College Park Rehabilitation and Care Center

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biological used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory cautionary instructions, and the expiration date when applicable for 1 (hall 400 nurse cart) of 4 medication carts reviewed for medication storage. The facility failed to keep each resident's medications in their original containers and stored separately. This failure could place residents at risk of receiving expired and/or improper medications. During an observation on [DATE] at 8:45 AM of the nurse's medication cart for hall 400 revealed, 2 loose pills were found in the bottom of the second drawer of the cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen, in that: The facility failed to ensure: A. 1 of 1 walk-in coolers were clean and free from sticky substances. B. Kitchen floor on the left side and underneath 1 of 1 ice machines were clean and from a brown sticky substance and dust. The facility's failure could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on observations and interviews, the facility failed to dispose of garbage and refuse properly for 2 (2 Dumpsters) of 2 garbage containers reviewed for food safety requirements. The facility failed to ensure two dumpsters in the parking lot was not overflowing with garbage. This failure could affect residents by placing them at risk of food borne illness, illnesses, or be provided a unsafe, unsanitary and uncomfortable environment.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement abuse, neglect policies that addresses screening of a potential employee's license which resulted in an employee being allowed to work as a nurse with no license or education check for 1 (Staff Member G) of 24 staff . The facility failed to screen Staff Member G to ensure she was licensed to practice as a GVN through the TX-BON. As a result Staff Member G was allowed to provide care and services to residents outside of her scope that included administration of medications that included PICC line normal saline flushes, short, long, sliding scale insulins and narcotics, wound care for stage III (3) wounds, monitoring of dialysis ports, PICC lines, and catheters with no direct supervision and providing supervision to certified nurse aides and medication aides. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure professional staff was licensed in accordance with applicable State laws for 1 (Staff Member G) of 24 personnel reviewed for licensed nursing. The facility failed to verify if Staff Member G was licensed to practice as a GVN through the TX-BON. As a result, Staff Member G was allowed to provide care/services/treatment to residents including PICC line normal saline flushes, short, long and sliding scale insulins, narcotics administration, stage 3 wound care, monitoring of dialysis ports and catheters for 26 of 92 residents on 400 hall. An Immediate Jeopardy to residents' health and safety was identified on 02/16/24. The Immediate Jeopardy Template was provided to the ADM on 02/16/24 at 8:55PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to evaluate and maintain and effective Quality Assurance and Performance Improvement program that focused on indicators of the outcomes of care and quality of life. The facility's QAPI plan had not been reviewed annually for need revisions. This failure placed the residents at risk for a decreased quality of care and decreased quality of life within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 2 of 3 residents (Residents #17 and #55) whose records were reviewed for baseline care plans following admission to the facility, in that: 1. Resident #17 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following her admission to the facility. 2. Resident #55 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following his admission to the facility. This failure placed the residents at risk for not receiving care and services to meet their needs and to promote physical and mental health and well-being within their new living environment.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, 1 of 8 residents (Resident #40) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan that included her weight bearing status for Resident #40 or that she should wear a knee brace. This failure could place the resident at risk for injury and providers not having the most current information for the Resident's plan of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who is incontinent receives appropriate treatment and services to prevent urinary tract infections for one 1 of 2 residents (Resident #67) reviewed for infection control practices. CNA H failed to clean bedside table before setting supplies up for incontinent care. CNA H failed to change gloves between clean and dirty brief change during incontinence care. CNA H failed to wipe from front to back during cleansing peri area including not cleansing from labia folds thru urethral opening. This failure could affect the 24 residents on hall 400 who were occasionally or frequently incontinent of bladder and bowel by placing them at risk for the spread of infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with currently accepted professional principles for 1 of 1 Medication rooms. 1. Discontinued medications were stored in an unsecured plastic box beneath the desk of ADON A. This failure placed the residents at risk for potential harm from access to medications that were controlled drugs and were not prescribed for their medical conditions.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, which were complete and accurate for 1 of 8 residents (Resident # 43) reviewed for resident records. The facility failed to ensure physician orders were written for Resident #40. This failure could place residents at risk of having errors in care and treatment.