Tate Springs Health & Rehab

Inspectors wroteBased on staff interview, facility document review, and clinical record review, the facility staff failed to follow professional standards regarding wound documentation for one of four residents in the survey sample (Resident #2).

Inspectors wroteBased on staff interview and clinical record review, the facility failed to develop a care plan for one of 21 residents. Resident #43 did not have a care plan for fluid restrictions. The Findings Include: Diagnoses for Resident #43 included: Congestive heart failure, end stage renal disease (ESRD), hypertension with heart failure, and diabetes. The most current MDS (minimum data set) was a 5 day assessment with an ARD (assessment reference date) of 2/17/23. Resident #43 was assessed with a cognitive score of 11 indicating moderately cognitively intact. On 4/17/23 Resident #43's active physician orders were reviewed and read in part: Fluid Restriction 1200 ML every shift for ESRD. Review of Resident #43's care plan did not evidence a care plan had been developed for fluid restrictions. [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure a vial of insulin was not expired for one out of 18 residents who were prescribed insulin. This failure had the possibility of negatively impacting all 18 insulin dependent residents.

Inspectors wroteBased on clinical record review and staff interview, the facility staff failed for one of 21 residents in the survey sample (Resident # 30) to ensure the resident's clinical record was complete and accurate. The circumstances of a fall sustained by the resident were not reflected in the clinical record.

Inspectors wroteBased on observation, interview, medical record review, and facility policy review, the facility failed to ensure physician orders were verified and followed for oxygen therapy flow rate for four of four residents (Resident (R) 40, R32, R44, and R47) reviewed for respiratory care.

Inspectors wroteBased on observation, resident interview, staff interview, and review of the facility policy, the facility failed to serve food that was palatable for three of 30 sample. Specifically, pureed food was unpalatable, pasta overcooked, and meat was tough.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure foods stored in the kitchen were labeled, dated when opened, and sealed closed. Also, pots and pans were not properly sanitized after washing and cups were not allowed to air dry before lids were reattached. These failures had the potential to affect all 90 residents in the facility who ate food from the kitchen.

Inspectors wroteBased on record review, review of facility policy, and interview, the facility failed to refer one resident of three residents (Resident (R) 40) reviewed for Preadmission Screening and Resident Review (PASARR) to the appropriate State-designated authority for a Level II PASARR evaluation and determination.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure a comprehensive care plan was developed and implemented for two of 30 sampled residents (Resident (R) 32, R47, and R186). Specifically, the facility failed to develop a care plans for R32's and R47's oxygen therapy; and an incontinence care plan for R186.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to include one resident of 25 sampled residents (Resident (R) 25) in the discharge planning process.

Inspectors wroteBased on observation, interview, policy review and record review, the facility failed to ensure professional standards of practice were maintained for the treatment of pressure ulcers, for one of one resident (Resident (R) 47) observed for pressure ulcer treatments. Staff failed to perform hand hygiene and ensure a clean environment prior to performing wound treatments.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to provide assistive devices to prevent accidents for one of five (Resident (R) 23) residents reviewed for accidents out of 30 sample residents.

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure the resident receiving enteral feeding received appropriate care and services to prevent complications for one of one resident (Resident (R)17) reviewed for tube feeding cares.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure there was a physician order for dialysis treatment for one resident of two residents (Resident (R) 25) reviewed for dialysis out of 30 sampled residents.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to remove expired medication from their medication room. This failure to remove expired medication had the potential to place the resident at an increased risk of receiving expired medications.

Inspectors wroteBased on observation, resident interview, staff interview, and clinical record review the facility staff failed to obtain dental services for Resident # 55. Resident # 55 had broken, carious bottom teeth, and had no dental care since admission.

Inspectors wroteBased on resident interview, staff interview and clinical record review, the facility staff failed to ensure a CCP (comprehensive care plan) was developed and implemented for one of 23 residents in the survey sample, Resident #24.

Inspectors wroteBased on observation, and staff interview, the facility staff failed to ensure a date was placed on opened medication and was readily available for use on one of 2 units. An opened multidose vial of Lantus (insulin) without a date was readily available for use on the second floor unit. The Findings Include: On 02/20/19 at 2:39 PM, storage of medications and biological's was observed on the second floor. A multidose vial of Lantus insulin was observed opened and without an open date in the refrigerator available for distribution. There was a sticker on the bottle to indicate that the Lantus would expire after 28 days of being opened. The Director of nursing (DON) was in the medication room at the time of the observation. When asked about the medication without an open date, the DON verbalized that the Lantus should have been dated with an open date and should not be in the refrigerator. [...]

Inspectors wroteBased on staff interview and clinical record review the facility staff failed to provide written notification of a hospital transfer for two of 23 residents in the survey sample: Residents #76 and # 93. 1. Resident #76 was discharged to hospital and the facility did not notify the Ombudsman or the responsible party (RP) in writing. 2. Resident #93 was discharged to hospital and the facility did not notify the Ombudsman or the responsible party (RP) in writing. The Findings Include: 1. Resident #76 was admitted to the facility on [DATE] with the most readmission on [DATE]. Diagnoses for Resident #76 included: Diabetes, end stage renal disease receiving dialysis, hypotension, sleep apnea, and morbid obesity. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 1/27/19. [...]

Inspectors wroteBased on clinical record review and staff interview, the facility failed for one of 23 residents in the survey sample (Resident # 101) to ensure an accurate Minimum Data Set. Resident # 101, who was discharged home, was identified on a Discharge - Return Not Anticipated Minimum Data Set as having been discharged to an acute hospital.

Inspectors wroteBased on clinical record review and staff interview the facility failed to ensure a PASARR (Pre-admission Screening and Resident Review) was completed for one of 23 resident's, Resident #62. Resident #62 did not have a PASARR screening when admitted to the facility. The Findings Include: Resident #62 admitted to the facility on [DATE]. The most recent MDS was a quarterly assessment with ARD (Assessment Reference Date) of 1/22/19. Diagnoses for Resident #62 included: Diabetes, dementia with lewy bodies, Parkinson's disease, depression, malignant neoplasm of uterus. Resident #62 had a cognitive score of 11 indicating moderately cognitively intact. On 2/19/19 Resident #62's medical record was reviewed and did not evidence that A PASSAR had been completed by the facility. [...]