Spanish Cove Housing Authority

In the surveyor’s words

From the most serious findings on record at Spanish Cove Housing Authority, in the surveyor’s own words.

• Actual harm, isolatedF689Sep 26, 2024

  Based on record review and interview, the facility failed to ensure adequate supervision and assistance with transfers for one (#3) of five sampled residents reviewed for accidents. The ADON identified 42 residents resided in the facility and 31 residents required assistance with transfers. Findings: The facility's Gait Belt policy, dated 2023, read in part, .Gait Belts promote the safe handling and mobility of residents .Spanish Cove requires a gait belt when assisting all residents with ambulation or transfer .Nursing assistants must wear gait belts at all times . […]

• No harm, potential for more than minimal, patternF689Aug 4, 2026

  Based on observation, record review, and interview, the facility failed to provide an environment free of accident hazards involving ingestion of potentially harmful chemicals for 1 (#18) of 2 sampled residents reviewed for accident hazards. The ADON identified two residents at high risk for wandering. Findings: On 08/02/26 at 1:45 p.m., Resident #18 was observed to be in their room with the door closed. There was a 4-foot bookshelf in the resident's which contained the following items:a. a half full spray bottle labeled perineal and skin cleanser was on the top shelf. The number 123 was handwritten on the bottle with a marker,b. an open squeeze bottle of hand sanitizer was observed on the top shelf, andc. a baggie of cookies was on same shelf beside the bottles of chemicals. […]

• No harm, potential for more than minimal, isolatedF641Oct 23, 2024

  Based on record review and interview, the facility failed to accurately code a MDS assessment for one (#37) of five residents sampled for accuracy for MDS assessments. The Administrator identified 44 residents resided in the facility. Findings: A MDS Assessment Coordinator policy, revised November 2019, read in part each individual who completes a portion of the assessment must certify the accuracy of that portion of the assessment Resident #37 was admitted on this date 09/21/24 with diagnosis that included fracture of right femur and depression. A Medication List from admission orders, dated 09/21/24, documented Quetiapine (Seroquel) 25mg one tablet given daily for 5 days. […]

• No harm, potential for more than minimal, isolatedF755May 10, 2023

  Based on record review and interview, the facility failed to ensure medications were administered according to physician's orders for one (#1) of three sampled residents whose medication profiles were reviewed. The Resident Census and Conditions of Residents report, dated 05/09/23, documented 43 residents resided in the facility. Findings: An Administering Medications policy, revised April 2019, read in part, .Medications are administered in accordance with prescriber orders . Res #1 had diagnoses which included Parkinson's disease and chronic pain. A Physician's Order for Res #1, dated 05/04/23, documented, Lactulose 30mls po once daily. Res #1's MAR, dated May 2023, had no initials for Lactulose on 05/04/23, 05/06/23, 05/08/23, nor 05/09/23. […]