Regency Florence

In the surveyor’s words

From the most serious findings on record at Regency Florence, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 25, 2023

  Based on interview and record review it was determined the facility failed to ensure staff provided a safe mechanical lift transfer during care for 1 of 3 sampled residents (#11) reviewed for accidents. Resident 11 sustained a pelvic fracture and bilateral leg fractures. Findings include: Resident 11 admitted to the facility in 7/2015 and readmitted on ,d+[DATE] with diagnoses including a pelvic fracture and bilateral leg fractures. An 8/9/23 Fall Incident Report revealed the following: -Resident 11 fell out of a mechanical lift during a two-person transfer. -Staff 8 (CNA) and Staff 24 (CNA) were getting Resident 11 ready for her/his smoke break, the bottom left side of the sling came off the hook. […]

• No harm, potential for more than minimal, patternF658Oct 9, 2023

  Based on interview and record review it was determined the facility failed to ensure Staff 2 (DNS), Staff 3 (RNCM), Staff 9 (LPN), Staff 15 (CMA) and Staff 19 (LPN) adhered to standards of practice regarding medication administration for 1 of 1 sampled residents (# 4) reviewed for significant medication error. Findings include: [NAME] 851 045 0040 Scope of Practice Standards for All Licensed Nurses indicated the following: (1) Standards related to the licensed nurse's responsibilities for client advocacy. […]

• No harm, potential for more than minimal, patternF684Oct 9, 2023

  Based on interview and record review it was determined the facility failed to ensure medications were available per physician orders for 6 of 6 sampled residents (#s 2, 3, 4, 9, 13 and 14) reviewed for medications. This placed residents at risk for medication-related adverse consequences. Findings include: The facility's 8/2023 Medication Administration Audit Report revealed the following sample of residents with missed medications: -Resident 3's 8/26/23 physician order for Carbidopa-Levodopa, two tablets, three times a day for Parkinson's Disease. The Medication Administration Audit Report revealed the resident did not receive the scheduled dose on 8/26/23 at 10:00 AM. -Resident 14's 8/17/23 physician order for a scheduled dose of Warfarin Sodium (blood clot prevention). […]

• No harm, potential for more than minimal, patternF686Oct 9, 2023

  Based on observation, interview, and record review it was determined the facility failed to ensure weekly skin and wound assessments were completed and completed timely and appropriate wound care treatment was provided for residents with wound vacuum systems for 2 of 2 residents (#s 5 and 6) reviewed for appropriate wound care and assessments. This placed residents at risk for delayed wound healing. Findings include: 1. Resident 5 was admitted to the facility in 8/2023 with diagnoses including Fournier's gangrene (rare but deadly infection of the genital and perineum) and Vacuum Assisted Closure wound therapy (wound vac) for a perirectal abscess wound. […]

• No harm, potential for more than minimal, patternF755Oct 9, 2023

  Based on observation, interview, and record review it was determined the facility failed to ensure policies and procedures were in place for the safe and secure handling of controlled medications and other drugs subject to abuse, and to adhere to best practices for ordering, refilling, receiving, documenting and disposition of medications for 1 of 1 facility reviewed for safe medication systems. This placed residents at risk for unmet care, medication needs and drug diversion. Findings include: The facility's 8/2023 Medication Administration Audit Report revealed the following sample of residents with missed medications: -Resident 3 had an 8/26/23 physician order for Carbidopa-Levodopa, two tablets, three times a day for Parkinson's Disease. […]