Egret Cove Center

In the surveyor’s words

From the most serious findings on record at Egret Cove Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF880May 16, 2024

  Based 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. Findings included: On 05/15/24 at 11:09 a.m., an interview was conducted with the Director of Nursing (DON) regarding infection control for isolation residents. The DON stated newly arrived residents are screened for any isolation precautions from the transferring facility. […]

• No harm, potential for more than minimal, patternF755Dec 3, 2024

  Based 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. […]

• No harm, potential for more than minimal, patternF919Oct 18, 2024

  Based 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. Findings include: A tour of the facility was initiated on 10/17/2024 at 9:32 a.m. The following observations were conducted during the tour. During an observation on 10/17/2024 at 9:35 a.m., Resident #7 was seen in bed with severe contractures of his arms and legs, curled in a fetal like position, and with his arm wrapped in his leg. He was observed watching television. Resident #7 was able to answer questions. When asked if he could use his call bell light. the resident did not answer but turned his head towards the feeding tube pole. […]

• No harm, potential for more than minimal, patternF657May 16, 2024

  Based 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. The findings include: Review of the Admission Record for Resident #73 revealed an admitted [DATE] and a recent admission of 3/16/2024 with diagnoses to include: end stage renal disease; heart failure; diabetes type 1; cachexia; hyperkalemia; protein-calorie malnutrition; muscle wasting and atrophy; and other co-morbidities. Review of the Minimum Data Set (MDS) from admitted d 3/18/2024, showed Resident #73 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated intact cognition. […]

• No harm, potential for more than minimal, patternF761May 5, 2022

  Based 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). Findings included: During an observation of room [ROOM NUMBER], on 05/03/2022 at 9:42 a.m., a small oval blue pill was observed at the entrance of the resident room. An immediate interview of Staff A, Licensed Practical Nurse (LPN), revealed the nurse was in the middle of medication administration and confirmed the presence of the unsecured tablet at the entrance of resident room [ROOM NUMBER]. She stated, I can't own it, I don't think it is mine. […]