Lakes of Monclova Health Campus the

In the surveyor’s words

From the most serious findings on record at Lakes of Monclova Health Campus the, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Jun 6, 2024

  Based on record review of staff schedules, review of posted staffing, and staff interview, the facility failed to use the services of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 56 residents residing in the facility. The census was 56. Findings include: Review of facility staffing schedules and posted staffing information from 05/02/24 to 06/02/24 revealed there was no Registered Nurse (RN) coverage in the facility on 05/18/24 or 05/19/24. Interview on 06/06/24 at 2:04 P.M., with the Director of Nursing (DON) verified there was no RN on duty in the facility on 05/18/24 and 05/19/24. The DON reported they had RN's on call but not in the facility. […]

• No harm, potential for more than minimal, patternF803Jun 6, 2024

  Based on observation, staff interview, review of resident diet list, and review of the menu spreadsheet, the facility failed to provide adequate portions of protein and mashed potatoes to residents on a mechanical soft diet. This had the potential to affect all 10 residents on a mechanical soft diet (#10, #16, #19, #20, #27, #30, #44, #262, #309, and #310). Additionally, the facility failed to provide adequate portions of protein and vegetables to residents on a pureed diet. This affected all four residents on a pureed diet (#4, #18, #37, and #40). The facility census was 56. Findings include: Observation during meal service on 06/04/24, between approximately 12:00 P.M. […]

• No harm, potential for more than minimal, patternF839Jun 6, 2024

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of medication administration records, review of staffing assignments, and review of Certified Registered Medication Aide (CRMA) licenses, the facility failed to ensure licensed staff were administering medications. This affected 21 residents (#8, #9, #12, #13, #15, #18, #19, #22, #23, #24, #27, #28, #31, #32, #24, #36, #37, #40, #42, #45, and #108) of 24 residents reviewed for medication administration. […]

• No harm, potential for more than minimal, patternF880Jun 6, 2024

  Based on observation, staff interview, record review, and review of the policy, the facility failed to ensure personal protective equipment (PPE) was worn by staff while performing care for a resident in contact precautions. This affected one (#307) of one resident reviewed for transmission based precautions and had the potential to affect all residents on the 100-hall (#20, #30, #39, #41, #47, #311, #312, #313, and #314). Additionally, the facility failed to ensure Enhanced Barrier Precaution (EBP) signage was posted appropriately for residents. This affected one (#26) of four residents reviewed for EBP. The facility census was 56. Findings include: Review of the medical record for Resident #307 revealed an admitted [DATE], with a diagnosis of Clostridium difficile (C. […]

• No harm, potential for more than minimal, patternF550Sep 30, 2021

  Based on observation, review of resident council minutes, resident and staff interviews, the facility failed to ensure residents were served meals on nondisposable dishes, glasses/cups and silverware, to promote a homelike environment. This had the potential to effect 51 of the 52 residents in the facility. Resident #11 received nothing by mouth. The facility census was 52. Findings include: Observation on 09/27/21 at 12:00 P.M., revealed residents seated in the dining room being served a variety of beverages in disposable Styrofoam cups. The meals were served on disposable thin plastic plates. Subsequent observation at 1:00 P.M., of hall trays delivered revealed the same disposable dinnerware was served to the residents in their rooms. […]