Inspection Reports for Sunterra Springs Independence

The investigation was complaint-driven based on allegations of failure to provide trauma informed care, insufficient nursing staff, and inadequate infection control practices.

The facility failed to provide trauma informed care for a resident with PTSD by not including mental health diagnoses and triggers in the care plan and staff were unaware of these triggers. The facility also failed to ensure sufficient nursing staff to respond to call lights in a timely manner, with documented delays up to 39 minutes. Additionally, the facility failed to ensure staff used Enhanced Barrier Precautions (gowns and gloves) consistently when providing care to residents with wounds or on isolation precautions.

The facility failed to document a comprehensive wound assessment and obtain physician's orders for a pressure ulcer on admission for one sampled resident. The wound care orders were obtained two days after admission, and the comprehensive wound assessment was delayed by four days. Nursing staff did not document detailed wound assessments as expected.

The investigation was triggered by a missing card of oxycodone 5 mg, quantity 30 for Resident #1. The facility discovered the medication was missing between 11/29/23 and 12/2/23. A staff member (LPN B) was suspended pending investigation. Surveillance footage showed discrepancies in medication card handling. The Director of Nursing filed a police report and notified the resident and pharmacy. Staff were re-educated on medication handling and reporting procedures.

The facility failed to ensure that a controlled drug card of 30 oxycodone tablets was properly accounted for, locked, and immediately reported as missing after delivery. Surveillance footage and investigation revealed discrepancies in medication card handling by staff, leading to the missing medication. The deficiency was corrected with staff education and suspension of a suspected employee.

The facility had multiple deficiencies including failure to ensure residents' rights to formulate advanced directives were fully honored and documented; incomplete background screening for new employees; failure to provide baseline care plans to residents within 48 hours of admission; lack of discharge recapitulation summaries; inadequate CPR certification tracking; failure to properly assess and educate staff on insulin pump use; improper management and documentation of CPAP and oxygen therapy; incorrect identification and assessment of dialysis access; and incomplete and unclear arbitration agreements.

The complaint investigation involved multiple allegations including failure to notify physicians, diversion of medications, failure to report abuse and injuries, failure to investigate abuse allegations, failure to withhold CPR per DNR, and narcotic count discrepancies. The facility census was 37 residents. Several residents and staff were interviewed, and multiple records were reviewed. The investigation found multiple deficiencies in compliance with regulatory requirements.

The facility failed to notify a physician of significant weight gain for a resident, failed to prevent diversion of Lorazepam from one resident to others, failed to timely report and fully investigate allegations of abuse and injuries of unknown origin, failed to withhold CPR per a resident's DNR order, failed to ensure narcotic counts were properly documented and signed, and failed to provide required CNA training hours. Investigations were incomplete or delayed, and policies were not fully followed.