in writing. at the time? I of admission to the nursing facility or, when the resident becomes eligible for Medicaid of the 3 items and services that are included in nursing I facility services under the State plan and for . I which the resident may not be charged; those I i other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and inform each resident when changes are made to I . i the items and services specified in paragraphs I Ii}(Al and (B) of this section. i The facility must inform each resident before, or I I LABORATORY OR PROVIDERJSUPPLIER SIGNATURE TITLE DATE We Ftny deficiency stagrd ending with an asterisk denotes a deficiency which the institution may be excused from correcting: providing it is that other safeguards provide sufiiciont protection to the patients. (Sec inslruct|ons.I Excerpt for nursing homes. the findings stated above are dlsciosable 90 days following the date or' survey whether or not a plan of correction is provided. For nursing homes. the above findings and plans of correction are ciisclocaple 14 days following the date these documents are made available to the facility. If deficiencies are cited. an approved plan or con-ectlon is requisite to continued program participation. -- - FORM Previous Versions Obsolete Event ID: QVMB1I Facility 35060915 A i--lf-oontinuatlorl sheet Page 1 or42 (.ua4 E5 PRINTED: 01124/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8! MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) OATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: A. BUILDING 195933 8' Wm 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) ID I SUMMARY STATEMENT OF DEFICIENCIES I I0 PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDEO BY FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE I DEFICIENCYContinued From page 1 . 156' I at the time of admission, and periodically during 1: 155 5 the resident's stay, of services available in the i facility and of charges for those services, including any charges for services not covered I under Medicare or by the facility's per diem rate. Resident. I 16 has been discharged from the facility. '1 Active Medicare Part A residents are I The facility must furnish a written description of I reviewed weekiy during Medicare meeting 5. legai rights which includes: I to discuss progress towards goals and I A description of the manner of protecting personal; funds, under paragraph of this section; I discharge pianning. I A description of the requirements and procedures Social Worker was in-serviced on Skilled 5 Ear eligibility for MedicIsIidi(Inciuding I I Nursing Advanced Beneficiary rig reques an assessmen un er section I - - 1924(c) which determines the extent of a couple's Nome (SNFABN) and "Once of 2 nonexempt resources at the time of I C?''er3ge- institutionalization and attributes to the community' I spouse an equitable share of resources which ED/designee will conduct a weekly random cannot be considered available for payment toward the cost of the institutionalized spouse's I medical care in his or her process of spending I audit of SNFABN notices for 1 month and I then for 2 months. down to Medicaid eligibmty Ieveis. I Result Of the audits will be reviewed by the I I QA committee for 3 months to A posting of names, addresses, and telephone I 1 ensure substantial compliance. I numbers of all pertinent State client advocacy Compliance we 2-12-2012 I A ombudsman program, the protection and advocacy network, and the Medicaid fraud control '1 unit; and a statement that the resident may file a complaint with the State survey and certification I agency concerning resident abuse, neglect, and I misappropriation of resident property in the I i facility, and non-compliance with the advance - directives requirements. I The facility must comply with the requirements I I I specified in subpart I of part 489 of this chapter FORM Previous Versions Obsolete Event Facility 35960915 if continuation sheet Page 2 Qf 42 l-.r-O PRINTED: 01/2412012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERIICLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING . 105983 01I12I2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 47153 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, Fl. 34232 (X4, .9 I SUMMARYSTATEMENT or DEFICIENCIES ID PROVIDERS or CORRECTION (X5) pRE|=lx I (EACH DEFICIENCY MUST BE PRECEDED sv FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE mg REGULATORY on LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE I DEFICIENCY) 156 Continued From page 2 156 I related to maintaining written policies and procedures regarding advance directives. These I requirements include provisions to inform and provide written information to all adult residents I concerning the right to accept or refuse medical I or surgical treatment and, at the individual's option, formulate an advance directive. This I includes a written description of the facility's I policies to implement advance directives and I applicable State law. The facility must inform each resident of the name, specialty, and way of contacting the i physician responsible for his or her care. I I The facility must prominently display in the facility 1 written information, and provide to residents and applicants for admission oral and written - information about how to apply for and use Medicare and Medicaid benefits, and how to I receive refunds for previous payments covered by I such benefitsThis REQUIREMENT is not met as evidenced 5 I by: I I Based on record review and interview, the facility failed to inform the resident or the responsible party of the termination of payment by Medicare of services received in the facility until after the services were terminated for 1 (Resident #116) of I 3 records reviewed for termination of medicare I benefits. The findings include; - Review of the liability and appeal notices given to I Resident #116 revealed the notice stated the I I . I . FORM Previous Versions Obsolete Event OVM611 Facility ID: 35960915 If continuation sheet Page 3 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 81 MEDICAID SERVICES 5 PRINTED: 01/24/2012 FORM APPROVED STATEMENT OF DEFICIENCIES (Xi) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105983 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED A. UILDIN BNNG 0111212012 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS. CITY, STATE, ZIP CODE 47815 FRUITVILLE ROAD SARASOTA, FL 34232 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PROVIDERS PUXN or CORRECTION pnerix (EACH CORRECTIVE ACTION SHOULD BE TAG CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) DATE I 156! Continued From page 3 1 Medicare benefits would expire on 11/28/11. This notice was signed by the responsible party on I 11/30/11, the day the resident was discharged. A . note written on the bottom of the page below the signature of the responsible party stated, "Notified letter needs signature prior to DC. Will come in and sign. This note had no date or time that it was written. During an interview on 1/10112 at 2:45 the social services worker stated the daughter of Resident #116 called to inform the facility she I would be taking her mother home on 11/30/11. The social worker stated she couid not remember . the date the daughter had called her about the 3 discharge. The social services director stated she informed the daughter of Resident #116 the 1 Medicare services payment would be ending on I 11/28111. She stated she could not remember the date she spoke with the daughter and realizes she should have dated the note she wrote indicating she had spoken to the daughter. She confirmed there is no documentation Resident #116 or her responsible party was notified I Medicare benefits would be ending prior to the i date the services ended. 253! HOUSEKEEPING 3. 55:13; MAINTENANCE SERVICES i The facility must provide housekeeping and I maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. I This REQUIREMENT is not met as evidenced by: I Based on observations and interview, the facility failed to maintain safe, sanitary, and comfortable I I F156 FORM CMS-2567102-99) Previous Versions Obsolete Event ID: QVMB11 Facility ID: 35950915 OMB NO. 0938-0391 (X5) COMPLETION lf continuation sheet Page 4 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES (TUE) JAN 24 2012 9 PRINTED: 01/24/2012 FORM APPROVED NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS, CITY, STATE. ZIP CODE 4733 FRUITVILLE ROAD SARASOTA. FL 34232 OMB NO. 0933-0391 1 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 105983 0111212012 - SUMMARY STATEMENT OF DEFICIENCIES conditions, as evidenced by resident rooms with scuff marks, missing and stained tiles and dirty privacy curtains. I The findings include: 1. Observation during the facility tour on 1/12/12 I between 8:00 am. and 10:30 am. in the presence of the Administrator, Administrator Assistant, Director of Maintenance and Director I of Housekeeping and Laundry revealed: I 1 Room 101D I Walls deeply marred I i Bathroom has light bulb not working Corner of wall down to metal . Dark red discoloration on privacy curtain; Room 101W I Walls behind and above bed area are marred Area near ale unit the wall protector is pulling 2 away Bathroom has light bulb not working i Wall in bathroom marred Curtain has brown stains on it; I Room 104W 8. 5 Loose tiles under sink in bathroom, walls scuffed; Room 105W Walls marred Dark red discoloration on privacy curtain; 5 Room 105 i Walls marred; 1 Room 107W Walls marred Wall paper peeling Bathroom tile stained beige; Room 200 Walls are marred Toilet seal brown dry wall nicked and scraped; 253 5 Room 101D-The walls were repaired, 1 bathroom bulb replaced, corner wall repaired, privacy curtain was changed. Room 101W- Wall repaired, wall protector near ac unit repaired, bathroom light bulb replaced, wall in bathroom repaired, curtain replaced. Room 104 d- Loose tiles under sink replaced, wall repaired. Room 105 Walls repaired. 1 Room 107 Walls repaired, privacy curtain replaced, wallpaper repaired. Bathroom tile cleaned. Room 200- Wall repaired, toilet seat replaced, drywall repaired. Room-205W Walls repaired, floor mats cleaned. Room 211W-walls repaired, stained - bathroom tile cleaned, over the toilet chair replaced. Room 300- Wall repaired (continued on next page) (x4) ID ID PLAN OF CORRECTEON (X5) (EACH DEFICIENCY MUST as PRECEDED av FULL PREFIX CORRECTIVE ACTION SHOULD BE COMPLETION . mg REGULATORY on LSC INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE WE DEFICIENCY) 253 2 Continued From page 4 253 FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 5 of 42 . 2:4 zulz 1U 01124/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES APPROVED CENTERS FOR MEDICARE SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (xai DATE sunvev AND PLAN oe CORRECUON NUMBER: COMPLETED A. 105983 3' Wm o1r12r2o12 NAME OF OR SUPPUER srneer ADDRESS, CITY. STATE. ZIP CODE 4783 ROAD ONSULAT HEALTH CARE OF SA ASOTA SARASOTA. FL 34232 pm in SUMMARY STATEMENT OF DEFICIENCIES 1D PLAN or CORRECTION (x5; PREHX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) i 253 Continued From page 5 3 253, 253 Room 205W (continued) 5 Walls are scuffed, floor mate with crumbs, . 5 hardened liquids; Room Room 211 Tile in residents bathroom cleaned. Scuffed walls, stained bathroom tile, over the toilet chair has rusty spot; Room 303D--tile in bathroom cleaned. 3 Room 304D- Wall behind bed repaired, missing tile by I Room 300 - Large area on wall in between resident beds with I Scuff marks shower stall In bathroom replaced. Tile 1 Dry wall peeling away from wall; cleaned. Room 3010 A Room 3051) i Tile in resident's bathroom discolored; however, when asked if it bothered her, seemed to be a 5 problem or wanted it fixed, she stated it was not a problem and felt they keep the facility clean; Toilet bowl cleaned. Sink fixed, privacy curtain replaced, tube feeding pole Cleaned. and items will be completed timely. Staff will be in-serviced on the process of notifying maintenance of any needed repairs. Ring around bottom of toilet bowl stained brown Sink very slow to drain Stained brown privacy curtain i Tube-feeding residue on pole. 2. Observations on 1/9/12 at 10:30 1/10/12 3 ED will make weekly rounds with at 12:30 p.m.and1l11I'l2 at 1:30 p.m. revealed I I . . . Maintenance Director to audit for residents rooms with a strong smell of urine. completion of repairs. Results of the audits i will be reviewed by the QA committee for 3 months to ensure substantial compliance. 0 3. Interview with the Administrator on 1/12/12 at 2:00 p.m. revealed the facility has been doing renovations slowly due to their Census capacity. When asked if he developed a plan to show how . the facility was going to proceed in finishing the renovations, he stated he didn't develop one Compliance date: 2- 1 2--20 1 2 I Room 303D Residents residing the facility have the Tile in residents bathroom discolored; potential to be affected i Room 304 i in bathroom i Maintenance Director will make 5X i_ Gray scuff marks embedded in tile in bathroom, weekly rounds in the facility *0 audit for I 'j and areas needing repair. He will maintain a log Room 3060 FORM Previous Versions Obsolete Event lD: QVM611 Facility ID: 35900915 ll' continuation sheet Page 6 of 42 F'ifiiGE CUNSULJEITE qmum i2i2resr2o12 11: so 94.13 mes mroizivi CENTERS FOR MEDICARE 5; MEDICAID SERVICES OMB NO. 09380391 STATEMENT OF UEFicIENcies om PROVIOERISUFPLIERICLIA (x2; l.tlULTll3'LE CONSTRUCTION (X33 cm-E AND PLAN OF CORRECTION IDENTIHCATION comm:-r59 A. mite 5, ii I. 105383 NAME 0' 0" Aooness. cmr_ STATE, ZIP coon 4753 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA rxai In 3 STATEMENT OF Io Pnovioee-s win OF CORRECTION 7 us, PREFIK (EACH MUST as Pnaceoeo cw FULL enema: (EACH CORRECTIVE ACTION SHOULD ee coMPLF.i'io~ mg REGULATORY on LSC IDENTIFYING INFORMATION) mo CROSS-RE-FERENCED io APPROPRIATE WE iJEi=IciENciri 253 Continued From page 6 253i 5 because it would be a lie and couldn't commit to ai i definitive time frame for completion. I 272 COMPREHENSIVE 2T2 35:0 ASSESSMENTS The facility must conduct' initially and periodically -- a comprehensive, accurate, standardized 272 reproducible assessment of each residents functional capacity, Resident -1.8 has correct: wound I I measurements and treatriient orders in IA aciity mus ma eacompre ensivc assessment of a resident's needs. using the phat" resident assessment instrument (RN) specified I by the State The assessment must mciude at An audit of.'cu.rren1: residents with presstirc least the following: . ulcers was completed. Identification and demographic information, I Customary routine; 3 I icensed nurses will be in--serviccd on 2 Cognitive patterns: . . I i communication; measuring and documenting wounds and j} I vision; obtaining physician orders for treatment. Mood and behavior patterns, ADCSi/desigiiee will audit the wound. care ll P5V?_h?s??ia' sheets weekly for 3 months. I Physical functioning and structural problems; Continence: . Disease diagnosis and health conditions; I The DCS/dcsigriec will do random weekly Dental and nutritional status; audits of the wound sheets for 3 I SW1 C0"dll5l0i]52 Results ofthe audits will be reviewed. by pursuni the QA committee for 3 months to I Medications; t. I I. . Special treatments and procedures. cnsme 5" Sm" '3 Comp lance' 3 Discharge potential; 2' Documentation of summary information regarding Compliance dale.' 2-l2--2t]l2 the additional assessment performed on the care I areas triggered by the completion oi the Minimum Data Set and I I i Documentation of participation in assessment I i FORM firevrous Vizrsions Obsolete Event Facility ID: 35960915 Ir continuation sheet Pnge qr' 0142 z-u. zulz 12 PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED I CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. . STATEMENT OF (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE ooNsTRucTIoN (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 8' WING o1I12I2o12 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 4763 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA This REQUIREMENT is not met as evidenced by: Based on observation, record review and . interview, the facility failed to conduct and document an accurate assessment of a resident's pressure ulcers for 1 (Resident #48) of 1 resident reviewed for pressure ulcer assessment and documentation. The findings include: I Interview with the nurse responsible for the care of Resident #48 on 119/12 revealed Resident #48 has a Stage pressure ulcer to her coccyx area. . i The nurse reports Resident #48 is a hospice resident, has poor nutrition which wouid cause skin to breakdown easiiy and cause poor/slow iheafing. Review of the medical record for Resident #48 . revealed she is a hospice patient. She had a I recent decline in her status and most recently has 5 a diagnosis of failure to thrive. She has a living I I wilt and the facility and family are honoring her choices to keep comfortable without additional means. Her eating status has declined and she no longer eats as much as she used to. Due to inadequate nutrition and the breakdown of her systems, she has developed Kennedy Ulcers. A I Kennedy Ulcer is a terminal ulcer that hospice 3 patients get with the breakdown of their systems. These were first observed on 1/4/12. On 1/10/12, the wound-care specialist saw her when he made (X4) .0 SUMMARY STATEMENT OF Io PLAN or CORRECTION (X5) pREf:|x (EACH DEFICIENCY IvIusT BE PRECEDED av ruu PREFIX (EACH CORRECTIVE ACTION SHOULD BE co~Ir=LEno~ TAG REGULATORY on LSC IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE DEFICIENCY) 272: Continued From page 7 272. . . I 5 I FORM Previous Versions Obsolete Event ID: QVM611 Facility 35960915 If continuation sheet Page 8 of 42A FROM 24 2012 14229131'. 13 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERWCES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION COMPLETED A. 105983 3' Wm 01/12/2012 I NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA I his weekly rounds in the at which time he provided the diagnosis of Kennedy Ulcers. i On 1/12/12, review of the pressure ulcer assessment sheets revealed the following documenting descriptions of the pressure ulcers for Resident #48: Dated 1/2/12 -- Coccyx 3x3x2 cm., Stage II. 1 Wound care indicates this area is covered with a I duoderm, which is changed every 3 days and pm; I I Dated 1/4/12 -- Area to the right of the Coccyx 2x2x0.2 cm, Stage ll, covered with a duoderm. A I second note of this area, same date/same page, 3 notes this area as a Stage and a third area on 1 i I this same line notes it as unstageable. An update i 1 I on 1/7/12 notes the area as Stage II. with I measurements of 2.3x2.3x1.2 Cm and a note that 1 says "no improvements;" Dated 1/6/12 and 1/7/12 - Left heel Stage II, 6x4 I cm. No improvement. observed first on 1/6/12Dated 1/6/12 and 1/7/12 - Right heel Stage II, 4x2 1 1 cm. ND improvement, observed first on 1/6/12. Visit on 1/10/12 from the wound care physician documents: heel - Stage i, Left heel - Stage I, Coccyx -- I unstageable. - 1 Plan of treatment is documented on the physician notes to include: cleansing the wound; applying 1 granulex spray, and leave the wound open to air. The physician assessment does not address two areas around the Coccyx area. Interview with the Unit Manager and the Director I of Nursing (DON) on 1/12/12 at 9:30 a.m. revealed the documentation by the nurse on the (X4) ID 5 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION ixsi PREFIX I (EACH DEFICIENCY MusT BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg I REGULATORY OR LSC TAG CROSS-REFERENCED To THE APPROPRIATE DATE I I DEFICIENCY) . I 272 Continued From page 8 2721 assessment of the pressure ulcers is inaccurate. 1 FORM Previous Versions Obsolete Event Facility lD: 35980915 |f continuatign sheet Page 9 of_42_ DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 4.1-I r' s-o PRINTED: 0'll24l2012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERJSUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION COMPLETED A. BUILDING 105983 8' Wm 0111212012 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS. CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 PROVIDERS PLAN OF CORRECTION SUMMARY STATEMENT oI= DEFICIENCIES ID (axon DEFICIENCY MUST as PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION saouro as COMPLETION REGUIATORY on LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . 9 DEFICIENCY) 272 Continued From page 9 272 They both report the pressure ulcers on the heels I are Stage i and have never been Stage it, as the I i skin was never broken but was only red and I blanchable. They both report the coccyx has two I areas; one has black eschar and is unstageabie and the other is a Stage tl. They both confirm I there is no Stage pressure ulcer. I Review of the medical record for Resident #48 2 revealed no physician's orders for the recommended treatment from the wound care 5 physician. I In an interview on 1112/12 at 9:45 the unit I manager on the unit for Resident #48 stated she was with the wound care physician when he visited with Resident #48 on 1/10/12. She stated the physician was aware the resident was under hospice care and wanted the current treatment to continue until the medication could be obtained I from hospice. When asked if she had contacted I hospice regarding the medication, she said she 3 "only received the documented treatment plan I 3 this morning" because they had been in her box 3 since 1/11/12. She further stated a nurse who I worked the hallway said she would contact hospice regarding wound care supplies and I I medication. The unit manager stated she had not checked to see if the orders were initiated, or if 1 I the nurse had contacted hospice. She confirmed -I there is no documentation in the medical record 1 regarding orders for the wound care or the notification to hospice. When asked why she did not contact hospice regarding the wound care 3 recommendations as she was with the physician i when he verbally reported to her the treatment I plan he wanted. she stated she thought the floor . nurse would be completing this task. When asked FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 10 of 42. -I (TUEJJAH 24 2012 15 PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 8' Wm 01/1 212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 ID I PROVIDERS PLAN OF CORRECTION (X4) ID SUMMARY STATEMENT OF OEFICIENCIES I (xs) (EACH DEFICIENCY MUST BE PRECEDED av FULL I PREFIX I (EACH CORRECTIVE ACTION snouup as COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCES TO THE APPROPRIATE DATE DEFICIENCY) I I 272 Continued From page 10 2 272 why she did not write the verbal Order for the 1 I treatment plan the wound care physician wanted I I she stated she was waiting to hear from hospice. I I I The wound Care treatment ordered by the wound i care physician on 1/10/12 had not been written, 3 implemented or applied as of 1/12/12 at 10:30 - a.m. Observation of the wounds for Resident #48 I I revealed the right foot wound was Clear, there was no redness or open areas and the heel . blanches well. The Stage I to the left inner heel I remained present. The left inner heel remained I red and is unblanchable. A red area was noted to I the tip of the great toe on the right foot. This area has a tiny Open spot on the tip. The wound to the I toe was classified by the physician as an arterial wound. The wound to the Coccyx/sacrum area was a very large reddened area. The caudal end of the wound had a dime--sized open area. A A . second, smaller open area was below the first I one and has a blackened area that is I unstageable. The physician documented this as a I Kennedy Terminal Ulcer. The wound has I increased in size since reviewed by the physician 3 on 1/10/12, however the physician has noted the treatment for this wound is palliation. Wound care plan of treatment by the physician indicates cleansing the wound, apply Granulex I every shift and leave open to air. As of 1/12/12 at I I I 10:30 am, there are no written physician orders, 3 the Granulex medication for treatment has not I been ordered or obtained by the facility, therefore I the treatment could not be applied as ordered. The area, noted on 1/10/12 by the wound care FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If Continuation sheet Page 11 of 42 FROM 24 2012 13 PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB N0. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (X3) DATE sunvr-:v PLAN oF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 3' Wm 01/12/2012 NAME 0" PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 944; In SUMMARY STATEMENT oF DEFICIENCIES ID 5 PFtovIoER's PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS--REFERENCED TO THE APPROPRIATE DATE A DEFICIENCY) I I 272 I Continued From page 11 physician to the great toe on the right foot, has I not been noted by the facility staff nor has it been addressed on the skin assessment sheets before I 272 or after it was noted by the MD. - On 1/12/12 at around 11:30 the unit I manager approached the surveyor with new I documentation regarding the wounds: -I Dated 1/12/12 -- Right great toe, t'J.2x0.2 cm, red scab, blister, vascular; first observed on 1/4/12. I This documentation was created on 1/12/12. I There is no documentation dated 1/4/12 of this I wound; I I Dated 1/12/12 - Right heel, Resolved (this is a I Continuation on the page above addressing the right heel); i Dated 1/16/12 - A new page has been created for . i the left inner heel, 6x4 cm., Stage dated 1/7/12 I -- 6x4 cm., Stage I, red, not open, blanches; dated I I I 1/12/12 -- 5.24 Cm., Stage I, red, not open, I I blanches. This page is now signed by the unit manager and not the nurse who Completed and I signed the original assessment on 1/6/12 and 1/7/12. I Dated 1/4/12 -- A new page has been created for I the left Coccyx area. Stage II Kennedy Ulcer, 2x2 5 cm.; 1/12/12 - 2.2x2.2x0.2 cm., pink drainage, open. This page is now signed by the nurse documenting this information on 1/12/12 and not I the nurse who actually completed the I assessment on 1/4/12. I Dated 1/6/12 -- A new page has been Created for I the right sacrum/Coccyx, unstageable. 3.2x3.2xO.2 cm., Kennedy Uicer; 1/12/12 - unstageable, 3.2x3.2x0.2 Cm., unstageable with eschar. This document is Completed by the nurse i documenting on 1/12/12 and not the nurse who did the original assessment on 1/6/12. FORM Previous Versions Obsolete Event 35960915 If continuation sheet Page 12 of 42 Lung If PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM CENTERS FOR MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (xn rrnovroenrsuepuerucm (x2; MULTIPLE CONSTRUCTION (X3) DATE suavsv AND PLAN OF CORRECTION NUMBER: COMPLETED A. 105983 at Wm 01/12/2012 NAME OF PROWDER OR SUPPLIER STREET ADDRESS, CITY, STATE. ZIP CODE 4783 ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) to SUMMARY STATEMENT or DEFICIENCIES ID PLAN OF CORRECTION (x5) 5 (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX 1 (EACH CORRECTTVE Acncm SHOULD as COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED To THE DATE . DEFICIENCY) I i 1 272 i Continued From page 12 272 Dated 1/4/'l2 -- An additionat new page has been created for the entire Coccyx area. Kennedy ulcer, no measurements; 1/12/12 -- unstageable and Stage ll, 5.2x3.5xO.2, Kennedy Ulcer. 1 Observation of the Coccyx area on 1/12/12 revealed a large reddened area that blanches slowly with a small area of eschar to the right of the Coccyx and a small open area to the left of the ycoccyx. Interview with the unit manager who created 9 these documents on 1/12/12 revealed she did not 1 complete the assessments on 1/4/12. 1/6/12 and 1/7/12. She stated she had taken the previous 3 documentation and corrected it on new pages 3 instead of noting the errors on the previous sheets. She stated she had not asked the nurse 1 . completing the original assessment to correct her documentation, but instead did it herself. When asked regarding the documentation of the right great toe being observed on 1/4/12 and where 1 4, that documentation existed, she stated she must i have put the wrong date on the document. She i left the room and returned in approximately 10 I minutes with a new document for the right great 1' toe, which now notes the date first observed to be 1/10/12. 1 I The documentation of the wounds for Resident #48 was not clear. It was not able to be determined on what date the wounds were first 1 I observed, what stages they were and the correct measurements. Documents have been recreated by staff who did not actually complete the assessments. These make the assessments inaccurate. FORM Previous Versions Obsolete Event Facility ID: 35960915 If continuation sheet Page 13 Of 42 aqua-uul I0 PRINTED: 01!24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN or CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 3' WW7 01/12/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4733 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA 944) ID SUMMARY STATEMENT or DEFICIENCIES Io PLAN or CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL pnanx (EACH CORRECTIVE ACTION st-|ouLn Be COMPLETION TAG I REGULATORY OR IDENTIFYING INFORMATION) I TAG CROSSREFERENCED To THE APPROPRIATE DATE 5 DEFICIENCYContinued From page 13 . 272; on 1/12/12 at 11:30 am, The unit manager also I I presented for review newly written verbal orders. I dated 1/12/12, from the physician for the wound care orders received from the wound Care physician on 1/10/12; to Cleanse the wound and I I apply Granulex every shift. These orders also I included the order to discontinue the wound care I of skin prep to the right outer ankle and to discontinue the Duoderm to the Coccyx. Review of the previous wound Care orders also included a treatment of zinc oxide to the buttocks 1 every shift and skin prep to the bilateral heels. The verbal order to discontinue these orders as a previous treatment was not written by the nurse receiving the order to discontinue previous I treatment. I A On 1/12/12 at 12:10 pm. in an interview, the Director of Nursing stated she realizes verbal - orders to discontinue all previous orders were not written. She stated she would review the record I 3 and get it corrected. At 12:30 p.m. additional verbal orders were written by the unit manager to discontinue the zinc oxide to the buttocks and to I discontinue the skin prep to the bilateral heels. In an interview on 1/12/12 at 1:00 the Director of Nursing stated she was in the process A of assessing the wounds of Resident #48 herself. 1 She stated the previous documentation which I I was created by the unit manager on 1I12I12 was 3 not accurate and she wanted to ensure accurate documentation from this day fonrvard so Resident I 1 #48 could receive the correct treatment and the 5 status of the wounds. 281 SERVICES PROVIDED MEET 281 I I I facility would be aware of the current correct I I I I I FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 14 of 42 FCLIIVI DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 24 2012 19 PRINTED: 01/2412012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 105933 0111212012 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 I The services provided or arranged by the facility must meet professional standards of quality. This REQUIREMENT is not met as evidenced - by: Based on observation, record review and interview, the facility failed to meet professional standards of quality care by documenting inaccurate assessments of a pressure ulcer, failing to write verbal orders received by the physician and failing to implement those treatment orders given by the physician as a verbal order in a timely manner for 1 (Resident #48) of 1 residents reviewed for pressure ulcer assessment and documentation. Professional standards of nursing as described 3 by the American Nursing Association for Standards of Care state, "The standards of care . detail the expected level of quality of all nursing activities throughout the entire nursing process. These involve assessment, diagnosis, identification of outcomes, planning, are important whether a nurse carried out her duties appropriately." The Standards for Assessment state, "Assessment is part of the nurse's responsibilities. They must coilect comprehensive data that is relevant to the patient's health situation in a systematic and ongoing process. Invoiving the family of the patient. the patient and other health care The nurse must document relevant data in a retrievable form." implementation and evaluation. Standards of care (x4) .9 i STATEMENT or DEFICIENCIES ID Pnoviosn-s PLAN or CORRECTION (X5) (amen DEFICIENCY MUST as PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE cormersow TAG REGULATORY on LSC IDENTIFYING INFORMATION) I TAG cnossnersnencso TO THE APPROPRIATE DATE DEFICIENCY) 281 I Continued From page 14 231 PROFESSIONAL STANDARDS I I I providers is important for holistidc data collecting. 1 I 281 Resident 48 has correct wound I measurements and treatment orders in place. An audit of current residents with pressure ulcers was completed. I I Licensed nurses will be in--serviced on I measuring and documenting wounds and I obtaining physician orders for treatment. I ADCS/designee will audit the wound sheets weekly for 3 months. The DCS/designee will do random weekly audits of the wound sheets for 3 months. Results of the audits will be reviewed by the QA committee for 3 months to I ensure substantial compliance. 1 Compliance date: 2--12~2012 9/ 1.1. in FORM Previous Versions Obsolete Event QVM611 Facility 35950915 if continuation sheet Page 15 of 42' 44 4-uuz lI4:z:-Ifio. 2U . 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 09384339'! STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA txzi MULTIPLE CONSTRUCTION (x3) DATE suRvEY AND PLAN oF CORRECTION IDENTIFICATION NUMBER. COMPLETED A. BUILDING 105983 3' Wm 01I12l2012 NAME OF PROVIDER OR SUPPLIER ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (x4) to 3 SUMMARY STATEMENT OF DEFICIENCIES In . I=RovioER's PLAN OF CORRECTION (X5) DEHCIENCY MUST BE PRECEDED av FULL PREFIX - (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG 3 TO THE APPROPRIATE DATE I DEFICIENCY) 281 Continued From page 15 281 I The findings include: I i Interview with the nurse responsible for the care 3 of Resident #43 on 1/9/12 revealed Resident #48 I I has a Stage pressure ulcer to her Coccyx area. The nurse reports Resident #48 is a hospice resident. has poor nutrition which would cause I skin to breakdown easily and cause poorlslow lheafing. Review of the medical record for Resident #48 . revealed she is a hospice patient. She had a recent decline in her status and most recently has 5 a diagnosis of failure to thrive. She has a living I will and the facility and family are honoring her I choices to keep Comfortable without additional i means. Hereating status has declined and she i no longer eats as much as she used to. Due to 2 inadequate nutrition and the breakdown of her . systems, she has developed Kennedy Ulcers. A i I Kennedy Ulcer is a terminal ulcer that hospice patients get with the breakdown of their systems. These were first observed on 1/4/12. On 1/10/12, I the wound-care specialist saw her when he made 5 his weekly rounds in the facility, at which time he 3 provided the diagnosis of Kennedy Ulcers. I On 1/12/12, review of the pressure ulcer assessment sheets revealed the foilowing documenting descriptions of the pressure ulcers 1. for Resident #48: Dated 1/2/12 - Coccyx 3x3x2 cm., Stage II. i . Wound care indicates this area is covered with a Dated 1/4/12 -- Area to the right of the Coccyx 2x2xO.2 cm., Stage 11, covered with a duoderm. A 5 second note of this area, same date/same page, . I duoderm, which is changed every 3 days and pmFORM Previous Versions Obsolete Event it): Facility ID: 35980915 if continuation sheet Page 16 of '42' PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIE5 (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBERZ COMPLETED AA BUILDING 105933 WING 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4733 HFRUITVILLE ROAD SARASOTA. FL 34232 CONSULATE HEALTH CARE OF SARASOTA (x4; is . SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDERS PLAN OF CORRECTION Ixs) PREFIX . (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE I DEFICIENCYContinued From page 16 281 I notes this area as a Stage and a third area on I I this same line notes It as unstageable. An update I on 1/7/12 notes the area as Stage II, with 1 measurements of 2.3x2.3xt.2 cm and a note that says "no improverhents;" I Dated 116/12 and 1/7/12 -- Left heel Stage 6x4 I cm. NO improvement, observed first on I I and Dated 1/6/12 and 1/7/12 - Right heel Stage II, 4x2 Cm. NO improvement, Observed first on 116/12. Visit On 1/10/12 from the wound care physician I . documents: heel - Stage I, Left heel - Stage I, Coccyx -- I unstageabie. I Plan of treatment is documented on the physician I notes to include: cleansing the wound; applying I granuiex spray, and leave the wound open to air. I I The physician assessment does not address two I I areas around the Coccyx area. I I I I Interview with the Unit Manager and the Director [of Nursing (DON) on 1/12/12 at 9:30 a.m. I revealed the documentation by the nurse on the assessment of the pressure ulcers is inaccurate. They both report the pressure ulcers on the heels are Stage I and have never been Stage II, as the skin was never broken but was only red and blanchabte. They both report the Coccyx has two A areas; one has black eschar and is unstageable and the other is a Stage it. They both Confirm I i there is no Stage pressure ulcer. Review of the medical record for Resident #48 I revealed no physician's orders for the recommended treatment from the wound Care physician. I I I FORM Previous Versions Obsolete Event Facility ID: 35960915 If continuation sheet Page 17 of 42 FROM 24 2012 22 PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-40391 STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN or-' CORRECTION NUMBER: COMPLETED A. BUILDING 105983 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. cm'. STATE. ZIP coDE 4783 FRUITVILLE ROAD SARASOTA. FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) PREFIX DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY on IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DEFICIENCY) 9 . 281 Continued From pag_e 17 281 in an interview on 1/12/12 at 9:45 am, the unit manager on the unit for Resident #48 stated she I was with the wound care physician when he I visited with Resident #48 on 1/10/12. She stated I the physician was aware the resident was under I I hospice care and wanted the current treatment to . I continue until the medication could be obtained I from hospice. When asked if she had contacted I i hospice regarding the medication. she said she I "only received the documented treatment plan I this morning" because they had been in her box since 1/11112. She further stated a nurse who worked the hallway said she would contact hospice regarding wound care supplies and medication. The unit manager stated she had not checked to see if the orders were initiated, or if the nurse had contacted hospice. She confirmed I i there is no documentation in the medical record I regarding orders for the wound care or the i notification to hospice. When asked why she did I I I not contact hospice regarding the wound care I recommendations as she was with the physician - when he verbally reported to her the treatment plan he wanted, she stated she thought the floor I . nurse would be completing this task. When asked I why she did not write the verbal order for the - treatment plan the wound care physician wanted she stated she was waiting to hear from hospice. The wound care treatment ordered by the wound I 5 care physician on 1/10/12 had not been written, implemented or applied as of 1/12/12 at 10:30 a.m. I I 3 Observation of the wounds for Resident #48 I I revealed the right foot wound was clear, there I I was no redness or open areas and the heel . blanches well. The Stage I to the left inner heel I FORM Previous Versions Obsolete Event ID: OVM811 Facility ID: 35960915 If continuation sheet Page 18 of 42 :44 2012 14: :31 23 . 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN or CORRECTION IDENTIFICATION COMPLETED A. BUILDING 105933 We o1I1 212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, ZIP CODE 4783 FRUITVILLE ROAD LT CONSULATE HEA CARE OF SA ASOTAN SARASOTA. FL 34232 (X4, .9 I SUMMARY STATEMENT oI= DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION (X5) pRE|=|x I (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY on LSC IDENTIFYING INFORMATION) TAG CROSS--REFERENCED To THE APPROPRIATE DATE DEFICIENCY) remained present. The left inner heel remained i red and is unblanchable. A red area was noted to I the tip of the great toe on the right foot. This area I has a tiny open spot on the tip. The wound to the I toe was classified by the physician as an arterial wound. The wound to the Coccyx/sacrum area was a very large reddened area. The caudal end of the wound had a dime-sized open area. A second, smaller open area was below the first one and has a blackened area that is 3 . unstageable. The physician documented this as a Kennedy Terminal Ulcer. The wound has increased in size since reviewed by the physician on 1/10/12, however the physician has noted the treatment for this wound is palliation. I I I I i 281 Continued From page Wound care plan of treatment by the physician i I indicates cleansing the wound, apply Granulex i every shift and leave open to air. As of 1/12/12 at 5 10:30 there are no written physician orders, the Granulex medication for treatment has not been ordered or obtained by the facility, therefore I the treatment could not be applied as ordered. 5 The area, noted on 1110112 by the wound care i physician to the great toe on the right foot, has i not been noted by the facility staff nor has it been addressed on the skin assessment sheets before or after it was noted by the MD. Dated 1/12/12 - Right great toe, 0.2xO.2 cm, red I scab. blister, vascular; first observed on I This documentation was created on 1/12/12. There is no documentation dated 1/4112 of this I wound; i Dated 1/12/12 - Right heel, Resolved (this is a I continuation on the page above addressing the . right heat): I I FORM Previous Versions Obsolete Event QVM611 Facility 35960915 If continuation sheet Page 19 of 42 PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY PLAN or CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 82 01/12/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. SIATE, ZIP come I 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4, in SUMMARY STATEMENT OF DEFICIENCIES 1 ID PLAN or CORRECTION (xs) pagpix I (EACH DEFICIENCY MUST BE PRECEDED av FULL I PREFIX (EACH coRREcTivE SHOULD BE COMPLETION mg 5 REGULATORY on IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE - ll DEFICIENCY) 281 - Continued From page 19 281 Dated 1/16/12 - A new page has been created for the left inner heel, 6x4 cm, Stage dated 1/7/12 - 6x4 cm, Stage I, red, not open, blanches; dated I 1/12/12-624 cm. Stage I, red. not open, blanches. This page is now signed by the unit manager and not the nurse who completed and signed the original assessment on 1/6/12 and I 1/7/12. Dated 1/4/12 - A new page has been created for the left coccyx area, Stage ll Kennedy Ulcer, 2x2 I cm.; 1/12/12 - 2.2x2.2x0.2 cm, pink drainage, open. This page is now signed by the nurse . documenting this information the nurse who actually completed the 1 i assessment on 1/4/12. 3 5 Dated 1/6/12 - A new page has been created for the right sacrumlcoccyx, unstageable, 3.2x3.2x0.2 cm., Kennedy Ulcer; 1/12/12 - I unstageable, 3.2x3.2x0.2 cm., unstageable with eschar. This document is completed by the nurse documenting on 1/12/12 and not the nurse who I did the original assessment on 1/6/12. Dated 1/4/12 - An additional new page has been I created for the entire Coccyx area, Kennedy ulcer, I no measurements; 1/12/12 - unstageable and Stage ll, 5.2x3.5xO.2, Kennedy Ulcer. I Observation of the coccyx area on 1112/ 12 revealed a large reddened area that btanches I slowly with a small area of eschar to the right of the coccyx and a smatl open area to the left of the coccyx. Interview with the unit manager who created i these documents on 1/12/12 revealed she did not complete the assessments on 1/4/12, 1/6/12 and i_ 1/7/12. She stated she had taken the previous I 3 documentation and corrected it on new pages I . I FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 20 of 42. DEPARTMENT OF HEALTH AND HUMAN CENTERS FOR MEDICARE 8. MEDICAID SERVICES PRINTED: 0112412012 FORM APPROVED OMB NO. 0938-0391 - instead of noting the errors on the previous sheets. She stated she had not asked the nurse 1 completing the original assessment to correct her I documentation, but instead did it herself. When asked regarding the documentation of the right i great toe being observed on 1/4/12 and where i that documentation existed, she stated she must I have put the wrong date on the document. She i left the room and returned in approximately 10 minutes with a new document for the right great i toe, which now notes the date first observed to be 1/10/12. The documentation of the wounds for Resident #48 was not clear. It was not able to be i determined on what date the wounds were first observed, what stages they were and the correct I measurements. Documents have been recreated . by staff who did not actually complete the . assessments. These make the assessments I inaccurate. I On 1/12/12 at 11:30 am, The unit manager also I presented for review newly written verbal orders, I dated 1/12/12, from the physician for the wound . care orders received from the wound care - physician on 1/10/12; to cleanse the wound and i apply Granulex every shift. These orders also included the order to discontinue the wound care 5 of skin prep to the right outer ankle and to i discontinue the Duoderrn to the Coccyx. - Review of the previous wound care orders also included a treatment of zinc oxide to the buttocks I every shift and skin prep to the bilateral heels. I The verbal order to discontinue these orders as a previous treatment was not written by the nurse receiving the order to discontinue previous STATEMENT OF DEFICAENCIES (X1) PROWDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING e. WING 105983 0111212012 NAME OF PROVIDER 09 SUPPLIER STREET ADDRESS. CITY, smre, cooe 4733 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4, .0 SUMMARY STATEMENT OF DEFICIENCIES lD Pnovioens PLAN OF CORRECTION ixsi pggirix (EACH DEHCIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD as COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE -I DEFICIENCY) I 281 Continued From page 20 281 FORM Previous Versions Obsolete Event QVM611 Facility ID: 35960915 lf continuation sheet Page 21 of 42 .- PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM APPROVED CENTERS FOR MEDICARE 8. MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (xn PROVIDERISUPPLIERKZLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE sunvev AND PLAN or IDENTIFICATION NUMBER: COMPLETED A. BUILDING . 105983 8 o1I12I2o12 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, crrv, STATE. ZIP coDE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) I0 I SUMMARY STATEMENT or DEFICIENCIES I ID I PROVIDERS PLAN oI= CORRECTION (X5) PREHX I (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I (EACH ACTION B5 COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . DEFICIENCY) I I 281 Continued From page 21 281 treatment. I On at 12:10 p.m. in an interview, the 1 Director of Nursing stated she realizes verbal orders to discontinue all previous orders were not I written. She stated she would review the record 5 and get it corrected. At 12:30 p.m. additional verbal orders were written by the unit manager to discontinue the zinc oxide to the buttocks and to discontinue the skin prep to the bilaterai heels I Iln an interview on 1/12/12 at 1:00 pm, the 3 Director of Nursing stated she was in the process of assessing the wounds of Resident #48 herself. She stated the previous documentation which was created by the unit manager on 1/12/12 was not accurate and she wanted to ensure accurate 4 documentation from this day foiward so Resident #48 could receive the correct treatment and the facility would be aware of the current correct status of the wounds. 329 DRUG REGIMEN IS FREE FROM 329 ss=o UNNECESSARY DRUGS Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any - drug when used in excessive dose (including I duplicate therapy); or for excessive duration; or - I I without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a I resident, the facility must ensure that residents who have not used drugs are not i 1 given these drugs unless drug FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35950915 If continuation sheet Page 22 of 42 - PRINTEDI 01l24l2012 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN or CORRECTION IDENTIFICATION NUMBER: BUMNNG COMPLETED 105983 We 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CFIY, STATE, ZIP CODE CONSULATE HEALTH CARE or SARASOTA 23232 (X4) to SUMMARY STATEMENT or DEFICIENCIES . to 1 PROVIDERS PLAN or CORRECTION (x5) pagnx (EACH DEFICIENCY MUST as PRECEDED av FULL PREFIX - (EACH CORRECTIVE ACTION SHOULD as cormetuon TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG - TO THE APPROPRIATE DATE 1 I DEFICIENCY) . 'iL 329 Continued From page 22 I 3291 therapy is necessary to treat a specific condition I as diagnosed and documented in the Clinical 329 record; and residents who use 1. Resident #48 and 20 parameters for drugs receive gradual dose reductions, and temperature and diagnosis have been ., behavioral interventions, unless clinically I corrected. Pharmacy nurse clinician to I contraindicated, in an effort to discontinue these I I ensure substantial compliance with I I parameters, diagnosis and discontinue I I medication. I 2. All other physician orders W111 2 be reviewed by our pharmacy consultant and facility nurses for appropri?lite . . . . - dia nosis and arameters as in icate . '$1.45 REQUIREMENT IS not met as evidenced 3' Surges and limit m-anager. Wm be 1.e_ Based on record review and interview, the facility edu?.ateC.l on proper I failed to ensure each resident's medication medlcauon and fink I regime was free from unnecessary medications 4- . . rders by failing to adequately provide an indication for I manager new 1' ysman 0 I use of Acetaminophen and to provide directions for Proper alnd parameters .1 on whento administer medication for constipation during mommg Results Ofthe I for 2 (Residents #48 and #20) of 10 residents . audits will be reviewed by the QA reviewed for unnecessary medications. Committee for 3 months to I ensure substantial compliance.. The findings inciude: I Compliance date: 2-12-2012 I On 1/11/12 review of the Medication D, I Administration Record (MAR) for Resident #48 I revealed physician's orders for. "Acetaminophen i 650 mg Suppository insert 1 suppository rectally I every 6 hours as needed for inc. temp." A 2 second order is for "Acetaminophen 650 mg suppository. insert 1 Suppository rectally every 6 hours pm (as needed) for pain. DX (diagnosis). Temp." There is no clarification order in the . record indicating what the temperature would 2; need to be elevated to in order for the i Acetaminophen to be administered as needed. I FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 23 of 42 I I DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8. MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERJCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 105983 01l12I2012 STREET ADDRESS. CITY. STATE. ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 I the Acetaminophen. She also confirmed the diagnosis for the Acetaminophen ordered pm for I pain has an inappropriate diagnosis of "Inc. Temp." I I Review of pharmacy recommendations for I Resident #48 revealed no recommendations regarding temperature parameters for the Acetaminophen. i There was no recommendation to correct the I diagnosis of the Acetaminophen which was I ordered for pain. 1 Interview with the Director of Nursing (DON) on 1/11/12 at 11:05 a.m. confirmed pharmacy has made no recommendations regarding any of the I physician's orders for Acetaminophen. She provided to her by the consulting pharmacist. 2. Review of the MAR for Resident #20 revealed an order for Duicolax Suppository 1 PR (rectally) at 6 a.m. pm (as needed) if Milk of Magnesia not effective for constipation. Further review of the I MAR reveaied the order for the Milk of Magnesia had been discontinued in April, 2011. There was I no order clarification for when to administer the 5 Dulcolax Suppository now that the Milk of Magnesia has been discontinued. Interview with the unit manager where Resident #20 resides revealed the orders for the Milk of Magnesia and the Dulcolax Suppository are routine facility bowel protocol medications and confirmed this after reviewing the reports (X4) ID I SUMMARY STATEMENT or "3 PROVIDERS PIAN OF CORRECTION (x5) (EACH DEFICIENCY MUST as PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg REGULATORY on LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) 329 5 Continued From page 23 329 Interview with the unit manager on 1I11l12 at 10:45 a.m. confirmed there were no parameters of a temperature elevation in which to administer I I FORM Previous Versions Obsolete Event Facility ID: 35960915 If continuation sheet Page 24 of 42 - PRINTED: 01l24l2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 105983 0111212012 STREET ADDRESS, CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA (X4) ID SUMMARY STATEMENT or DEFICIENCIES I in I i=RoviDER's PLAN or CORRECTION Ixsi PREFIX (EACH DEFICIENCY MUST BE PRECEDED sv FULL PREFIX 5 (EACH coRREcTivE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE WE 329 I Continued From page 24 329 pharmacy prints them for everybody, every month i 3 I and the orders have to be hand corrected each 3 month by the nurse performing the 5 change over. She confirmed the order for the I Milk of Magnesia had been discontinued I I approximately 10 months ago, but the pharmacy I had not removed it from the physician's orders and the MAR. I Review of the physician's orders for I December, 2011 reveal the Milk of Magnesia had been hand corrected to reflect the 5 discontinuation. However, the review of the i orders for January, 2012 revealed the order had not been hand corrected to be discontinued and was now signed by the 3 physician making it again an active order. There I were no clarification orders in the chart for the I Milk of Magnesia and the Dulcolax Suppository. I Review of the pharmacy recommendations for Resident #20 revealed there were no recommendations regarding the removal of the discontinued medications. There was no documented recommendations I I regarding clarification of the directions on when to . administer the Dulcolax Suppository. The pharmacy consuitant was not available for interview during this survey. 367 483.35(e) THERAPEUTIC DIET PRESCRIBED I BY PHYSICIAN I 1 Therapeutic diets must be prescribed by the I I I attending physician. 1 I This REQUIREMENT is not met as evidenced I FORM Previous Versions Obsolete Event ID: QVMB11 Facility ID: 35960915 If continuation sheet Page 25 of 42 F'fliGE ATE . H;-rr 3233:2312 11:55 3413i?1454, CDNSUL CENTERS FOR 8. MEDICAID SERVICES OMB No_ o93a.o391 STATEMENT or DEFICIENCIES ixzi coivsrniitzriou 043, DATE gugvgy AND PLAN OF CORRECTION NUMBER A BUIIDWG 1?59" 5 WM o1i12i2n12 0' 9" STREETADDRESS. on v, sure. ZIF com: coiisuum-: HEALTH cane or SARASOTA Rom SARASOTA, FL 34232 (X5: io summer STATEMENT oi= oEi=iciEnciEs to Pnovioen-s Pmiv or CORRECTION 4x5, PREFIX i tFfiCH DEFICIENCY BE PRECEDEU BY FULL erteirix iiytci-I ACTION SHOULD BE COMPLETION TAG REGIJLATORY OR LSC WFORMATION) 1 'mg CROSSREFERENCED To THE APPROFHMTE on-Continued From page 25 36? i by: Based on Observation, record review and staff . interview, the failed to provide the-r'apetitic diets as ordered by the physician for 5 (Residents #66, #68. #41, #43, #20) of 23 residents reviewed This has the potential to effect the i health of the residents. . - 367 The findings include? i. Resident #66 and #20 will be provided . . with a protein stibstiizure. 63, 43 1' The dietary "Om. State #56 '5 and 4] will receive foods as ordered. vegetanan arid fequlres fomhed foods' The . 2. In-house audit will be conducted For mommy phyisman Order for January.' 2.012' Sign-ed ordered diet and compare to tray ticket. - by the physician on 115/12. states diet 'puree with 1 . . taffwm be honey thick liquids. fortified vegetarian. fortified Um aw an foods at meals." The tray ticket states puree and what Ordered is printed out as a 'Regular' diet with the meat '5 entree' instructions printed on the tray ticket the 35 f'eed'ed' i documenting' v-no meaty r1,CDM/Dictaiyinanagcr will audit tray 1 time and dinning room monitor will 5 During observation of the lunch service on monitor meal tray For proper diet as -I 1t11I12 at 11.45 am. the resident's tray ticket i ordered 3 times weekly, results oftt-ic 3 listed "Braised pork tips, parsley carrots, rice and audits will be reviewed by QA committee gravy." When the tray was made up there was no mgmhiy for 3 months to ensure i protein 3Ub5"iUi9 the bl'3l5-ed POW substantial compliance. 5 During an interview on 1/11112 at 2:30 Compliance date;2_12_2012 dietary staff stated they called out no meat when making up tray. Surveyor observed no protein i substitute was served. 7 in an interview on tf12i't2 at 9:00 a,tTt., the certified dietary manager (COM) confirmed the substitutes for a renal diet are not listed on the i I tray ticket. The CUM acknowledged that with the . "no meat" note on the tray ticket the resident is i i not provided with a protein substitute and is not 4 i i provided with a vegetarian diet. i FORM Obsolete Evoni Facility 359609i5 it continuation 5|-my page 2.3 or 4; FRQM (TUEIIJAN 24 2012 :31 PRINTED: 0112412012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPFLIERICLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105933 8' Wm 0111212012 NAME PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARA A FL 34232 (X4) .9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (xsl DEFICIENCY MUST BE PRECEDED av FULL I PREFIX (EACH CORRECTIVE ACTION snoum are COMPLETION TAG REGUUITORY OR LSC IDENTIFYING WFORMAT ION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 367 I Continued From page 26 367: 2. Observation of the tray tickets for three l_ residents on 1/9/12 at 12:15 p.rn. at lunch in the I 1 main dining room revealed two of the tickets were I I i for fortified food and one stated resident to I receive nectar--thick tea. - I Resident #88's tray slip stated super soup. mighty I shake, and coffee; none of which were on the I tray. Resident#-43 did not receive fortified food on her I I tray, as ordered. I I Resident #41 did not get nectar-thick tea. Also. diet beverage of choice was not provided. I The CDM acknowledged the residents were not I served the diets as ordered. 3. A review of the records revealed Resident #20 . is on a diabeticilow concentrated sweets (LCS) 1 and Renal diet. The tray ticket selects the items 5 for the diabetic diet and does not select the I appropriate substitutes for the renal diet. The diet I is not adjusted to the renal diet items. I I A review of the dietary menu extensions showed I potatoes on the diabetic diet should be replaced I with rice for the renat diet and sweet potatoes should be replaced with noodles, for example. I I The CDM confirmed the extension for renal diet is I I not followed. The CDM acknowledged the . I resident is not receiving a renal diet with the LCS I diet. 428 2 483.60(c) DRUG REGIMEN REVIEW, REPORT 428, ss=Dj IRREGULAR, ACT ON 7 The drug regimen of each resident must be I a I FORM Previous Versions Obsolete Event Facility ID: 35960915 If continuation sheet Page 27 of 42 PRINTED: 01124/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE suavsv AND PLAN or CORRECTION IDENTIHCATION NUMBER: COMPLETED A. BUILDING 105933 B) W6 0111212012 NAME PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE 4783 FRUITVILLE ROAD CA EOF A SOTA ONSULA EHEALTH RA SARASOTA FL 34232 (xi, .0 summer STATEMENT OF DEFICIENCIES ID i PROVIDERS PLAN or CORRECTION (X5) PREFIX (EACH MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTICN SHOULD BE COMPLETION TAG REGULATORY OR LS0 IDENTIFYING INFORMATION) I TAG CROSS-REFERENCED TO THE APPROPRIATE DATE A 3 DEFICIENCY4281 Continued From page 27 I 423' reviewed at ieast once a month by a iicensed - pharmacist. 428 1. Resident 48 physician has clarified I, The pharmacist must report any irregularities to I for parametersand diagnosis. I the attending physician, and the director of i 2. Pharmacy consultant will reviewed nursing, and these reports must be acted upon. 1 orders during visits for parameters and diagnosis 3. Pharmacy consultant, nurses have been 3 re-educated on proper diagnosis and 'i 3 parameters for medications. . 4. 1' 211 Service unit I Ems REQUIREMENT is not met as evidenced mangjg Orders yz . . . . . during morning meeting for diagnosis and Based on record review andinterview, the facility I parameters. Pharmacy Consultant will to the attending physician and the Director of audits will be reviewed at.QA for 3. 5 Nursing for 2 (Residents #48 and #20) of 10 months to ensure substantial compliance residents reviewed for unnecessary medications I and be take" t? QA and pharmacy review. Compliance date: 2-12-2012 . The findings include: i 1. on 1/11/12 review of the Medication I I Administration Record (MAR) for Resident #48 1 revealed physician's orders for, "Acetaminophen 3 650 mg Suppository insert 1 Suppository rectally every 6 hours as needed for inc. temp." A second order is for "Acetaminophen 650 mg suppository, insert 1 suppository rectaliy every 6 I hours pm (as needed) for pain. DX (diagnosis), 1 "Inc. Temp" There is no clarification order in the record indicating what the temperature would need to be elevated to in order for the I Acetaminophen to be administered as needed. Interview with the unit manager on 1/11/12 at I 10:45 a.m. confirmed there were no parameters i i i FORM Previous Versions Otisoiete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 28 of 42 FROM 24 2012 :33 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) PROVIDERISUPPLIERICLIA Ixzi MULTIPLE CONSTRUCTION Ixai DATE SURVEY AND PLAN oI= CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BU1LDING 105983 3' Wm 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP coDE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (x4)1D 3 SUMMARY STATEMENT OF DEFICIENCIES i ID 1 PLAN OF CORRECTION (X5) 2 (EACH DEFICIENCY MUST BE PRECEDED BY FULL I (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg I REGULATORY OR LSC INFORMATION) TAG I CROSS-REFERENCED TO THE APPROPRIATE DATE - DEFICIENCY) I 428 Continued From page '.28 428' of a temperature elevation in which to administer the Acetaminophen. She aiso confirmed the diagnosis for the Acetaminophen ordered pm for I pain has an inappropriate diagnosis of "Inc. I . 1 Temp." I Review of pharmacy recommendations for I Resident #48 revealed no recommendations regarding temperature parameters for the Acetaminophen 5 There was no recommendation to correct the I i diagnosis of the Acetaminophen which was I ordered for pain. i 1 . I Interview with the Director of Nursing (DON) on 1/11/12 at 11:05 a.m. confirmed pharmacy has 1 made no recommendations regarding any of the physician's orders for Acetaminophen. She confirmed this after reviewing the reports I provided to her by the consulting pharmacist. 1 2. Review of the MAR for Resident #20 revealed an order for Dulcolax Suppository PR (rectally) at 6 am, pm (as needed) if Miik of Magnesia not I effective for constipation Further review of the I MAR revealed the order for the Milk of Magnesia had been discontinued in April, 2011 There was I no order clarification for when to administer the I Dulcolax Suppository new that the Milk of Magnesia has been discontinued. 1 Interview with the unit manager where Resident I #20 resides revealed the orders for the Mitk of I Magnesia and the Dulcolax Suppository are 1 I routine facility bowel protocol medications and I 5 pharmacy prints them for everybody, every month and the orders have to be hand corrected each I FORM Previous Versions Obsolete Event Facitity ID: 35960915 If continuation Sheet Page 29 of 42 I DEPARTMENT OF HEALTH AND HUMAN SERVICES 14 zuuz Iqzuaslbl. :54 PRINTED: FORM APPROVED CENTERS FOR MEDICARE 3. MEDICAID OMB NO. STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION COMPLETED A. BUILDING 105933 8' Wm 01!12l2012 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA ADDRESS, CITY, STATE, ZIP CODE 47233 FRUITVILLE ROAD SARASOTA, FL 34232 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID 3 PREFIX 1 TAG I To PLAN OF CORRECTION (X5) (EACH CORRECTIVE ACTION SHOULD BE commerron TAG CROSS-REFERENCED To THE DATE DEFICIENCY) I 4428' Continued From page 29 month by the nurse performing the change over. She confirmed the order for the I Milk of Magnesia had been discontinued approximately 10 months ago, but the pharmacy had not removed it from the physician's I orders and the MAR. Review of the physician's orders for I December, 2011 reveal the Milk of Magnesia had I been hand corrected to reflect the I I I discontinuation. However, the review of the orders for January, 2012 revealed the order had not been hand Corrected to be discontinued and was now signed by the physician making it again an active order. There were no clarification orders in the chart for the i Milk of Magnesia and the Dulcoiax Suppository. 1 Review of the pharmacy recommendations for Resident #20 revealed there were no recommendations regarding the i removal of the discontinued medications. There was no documented recommendations regarding clarification of the directions on when to i administer the Dulcolax Suppository. The pharmacy consultant was not available for I interview during this survey. 455} ESSENTIAL EQUIPMENT, SAFE . OPERATING CONDITION The facility must maintain all essential I I mechanical, electrical, and patient care 1 1 equipment in safe operating condition. A I This REQUIREMENT is not met as evidenced . by. 428 456 FORM Previous Versions Obsolete Event Facility ID: 36960915 if continuation sheet Page 30 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: 0112412012 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF OEFICIENCIES (X1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 105983 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA (x2; MULTIPLE CONSTRUCTION (x3) DATE SURVEY COMPLETED A. BUILDING B. WING 01I1 21201 2 STREET ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 (x4) In 1 SUMMARY STATEMENT or DEFICIENCIES ID i PLAN or CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL pnenx (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY on IDENTIFYING INFORMATION) me CROSS-REFERENCED TO THE APPROPRIATE DATE I I 455 - Continued From page 30 456I Based on observation and interview, the facility failed to ensure equipment in the laundry room 1: 455 was in safe operating condition. I Inside of dryer was Cleaned The findings include: each for Observation during the facility tour on 1/12/12 at 3' La""d"3' Siaffhas bee" 0" I 9:30 a.m. in the Dresence of the Administrator pmger cleanmg of dryer fm debris and I Administrative Assistant, Director of Maintenance, I re" .ue and Director of Housekeeping and Laundry I 4' DIreC.t0.r of Hous?kfieping/Laundry and i revealed the inside of dryer #1 (of the 2 dryers in or Conduct random the laundry room) with a large accumulation of dryer drums for debris I rust, dried name tags and dried residue lining the and_reS1due- Results of the audits will be I drum inside the dryer. Faiture to ensure the by the QA C0mmittEUR'3 m011thI)' inside of the dryer is free of hardened debris and I0 ensure Substantial compliance, residue increases the potential risk of a fire. . Compliance date: 2-12-2012 I The Director of Housekeeping/Laundry indicated they clean their dryers at least once a quarter; however, stated he wouid have it cleaned immediately. A 469 I MAINTAINS EFFECTIVE PEST I 4639; 35:0 5 CONTROL PROGRAM I I I I The facility must maintain an effective pest I 1 i oontroi program so that the facility is free of pests 3 and rodents. I I i I This REQUIREMENT is not met as evidenced i by: I Based on observation and interview, the facility failed to maintain an effective pest control program as evidenced by moth nests lining the corners of the tops of the walls in the storage 3 room on the SSU unit. FORM Previous Versions Obsolete Event ID: Facility '01 35960915 If continuation sheet Page 31 of 42 LIJIA: :38 PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) PROWDERISUPPLIERICLIA (X2) CONSTRUCTION (x3) DATE SURVEY AND PLAN OF IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105933 at We o1Ii212o12 NAME OF PROVKJER 0R 3U PPUER STREET ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD LT CAR OF SARA TA CON ULATE HEA S0 SARASOTA, FL 34232 I (X4) ID SUMMARY STATEMENT OF I ID PLAN OF CORRECTION (K5) (EACH MUST BE PRECEDED av run A PREFIX CORRECTNE ACTION SHOULD se COMPLETION TAG REGULATORY on LSC INFORMATION) - TAG I CROSS-REFERENCED TO THE APPROPRIATE DATE It 1 469i Continued From page 31 469 469 1. Moth nests have been removed from storage room on the SSU unit. Areas has been thoroughly cleaned. 2. Pest control service will be maintained and as needed 3. Staff will in-serviced on the process of i The findings include: Observation during the tour of the facility on 1/12/12 at 10:00 a.m. in the presence of the 1 Administrator, Assistanmdministrator, 4 Housekeeping and Laundry Director as well as 1 Director of Maintenance (DM) revealed small . . . nests creviced in between the seams of the wall 3 repereng any Pest to the Dlreeter and the ceiling in the clean storage room where ef melntenemee and er the Direeter 0f i res'ident--care equipment (wheelchairs, positioning He"5ekeeP1"g- devices) was stored.. The DM stated finch food 4- Randvm Rounds be conducted by used to_be kept in this room and would notify pest the Direct" Of Maintenance/Designm 3 control immediately to evaluate the situation. Findings Will be 13)/the QA committee for 3 months to ensure Interview with the DM on 1/12/12 at 1:00 p.m_ I substantial compliance. revealed the pest control company had found a 50 lb bag of bird food in which moths were hatching and then going up to the ceiling to nest. Compliance date: 2-12-2012 i He stated they would work on removing the pests 1 immediately. 5141 RES 514 LE .. . . . 9* The facility must maintain clinicai records on each I 5 resident in accordance with accepted professional 1, standards and practices that are complete; accurately documented; readily accessible; and systematically organized. 5 The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; A 5 and progress notes. I I FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 lf continuation sheet Page 32 of 42 . DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES . - U- PRINTED: 0112412012 FORM APPROVED OMB NO. 0938-0391 means. Her eating status has declined and she no longer eats as much as she used to. Due to inadequate nutrition and the breakdown of her systems, she has developed Kennedy Ulcers. A Kennedy Ulcer is a terminal ulcer that hospice i patients get with the breakdown of their systems. These were first observed on 1/4/12. On 1l10/12, i the wound-care specialist saw her when he made his weekly rounds in the facility, at which time he . STATEMENT or DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION ixai DATE SURVEY mo PLAN or CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 8' WW3 01I12I2012 NAME OF PROVIDER OR SUPPUER srneer ADDRESS, CITY, STATE. ZIP cone 4733 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4) lo SUMMARY STATEMENT or DEFICIENCIES ID Pnovioens PLAN or CORRECTION 3 (X5) pagnx (EACH MUST ee PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD se COMPLETION TAG REGULATORY on LSC mg TO me APPROPRIATE DATE IIENCY) 514 2 Continued From page 32 514 This REQUIREMENT is not met as evidenced by: Based on observation, record review and interview, the facility failed to ensure clinical F514 records are complete and accurate by failing to i i document accurately pressure ulcer assessment, Resident #48 Skin issues have been re 5 failure to write verbal physician 5 orders for 2 assessed medical record has been days after they were received and failing to . ted' transcribe and implement those orders until after they were written for 1 (Resident #48) of 1 2- other . i resident who was reviewed for pressure ulcer ha" been revlewe an 'i assessment and documentation. record have been uPdatEURd- i 3. Nurses Will be re--educated on physician The findings include: orders being resident medical record as indicated. interview with the nurse responsible for the care 1 4. Director of Clinical services/ and of Resident #48 on 1/9/ 12 revealed Resident #48 I designee will audit skin sheets times i has a Stage lli pressure ulcer to her coccyx area. 3 weekly. Results of the audits will be i The nurse reports Resident #48 is a hospice I reviewed by the QA committee i resident, has poor nutrition which would cause for 3 months to ensure substantial skin to breakdown easily and cause poor/slow I Compiianm lheafing. i . {Compliance date: 2-12-2012 Review of the medical record for Resident #48 revealed she is a hospice patientrecent decline in her status and most recently has i I), a diagnosis of failure to "thrive. She has a living will and the facility and family are honoring her choices to keep comfortable without additional FORM Previous Versions Obsolete Event ID: Facility ID: 359609'l5 if continuation sheet Page 33 of 42 tosacboonuuvo av PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 WM o1/12/2012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD CONS LATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4, In . SUMMARY STATEMENT OF DEFICIENCIES Io PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX - (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE I DEFICIENCY) I 1 514! Continued From page 33 514 provided the diagnosis of Kennedy Ulcers. On 1/12/12, review of the pressure ulcer 1 assessment sheets revealed the following I documenting descriptions of the pressure ulcers 1 for Resident #48: Dated 1/2/12 - Coccyx 3x3x2 cm., Stage II. I Wound care indicates this area is covered with a i duoderm, which is Changed every 3 days and prn; 1, Dated 1/4/12 -- Area to the right of the Coccyx 2x2x0.2 cm, Stage 11, covered with a duoderm. A - second note of this area, same date/same page, . notes this area as a Stage and a third area on this same line notes it as unstageable. An update 1 on 1/7/12 notes the area as Stage II, with . 3 measurements of2.3x2.3x1.2 cm and a note that 3 1 says "no improvements," - Dated 1/6/12 and 1/7/12 Left heel Stage II, 6x4 . cm. No improvement, observed first on 1/6/12, I and I Dated 1/6/12 and 1/7112 - Right Iteet Stage II, 4x2 I cm. NO improvement, observed first on 1/6/12, I Visit on 1/10/12 from the wound care physician documents: 1 heel -- Stage I, Left heel -- Stage I, Coccyx - unstageable. Plan of treatment is documented on the physician notes to include; cleansing the wound; applying . granulex spray, and leave the wound open to air. i The physician assessment does not address two I areas around the Coccyx area. Interview with the Unit Manager and the Director I of Nursing (DON) on 1/12/12 at 9130 a.m. I I revealed the documentation by the nurse on the I assessment of the pressure ulcers is inaccurate. I They both report the pressure ulcers on the heels 1 I I I FORM cMs-2se7(o2--99) Previous Versions Obsotele Event ID: Facility ID: 35960915 If continuation sheet Page 34 of 420 PRINTED: 01/2412012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FQRM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 09380391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLTERICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMELETED A. BUILDING . 105933 3 0111212012 NAME OF PROVIDER OR SUPPUER STREET ADDRESS. CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD SARASOTA. FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) ID i SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) pREFlx I (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG TO THE DATE DEFICIENCY) 514 Continued From page 34 I 514 are Stage I and have never been Stage ll, as the I skin was never broken but was only red and blanchable. They both report the Coccyx has two I. areas; one has black eschar and is unstageable A . and the other is a Stage ll. They both Confirm 1 there is no Stage pressure ulcer. Review of the medical record for Resident #48 1 revealed no physician's orders for the 3 recommended treatment from the wound care 1 physician. in an interview on 1/12/12 at 9:45 the unit I manager on the unit for Resident #48 stated she I I was with the wound care physician when he I I visited with Resident #48 on 1/10/12. She stated the physician was aware the resident was under hospice care and wanted the current treatment to continue until the medication could be obtained 1 from hospice. When asked if she had contacted I hospice regarding the medication, she said she "only received the documented treatment plan this morning" because they had been in her box . since 1/11/12. She further stated a nurse who I I worked the hallway said she would Contact hospice regarding wound care supplies and I medication. The unit manager stated she had not I I I checked to see if the orders were initiated, or if the nurse had contacted hospice. She confirmed there is no documentation in the medical record regarding orders for the wound care or the notification to hospice. When asked why she did not contact hospice regarding the wound Care I recommendations as She was with the physician when he verbally reported to her the treatment I plan he wanted, she stated she thought the floor . nurse would be completing this task. When asked i why she did not write the verbal order for the i FORM Previous Versions Obsolete Event Facility ID: 35950915 |f continuation sheet Page 35 of 42p PRINTED: DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-D391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 3' Wm 0111212012 NAME OF PROWDER OR SUPPUER STREET ADDRESS. CITY. STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (X4) In I SUMMARY STATEMENT OF DEEICIENCIES ID PLAN OF CORRECTION (X5) PREFIX I (EACH MUST BE PRECEDED BY FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD as COMPLETION TAG REGULATORY OR INFORMATION) TAG TE: THE APPROPRIATE . DEFI I CY) I I 514 Continued From page 35 i 514 I treatment plan the wound care physician wanted i she stated she was waiting to hear from hospice. i The wound care treatment ordered by the wound - care physician on 1/10/12 had not been written. implemented or applied as of 1/12/12 at 10:30 a.m. i Observation of the wounds for Resident #48 revealed the right foot wound was clear, there . was no redness or open areas and the heel 1 blanches well. The Stage I to the left inner heel I remained present. The left inner heel remained . red and is unblanchable. A red area was noted to . the tip of the great toe On the right foot. This area has a tiny open spot on the tip. The wound to the toe was classified by the physician as an arterial wound. The wound to the Coccyx/sacrum area was a very large reddened area. The caudal and I of the wound had a dime~sized open area. A second, smaller open area was below the first one and has a blackened area that is 1 unstageable. The physician documented this as a Kennedy Terminal Ulcer. The wound has increased in size since reviewed by the physician on 1/10/12, however the physician has noted the treatment for this wound is palliation. Wound care plan of treatment by the physician i indicates cleansing the wound. apply Granulex every shift and ieave open to air. As of 1/12/12 at 10:30 am, there are no written physician orders, . the Granulex medication for treatment has not i - been ordered or obtained by the facility, therefore I the treatment could not be applied as ordered. . The area, noted on 1/10/12 by the wound care physician to the great toe on the right foot, has I i I i FORM Previous Versions Obsolete Event l0: QVM611 Facility ID: 35960915 If continuation sheet Page 35 of 42 PRINTED: DEPARTMENT OF HEALTH AND HUMAN FORM APPROVED CENTERS FOR MEDICARE 8i MEDICAID OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) (x2) MULTIPLE CONSTRUCTION (x3) DATE sunvev AND PLAN OF coRRecTioI~r IDENTIFICATION COMPLETED A. BUILDING 105983 3' W6 01/12/2012 NAME OF PROVIDER OR SUPPLIER srneer Aooness. CITY, STATE, ZIP code 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (x4; is SUMMARY STATEMENT OF oei=IcIeNcIEs i to PLAN OF CORRECTION (X5) PREFIX (EACH MUST BE PReceoEo av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg; REGULATORY oR LSC IDENTIFYING INFORMATION) I TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 514 3 Continued From page 36 514 not been noted by the facility staff nor has it been i addressed on the skin assessment sheets before or after it was noted by the MD. On 1/12/12 at around 11:30 the unit manager approached the surveyor with new documentation regarding the wounds: . Dated 1/12/12 - Right great toe, 02x02 cm, red I scab, blister, vascular; first observed on 1/4/12. This documentation was created on 1/12/12. There is no documentation dated 1/4/12 of this wound; Dated 1/12/12 -- Right heel, Resolved (this is a continuation on the page above addressing the I right heel); Dated 1/16/12 - A new page has been created for the left inner heel, 6x4 cm., Stage dated 1/7/12 - 6x4 cm., Stage 1, red, not open, blanches; dated 1/12/12 -- 6.24 cm., Stage I, red, not open, . blanches. This page is now signed by the unit manager and not the nurse who completed and signed the original assessment on 1/6/12 and 1/7/12. i Dated 1/4/12 -- A new page has been created for the left coccyx area, Stage II Kennedy Ulcer, 2x2 cm.; 1/12/12 cm., pink drainage, open. This page is now signed by the nurse documenting this information on 1/12/12 and not the nurse who actually completed the I assessment on 1/4/12. i Dated 1/6/12 - A new page has been created for i the right sacrum/coccyx, unstageable, i 3.2x3.2x0.2 cm., Kennedy Ulcer; 1/12/12 - - I i unstageable, 3.2x3.2x0.2 cm., unstageable with eschar. This document is completed by the nurse documenting on 1/12/12 and not the nurse who i did the original assessment on 1/6/12. Dated 1/4/12 - An additional new page has been i - i FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 37 of 42 . -v4. PRINTED: 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE 8: MEDICAID SERVICES OMB NO. 0933-0391 STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN oF CORRECTION NUMBER: COMPLETED A. BUILDING I 7 ..- .1 105983 01/12/2012 NAME OF PROVIDER OR SUPPLIER STREET AooREss, CITY, STATE. ZIP cone 4733 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA out In SUMMARY STATEMENT OF ID PLAN OF CORRECTION (x5) A (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECT SVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) 1 TAG . CROSS-REFERENCED TO THE APPROPRIATE DATE I I I DEFICIENCY) I I 514 . Continued From page 37 5142 . created for the entire coccyx area, Kennedy ulcer, no measurements; 1/12/12 -- unstageable and I Stage II, 5.2x3.5xO.2, Kennedy Ulcer. 3 Observation of the coccyx area on 1/12/12 I revealed a large reddened area that blanches . slowly with a smalt area of eschar to the right of I the Coccyx and a small Open area to the left of the' . . coccyx. i I lnterview with the unit manager who created I these documents on 1/12/12 revealed she did not complete the assessments on 1/4/12, and I 1/7/12. She stated she had taken the previous documentation and corrected it on new pages instead of noting the errors on the previous i sheets. She stated she had not asked the nurse I I completing the original assessment to correct her I documentation, but instead did it herself. When I asked regarding the documentation of the right great toe being observed on 1/4/12 and where that documentation existed, she stated she must 3 have put the wrong date on the document. She left the room and returned in approximately 10 minutes with a new document for the right great I toe. which now notes the date first observed to be 1/10/12. I The documentation of the wounds for Resident I #48 was not clear. It was not able to be I determined on what date the wounds were first I observed, what stages they were and the correct I measurements. Documents have been recreated by staff who did not actualiy complete the I assessments. These make the assessments 1. inaccurate. I On 1/12/12 at 11:30 am., The unit manager also I I FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 38 at 42' PRINTED: 01/2412012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) PROWDERISUPPLIERICLIA Ix2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 8' Wm 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODE CONSULATE HEALTH CARE OF SARASOTA '"83 Rm" SARASOTA. FL 34232 (X4, In I SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) pagsix - (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX - (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg I REGULATORY OR LSC TAG I TO THE APPROPRIATE W5 I I DEFICIENCY) i 514 Continued From page 38 I 514' . presented for review newly written verbal orders. dated 1/12/12, from the physician for the wound care orders received from the wound care I I physician on 1/10/12; to cieanse the wound and I apply Granulex every shift. These orders also i included the order to discontinue the wound care of skin prep to the right outer ankle and to . discontinue the Duoderm to the coccyx. Review of the previous wound care orders also included a treatment of zinc oxide to the buttocks every shift and skin prep to the bilateral heels. The verbal order to discontinue these orders as a I previous treatment was not written by the nurse . 1 receiving the order to discontinue previous I treatment. I On 1/12/12 at 12:10 p.m. in an interview. the I i Director of Nursing stated she realizes verbal orders to discontinue all previous orders were not written. She stated she would review the record and get it corrected. At 12:30 p.m. additional verbal orders were written by the unit manager to I discontinue the zinc oxide to the buttocks and to I discontinue the skin prep to the bilateral heels. In an interview on at 1:00 the Director of Nursing stated she was in the process I of assessing the wounds of Resident #48 herself. 5 She stated the previous documentation which i was created by the unit manager on 1112/12 was I not accurate and she wanted to ensure accurate documentation from this day forward so Resident #48 could receive the correct treatment and the facility would be aware of the current correct I status of the wounds. I - 520! OAA I 520 33:13 COMMITTEBMEMBERSIMEET FORM Previous Versions Obsolete Event ID: QVM611 Facility ID: 35960915 If continuation sheet Page 39 of 42 . -cw PRINTED: 01124/2012 FORM APPROVED OMB NO. 0938-0391 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICAID SERVICES STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIEFUCLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 105933 0111212012 NAME OF PROVIDER OR SUPPUER smear ADDRESS. CITY. STATE, ZIP cooe 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID I r=RovIoER's PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX I (EACH CORRECTIVE ACTION SHOULD as COMPLETION mg REGUIATORY on LSC IDENTIFYING INFORMATION) TAG . CROSS--REFERENCED TO THE APPROPRIATE DATE 1 DEFICIENCY) I 520 Continued From page 39 520i 5 I I I A must maintain a quality assessment and F520 nursing services; a physician designated by the facility; and at least 3 other members of the I facility's staff. The facility will conduct 5 weekly I standup QA committee meetings to discuss facility issues and develop plans of action for correction and satisfactory resolution. assurance committee consisting of the director of Deficiencies Cited will be Corrected. I I The quality assessment and assurance I committee meets at least quarterly to identity I 3 issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of - action to correct identified quality deficiencies. Facility will conduct quarterly QA meetings to include reports, audits, trends, etc to develop plans for satisfactory A State or the Secretary may not require I disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the I requirements of this section. i Good faith attempts by the committee to identify I and correct quality deficiencies will not be used as I a basis for sanctions. This REQUIREMENT is not met as evidenced by: . Based on observation, review of the facitity's 5 quality assurance program and interview with the I Administrator responsible for the oversight of the I program, the facility failed to develop and . implement and appropriate a plan of action 5 related to maintaining a safe, comfortable and sanitary environment. The findings include: - i outcomes and monitoring. Continued compliance will be monitored by the QA Committee. Compliance date: 2-12-2012 9/at FORM Previous Versions Obsolete Event ID: OVM611 FaCili1yID: 35960915 if continuation sheet Page 40 of 42 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8. SERVICES PRINTED: 01/24/2012 FORM APPROVED OMB N0. 0938-0391 I An annual recertification survey was conducted at I the facility on 1/9/12 through 1/12/12. During the Stage I investigation of the numerous . I resident rooms were observed to be in disrepair. A focused tour of the environment was conducted on 1/12112 between 8:00 am. and 10:30 a.m. in i the presence of the Administrator (ADM), Administrator/Assistant, Director of Maintenance (DOM) and Director of Housekeeping and 2 Laundry (DHL). The disrepair in the resident 5 rooms was confirmed. Refer to F253. 5 Additional environmental concerns as well as equipment concerns were also identified on 1/12/12 during this same focused tour. Refergto F456 and F469. 5 During the quality assurance program review on 1112/12 at 11:10 the Administrator indicated they identified resident rooms were in need of repair and were working on those repairs. He did not have available -- at the time of the review - the i plan of action toward room completion and I "wanted to meet later" and show the survey team the plan of action. i lnterview with the Administrator on 1/12/12 at i 2:00 p.m. revealed the facility has been doing renovations slowly due to their census capacity. When asked if he developed a plan to show how i . the facility was going to proceed in finishing the renovations. he stated, "he didn't develop one because he couldn't lie and therefore couldn't commit to a definitive time frame for completion 1 I of room renovation." He confirmed the facility 5 faiied to develop a plan of action or target goals STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE surzvev AND PLAN or-' CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 105983 3' Wm 0111212012 NAME OF PRUWDER OR STREET ADDRESS. CITY. STATE, ZIP cope A 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4, in SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED av FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING - TAG CROSS-REFERENCED TO THE APPROPRIATE DATE 3 . DEFICIENCY) - 520 . Continued From page 40 FORM Previous Versions Obsolete Event ID: CNM611 Facility 35960915 lf continuation sheet Page 41 of 42 24 2012 14:35/sr. 46 01/24/2012 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT or DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE sunvev AND PLAN or CORRECTION IDENTIFICATION A. BUILDING 105933 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 CONSULATE HEALTH CARE OF SARASOTA 4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS OF CORRECTION i (X5) (EACH DEFICIENCY MUST BE PRECEDED av FULL I PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION mg REGULATORY OR LSC INFORMATION) mg TO THE APPROPRIATE DATE I i DEFICIENCY) i . . 520 Continued From page 41 I 520 2 toward room Completion. I The quality assurance Committee failed to identify areas of environmental concerns within the I failed to develop and imptement a plan of action as to how they were going to Correct the . areas of concern. and failed to monitor the effect of any renovations they had Completed in order to I make needed revisions as necessary. i I I FORM CMS-256302-99) Previous Versions Obsolete Event ID: QVM611 Fa-Cility ID: 35960915 If continuation sheet Page 42 of 42 B5l'85 consuLnTE oz/o3r2e12 11:55 Agency for Health Care Administration STATEMENT OF DEFICIENCIES AND Pultrt (xii FROVIDERJSUPPLIERICLM NUMBER 35960915 NAME OF PROVIDER St_lPPLifiR CONSULATE HEALTH CARE OF SARASOTA FORM APPROVED my MULTIPLE (13) DATE SURVEY BIUILDING I3. WING 01l1 212012 STREET ADDRESS. STATE. CODE 4733 FFIUITVILLE ROAD SARASOTA. Fl. 34232 5 prescribed and if not followed, the reason shall be recorded on the residents medical record during that shift. i This Statute or Rule is not met as evidenced by? Based on observation, record review and interview, the facility failed to follow physician's orders by failing to write verbal orders for 2 days after they were received and failing to implement those orders until after they were written for 1 (Resdient #43) of 1 resident records reviewed for pressure ulcer treatment orders. The findings include: . interview with the nurse responsible for the care of Resident #48 on 1i9r12 revealed Resident #48 has a Stage pressure ulcer to her coccyx area. The nurse reports Resident #48 is a hospice' 5 resident, has poor nutrition which would cause skin to breakdown easily and cause poor/slow in; ID SUMMARY smremeur or oemclencies fl peovroen-s PLAN or connecrion rxsi iertcn DEFICIENCY MUST I:-is nneceneo av . Pfigpix iiyxcn CORRECTIVE ACTION SHOULD ee COMPLETE TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-QEFERENCED To THE APPROPRIATE DATE- DEFICIENCY) I 4 INTTIAL 000 This is annual re-certification survey conducted 1f9i'12 through at Consulate of Sarasota, a skilled nursing facility (SNF). The facility does not comply with Chapter 429 . Florida Statute and 58A-4 Florida Administrative lCode. . 054: Follow Physician Orders 054 35:01 i lssneioirsy 054 All physician orders shall be followed as Resident ti 43 has correct' wound measurements and treatment orders in i place. An audit of current residents with pressure ulcers was corn.plcted.. Licensed nurses will be in-serviced on measuring and documenting wounds and obtaining physician orders for treatment. will audit the wound care sheets weekly for 3 months. The will do random weekly audits of the wound sheets for 3 months. Results ofthc audits will be reviewed by the QA committee for 3 months to ensure substantial compliance. Compliance date: 2-l2--20l.2 healing. AHCA Form 309 - U01 (J3-Q, TITLE DATE meonaroev or '5 on nerreeseurxmve-s M, or?" 2.. 1' Zr" STATE FORM saw QVM51, continuation sheet 1 or 32 Lexi 22 1 ll: 1 ll: 1(3l1 F5 5511 PRINTED: 01/24/2012 FORM APPROVED Aqency for Health Care Administration STATEMENT OF DEHCIENCIES (X1) X2 CONSTRUCTIO (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. BUILDING B. WING 35950915 01/12/2012 NAME 0.: PROVIDER on suppugn STREET ADDRESS, CITY, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4) to . SUMMARY STATEMENT OF in PLAN OF CORRECTION (X5) PREFIX - (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFI (EACH CORRECTIVE ACTION SHOULD as COMPLETE TAG REGULATORY OR LSC IDENTIFYING TAG CROSS--REFERENCED TO THE APPROPRIATE one I DEFICIENCY) - 054 Continued From page 1 054 i I I Review of the medical record for Resident #48 revealed she is a hospice patient. She had a recent decline in her status and most recently has 1 a diagnosis of failure to thrive. She has a living will and the facility and family are honoring her choices to keep comfortable without additional means. Her eating status has declined and she - no longer eats as much as she used to. Due to inadequate nutrition and the breakdown of her systems, she has developed Kennedy Ulcers. A Kennedy Ulcer is a terminal ulcer that hospice patients get with the breakdown of their systems. These were first observed on 1/4/12. On 1/10/12, the wound-care specialist saw her when he made his weekly rounds in the facility, at which time he provided the diagnosis of Kennedy Ulcers. . On 1/12/12, review of the pressure ulcer assessment sheets revealed the following documenting descriptions of the pressure ulcers for Resident #48: Dated 1/2/12 - Coccyx 3x3x2 cm., Stage ll. Wound care indicates this area is covered with a duoderm, which is changed every 3 days and pm; 0 Dated 1/4/12 - Area to the right of the coccyx 2x2x0.2 cm., Stage ll, covered with a duoderm. A second note of this area, same date/same page, notes this area as a Stage and a third area On this same line notes it as unstageable. An update on 1/7/12 notes the area as Stage II, with 5 measurements of2.3x2.3x1.2 cm and a note that says "no improvements;" Dated 1/6/12 and 1/7/12 - Left heel Stage II, 6x4 cm. NO improvement, observed first on 1/6/12, and 7 Dated 1/6/12 and 1/7/12 - Right heel Stage ll, 4x2 cm. NO improvement, Observed first on 1/6/12. Visit on 1/10/12 from the wound care physician documents: I 1 AHCA Form 3020-0001 STATE FORM 6899 QVM611 If continuation sheet 2 oi 32_ ulifd 2211 QZCI1 S2 1 ll 1 11: 5255 1 (311 5553 01i24l2012 FORM APPROVED Aqency for Health Care Administration STATEMENT OF (X1) x2 (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. B. WING 35950915 0111212012 NAME or pnovtoea on suppuga STREET ADDRESS. CITY. STATE. ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE os SARASOTA SARASOTA FL 34232 (X4) 513 3 SUMMARY STATEMENT OF so PLAN OF CORRECTION (X5) 1 (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSSREFERENCED TO THE DATE DEFICIENCY) 054 Continued From page 2 054 heel Stage l, Left heel -- Stage 1, Coccyx -- I unstageable. Plan of treatment is documented on the physician 1 notes to include: cleansing the wound; applying granulex spray. and leave the wound open to air. The physician assessment does not address two areas around the coccyx area. interview with the Unit Manager and the Director of Nursing (DON) on 1/12/12 at 9:30 a.m. 5 revealed the documentation by the nurse on the assessment of the pressure ulcers is inaccurate. They both report the pressure ulcers on the heeis are Stage I and have never been Stage H, as the skin was never broken but was only red and bianchable. They both report the coccyx has two areas; one has black eschar and is unstageable and the other is a Stage ll. They both confirm there is no Stage pressure ulcer. Review of the medical record for Resident #48 3 revealed no physician's orders for the recommended treatment from the wound care physician. 1 In an interview on 1/12/12 at 9:45 am.. the unit manager on the unit for Resident #48 stated she was with the wound care physician when he . visited with Resident #48 on 1/10/12. She stated the physician was aware the resident was under hospice care and wanted the current treatment to continue until the medication could be obtained from hospice. When asked if she had contacted hospice regarding the medication, she said she "only received the documented treatment plan this morning" because they had been in her box since 1/11/12. She further stated a nurse who worked the hallway said she would contact hospice regarding wound care supplies and medication. The unit manager stated she had not AHCA Form S020-0001 STATE FORM 6889 QVM611 It continuation sheet 3 of 32' 5-pzgm 24 2012 14:25/No. 7538551104 58 PRINTED: 0112412012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING B. WING 35950915 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA FL 34232 (x4, "3 SUMMARY STATEMENT or DEFICIENCIES in PIAN or CORRECTION (x5; - pREFix (EACH DEFICIENCY MUST BE PRECEDED BY FULL I (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 'j me CROSSREFERENCED TO THE APPROPRIATE DATE I DEFICIENCY) 054: Continued From page 3 054 checked to see if the orders were initiated, or if the nurse had contacted hospice. She confirmed - there is no documentation in the medical record regarding orders for the wound care or the notification to hospice. When asked why she did not contact hospice regarding the wound care recommendations as she was with the physician when he verbally reported to her the treatment plan he wanted, she stated she thought the floor nurse would be completing this task. When asked why she did not write the verbal order for the treatment plan the wound care physician wanted she stated she was waiting to hear from hospice. The wound care treatment ordered by the wound care physician on 1/10/12 had not been written, Imptemented or applied as of 1I12l12 at 10:30 a.m. I Observation of the wounds for Resident #48 revealed the right foot wound was clear, there was no redness or open areas and the heel blanches well. The Stage I to the left inner heel remained present. The left inner heel remained red and is unblanchable. A red area was noted to the tip of the great toe on the right foot. This area has a tiny open spot on the tip. The wound to the toe was classified by the physician as an arterial wound. The wound to the coccyx/sacrum area was a very large reddened area. The caudal end of the wound had a dime-sized open area. A second, smaller open area was below the first one and has a blackened area that is unstageable. The physician documented this as a Kennedy Terminal Ulcer. The wound has increased in size since reviewed by the physician I on 1/10/12, however the physician has noted the I treatment for this wound is palliation. Wound care plan of treatment by the physician AHCA Form 3020-0001 STATE FORM 5399 If continuation sheet 4 of 32' FROM 24 2012 14:25/No. 7538551104 57 PRINTED: 01/24/2012 fl FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE (X3) SURVEY AND PLAN CORRECVON IDENTIFICATION COMPLETED A. B. WING 35950915 01/12/2012 NAME OF PROVIDER QR STREET ADDRESS. CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSU LATE HEALTH CARE OF SARASOTA 3 AR A501-A. FL 34232 (x4, In SUMMARY STATEMENT or DEFICIENCIES ID PLAN OF CORRECTION (x5) . PREFIX (EACH DEFICIENCY MUST BE PRECEDED sv FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC TAG CROSS--REFERENCED TO THE APPROPRIATE DATE 1 DEFICIENCY) 3 054; Continued From page 4 054 indicates cleansing the wound, apply Granulex every shift and leave open to air. As of 1/12/12 at 10:30 am, there are no written physician orders, the Granulex medication for treatment has not been ordered or obtained by the facility, therefore the treatment could not be applied as ordered. The area, noted on 1/10/12 by the wound care physician to the great toe on the right foot, has not been noted by the facility staff nor has it been addressed on the skin assessment sheets before 5 or after it was noted by the MD. A On 1/12/12 at around 11:30 a.rn., the unit manager approached the surveyor with new - documentation regarding the wounds: Dated 1/12/12 - Right great toe, 0.2x0.2 cm, red scab, blister, vascular; first observed on 1/4/12. This documentation was created on 1/12/12. - There is no documentation dated 1/4/12 of this wound; Dated 1/12/12 - Right heel, Resolved (this is a continuation on the page above addressing the right heel); I Dated 1/16/12 - A new page has been created for the left inner heel, 6x4 crn., Stage dated 'l/7/12 -- 6x4 cm., Stage I, red, not open, blanches; dated 1/12/12 - 6.24 cm., Stage I, red, not open, blanches. This page is now signed by the unit manager and not the nurse who completed and signed the original assessment on 1/6/12 and I 1/7/12. Dated 'l/4/12 - A new page has been created for the left coccyx area, Stage II Kennedy Ulcer, 2x2 I cm.; 1/12/12 - 2.2x2.2x0.2 cm., pink drainage, open. This page is now signed by the nurse I documenting this information on 1112/ 12 and not the nurse who actually completed the assessment on 1/4/12. Dated 1/6/12 - A new page has been created for i I AHCA Form 3020-0001 STATE FORM 0899 QVM6 1 If continuation sheet 5 of 32 FROM 24 2012 14225/No. 7538551104 59 PRINTED: 01/24/2012 . FORM APPROVED Agency for Health Care Administration STATEMENT or or--;riciENciEs (X1) x2 Mu co 5 (x3) DATE sunvev AND PLAN OF CORRECVON ioENTii=icATioN NUMBER: TRUCTION COMPLETED A. BUILDING e. WING 35950915 01/12/2012 NAME or PRGVEDER OR suppugn STREET ADDRESS. CITY, STATE, ZIP CODE 4783 ROAD CONSU LATE HEALTH CARE OF SARASOTA 3 AR A501-A1 FL 34232 (X4, [0 5 SUMMARY STATEMENT or DEFICIENCIES .9 PLAN OF CORRECTION (X5) (EACH MUST BE PRECEDED av FULL I (EACH CORRECTIVE AcTioN SHOULD BE COMPLETE TAG REGULATORY OR IDENTIFYING -mg TO THE APPROPRIATE DATE 0541 Continued From page 5 054 the right sacrum/Coccyx, unstageable, 2 3.2x3.2xO.2 cm, Kennedy Ulcer; 1/12/12 - unstageable. 3.2x3.2x0.2 cm., Unstageable with eschar. This document is completed by the nurse documenting on 1/12/12 and not the nurse who did the original assessment on 1/6/12. Dated 1/4/12 -- An additional new page has been created for the entire coccyx area, Kennedy ulcer, no measurements; 1/12/12 - unstageable and Stage ii, 5.2x3.5x0.2, Kennedy Ulcer. Observation of the coccyx area on 1/12/12 i revealed a large reddened area that blanches slowly with a small area of eschar to the right of the coccyx and a small open area to the left of the Coccyx. interview with the unit manager who created these documents on 1/12/12 revealed she did not 3 complete the assessments on 1/4/12, 1/6/12 and 1/7/12. She stated she had taken the previous it documentation and corrected it on new pages 3 instead of noting the errors on the previous sheets. She stated she had not asked the nurse i completing the original assessment to correct her documentation, but instead did it herself. When asked regarding the documentation of the right great toe being observed on 1/4/12 and where that documentation existed, she stated she must 3 have put the wrong date on the document. She left the room and returned in approximately 10 minutes with a new document for the right great toe. which now notes the date first observed to be 1/10/12. 3 The documentation of the wounds for Resident #48 was not Clear. It was not able to be determined on what date the wounds were first observed, what stages they were and the correct I measurements. Documents have been recreated AHCA Form 302043001 STATE FORM QVM611 It continuation sheet 6 O1 32 \l I-Q.-ourrol . Luluwu. I 1 1..--0 co PRINTED: 01124/2012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA (X2) MULTIPLE coivsraucriou (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. BUILDING B. 35960915 01I12l2012 NAME oi: pnovinga on suppueg STREET ADDRESS. CITY, STATE. CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA 3 AR A301-AI FL 34232 (x4) lo SUMMARY STATEMENT OF DEFICTENCIES ID PROVIDERS PLAN OF CORRECTION i (x5; - (EACH DEFICIENCY MUST BE PRECEDED av FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS--REFERENCED TO THE APPROPRIATE DATE i DEFICIENCY) 0549 Continued From page 6 054 by staff who did not actually complete the assessments. These make the assessments inaccurate. on 1/12/12 at 11:30 am, The unit manager also I presented for review newly written verbal orders, dated 1/12f12, from the physician for the wound care orders received from the wound care physician on 1/10/12; to cleanse the wound and apply Granulex every shift. These orders also included the order to discontinue the wound care of skin prep to the right outer ankle and to . discontinue the Duoderm to the coccyx. Review of the previous wound care orders also included a treatment of zinc oxide to the buttocks 2 every shift and skin prep to the bilaterai heels. The verbal order to discontinue these orders as a - previous treatment was not written by the nurse receiving the order to discontinue previous treatment. On1/12112 at 12:10 p.m. in an interview, the Director of Nursing stated she realizes verbal orders to discontinue all previous orders were not written. She stated she would review the record and get it corrected. At 12:30 p.m. additional discontinue the zinc oxide to the buttocks and to discontinue the skin prep to the bilateral heels. . In an interview on 1/12/12 at 1:00 the Director of Nursing stated she was in the process i of assessing the wounds of Resident #48 herself. She stated the previous documentation which was created by the unit manager on 1112/12 was not accurate and she wanted to ensure accurate documentation from this day forward so Resident #48 could receive the correct treatment and the I would be aware of the current correct verbal orders were written by the unit manager to AHCA Form 3020-0001 STATE FORM 6699 QVM61 1 If continuation sheet 7 of 32 FROM Agency for Health Care Administration 24 2012 14125/No- 7538551104 30 PRINTED: 01/24/2012 FORM APPROVED STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 35960915 NAME or PROVIDER oa SUPPLIER CONSULATE HEALTH CARE OF SARASOTA 4783 FR (X2) MULTIPLE CONSTRUCTION A. BUILDING B. WING STREET ADDRESS. CITY. STATE. ZIP CODE UITVILLE ROAD SARASOTA, FL 34232 (X3) DATE SURVEY COMPLETED 0111212012 1 Each resident admitted to the nursing home facility shall have a plan of care. The plan of care shall consist of: 5 Physician's orders, diagnosis medical history, physical exam and rehabilitative or -restorative potential. 3 A preliminary nursing evaluation with physician's orders for immediate care, completed on admission. A complete. comprehensive, accurate and I reproducible assessment of each residents I, functional capacity which is standardized in the 1, facility, and is completed within 14 days of the resident's admission to the facility and every twelve months, thereafter. The assessment shall be: 1. Reviewed no less than once every 3 months, 2. Reviewed after a significant change in the resident's physical or mental condition, 3. Revised as appropriate to assure the I continued accuracy of the assessment. I I This Statute or Rule is not met as evidenced by: I Based on observation, record review and I interview the facility failed to ensure the plan of care for each resident included physician's orders (x4) In I SUMMARY STATEMENT oI= In PLAN or CORRECTION (x5) PREFIX I (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG I REGULATORY on IDENTIFYING INFORMATION) -mg CROSS-REFERENCED TO THE APPROPRIATE DATE I DEFICIENCY) I 054 Continued From page 7 054 status of the wounds. Isolated Class . Correction Date: 2/13/12 071 F.A.C. Components of Care Plan 071 N-71 1. Resident #48 care plan has been updated and resident #48 has correct wound measurements and treatment orders in place. 2. Physician orders reviewed at morning meeting and care plans are updated to reflect change in resident condition. 3. Licensed nursing in-service on obtaining and following physician orders. Physician orders reviewed 5 times weekly in morning meeting and care plans are updated as needed. 4. Director of Clinical Services/ designee will do weekly audits of physician orders and care plans. Results will be reviewed by QA. Compliance date: 2-12-2012 AHCA Form 3020-0001 STATE FORM 6599 QVM611 Ir oonlinuation sheet 3 or 327 FROM 24 2012 14225/No.7539551104 31 PRINTED: 0112412012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES 0(1) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION COMPLETED A. BUILDING B. WING 35950915 01l12I2012 NAME OF pnovinea on suppuz-;R STREET ADDRESS. CITY, STATE. ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA. FL 34232 (x4) 10 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS--REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 071i Continued From page 8 071 given to the nurse as verbal orders and a complete and accurate assessment of a resident's pressure ulcers and revising the assessment as appropriate to assure the I continued accuracy of the assessment for 1. I (Resident#48) of1 residents reviewed for I pressure ulcer assessment and documentation. The findings include: Interview with the nurse responsible for the care of Resident #48 on 1/9/12 revealed Resident #48 1 has a Stage pressure ulcer to her coccyx area, The nurse reports Resident #48 is a hospice resident, has poor nutrition which would cause skin to breakdown easily and cause poor/slow heafing. Review of the medical record for Resident #48 revealed she is a hospice patient. She had a recent decline in her status and most recently has a diagnosis of failure to thrive. She has a living i will and the facility and family are honoring her choices to keep comfortable without additional i means. Her eating status has declined and she no longer eats as much as she used to. Due to inadequate nutrition and the breakdown of her systems. she has developed Kennedy Ulcers. A Kennedy Ulcer is a terminal ulcer that hospice patients get with the breakdown of their systems. These were first observed on 1!4/12. On 1/10/12, the wound-care specialist saw her when he made his weekly rounds in the facility, at which time he I provided the diagnosis of Kennedy Ulcers. I On 1/12/12, review of the pressure ulcer I assessment sheets revealed the following I documenting descriptions of the pressure ulcers for Resident #48; Dated 1/2/12 - Coccyx 3x3x2 cm, Stage II. 4 AHCA Form 3020-0001 STATE FORM 6599 If continuation sheet 9 or 32' S241 i21'Dl<) . 1 1 (341 F5 EUR322 PRINTED: 01/24/2012 FORM APPROVED Agency for Health Care Administration STATEMENT (X1) (X2) CONSTRUCTION DATE SURVEV AND PLAN OF CORRECTION COMPLETED A. suitoaive B. WING 35960915 01/12/2012 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS, STATE, ZIP CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 Wound care indicates this area is covered with a duoderrn, which is changed every 3 days and pm; Dated 1/4/12 -- Area to the right of the coccyx 2x2x0.2 cm., Stage II, covered with a duoderm. A second note of this area, same date/same page, notes this area as a Stage Ill; and a third area on this same line notes it as unstageable. An update on 1/7/12 notes the area as Stage II, with 3 measurements of 2.3x2.3x1.2 cm and a note that says "no Dated 1/6/12 and 1/7/12 - Left heel Stage II, 5x4 cm. No improvement, observed first on 1/6/12, and Dated 1/6/12 and 1/7/12 - Right heel Stage I1, 4x2 cm. No improvement, observed first on 1/6/12. Visit on 1/10/12 from the wound care physician documents: heel - Stage I, Left heel - Stage I, Coccyx - unstageable Plan of treatment is documented on the physician notes to include: cleansing the wound; applying granulex spray, and leave the wound open to air. The physician assessment does not address two areas around the coccyx area. Interview with the Unit Manager and the Director of Nursing (DON) on 1/12/12 at 9:30 a.m. revealed the documentation by the nurse on the assessment of the pressure ulcers is inaccurate. They both report the pressure ulcers on the heels are Stage I and have never been Stage It, as the skin was never broken but was only red and blanchable. They both report the coccyx has two areas; one has black eschar and is unstageable and the other is a Stage ll. They both confirm there is no Stage ill pressure ulcer. Review of the medical record for Resident #48 revealed no physician's orders for the (x4) .0 sumimnv STATEMENT or ID PROVIDERS PLAN or CORRECTION 1 (EACH DEFICIENCY MUST BE PRECEDED av FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG - necumronv on LSC IDENTIFYING INFORMATION) 1-AG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 071 Continued From page 9 071 AHCA Form 3020~0001 STATE FORM B898 QVM611 it continuation sheet 10 of 32 ZKJIZ Ill: . 1 1 LJII I1 01/2412012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) (X2) MULYWLE (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. BUILDENG B. WING 35960915 0111212012 . 1, NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS, CITY, STATE. CODE 4783 FRUITVILLE ROAD SARASOTA, FL 34232 recommended treatment from the wound care physician. 5 In an interview on 11112112 at 9:45 a.rn., the unit 1 manager on the unit for Resident #48 stated she was with the wound care physician when he visited with Resident #48 on 1/10/12. She stated the physician was aware the resident was under hospice care and wanted the current treatment to continue until the medication could be obtained i from hospice. When asked if she had contacted hospice regarding the medication, she said she i "only received the documented treatment plan 3 this morning" because they had been in her box 5 since 1/11/12. She further stated a nurse who A worked the hallway said she would contact hospice regarding wound care supplies and . medication. The unit manager stated she had not 5 checked to see if the orders were initiated, or if the nurse had contacted hospice, She confirmed there is no documentation in the medical record I regarding orders for the wound care or the - notification to hospice. When asked why she did not contact hospice regarding the wound care I recommendations as she was with the physician when he verbally reported to her the treatment i plan he wanted, she stated she thought the fioor nurse wouid be completing this task, When asked why she did not write the verbal order for the treatment plan the wound care physician wanted she stated she was waiting to hear from hospice. The wound care treatment ordered by the wound care physician on 1/10/12 had not been written, implemented or applied as of 1/12/12 at 10:30 am. Observation of the wounds for Resident #48 revealed the right foot wound was clear, there was no redness or open areas and the heel in SUMMARY STATEMENT or .9 przovioens PLAN OF CORRECTION (X5) - (EACH DEFICIENCY MUST BE PRECEDED av FULL PREHX (EACH CORRECTIVE ACTION SHOULD BE . COMPLETE TAG REGULATORY on LSC IDENTIFYING INFORMATION) TAG TO THE DATE 1 DEFICIENCY) i 071 Continued From page 10 071 AHCA Form l3020-0001 STATE FORM 6689 QVM611 If continuation sheet 11 at 32 Z4 ZCLJIZ 64 PRINTED: 0112412012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (xi) (X2) MUL-HPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. B. 35960915 01l'12I2012 NAME oi: ppzoviogn OR SUPPUER STREET ADDRESS. CITY, STATE, CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA FL (X4) I SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (X5) i (EACH DEFICIENCY MUST BE PRECEDED BY FULL 1 (EACH CORRECTIVE SHOULD BE COMPLETE mg REGULATORY on LSC INFORMATION) mg; CROSS-REFERENCED TO THE APPROPRIATE DATE 5 071 5 Continued From page 11 071 blanches well. The Stage to the left inner heel remained present. The left inner heel remained red and is unblanchable. A red area was noted to the tip of the great toe on the right foot. This area has a tiny open spot on the tip. The wound to the toe was classified by the physician as an arterial wound. The wound to the coccyx/sacrum area was a very large reddened area. The caudal end of the wound had a dime--sized open area. A 1 second, smaller open area was below the first one and has a blackened area that is unstageable. The physician documented this as a Kennedy Terminal Ulcer. The wound has increased in size since reviewed by the physician . on 1/10/12, however the physician has noted the treatment for this wound is palliation. i Wound care plan of treatment by the physician indicates cleansing the wound, apply Granulex every shift and leave open to air. As of 1/12/12 at 10:30 there are no written physician orders, the Granulex medication for treatment has not . been ordered or obtained by the facility, therefore the treatment could not be applied as ordered. The area, noted on 1l10l12 by the wound care physician to the great toe on the right foot, has not been noted by the facility staff nor has it been addressed on the skin assessment sheets before . or after it was noted by the MD. 1 On 1/12/12 at around 11:30 am., the unit manager approached the surveyor with new documentation regarding the wounds: Dated - Right great toe. 0.2x0.2 cm, red scab, blister, vascular; first observed on 1/4/12. This documentation was created on 1/12/12. There is no documentation dated 114/12 of this wound; i Dated 1/12/12 - Right heel, Resolved (this is a AHCA Form 3020-0001 STATE FORM 6599 QVM611 ll continuation sheet 12 of 32 2211 22!) 1 22 1 41 1 13534723"? . 1 11 I 2253 . 1 E355 PRINTED: 01/24/2012 FORM APPROVED Aqency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) (X2) CONSTRUCTION (X3) DATE SURVEY ANDPLANOFCORRECUON COMPUHED A, BUILDING B. WING 35960915 0111 212012 NAME OF OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE - 4783 FRUITVILLE ROAD HEALTH CARE OF SARASOTA SARASOTA, FL 3423, ID I SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) I (EACH DEFICIENCY MUST BE PRECEDED av FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) 071 Continued From page 12 071 continuation on the page above addressing the A Dated 1/16/12 - A new page has been Created for the left inner heel, 6x4 cm., Stage dated 1/7/12 - 6x4 cm., Stage 1, red, not open, blanches; dated 1/12/12 6.24 cm., Stage I, red, not open, blanches. This page is now signed by the unit manager and not the nurse who Completed and signed the original assessment on 1/6/12 and 1/7/12. Dated 1/4/12 - A new page has been created for the left Coccyx area, Stage II Kennedy Ulcer, 2x2 Cm.; 1/12/12 - 2.2x2.2x0.2 cm., pink drainage, open, This page is now signed by the nurse documenting this information on 1/12/12 and not I the nurse who actually completed the assessment on 1/4/12. I Dated 1/6/12 - A new page has been created for the right sacrum/Coccyx, unstageable, 3.2x3.2x0.2 cm., Kennedy Ulcer; 1/12/12 - unstageable, 3.2x3.2x0.2 cm., unstageable with eschar_ This document is completed by the nurse I documenting on 1/12/12 and not the nurse who did the original assessment on 1/6/12. . Dated 1/4/12 - An additional new page has been created for the entire Coccyx area, Kennedy ulcer, no measurements; 1/12/12 - unstageable and Stage II, 5.2x3.5x0.2. Kennedy Ulcer. Observation of the Coccyx area on 1/12/12 revealed a large reddened area that blanches I slowly with a small area of eschar to the right of I the Coccyx and a small open area to the left of the Coccyx. Interview with the unit manager who created these documents on 1/12/12 revealed she did not complete the assessments on 1/4/12, 1/6/12 and I 1/7/12. She stated she had taken the previous I documentation and corrected it on new pages I 4 AHCA Form 3020-0001 STATE FORM B899 QVM611 It continuation sheet 13 of 32, 24 2012 33 01/24i'2012 FORM APPROVED Agency for Health Care Administration (X1) (X3) AND PLAN OF CORRECTION NUMBER COMPLETED A. B. WING 35950915 01I1 21201 2 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA, FL 34232 (X4) in 7 SUMMARY STATEMENT OF DEFICIENCIES ID 1' PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) 1 'mg CROSS-REFEFIENCED TO THE APPROPRIATE UATE DEFICIENCY) 071 Continued From page 13 071 instead of noting the errors on the previous sheets. She stated she had not asked the nurse completing the original assessment to correct her documentation, but instead did it herself. When asked regarding the documentation of the right great toe being observed on 1/4/12 and where I that documentation existed. she stated she must have put the wrong date on the document. She left the room and returned in approximately 10 minutes with a new document for the right great toe, which now notes the date first observed to be . 1/10/12. The documentation of the wounds for Resident #48 was not clear. it was not able to be determined on what date the wounds were first observed, what stages they were and the correct measurements. Documents have been recreated by staff who did not actually complete the assessments. These make the assessments inaccurate. on 1/12/12 at 11:30 The unit manager also presented for review newly written verbal orders, dated 1/12/12, from the physician for the wound a care orders received from the wound care physician on 1/10/12; to cleanse the wound and apply Granulex every shift. These orders also included the order to discontinue the wound care of skin prep to the rightouter ankle and to discontinue the Duoderm to the Coccyx. Review of the previous wound care orders also included a treatment of zinc oxide to the buttocks every shift and skin prep to the bilateral heels. 1 The verbal order to discontinue these orders as a 1 previous treatment was not written by the nurse receiving the order to discontinue previous treatment. AHCA Form *3020-0001 STATE FORM I 8599 QVM511 If continuation sheet 14 of 32 xlunzgunn .44 LLII4 6! PRINTED: 01/24/2012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (X1) (X2) (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. BUILDING B. WING 35950915 0111212012 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE, ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA SARASOTA FL 34232 (x4) :0 I SUMMARY STATEMENT OF DEFICIENCIES I PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG . REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS--REFERENCED TO THE APPROPRIATE DATE 2 DEFICIENCY) 071 Continued From page 14 071 On 1/12/12 at 12:10 p.m_ in an interview, the Director of Nursing stated she realizes verbal orders to discontinue all previous orders were not written. She stated she would review the record and get it corrected. At 12:30 p.m. additional verbal orders were written by the unit manager to discontinue the zinc oxide to the buttocks and to discontinue the skin prep to the bilateral heels. In an interview on 1/12/12 at 1.00 the Director of Nursing stated she was in the process of assessing the wounds of Resident #48 herself. I She stated the previous documentation which was created by the unit manager on 1/12/12 was not accurate and she wanted to ensure accurate documentation from this day forward so Resident #48 could receive the correct treatment and the 4. facility would be aware of the current correct status of the wounds. Isolated Class . Correction Date: 2/13/12 oral 4o0.o21i1e), FS Care Plan 073 - Resident Involvement Signature At the resident's option, every effort shall be i made to include the resident and family or responsible party, inciuding private duty nurse or nursing assistant, in the development, 3 implementation, maintenance and evaluation of - the resident plan of care. A 400.021 (16) The resident care plan must be signed by the resident, the resident's deslgnee, or the AHCA Form 3020-0001 STATE FORM 689? QVM611 If continuation sheet 15 of 32: *gu& 88 PRINTED: 01l2-M2012 . FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCHES (X1) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION A COMPLETED 35960915 8' WING 0111212012 NAME or: pact/toga on SUPPUER STREET ADDRESS. CITY, STATE, ZIP CODE CONSULATE HEALTH CARE oe SARASOTA (X4) .0 SUMMARY STATEMENT or DEFICIENCIES .9 PLAN or CORRECTION (x5) PREHX (EACH DEHCIENCY MUST BE PRECEDED ev FULL (EACH CORRECTNE ACTION SHOULD BE COMPLETE TAG REGULATORY oe LSC INFORMATION) TAG CROSS-REFERENCEO TO THE APPROPRIATE DATE . DEFICIENCY) 073i Continued From page 15 073 I resident's legal representative. N073 This Statute or Rule is not met as evidenced by: Based on record review and staff interview, the facility failed to have the resident's representative 1' Legal representame of resldem 66 sign the care plan for 1 (Resident #66) of 23 has been Properly notified of resident's residents surveyed. care plan goalsCare plan lists (residents and invitees) in In mo e' will be reviewed at moming meetings. 0 A review of the medical record for Resident #66 3' will be P1'?Vlded 5 revealed the Minimum Data Set (MDS) to the Social Services Director on comprehensive assessment shows an increase in proper documentation for with and . of 2 (4 to 6 days but 'ass than daily) for or legal representatives of residents. "Physical behavior directed toward 4- The Designee will do random I others." and "Verbal behavior directed weekly audits of the care conference i t0W3rd 0the'_" to 3 f' Of this W99 records for 3 months. Results of audits be by QA . not directed at others." for 3 months to ensure substantial compliance. During an interview on 1/10/12 at 3:05 the MDS coordinator stated the social worker compliance Date; 2_12_2012 performed the interview and assessment. The MDS coordinator stated care plan meetings were held on 9/15/11 and 1216/11. 9' ,3 i A review of the resident's record revealed the supporting documentation of observation and interview for the MDS initial assessment, dated 9/14/11, documents the resident demonstrates Mood or Behavior problem that impacts interpersonal relationship. The resident has clinical issues of communication problems, neurological disease, and dementiafcognitive decline. Contributing factors: "dlt Huntington and I AHCA Forrn 3020-0001 STATE FORM 6593 QVM611 ll continuation sheet 16 of 32' 44 zuI4 31:! . PRINTED: FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (xi) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. BUILDING B. WING 35960915 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE 4783 FRUITVILLE ROAD CONSULATE HEALTH CARE OF SARASOTA FL 34232 (X4) SUMMARY STATEMENT OF DEFICIENCIES I PROVIDERS PLAN OF CORRECTION (XS) I (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREHX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE 1 DEFICIENCY) 073i Continued From page 16 073 dementia, recent transfer to facility contributes to her mood disorder. Receives med daily." -- During an interview on 1/11/12 at 2:50 the director of social services stated the legal representative and resident were notified of the care plan meetings. A review of the record revealed all contacts and consents were signed by the resident's legal representative. When discussing the resident's care issues -- including how to manage the behaviors - the resident refused to attend and the legal representative did not attend. There is no documentation in the record that the legal representative was notified of the decisions from the care plan meeting. The care plan conference record was not signed by the legal representative. The social services director confirmed the legal 5 representative has not signed the care conference record and acknowledged there is no documentation the legal representative was informed of the care goals following the care plan meeting. Isolated Class Correction Date: 2/13/12 101. FAC Resident 101 Medical Records i4oo.141(1) 0) Keep full records of resident admissions and discharges; medical and general health status, including medical records, personal and social history. and identity and address of next of kin or other persons who may have responsibility for the AHCA Form 3020-0001 STATE FORM 95" QVM611 ll continuation sheet 17 of 321 FRIJM Agency for Health Care Administration 24 2012 14225/No. 7538551104 70 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA 35960915 FORM APPROVED (x DATE SURVEY (X2) MULTIPLE CONSTRUCTION 3) COMPLETED A. BUILDING e. WING 011121201 2 NAME OF PROVIDER OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS, CITY, STATE, ZIP CODE 4733 ROAD SARASOTA. FL 34232 ID I affairs of the residents; and individual resident care plans including, but not limited to, prescribed services, service frequency and duration, and service goals. The records shall be open to inspection by the agency. 59A-4.118 - (2) Each medical record shall contain sufficient information to clearly identify the resident, his diagnosis and treatment, and results. . This Statute or Rule is not met as evidenced by: i Based on observation, record review and interview, the facility failed to ensure clinical records are complete and accurate by failing to document accurately pressure ulcer assessment, faiiure to write verbal physician's orders for 2 days after they were received and failing to transcribe and implement those orders until after they were written for 1 (Resident #48) of i resident who were reviewed for pressure ulcer assessment and documentation. 3 The findings include: Interview with the nurse responsible for the care 2 of Resident #48 on 1/9/12 revealed Resident #48 has a Stage pressure ulcer to her Coccyx area. The nurse reports Resident #48 is a hospice resident, has poor nutrition which would cause skin to breakdown easily and cause poor/slow healing. Review of the medical record for Resident #48 revealed she is a hospice patient. She had a recent decline in her status and most recently has a diagnosis of failure to thrive. She has a living will and the facility and family are honoring her N101 Resident 48 has correct wound measurements and treatment orders in place. ulcers was completed. Licensed nurses will be inwserviced on A measuring and documenting wounds and obtaining physician orders for treatment. sheets weekly for 3 months. audits of the wound sheets for 3 months. Results of the audits will be reviewed by ensure substantial compliance. Compliance date: 2-12~2012 An audit of current residents with pressure ADCS/designee will audit the wound care The DCS/designee will do random weekly the QA committee for 3 months to (X4) SUMMARY STATEMENT OF DEFICIENCIES PROVIDERS PLAN OF CORRECTION (x5) pREFix I (EACH DEFICIENCY MUST BE PRECEDED BY FULL pagpix I (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG ACROSS-REFERENCED TO THE APPROPRIATE DATE 3 DEFICIENCY) I I 101 Continued From page 17 101 AHCA Form 3020--0001 STATE FORM 8899 OVM6 1 1 If continuation sheet 18 or 32. F=F2(3lfl ellfili 2211 S2 1 1 ll: I (311 1'1 PRINTED: 01/24/2012 FORM APPROVED Agency for Health Care Administration STATEMENT OF DEFICIENCIES (K1) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION COMPLETED A. B. WING 35960915 01/12/2012 NAME OF OR SUPPLIER CONSULATE HEALTH CARE OF SARASOTA STREET ADDRESS. STATE. ZIP CODE 4783 ROAD SARASOTA, FL 34232 (x4) so SUMMARY STATEMENT OF DEFICIENCIES PLAN OF CORRECHON (X5) COMPLETE choices to keep comfortable without additionat means. Her eating status has declined and she no longer eats as much as she used to. Due to inadequate nutrition and the breakdown of her systems, she has developed Kennedy Ulcers A Kennedy Ulcer is a terminal ulcer that hospice patients get with the breakdown of their systems. These were first observed on 1/4/12. On 1/10/12, the wound~care specialist saw her when he made his weekly rounds in the facility, at which time he . 1 provided the diagnosis of Kennedy Ulcers. On 1/12/12, review of the pressure ulcer assessment sheets revealed the following A documenting descriptions of the pressure ulcers for Resident #48: Dated 1/2/12 - Coccyx 3x3x2 cm., Stage II. Wound care indicates this area is covered with a duoderm, which is changed every 3 days and prn; Dated 1/4/12 -- Area to the right of the coccyx 2x2x0.2 cm., Stage II, covered with a duoderm. A second note of this area, same date/same page, 3 notes this area as a Stage Ill; and a third area on this same line notes it as unstageable. An update on 1/7/12 notes the area as Stage II, with measurements of 2.3x2_3x1 .2 cm and a note that . says "no improvements;" Dated 1/6/12 and 1/7/12 - Left heel Stage II, 6x4 cm. No improvement, observed first on 1/6/12, and Dated 1/6/12 and 1/7/12 -- Right heel Stage ll, 4x2 cm. No improvement, observed first on 1/6/12. Visit on 1/10/12 from the wound care physician documents: heel - Stage 1, Left heel - Stage i, Coccyx -- unstageable. Plan of treatment is documented on the physician notes to include: cleansing the wound; applying granulex spray, and leave the wound open to air. PREFIX (EACH DEFICIENCY MUST BE PRECEDED sv FULL ts/<