Egret Cove Center

Inspectors wroteBased on observations, interviews and record review, the facility did not ensure timely administration of medications for two Residents (#2 and #3) of two Residents reviewed for receipt of prescribed medications and for two of two medication administration passes observed, resulting in thirty-one residents receiving medications outside of the facility's medication timing parameters. Findings Included: 1. A review of Resident #2's Medication Administration Audit Report for the month of October 2024 indicated the following: On 10/8/24, the following medications were scheduled to be administered at 9:00 a.m. and were documented on the Medication Administration Audit Report as administered at the following times: - Celebrex oral capsule 200 mg (milligrams), give 200 mg by mouth two times a day for moderate pain: Documented as administered at 10:54 a.m. [...]

Inspectors wroteBased on observation, and interview, the facility failed to ensure adequate placement of call assistance equipment to call for staff assistance for six (#7, #8, #9, #10, #11, and #13) of fourteen sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to have evidence of the provision of a summary of the baseline care plan to the resident and their representative for one (#12) of fourteen sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to develop and/or implement a comprehensive person-centered care plan for four (#7, #8, #9, and #11) of fourteen sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a timely respiratory assessment and care in accordance with professional standards of practice for one (#2) of three sampled residents related to an assessment of a resident in distress.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the clinical record contained documentation of the services provided for meal consumption for one (#7) of fourteen sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility 1) failed to initiate an Enhanced Barrier Precautions (EBP) isolation program for thirteen out of thirteen residents on EBP and, 2) failed to implement an effective infection control program related to facility failure to handle, store, process, and transport all linens and laundry in accordance with infection control practices to produce hygienically clean laundry for 105 out of 105 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the development, revision, and/or implementation of comprehensive care plans was completed for two (Resident #259 and #73) of six sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to give the opportunity to choose urinal placement and length of the bed frame for one (Resident #104) of one resident sampled. An interview was conducted with Resident #104 on 5/13/2024 at 10:30 a.m. He stated he did not want the urinal on the over the bed table all of the time. He said he was able to smell the urine all the time, even when the urinal was empty. He said he had numerous conversations with personnel in the past. He stated there was not anywhere else for the urinal to be placed without having to call for assistance. He stated, They [the facility] doesn't have a place for the urinal and they don't listen, I have told them numerous times and continue to tell them, I don't like to eat with the urinal next to my tray. [...]

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure the comprehensive Minimum Data Set (MDS) assessment was accurately coded for two (Residents #24 and #17) of twenty-six sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a care plan related to trauma informed care for one (Resident #103) out of 37 sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Activities of Daily Living ADL grooming was provided for one (Resident # 101) out of eight residents sampled.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice related to 1. transportation for coordination of care to their doctors' appointment for four (Residents # 209, #33, #7, and #58) out of 10 residents sampled and 2. application of a medication patch for one (Resident #81) of one sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility 1. failed to ensure a physician order was in place for the administration of oxygen for one (Resident #21) out of four residents reviewed for respiratory care, and 2. failed to ensure emergency tracheostomy supplies were readily available for one (Resident #97) out of one resident with a tracheostomy tube.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the comprehensive person-centered care plan and physician orders for one (Residents #73) of one sampled resident who required dialysis, which included providing dietary needs (breakfast/snacks).

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data to ensure the information was readily accessible to all residents and visitors during two of four days of survey.

Inspectors wroteBased on interview and record review, the facility did not ensure residents who entered arbitration agreements understood the contract contents for one (Resident #259) of three residents sampled.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to appropriately secure medications in the entrance of two resident rooms (Rooms #18 and #305); and failed to ensure appropriate storage of medications in three of three medication carts located on 100 (South Hall), 300 and 400 (North Halls).

Inspectors wroteBased on interview and record review, the facility failed to notify the physician and document the refusal of laboratory blood tests on two occasions for one (Resident #59) of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall risk care plan interventions of floor mats for one (Resident #30) of three residents sampled for falls.