Manorcare Health Services

F-F759 for details.

The DON stated that a plan of correction was completed on 04/11/25 for 'Free of Medications Errors' and the last meeting for Quality Assurance and Performance Improvement (QAPI) was held on 03/19/25.

Review of the facility's plan of correction for the recertification survey with a correction date of 04/11/25 was conducted and revealed the Licensed Nursing staff were re-educated on 04/11/25 by the Staff Development Nurse / designee on the medication administration process with emphasis on timeliness.

Review of the facility's plan of correction included a Medication Pass Observation record dated 04/03/25 signed by the Consultant Pharmacist for Staff A, Licensed Practical Nurse.

Review of the facility's plan of correction included a Medication Pass Observation record dated 04/05/25 signed by the Consultant Pharmacist for Staff C, Licensed Practical Nurse (LPN).

Review of Staff B, Licensed Practical Nurse Agency Orientation Checklist signed on 04/11/25 documented that the staff completed orientation to the medication and treatment guidelines.

The facility failed to have an effective QAPI program that ensured the medication error rate was not greater than 5% (percent).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 106005 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106005 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50370 potential for actual harm Based on observations, interviews and record reviews, the facility failed to follow the Center for Disease Residents Affected - Few Control and Prevention (CDC) guidelines for Standard Precautions during resident personal care for 1 of 1 sampled resident, Resident #25, observed following care; and failed to disinfect essential vital signs equipment used for Resident #31 and #72.

The findings included:

Review of the Center for Disease Control and Prevention (CDC) guidelines for Standard Precautions Core Practices included: a) Hand Hygiene: involves washing hands with soap and water or using alcohol-based hand rub before and after patient contact, before and after gloving, and after touching contaminated surfaces; b) Personal Protective Equipment (PPE): Using appropriate PPE, such as gloves, gowns, masks, and eye protection, to protect healthcare workers from potential exposure to infectious materials; c) Safe Handling of Potentially Contaminated Equipment: Cleaning and disinfecting equipment and surfaces that may be contaminated with blood or body fluids; d) Environmental Cleaning: Regularly cleaning and disinfecting patient care areas and equipment.

1. Record review revealed Resident #25 was admitted to the facility on [DATE REDACTED] with diagnoses that included Multiple Sclerosis, Benign Prostatic Hyperplasia with Lower Urinary Tract symptoms, Major Depressive Disorder, Type 2 Diabetes Mellitus with Diabetic Autonomic Polyneuropathy, Tinea Pedis and Sacroiliitis.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/26/25, under Section C revealed a Brief Interview of Mental Status (BIMS) score of 13 indicating intact cognitive function.

During an observation on 03/10/25 at 9:30 AM, Staff Q, Certified Nursing Assistant (CNA), opened Resident #25's door with her gloved hands to let surveyor in, stating, I am done with resident's care. She was observed removing the plastic trash from a small plastic bin next to the bathroom and putting it inside a bigger plastic bag. With the same set of gloves, she moved Resident #25's meal table closer to the resident.

She then rubbed Resident #25's hair and head using the same set of gloves. She stated she would help the resident in brushing his teeth. On 03/10/25 at 9:45, Staff Q was observed putting the resident's bed linen and pillows onto resident's bed, before wheeling Resident #25 into the bathroom using the same set of gloves.

2. Record review for Resident # 31 revealed the resident was admitted to the facility on [DATE REDACTED] with diagnoses that included Acute Respiratory Failure with Hypoxia, Type 2 Diabetes Mellitus with Diabetic Neuropathy, and Congestive Heart Failure. The resident was readmitted on [DATE REDACTED] after hospitalization due to Congestive Heart Failure exacerbation, Chronic Obstructive Pulmonary Disease exacerbation, Hypertension Emergency, Multi Drug Resistant Klebsiella Urinary Tract Infection, and positive Respiratory Syncytial Virus.

Review of the quarterly MDS assessment, dated 03/04/25, under Section C revealed a Brief Interview of Mental Status (BIMS) score of 11 indicating moderate cognitive impairment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 106005 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106005 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the physician orders, dated 02/13/25, documented to change and date oxygen tubing weekly every night shift, every Sunday. Level of Harm - Minimal harm or potential for actual harm Further review of the orders dated 01/25/25 documented to obtain temperature and oxygen saturation daily. Report fever and/or drop in oxygen readings to Medical Doctor (MD) and Director of Nursing (DON) Residents Affected - Few immediately, every shift for daily screening.

Review of progress notes dated 02/11/25 revealed Resident #31 received steroids, diuretics and IV (intervenous) antibiotics during hospitalization , related to pulmonary edema with bilateral infiltrates, edema and small bilateral effusions.

During observation on 03/10/25 at 9:59 AM, Staff O, Registered Nurse (RN), rolled the Unit 2 vital signs machine towards Resident #31's door. She removed the blood pressure (BP) cuff previously used in Resident #72's arm without disinfection. She applied the 'not disinfected' BP cuff to Resident #31's right upper arm on 03/10/25 at 10:00 AM. Staff O clipped the oxygen saturation clip on Resident #31's left pointer finger on 03/10/25 at 10:00 AM. She was not observed to disinfect the clip before applying it to the Resident #31's finger.

Staff O was observed to remove the BP cuff from right arm of the resident. She did not disinfect the brown BP cuff after usage and put it back inside the white basket of the Unit 2 vital signs rolling machine cart. She was not observed to disinfect the oxygen saturation clip applied on Resident #31's finger on 03/10/25 at 10:02 AM after usage.

When asked the name of the rolling vital signs machine, Staff O responded, Unit 2 Dynamap machine. There was no disinfectant observed on the basket of the Unit 2 rolling Dynamap Machine on 03/10/25 at 10:00 AM.

3. Record review revealed Resident #72 was admitted to the facility on [DATE REDACTED] with diagnoses that included Neuromuscular Dysfunction of the Bladder, Heart Failure, and Paroxysmal Atrial Fibrillation

Review of Resident #72's MDS under Section C revealed a BIMS score of 13 indicating intact cognitive function.

Review of the physician orders dated 12/18/24 revealed Nizoral external shampoo, apply to scalp topically every evening shift every Tue, Thu, Sat [Tesuday, Thursday, Saturaday] for Seborrheic Dermatitis for 3 months, was ordered.

Another order dated 03/13/25 documented for a dermatology consultation for dandruff.

An order dated 01/19/22 documented for Xarelto tablet 20 MG (milligram), give 1 tablet by mouth one time a day for Atrial Fibrillation.

During observation on 03/10/25 at 09:39 AM, Resident #72 was sitting in wheelchair, and watching Staff. On 03/10/25 at 09:46 AM, resident stated, No Staff had taken my blood pressure yet. I have been waiting for my 6 medications. Staff are moving slowly today.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 106005 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 106005 B. Wing 03/12/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

West Delray Nursing & Rehab Center 16200 S Jog Road Delray Beach, FL 33446

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 A continuing observation on 03/10/25 at 9:48 AM revealed Staff O took a BP cuff from the basket of a rolling vital signs machine and applied it to Resident #72's left arm. She was not observed to properly disinfect the Level of Harm - Minimal harm or BP cuff. Staff O did not perform hand hygiene before applying the BP cuff to resident's upper arm and she potential for actual harm was not wearing gloves.

Residents Affected - Few After using the BP cuff, Staff O immediately put the BP cuff back inside the white basket of the vital signs rolling machine on 03/10/25 at 9:50AM. She did not disinfect the cord of the BP cuff, the BP cuff itself and

the inside and outside of the white basket of the rolling vital signs machine. She did not perform hand hygiene. SHortly after this observation, Resident #72 was observed putting her left hand on top of the white basket of the Unit 2 rolling vital signs machine.

An interview was conducted with Staff R, RN, on 03/12/25 at 10:40 AM, who when asked regarding hand hygiene, stated staff were trained to perform hand hygiene before and after resident's contact. When asked when staff don gloves and gowns, she responded, whenever staff are contacting resident's wounds, and urinary catheter, they must wear gown and gloves, but when doing personal resident's care, and the resident does not have sacral wounds, PEG (percutaneous endoscopically inserted gastrostomy) tube or urinary catheter, they must wear gloves. When asked regarding equipment cleaning, she stated the rolling vital signs machine on each unit has to always have a canister of disinfectant to be used by staff before and after each resident's usage. When asked if she observed staff disinfecting the vital signs equipment before and after resident's usage, she responded , Yes, all the time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 106005