Tate Springs Health & Rehab

In the surveyor’s words

From the most serious findings on record at Tate Springs Health & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF695Nov 18, 2021

  Based on observation, interview, medical record review, and facility policy review, the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility's policy, titled OXYGEN ADMINISTRATION, updated 07/17, revealed .Verify physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Review of R40's electronic medical record (EMR), under tab Clinical, revealed R40's initial admitted was 07/13/19. Review of the EMR under Med Diag (Medical Diagnoses) tab, revealed R40's diagnoses included [CONDITION(S)] ([CONDITION(S)] (lung disease that blocks airflow and makes it difficult to breath)), dated 07/13/19. […]

• No harm, potential for more than minimal, patternF804Nov 18, 2021

  Based 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. Findings include: Review of the facility's menu for 11/18/21 indicated the facility was served country fried steak with gravy, mashed potatoes, squash casserole, Texas toast, and strawberry [MEDICATION(S)] pie. The alternate choices were baked fish, orzo pilaf, and broccoli. Pureed foods included beef, mashed potatoes, the orzo, broccoli, squash casserole, bread, and pudding. […]

• No harm, potential for more than minimal, patternF812Nov 18, 2021

  Based 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. Findings include: Review of the facility's policy titled, Labeling Food and Date Marking, dated November 2020, documented .foods are labeled following preparation or opening to identify the item and to provide date, and time information .Use-by date is the last date recommended for the use of the product while at peak quality. […]

• No harm, potential for more than minimal, isolatedF658Sep 4, 2024

  Based 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). The findings include: Facility staff failed to document assessments for Resident #2 that included measurements, appearance, description and/or status of a wound. Resident #2 (R2) was admitted to the facility with diagnoses that included metabolic encephalopathy, diabetes, acute kidney failure, history of sepsis, ulcerative colitis, cognitive communication deficit, bipolar disorder and depression. The minimum data set (MDS) dated [DATE] assessed R2 as cognitively intact. R2's clinical record documented a sacral wound on 11/29/24. […]

• No harm, potential for more than minimal, isolatedF656Apr 19, 2023

  Based 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. […]