Beneva Lakes Healthcare and Rehabilitation Center is a for-profit nursing home located at 741 Beneva Road, Sarasota, Florida 34232. This nursing home has been owned and operated by Consulate Health Care since 2012. Consulate Health Care is one of the largest nursing home operators in the United States and is based in Maitland, Florida. The Florida Agency for Healthcare Administration, which licenses and regulates nursing homes in Florida, conducted an unannounced recertification survey and a complaint investigation from August 15, 2016 through August 18, 2016 at Beneva Lakes Healthcare and Rehabilitation Center. At that time, the State of Florida investigators cited this nursing home for numerous violations of law under the federal Nursing Home Reform Act and state law. Those violations based upon the recertification and complaint survey filed against Beneva Lakes Healthcare and Rehabilitation Center included:
F 272 Comprehensive Assessments. The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident’s functional capacity. Investigators concluded that the nursing home failed to complete an accurate assessment of the functional capacity of 1 of 3 residents reviewed for bladder incontinence. Findings included: the resident was admitted on 4/15/16. Review of the bowel & bladder elimination pattern evaluation showed resident was incontinent of bladder 8 times on both 4/16/16 and 4/17/16. Review of the activities of daily living (ADL) tracking form for April 2016 showed resident was incontinent on the 11:00 p.m. – 7:00 a.m. shift for five out of seven days reviewed for the comprehensive assessment. The Admission Minimum Data Set (MDS) dated 4/22/16 bowel and bladder function was coded the resident was always continent of bowel and bladder and was not on a urinary training program.
F 274 Comprehensive Assessments After Significant Change. A facility must conduct a comprehensive assessment of a resident within 14 days after the facility determines, or should have determined, that there has been a significate change in the resident’s physical or mental condition. The Agency concluded during its investigation that Beneva Lakes Healthcare and Rehabilitation Center failed to complete a significant change Minimum Data Set (MDS) 3.0 assessment for 1 of 1 sampled resident who elected the Hospice benefit for end of life care.
F 285 PASRR Requirements for MI & MR. A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicate testing and effort. The State of Florida also cited Beneva Lakes Healthcare and Rehabilitation Center for failing to ensure 1 of 40 residents surveyed received a required level II Preadmission Screening and Resident Review (PASRR) resulting in a resident being admitted to the facility with a history of mental illness without a level II screening. Review of the resident’s Level I PASRR whoed the resident had schizophrenia a serious mental illness (SMI). The form showed this was based on the individual, legal guardian or family report. Page 4 of the Level 1 PASRR showed the resident had no diagnosis of SMI and a level II PASRR was not required. On 8/17/16 the Director of Nursing (DON) said she was checking to see if [the] resident really had schizophrenia. The DON verified this action should have been completed before the resident was admitted to the facility.
F 315 No Catheter, Prevent UTI, Restore Bladder. Based on the resident’s comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident’s clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.
Based on record review and interview, the Agency found that the facility failed to follow their bowel and bladder policy and procedure by not attempting to restore continence of bowel and bladder for 1 of 3 residents reviewed. The facility’s failure to follow its policy to accurately evaluate the resident lead to the residents worsening condition. The findings included: Resident was admitted to the facility on 4/4/16, and the admission MDS (minimum data set) dated 4/21/16 coded the resident as: 2 (frequently incontinent 7 or more episodes or urinary incontinence, but at least 1 episode of continent voiding). At the quarterly MDS dated 7/14/16, the resident was identified as: 3 (always incontinent, no episodes of continent voiding). Record review found bowel and bladder elimination pattern evaluation for the resident dated 4/14/16 and completed 4/16/16. Per evaluation the resident was deemed as incontinent. Further review for the resident found no attempt to restore continence of bowel or bladder. There was no explanation as to why no attempt was made. On 8/18/16, the DON (Director of Nursing) said she still did not know why the resident was not placed in a bowel and bladder program. The DON said the staff probably assumed she was already incontinent upon admission and that was why they did not attempt to place her in a program. The DON said that was not an excuse and acknowledged the lack of appropriate assessment.
F 329 Drug Regimen is Free from Unnecessary Drugs. Each resident’s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
The Agency cited Beneva Lakes Healthcare and Rehabilitation Center for failing to ensure 1 of 7 residents surveyed was free from unnecessary medications resulting in the resident receiving a discontinued medication for 16 days and a potentially contributing to a residents frequent urination. Specifically, a resident was ordered Flomax (a breathing medication), which was discontinued on 6/8/16 by a physician’s progress note, which read “Urinary Frequency: will D/C [discontinue] Flomax.” According to the medication administration record, the resident continued to receive Flomax from 8/1/16 to 8/16/16. On 8/18/16 the resident verified that he continued to have urinary frequency and asked if there was a medication that would help to decrease his frequent urinating.
F 332 Free of Medication Error Rates of 5% or More. The facility must ensure that it is free of medication error rates of five percent or greater.
Based on record review, interview and observation, the Agency indicated that the facility had failed to ensure the medication error rate was less than 5% having a medication error rate of 7.1% in 29 opportunities resulting in a potential for one resident aspirating (breathing material into the airways) stomach contents and the potential for one resident to have a hypoglycemia (low blood sugar). Findings, in part, included: Staff member of the facility verified that he did not check the residual of the resident’s stomach before administering the medication. He verified there was a potential for aspiration of the stomach contents when administering the medications and adding fluid if the stomach was full from the tube feeding.
F 465 Safe/Functional/Sanitary/Comfortable Environment. The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.
AHCA cited the facility for failure to provide maintenance services necessary to maintain a safe, sanitary, orderly and comfortable interior environment for 18 of 35 resident rooms sampled. Some of the State’s findings included: strong urine smell in the bathroom of one room; sink corrosion of faucets; large chipped area on a bathroom sink (the area had sharp edges); stained and / or discolored toilets; and black buildup around the door post.
As a nursing home abuse lawyer who frequently handles cases involving nursing home understaffing, medication errors and the failure to perform timely and accurate nursing assessments, I can confirm that these are serious issues which may significantly impact the health and well-being of vulnerable nursing home residents. If you suspect that a loved one has not received proper care in a nursing home or has become the victim of nursing home abuse and neglect, you have the right to take action under Florida law. I provide a free, confidential consultation to discuss your rights. James Edwin Keim, Florida Nursing Home Abuse Lawyer. Call Me at: (844) 485-7600.