Royal Care of Avon Park

In the surveyor’s words

From the most serious findings on record at Royal Care of Avon Park, in the surveyor’s own words.

• Actual harm, isolatedF686May 9, 2024

  Based on observations, resident and staff interviews, and record review, the facility failed to identify a new area of skin impairment, until it was an advanced stage pressure ulcer for one resident (#58) of two residents reviewed for pressure ulcers. This failure resulted in actual harm because a facility-acquired unstageable pressure ulcer, which is an advanced stage of skin breakdown that is full-thickness tissue loss is difficult to heal, at increased risk for infection, and disfiguring. The findings included: On 5/7/24 at 10:45 AM, Resident #58 was cycling in the therapy gym. He said that he got a Stage 4 pressure ulcer on his back because the facility didn't do anything after they discovered the pressure ulcer. […]

• No harm, potential for more than minimal, widespreadF867May 9, 2024

  Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to ensure a medication administration error rate of less than 5%. A total of forty-three medication administration opportunities were observed with twenty-two errors for three (#5, #10, and #12) of five residents observed (F759). This resulted in a medication administration error rate of 51.16% during the revisit survey conducted 7/17/2024. Findings included: A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, widespreadF867May 9, 2024

  Based on observation, interview, and record review, the facility failed to provide Quality Assurance and Performance Improvement (QAPI) practice that demonstrated identification, monitoring and implementation of an effective action plan to correct citations related to failing to ensure a medication administration error rate of less than 5%. A total of forty-three medication administration opportunities were observed with twenty-two errors for three (#5, #10, and #12) of five residents observed (F759). This resulted in a medication administration error rate of 51.16% during the revisit survey conducted 7/17/2024. Findings included: A review of Resident #5's medical record revealed Resident #5 was admitted to the facility on [DATE]. […]

• No harm, potential for more than minimal, patternF584May 9, 2024

  Based on observation and interview, the facility failed to provide a clean and homelike environment, in that the facility was not free from offensive odors. This involved the front lobby area, the area in front of the [NAME] nurses' station, and four resident rooms (Rm103, Rm107, Rm109 and Rm110) out of 18 resident rooms on the [NAME] unit. Findings included: On 5/6/24 at 9:00 a.m. the lobby smelled of old urine when the survey team entered the facility. At 11:10 a.m. the area in front of the [NAME] nurses' station smelled of old urine. On 5/6/24 at 2:31 p.m. room [ROOM NUMBER] had a very offensive odor in the room, that was not urine. On 5/7/24 at 10:03 a.m. room [ROOM NUMBER] had an offensive odor that was not urine. On 5/7/24 at 10:38 a.m. […]

• No harm, potential for more than minimal, patternF645May 9, 2024

  Based on record review, interview, and review of the facility's policy the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASARR) was accurate for four residents (#15, #26, #28, #38) of 17 residents sampled for PASARR review. Findings included: Review of the electronic medical record (EMR) revealed Resident #15 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included vascular dementia severe, bipolar disorder, and major depressive disorder. Review of the Level I PASARR, dated 7/31/23, showed qualifying diagnoses were not checked or indicated, and that no Level II PASARR was required. […]