Debary Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 27, 2021

  Based on record reviews and staff interviews, the facility failed to provide cardiopulmonary resuscitation (CPR) to a resident with a CPR order when she was discovered to be unresponsive and without vital signs. This involved one (Resident #1) of three residents reviewed for quality of care. Resident #1 was discovered unresponsive and without respirations by two certified nursing assistants (CNAs). The resident's assigned nurse was immediately notified. She went to the resident's bedside and found her without a pulse or respirations but did not initiate CPR. Resident #1was a full code. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2022

  Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Specifically, the facility failed to ensure that the dietary staff were trained and knowledgeable about proper sanitation practices in the kitchen. Specific instruction on hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents, due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. […]

• No harm, potential for more than minimal, patternF684Feb 5, 2026

  Based on observations, interviews, record reviews, and review of facility's bowel management process, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for three (Resident #1, #2, and Resident #4) of three residents reviewed for management of constipation, by failing to implement medical director's directive/order to administer stool softeners/laxatives. The findings include:1.Review of Resident #1's medical record revealed an admission date of 9/7/23, and a discharge date of 2/2/26. Her diagnoses included unspecified Sequelae of Cerebral Infarction, Cerebral Palsy, generalized anxiety disorder, and constipation, unspecified. […]

• No harm, potential for more than minimal, isolatedF677Jan 19, 2024

  Based on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to provide one dependent resident (#8) from a total sample of 35 residents, with services to carry out activities of daily living necessary to maintain appropriate grooming and personal hygiene. Resident #8 was not provided adequate fingernail care. The findings include: On 01/16/24 at 11:56 AM, Resident #8's hands were observed and his fingernails on both hands had jagged edges and brown matter underneath the fingernails. He was asked if staff provided his nailcare and he answered yes. (Photographic evidence obtained) On 01/17/24 at 9:06 AM, Resident #8 was observed in bed. […]

• No harm, potential for more than minimal, isolatedF684Jan 19, 2024

  Based on observation, interviews, and record review, the facility failed to ensure that one (Resident #96) of 35 sampled residents received treatment and care in accordance with professional standards of practice, the resident's plan of care and resident choices, based on the resident's and resident representative's desire to have bilateral compression stockings placed on lower extremities daily as ordered. The findings include: On 1/16/24 at 12:18 PM, Resident #96 was observed seated in his wheelchair. He was dressed in a long-sleeved shirt, long dark pants, and dark-colored crew socks. When greeted, he smiled and said hello. He was accompanied by his niece, who reported that she visited every day. […]