Inspection Reports for
Renaissance Park Multi Care Center

The facility failed to provide adequate pharmaceutical services for one resident by not notifying the physician of multiple refusals of prescribed medications, which could place residents at risk of not receiving appropriate treatment. Interviews and record reviews confirmed that medication refusals were not properly communicated to the physician or nurse practitioner as required by facility policy.

The facility failed to develop and implement comprehensive care plans for residents, including failure to care plan for Resident #1's sickle cell crisis and failure to provide treatment for Resident #4's burns as ordered. Additionally, the facility failed to obtain informed consent, physician orders, and assessments for bed rails for Residents #2 and #3. The facility also failed to accurately transcribe admitting diagnoses and physician orders for Residents #1 and #4.

The complaint investigation revealed that Resident #1's next of kin had requested medical records after the resident's death but had not received them after over two months. The facility's Director of Medical Records (DMR) and Administrator explained the delay was due to the legal department and a change in the attorney responsible for the request. The next of kin provided documentation proving their status and repeatedly requested updates. The facility policy supports the right to access records within 30 days, but this was not met.

The facility failed to provide requested medical records to Resident #1's next of kin, delaying the release for over two months. The delay was attributed to legal department issues and a change in the attorney handling the request. The facility acknowledged the right of next of kin to access medical records and had policies in place requiring records to be provided within 30 days.

The complaint investigation found substantiated failures in pressure ulcer prevention and skin assessment documentation, leading to immediate jeopardy. Resident #95 was transferred to hospital with a stage 3 pressure ulcer and sepsis and later died. The facility was out of compliance and required to implement corrective actions.

The facility failed to implement interventions to prevent a stage 3 pressure ulcer for Resident #95, failed to accurately assess and document skin conditions and refusals of skin assessments, resulting in immediate jeopardy to resident health. Resident #95 developed sepsis and other complications and subsequently died. The facility submitted a plan of correction and provided staff education on skin assessments and wound care.

The complaint investigation focused on Resident #95's pressure ulcer care and related quality of care issues, including skin assessments, documentation of refusals, and wound care. Additional complaint-related findings involved Resident #143's enteral feeding care and infection control practices.

The facility failed to prevent a stage 3 pressure ulcer in Resident #95, failed to accurately assess and document skin conditions and refusals, and failed to provide appropriate wound care and infection control. Additional deficiencies included improper medication administration via G-tube for Resident #143, failure to wear beard restraint in the kitchen, failure to maintain resident personal refrigerators, and failure to enforce infection control policies for visitors.

The complaint investigation was triggered by a medication error incident where MA D administered Resident #2's morning medications to Resident #1, including narcotic and psychoactive medications. The incident caused Resident #1 to become lethargic and confused, requiring Narcan administration. The facility initially did not report the incident to Health and Human Services, considering it a medication error without harm. The Administrator later self-reported after surveyor inquiry. The medication error was substantiated.

The facility failed to report a significant medication error timely in which Resident #1 received Resident #2's medications, including narcotics, resulting in Resident #1 becoming lethargic and confused and requiring Narcan administration. The facility conducted in-service training and competency checks for medication aides following the incident. The Administrator self-reported the incident after surveyor inquiry. Resident #1 did not suffer lasting harm, but the error posed a risk of serious harm or death.

The facility failed to maintain an effective infection prevention and control program, specifically during wound care for Resident #1, where improper procedures increased risk of infection and cross contamination. Additionally, the facility failed to maintain a safe and clean environment, with issues such as stained ceilings, damaged walls, and unresolved water leaks in the dietary department and employee restroom areas.

The complaint investigation focused on Resident #5's hospital transfer and discharge process, which was found to be inadequately documented and communicated, leading to family distress and risk to resident care. The investigation also included concerns about the qualifications of the Activities Director and pest control issues affecting multiple residents.

The facility failed to ensure safe and documented transfer of Resident #5 from the ER back to the facility, resulting in communication breakdowns and risk to resident care. The activities program was directed by an unlicensed Activities Director still in training, potentially impacting resident quality of life. The facility also failed to maintain an effective pest control program, resulting in residents being bitten by horse flies and gnats, posing infection risks.

The facility failed to maintain an effective infection prevention and control program, as evidenced by a CNA not performing hand hygiene before providing care to a resident, potentially placing residents at risk of cross-contamination and infection.

The facility was found deficient in ensuring registered nurse coverage for eight consecutive hours on certain weekend days, secure storage of controlled medications, proper food storage practices to prevent food-borne illness, and maintaining an effective infection prevention and control program, including sanitization of blood pressure cuffs between resident uses.

The complaint investigation focused on the failure to report an allegation of neglect for Resident #1 who sustained a serious injury from a fall. The incident was not reported to the State Agency as required. Interviews with the Director of Nursing and Administrator confirmed the incident was not self-reported due to existing fall interventions and absence of fracture.

The facility failed to report an allegation of neglect to the State Agency when Resident #1 sustained a serious injury from a fall on 11/21/23. Resident #1 had multiple bruises, bleeding, and required stitches, but the incident was not self-reported as neglect. The facility policy on abuse and neglect reporting was reviewed and found to require effective training and procedures for reporting such incidents.

The complaint investigation revealed that Resident #1 developed avoidable pressure ulcers due to inadequate skin assessments and lack of physician notification. Resident #4 reported call light failures in his room, confirmed by staff and maintenance, indicating a failure in the call system.

The facility failed to perform weekly skin assessments and notify the physician for Resident #1, resulting in multiple pressure ulcers and an Immediate Jeopardy situation that was corrected prior to the survey. Additionally, the facility failed to ensure Resident #4 had a working call light in the room, placing residents at risk of not getting assistance when needed.

The facility failed to ensure weekly skin assessments were performed and documented for 4 of 5 residents reviewed for pressure ulcers, placing residents at risk of unidentified deterioration or development of pressure ulcers. Deficiencies were noted in assessment documentation and care planning.

The investigation was complaint-driven, focusing on Resident #1's care related to skin integrity and pressure ulcer prevention. The complaint was substantiated based on findings of inadequate care planning and failure to identify and treat a pressure injury.

The facility failed to develop a baseline care plan addressing Resident #1's skin integrity concerns and failed to prevent the development and delayed treatment of a deep tissue pressure injury to the sacral area. The wound was not identified by facility staff until the resident was admitted to a local hospital. Interviews and record reviews revealed gaps in skin assessments, care planning, and communication among nursing staff.