Blue Palms Health and Rehabilitation Center at Fle

In the surveyor’s words

From the most serious findings on record at Blue Palms Health and Rehabilitation Center at Fle, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 28, 2022

  Based on observations, interviews with facility staff, the Medical Director (MD), a resident, a family member, and an Apartment Manager, and review of medical records, policies and procedures, and additional resource documentation, the facility failed to provide adequate supervision and manage risk associated with accident prevention for one (Resident #1) of four facility residents identified as at risk for elopement out of a total sample of 10 residents. On 7/12/2022, Resident #1 ambulated with a 4-wheeled walker, while wearing a wanderguard (electronic monitoring device) on his ankle when he exited the building. The electronically monitored door opened before the wander monitoring device signal was picked up. […]

• Actual harm, isolatedF689Apr 10, 2024

  Based on observation, interview, record review and policy review, the facility failed to ensure adequate supervision and assistive devices to prevent an unwitnessed fall that resulted in serious bodily injury (nondisplaced fracture of second cervical vertebra) as a result of an over inflated air mattress that was not monitored by staff for one dependent resident (#44) out of the sampled two residents. Findings included: On 04/08/24 at 11:15 a.m. Resident #44 was observed in bed with a cervical collar around her neck. During an attempt to interview her, the resident did not speak. On 04/10/24 at 9:12 a.m. Resident #44 was observed in bed with a cervical collar around her neck. […]

• No harm, potential for more than minimal, patternF725Apr 10, 2024

  Based on observations, interviews with residents and facility staff, and review of the facility's records and policies, the facility failed to provide sufficient staff to provide meal assistance on one floor (second floor) of two floors for six (#32, #15, #30, #3, #18 and #54) of 17 dependent residents, and failed to respond to a call light for Resident #20 for two days (04/09/2024 and 04/10/2024) of a three day survey. Findings included: An observation on 04/09/24 of the lunch meal service revealed the residents in the dining room received their trays starting at 11:34 a.m. Resident #32 was the last one to receive her tray in her room at 12:45 p.m., having waited approximately one hour and twenty minutes. During a facility tour on 04/09/24 at 11:43 a.m. […]

• No harm, potential for more than minimal, patternF880Apr 10, 2024

  Based on observations, interviews, and record reviews, the facility failed to implement an effective infection prevention and control program related to: 1) failing to ensure a contact precautions sign was displayed timely for one resident (#24) diagnosed with Clostridioides difficile (C-Diff), 2) failing to ensure proper usage of personal protective equipment (PPE) by staff and volunteers (I, Q, R, V, and Dog Handler), 3) failing to ensure four staff members (Staff Q, B, C, Director of Nursing) performed hand hygiene, and 4) failing to ensure staff provided hand hygiene for 14 residents (#54, #19, #3, #1, #36, #670, #23, #10, #2, #53, #37, #17, #57, and #33) prior to dining for three days of a three day survey. Findings included: An observation was conducted on 4/8/24 at 10:15 a.m. […]

• No harm, potential for more than minimal, patternF656Nov 5, 2021

  Based on observations, record reviews, and interviews the facility failed to ensure, six residents (#25, #34, #69, #75, #87 and #99) and a representative for one resident (#40) were invited and/or participated in their plan of care meetings out a total of 43 sampled residents. Findings included: The policy, Resident/Family Participation in Goal Planning, revised 11/2016, indicated, To assure the residents and resident representative's right to participate in planning the resident's care in making informed decisions regarding medical treatment. The procedure identified the following: - 1. […]