Cura of Watkins

In the surveyor’s words

From the most serious findings on record at Cura of Watkins, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Mar 21, 2024

  Based on observation, interview and document the review the facility failed to ensure the dishwashing machine temperatures reached adequate washing temperatures to clean and sanitize ddishware. This deficient practice had the potential to affect all 46 residents who received meals from the facility's kitchen. Findings include: On 3/20/24 at 8:22 a.m., while observing the dishwasher, the wash cycle was observed 4 times and the temperatures were as follows: Wash cycle #1 at 8:22 a.m. =147 degrees Fahrenheit ( F) Wash cycle #1 at 8:23 a.m. =148 F Wash cycle #1 at 8:25 a.m. =149 F Wash cycle #1 at 8:27 a.m. […]

• No harm, potential for more than minimal, patternF755Sep 20, 2021

  Based on interview and document review, the facility failed to identify corrective action following a drug diversion to develop a systematized oversight process to better identify discrepancies and unusual patterns related to narcotic and controlled medication administration, reconciliation and documentation practices for 4 of 4 residents (R1, R2 ,R3 and R4) who received controlled substance. Findings include: R1's admission Minimum Data Set (MDS), dated [DATE], indicated R1 had intact cognition, [CONDITION(S)] and received opiod medication with pain rated at a 10 (severe). R1's physician order dated 7/21/21, indicated an order for [MEDICATION(S)] 5 mg give orally as needed every 4 hours for pain rated 3-6 and give 10 mg for pain rated 7-10 using a scale of 1-10. […]

• No harm, potential for more than minimal, isolatedF623Mar 21, 2024

  Based on interview and document review, the facility failed to notify the Ombudsman for Long Term Care (LTC) of resident transfers to the hospital for 2 of 2 residents (R19, R32), reviewed for hospitalization . This had the potential to affect all residents transferred to hospital. Findings include: R19's significant change Minimum Data Set (MDS) dated [DATE], indicated R19's diagnoses included chronic obstructive pulmonary disease (COPD) and heart failure, and R19 was cognitively intact. R19's progress notes indicated R19 was hospitalized from 6/3/23 through 6/8/23. R19's medical record lacked evidence the Ombudsman for LTC was notified of R19's transfer to the hospital. […]

• No harm, potential for more than minimal, isolatedF684Mar 21, 2024

  Based on interview and document review, the facility failed to notify the physician and/or nurse practitioner (NP) for 1 of 3 residents (R34) reviewed for change of condition. Findings include: R34's quarterly minimum data set (MDS) dated [DATE], identified R34 had severe cognitive impairment and diagnoses which included dementia, Alzheimers, chronic kidney disease, edema and constipation. A review of R34's medical record revealed on 3/16/2024, at 4:41 a.m. a nursing progress note indicated Resident had small blood clots in her incontinent product. Further progress note on 3/16/2024 2:22 p.m. indicated resident had an emesis during lunch. After lunch, resident also had blood clots in her stool noted. Progress note on 3/18/2024, at 2:26 a.m. […]

• No harm, potential for more than minimal, isolatedF693Feb 2, 2023

  Based on observation, interview, and document review, the facility failed to ensure an eternal (feeding) tube was consistently checked for placement prior to the administration of medications through for 1 of 1 residents (R1) whose medication administration was offered through a stomach tube. Findings include: R1's quarterly Minimum Data Set (MDS) dated [DATE], identified R1 had unspecified intracranial injury with loss of consciousness for unknown period of time (injury to the brain without being awake for an unknown length of time) with related diagnosis of dysphagia (difficulty swallowing), and use of an abdominal feeding tube (a type of tube going straight into the stomach). […]