Healthcare at College Park, LLC

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to assure that the ice machine was clean and properly functioning. The facility failed to maintain clean facility equipment and failed to document the cleaning of the ice machine. The census of the facility was 65.

Inspectors wroteBased on interviews, record review and facility policy titled Antibiotic Stewardship, the facility failed to properly maintain an Antibiotic Stewardship Program. The deficient practice placed the resident at risk for not receiving the appropriate antibiotics to treat their infection and could place the resident at risk for developing antibiotic resistant infections. The facility census was 65.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services that met professional standards of quality by the failure to administer 5:00 pm medications on 8/9/24, for seven of nine Residents (R) 27, R32, R20, R21, R45, R26 and R13. This failure could have caused adverse reactions in all seven of the residents who missed their medications. Findings Include: On 8/6/24 at 8:35 pm Certified Medication Aide (CMA) FF began her medication administration for the first-floor residents. As she passed her scheduled medications, she would tear off pouches from the roll in each resident labeled box, in her medication cart. The perforated individual pouches with resident names, medication names, and time, and date to be administered were then put in a separate drawer in her cart. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure seven of nine sampled Residents (R) 27, R32, R20, R21, R45, R26 and R13 were free from a significant medication error related to not administering medications according to the physician orders. Specifically, when medications, such as metoprolol tartrate, potassium, venlafaxine, Xarelto, and gabapentin, scheduled for 5:00 pm on 8/6/24 were not administered as ordered. Findings Include: On 8/6/24 at 8:35 pm, Certified Medication Aide (CMA) FF passed medications for her assigned first-floor residents. As she passed her scheduled medications, it was noted that the following resident's did not receive their 5:00 pm medications as ordered., and CMA FF did not notify licensd staff. R27 - med order dated 7/1/24, for Potassium Chloride 10 MEQ with the adverse effect of hypokalemia, scheduled at 5:00 pm. [...]

Inspectors wroteBased on observation, interviews, review of relevant facility documentation, and review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation-Reporting and Investigating, the facility failed to protect one of seven sampled residents (R5) from sexual abuse by another resident, R425. This deficiency had the potential to place R5 and other residents at risk for repeated sexual abuse.

Inspectors wroteBased on record review, staff interviews and review of the facility policy titled, Resident Assessment- Coordination with PASARR Program the facility failed to follow PASARR level II program recommendations for one of 28 residents (R)420 with a PASARR level II.

Inspectors wroteBased on record review, staff interview, and a review of the facility's policy Comprehensive Care Plans the facility failed to develop a care plan that was consistent with the resident's specific conditions, risks, needs, and current standards of practice for one residents (R) R45. The sample size was 39.

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to provide two hour check and change for one Resident (R14) dependent on staff for activities of daily living (ADLs) The sample size was 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to secure a central supply storage room that contained medications and medical supplies. Findings Include: On 8/7/24 at 3:03 pm a central supply room on the first floor was observed open with no staff member in the room. On 8/7/24 at 3:05 pm, licensed practical nurse (LPN) PP confirmed and verified the door to the central supply room on the first floor was open and not locked. LPN PP confirmed there were no other staff members in the central supply room on the first floor. LPN PP stated the door to the central supply room didn't have to be kept shut or locked, it was where they stored supplies and where staff obtained supplies needed. LPN PP confirmed that there were over the counter medications in the room and stated they had never been told to keep this room closed and locked. [...]

Inspectors wroteBased on observation, record review, and resident and staff interviews, the facility failed to properly protect resident (R) R37 from the risk of infection related to resident having an external catheter and per policy, was on enhanced barrier precautions. The staff were to use personal protective equipment (PPE) when rendering care for R37. The facility census was 65.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety in the kitchen. Specifically, the facility failed to: - Store food items off the floor in the dry storage area and - Maintain a clean dry storage area. This deficient practice had the potential to affect 66 residents who received nutrition from the kitchen (total census: 68).

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to maintain confidentiality of medical records that had been damaged in 1 of 1 record storage rooms. Observations revealed water-damaged medical records were stacked outside a storage building with protected health information (PHI) exposed.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Electronic Transmission of the Minimum Data Set (MDS), the facility failed to ensure MDS assessments were transmitted within 14 days of completion to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment and Submission and Processing (ASAP) system for 5 of 19 residents (R) (R#1, R#4, R#22, R#25, and R#43) reviewed for MDS transmittal.

Inspectors wroteBased on interview, record review, and facility policy review, it was determined that the facility failed to ensure interventions were developed, care planned, and implemented to address behavioral symptoms for 1 (Resident #11) of 4 sampled residents reviewed for psychotropic medications. Resident #11 exhibited behavioral changes related to telephone use and the facility failed to develop behavioral health interventions to address the behaviors.

Inspectors wroteBased on observation, interviews and reviews of policy titled Cleaning Instructions: Microwave Oven, the facility failed to appropriately label and date sealed and opened, food items, in the refrigerator and freezer, maintain clean microwave ovens, a trash bin with foot peddle and lid near the hand wash sink, and failed to allow air dry kitchen ware to air dry. This had the potential to affect 74 residents receiving an oral diet.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe and clean wheelchair for one Resident (R)#1 and failed to maintain clean enteral tube feeding pump poles and bases for two residents, R#6 and R#17 of 36 sampled residents.

Inspectors wroteBased on record review, staff interviews, Pharmacist interview, and review of the facility policy Medication Destruction, the facility failed to establish a system of records of receipt for destroying unused controlled medications. In addition, the records of controlled medication destruction were not readily accessible for review. The facility census was 80 residents.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure that Minimum Data Set (MDS) Assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment and Submission and Processing (ASAP) system for ten residents (R) R#1, R#9, R#5, R#6, R#7, R#3, R#4, R#11, R#22 and R#10 and a Discharge Assessment for one resident R#8 of 36 sampled residents.