Margate Health and Rehabilitation, LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Nov 20, 2024

  Based on observations, record review, staff, Nurse Practitioner, Funeral Home Representative and Hospitalist interviews the facility failed to provide care in a safe manner. On [DATE] Nurse Aide (NA) #1 was performing incontinence care for Resident #195 who was resting on an air mattress raised to waist height and rolled Resident #195 on her side away from NA #1 who proceeded to walk around to the other side of the bed at which time the air mattress decompressed. Resident #195 rolled off the side of the bed to the floor and was wedged between the bed and the wall. Resident #195 was transferred to the hospital where she was diagnosed with a right femur fracture, right inferior and superior pubic rami (pelvic) fractures, questionable nondisplaced sacral alar (lower spine) fracture. […]

• Immediate jeopardy, isolatedF726Nov 20, 2024

  Based on record review and staff interviews the facility failed to verify that a Nurse Aide (NA) was competent in providing care for a dependent resident. Resident #195 rolled out of bed and sustained a right femur (long bone of the upper leg), right inferior and superior pubic rami (pelvic) fractures and questionable nondisplaced sacral alar (lower spine) fracture during care. Resident #195 was a poor surgical candidate and was admitted to the hospital for comfort care. Resident #195 died on [DATE]. The deficient practice occurred for 1 of 6 NAs (NA #1) reviewed for competencies. Immediate jeopardy began on [DATE] when NA #1 performed care without competencies being verified Resident #195 rolled off the side of the bed. […]

• Actual harm, isolatedF604Oct 25, 2023

  Based on observation, record review, resident, staff, family, and Medical Director interviews the facility failed to protect Resident #1 from being physically restrained by Nurse Aide (NA) #1. NA #1 grabbed Resident #1's left forearm and held it when the resident became combative during incontinent care and Resident #1 was trying to hit NA #1 and NA #2. Resident #1 received a large purple bruise on her left forearm. This deficient practice affected 1 of 3 residents reviewed for dignity. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included dementia, delirium, anxiety, and chronic atrial fibrillation (irregular heart rhythm). […]

• Actual harm, isolatedF607Oct 25, 2023

  Based on observation, record review, resident, and staff interviews the facility failed to remove Nurse Aide (NA) #1 from a resident care assignment after NA #2 witnessed the NA grab Resident #1's left forearm to prevent her from hitting NA #1 and NA #2 when the resident became combative during incontinent care. In addition, the facility failed to identify, thoroughly investigate, and report the incident to the state agency, Adult Protect Services, and local Law Enforcement for 1 of 3 residents reviewed for dignity. […]

• No harm, potential for more than minimal, patternF561Nov 20, 2024

  Based on observations, record review, and staff and family interviews, the facility failed to honor a resident's choice to have a communal dining experience for 1 of 1 resident reviewed for choices (Resident #87). This had the potential to affect all residents who wish to have a communal dining experience. The findings included: Resident #87 was admitted to the facility on [DATE]. A review of Resident #87's quarterly Minimum Data Set assessment dated [DATE] revealed Resident #87 to be severely cognitively impaired. […]