Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paradigm At Kountze during CMS and state inspections, most recent first.
Several residents' MDS assessments were not accurately completed, including failures to document current tobacco use for multiple residents who smoked or used smokeless tobacco, incorrect coding of a resident as receiving tube feeding when only a mechanical soft diet was provided, and failure to indicate a resident's PASRR status for ID/DD despite supporting documentation. Staff interviews and observations confirmed these discrepancies, and the errors were acknowledged by the MDS nurse and DON.
Surveyors found that food items in a kitchen refrigerator were not labeled, dated, or properly sealed, including lunchmeat, cheese, and a container of chili. A dietary aide could not identify when the items were opened or last used, and the Dietary Manager was unable to explain why expired or spoiled foods had not been removed, despite staff having completed required food safety training. Facility policy and FDA Food Code require all refrigerated foods to be labeled, dated, and tightly sealed.
The facility did not coordinate assessments with the PASRR program or refer residents for necessary services, resulting in a failure to meet regulatory requirements.
A resident with cognitive impairment suffered a second-degree burn after spilling hot coffee on himself in the dining room. The facility failed to implement safety measures or assess residents' ability to handle hot liquids, leaving the coffee pot unattended. Staff did not update care plans or conduct a thorough investigation, contributing to the deficiency.
The facility's kitchen failed to meet food safety standards, with issues such as unlabeled food items, improper hair restraints, and unclean equipment. Staff did not follow protocols for cleanliness, leading to potential risks of cross-contamination and foodborne illness.
The facility's arbitration agreement failed to include required elements, specifically prohibiting residents or their representatives from communicating with officials. The Admission Director and Administrator were unaware of these requirements, affecting 35 residents who entered into binding arbitration under the flawed agreement. No policy or procedure was in place to ensure compliance.
The facility failed to ensure accurate MDS assessments for five residents, leading to incorrect coding of medications and discharge status. Plavix and Aspirin were wrongly coded as anticoagulants, a resident was inaccurately recorded as receiving dialysis, and another was incorrectly noted as discharged to the hospital. These errors were identified through interviews and record reviews, highlighting the importance of accurate documentation for resident care and facility billing.
The facility failed to update care plans for three residents, resulting in discrepancies in code status and fall interventions. Two residents' care plans did not reflect their DNR status, and fall interventions were not updated for two residents who experienced multiple falls. Staff interviews revealed communication gaps and a lack of follow-through in updating care plans, despite previous identification of these issues in an internal survey.
The facility failed to meet residents' nutritional needs by using an incorrect scoop size for ground chicken during a lunch meal. A staff member used a #8 scoop instead of the required #12, due to not reviewing the production sheet and choosing a scoop with holes to drain broth. The Dietary Manager and Administrator acknowledged the issue, emphasizing the importance of correct portion sizes as per the facility's portion control policy.
A long-term care facility failed to maintain an effective infection prevention and control program, as observed in the actions of a CNA and an RN. The CNA did not perform hand hygiene before providing care, failed to change gloves, and transported dirty linens without bagging them. The RN used a disinfectant wipe instead of gauze for a blood sugar check and did not prepare a barrier for supplies. These actions were against the facility's policies and acknowledged by the staff as potential infection control issues.
A resident with Huntington's disease and severe cognitive impairment alleged that a CNA sat her down too hard on the toilet, resulting in a red mark on her back. The incident was not documented, and the facility failed to report the allegation to the state within the required two-hour timeframe. The resident provided inconsistent accounts, and the administrator was informed of the incident the following day, acknowledging the delay in reporting.
A resident with Huntington's disease and severe cognitive impairment alleged that a CNA let her sit down too hard on the toilet, causing a red mark on her back. The incident was not reported within the required two-hour timeframe, as the DON believed the mark was due to the resident's spastic movements. The administrator was informed the next day and reported the incident to the state. The resident gave inconsistent accounts of the incident, and the facility's policy on immediate reporting was not followed.
A CNA failed to provide privacy for a resident during dressing, leaving the door open and not pulling the curtain, which compromised the resident's dignity. The resident, staff, and management acknowledged the importance of maintaining privacy, as outlined in the facility's policy.
A resident with multiple health conditions, including dementia and diabetes, experienced a coffee spill resulting in a second-degree burn. Despite medical interventions being ordered, the facility failed to update the resident's care plan to address the risk of injury from hot liquids. Interviews with staff revealed that the MDS nurse was responsible for care plan updates, but the incident was not documented, highlighting ongoing issues with care plan accuracy and consistency.
A resident with a history of heart disease and Alzheimer's was observed not using oxygen despite an active order for continuous oxygen therapy. Staff interviews confirmed the resident no longer required continuous oxygen, but the order was not updated, leading to incorrect documentation. The facility's policies on oxygen therapy and medication management were not followed, resulting in a deficiency.
A facility failed to ensure a resident was seen by a physician within the first 30 days of admission, as required. The resident, with chronic obstructive pulmonary disease and other conditions, was not seen until after the 30-day period. Interviews with staff revealed a lack of communication and monitoring to ensure compliance with physician visit requirements.
A resident with COPD did not receive nasal spray medication according to protocol, as LVN A failed to instruct the resident to blow her nose before administration. This oversight was confirmed by the DON, Pharmacist Consultant, and Administrator, who all acknowledged the importance of following the manufacturer's guidelines and facility policy to ensure medication effectiveness.
A resident with a history of hypertension and heart disease was administered blood pressure medications outside of the ordered parameters on multiple occasions. Despite blood pressure readings being below the specified thresholds, amlodipine and losartan were given, as confirmed by staff interviews and medication records. This failure to follow medication administration protocols posed a risk to the resident's health.
A resident with a seizure disorder did not have their Keppra levels monitored as required, due to a failure in processing and tracking laboratory orders. The resident's care plan required Keppra levels to be drawn every three months, but this was not adhered to, with the last level drawn several months apart. Interviews revealed a lack of communication and documentation regarding order changes, and the absence of a lab tracking system contributed to the oversight.
The facility failed to ensure a dietary staff member maintained a current food handler certificate, as required by policy. The Dietary Manager was responsible for ensuring staff completed their training, but Cook E continued working with an expired certificate. This oversight could potentially risk residents' safety due to foodborne illness and cross-contamination.
A resident with COPD refused Lasix, and the LVN failed to document notifying the physician, as required by facility policy. The DON and Administrator acknowledged the importance of documentation to ensure proper care.
The facility failed to coordinate hospice care and maintain updated documentation for two residents receiving hospice services. One resident's hospice plan of care and medication record were not updated, while another resident's hospice binder lacked essential documents. Interviews revealed confusion and lack of responsibility between hospice and facility staff, leading to potential risks in care coordination.
Inaccurate MDS Assessments for Tobacco Use, Nutrition, and PASRR Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the current status of five residents. For several residents who used tobacco products, including cigarettes and smokeless tobacco, the MDS assessments did not indicate current tobacco use, despite documentation in care plans, smoking safety screens, and direct observations of tobacco use during the assessment periods. Interviews with the residents confirmed their ongoing tobacco use, and staff, including the RN and MDS nurse, acknowledged that these residents used tobacco daily. However, the MDS assessments for these residents were not coded to reflect this, resulting in inaccurate documentation. In another instance, a resident was incorrectly coded on the MDS as receiving a feeding tube for nutritional support, despite physician orders, care plans, and direct observation confirming that the resident was on a mechanical soft diet and had never had a feeding tube. The MDS nurse admitted to coding this incorrectly, attributing the error to a busy admission day. The DON also acknowledged the error and recognized that it could impact the resident's care. Additionally, a resident with a diagnosis of cerebral palsy and a positive PASRR for intellectual and developmental disabilities (ID/DD) was not coded appropriately on the MDS. The care plan and physician documentation indicated the presence of ID/DD, but the MDS assessment did not reflect this. The MDS nurse admitted to coding the PASRR status incorrectly. Throughout these cases, the facility's policy required accurate and timely completion of the MDS based on direct observation, interviews, and record review, but these requirements were not met for the residents involved.
Failure to Properly Store, Label, and Date Refrigerated Food Items
Penalty
Summary
The facility failed to properly store, label, date, and seal food items in one of the kitchen refrigerators, as observed during a survey. Specific findings included a Ziploc bag of lunchmeat slices, a large Rubbermaid container with a reddish-brown substance, a Rubbermaid container of sliced yellow cheese, and an opened Ziploc bag containing a manufacturer-labeled bag of mozzarella cheese. None of these items were labeled or dated, and some were not properly sealed. The dietary aide present was unable to identify when the items were opened or last used and stated that, without a date, she would discard the food to ensure safety. The dietary aide confirmed receiving orientation training on food handling but was unaware of the specifics regarding these items. The Dietary Manager (DM) acknowledged responsibility for ensuring staff followed facility policy and for checking food storage areas weekly for expired or spoiled foods but could not explain why these items had not been removed. The DM confirmed that all kitchen staff had completed required food preparation and storage training. The facility's policy and the FDA Food Code require all refrigerated foods to be labeled, dated, and tightly sealed, with leftovers used within 48 hours. The Administrator stated that all products should be labeled and dated according to policy and that it was the DM's responsibility to ensure compliance.
Failure to Coordinate PASRR Assessments and Referrals
Penalty
Summary
The facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program and did not refer residents for services as needed. This deficiency indicates that required assessments and referrals for appropriate services were not completed in accordance with regulatory requirements. No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Resident Burned by Hot Coffee Due to Lack of Supervision
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, resulting in a second-degree burn for one resident. The resident, who was cognitively moderately impaired and required assistance with various activities, spilled hot coffee on his left leg while in the dining room. The incident led to redness and blisters on the resident's foot, which required medical treatment. The facility did not have a care plan in place for the risk of injury from hot liquids for this resident. Interviews and observations revealed that the coffee pot was left unattended in the dining room, allowing residents to serve themselves. Staff members, including the DON and Administrator, were aware of the incident but did not take immediate action to remove the coffee pot or implement safety measures to prevent further accidents. The facility's policy on hot liquids was not followed, as there was no assessment of residents' ability to safely consume hot liquids, nor were care plans updated to reflect necessary interventions. The facility's failure to implement safety measures and assess residents for hot liquid risks placed residents at risk for injury. Despite the occurrence of the burn, the facility did not conduct a thorough investigation or update the resident's care plan to prevent recurrence. The lack of immediate corrective actions and communication among staff contributed to the deficiency.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety in its kitchen, as observed during a survey. Key deficiencies included the lack of labeling and dating on food items such as margarine, minced garlic, and vegetable oil. Additionally, the kitchen staff did not wear proper hair restraints, with hairnets not fully covering their heads. The microwave was found to be dirty with food debris, and the trash can used for food waste lacked a lid, which are both essential for maintaining hygiene and preventing contamination. Further observations revealed that the outside of the ice machine and the iced tea maker cart were not clean, with brown and white substances present. The condiment cart also had a dark/light substance, and the plate domes were stacked with water pooled between them, indicating improper drying practices. A staff member, identified as [NAME] D, was noted to have unclean nails with a black substance while preparing food without gloves, which poses a risk of cross-contamination. Interviews with the dietary staff and management confirmed these practices were against the facility's policies and food safety standards. The Dietary Manager and Administrator acknowledged the importance of cleanliness and the potential risk of foodborne illness due to these failures. The facility's policies on food storage, safe food handling, and sanitation were not followed, as evidenced by the observations and staff interviews.
Deficient Arbitration Agreement Lacks Required Communication Rights
Penalty
Summary
The facility failed to ensure that its arbitration agreement contained all the required elements, specifically regarding the rights of residents or their representatives to communicate with federal, state, or local officials. The arbitration agreement, revised in June 2021, included language that prohibited or discouraged such communication, which is a violation of regulatory requirements. This oversight was identified during a record review and interviews with facility staff. The Admission Director, responsible for admission agreements, was unaware of the specific requirements for arbitration agreements and acknowledged that 35 residents had entered into binding arbitration under the flawed agreement. The Administrator also admitted to being unaware of the need to address communication rights with officials in the agreement, indicating that corporate oversight was relied upon for compliance. There was no existing policy or procedure regarding arbitration agreements, which contributed to the deficiency.
Inaccurate MDS Assessments and Coding Errors
Penalty
Summary
The facility failed to ensure accurate assessments for five residents, leading to incorrect coding on the Minimum Data Set (MDS) assessments. For three residents, Plavix, an antiplatelet medication, was incorrectly coded as an anticoagulant. Additionally, one of these residents also had Aspirin incorrectly coded under the same category. These errors were identified during interviews and record reviews, where it was noted that the MDS Coordinator had misunderstood the classification of these medications according to the Resident Assessment Instrument (RAI) manual. Another resident was inaccurately coded as having received dialysis on their MDS assessment, despite no orders or care plan indicating such treatment. This discrepancy was confirmed through interviews with the resident, who stated they had never been on dialysis. The lack of accurate documentation and coding could potentially mislead care planning and service delivery for the resident. Furthermore, a resident was incorrectly coded as being discharged to the hospital instead of home. This error was discovered through a review of progress notes, which indicated the resident was discharged home with a family member. The MDS Coordinator acknowledged the importance of accurate MDS coding, as it directly impacts the resident's care plan and the facility's billing processes.
Failure to Update Care Plans for Code Status and Fall Interventions
Penalty
Summary
The facility failed to review and revise the person-centered care plans to reflect the current conditions of three residents. Specifically, the care plans for two residents were not updated to reflect their Do Not Resuscitate (DNR) status, despite having physician orders indicating this change. This oversight could lead to inappropriate interventions, such as resuscitating a resident who has opted for DNR, thereby not honoring their end-of-life wishes. Additionally, the facility did not update the care plans for fall interventions for two residents who experienced multiple falls. The care plans lacked new interventions following these incidents, which could result in staff being unaware of necessary measures to prevent further falls. The MDS nurse, responsible for updating care plans, acknowledged the failure to update these critical aspects, despite being aware of the residents' falls and changes in code status. Interviews with various staff members, including the MDS nurse, social worker, and administrative personnel, revealed a lack of communication and follow-through in updating care plans. The facility's internal survey had previously identified inconsistencies in care plan updates, and the MDS nurse was placed on a Performance Improvement Plan (PIP) to address these issues. However, the deficiencies persisted, indicating a systemic problem in ensuring care plans accurately reflect residents' current needs and conditions.
Incorrect Scoop Size Used for Meal Preparation
Penalty
Summary
The facility failed to ensure that meals served met the nutritional needs of residents, specifically during a lunch meal where the incorrect scoop size was used for ground chicken. The production sheet indicated that a #12 scoop size should have been used, but during observation, it was noted that a #8 scoop size was used instead. This discrepancy was due to the dietary staff member not reviewing the production sheet prior to meal preparation and choosing a scoop with holes to drain broth, which was not the correct size. This failure was acknowledged by the staff member, who admitted that it could potentially put residents at risk for malnutrition or weight changes. The Dietary Manager confirmed that it was her responsibility, along with the cook, to ensure correct portion sizes were served. She admitted to noticing issues with staff not using the correct scoop sizes and had verbally trained and in-serviced staff on the importance of using the correct utensils. The Administrator also emphasized the importance of using the correct scoop size to ensure residents receive the correct amount of food. The facility's policy on portion control, approved in 2018, mandates the use of standard portion control procedures and utensils to ensure adequate portions are served to residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One of the deficiencies involved a certified nursing assistant (CNA) who did not perform hand hygiene before providing incontinent care to a resident. The CNA also failed to change gloves when transitioning from handling a dirty brief to applying a clean one. Additionally, the CNA transported dirty linens without bagging them, which is against the facility's infection control policy. These actions were acknowledged by the CNA, who admitted to not following proper procedures and recognized the potential infection control issues. Another deficiency was observed with a registered nurse (RN) who did not use a 2x2 gauze to wipe a resident's finger after checking blood sugar, instead using a disinfectant wipe. The RN also failed to prepare a barrier for her supplies and improperly disposed of the disinfectant wipe on the resident's bed. The RN admitted to these oversights and acknowledged that they could lead to infection control issues. The facility's policies clearly outline the correct procedures for hand hygiene, perineal care, and blood glucose monitoring, which were not followed in these instances. Interviews with the Assistant Director of Nursing (ADON), Director of Nursing (DON), and the Administrator confirmed that the staff did not adhere to the expected infection control practices. The ADON, who is also the Infection Control Preventionist, and the DON both emphasized the importance of following proper procedures to prevent the spread of infections. The Administrator reiterated the expectations for staff to perform hand hygiene, bag soiled linens, and use appropriate materials for blood glucose monitoring, highlighting the responsibility of the staff to adhere to these protocols.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to implement its written policies and procedures prohibiting mistreatment, neglect, and abuse of residents, specifically in the case of a resident with Huntington's disease, anxiety disorder, and dementia. The resident alleged that a CNA sat her down too hard on the toilet, causing a red mark on her back. The incident was not documented in the progress notes, and the facility did not report the allegation to the state within the required two-hour timeframe. The resident, who had severe cognitive impairment, provided inconsistent accounts of the incident, complicating the investigation. Interviews revealed that the CNA responded to an emergency call light and found the resident on the commode. The resident began yelling when the CNA attempted to assist her, prompting a nurse to intervene. The nurse observed a red mark on the resident's back and reported the incident to the DON, who delayed reporting it to the administrator. The administrator acknowledged the requirement to report abuse allegations within two hours but was informed of the incident the following day. The facility's failure to adhere to its abuse reporting policy could place residents at risk of harm.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to report an alleged incident of abuse involving a resident with Huntington's disease, anxiety disorder, and dementia, within the required two-hour timeframe. The resident, who had severe cognitive impairment, alleged that a CNA had let her sit down too hard on the toilet, resulting in a red mark on her back. The incident was not documented in the progress notes, and the Director of Nursing (DON) was informed of the incident after 9:00 p.m., but did not report it immediately to the administrator, believing the resident's spastic movements due to her condition might have caused the mark. The administrator was informed of the incident the following day and reported it to the state as soon as she was made aware. During the investigation, it was noted that the resident gave inconsistent accounts of the incident, including naming different individuals as the person who hurt her. The facility's policy requires immediate reporting of such incidents, but this protocol was not followed, leading to a deficiency in timely reporting of suspected abuse.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to protect and promote the rights of a resident by not ensuring privacy during personal care. On the specified date, a CNA assisted a resident with dressing without closing the door or pulling the privacy curtain, leaving the resident exposed to potential view by others, including the roommate who was awake in the room. The CNA acknowledged forgetting to provide privacy and recognized the importance of doing so to ensure the resident's comfort and dignity. Interviews with the resident, ADON, DON, and Administrator confirmed the expectation that privacy should be maintained during care. The resident expressed discomfort at the thought of being seen by strangers while being dressed. The ADON, DON, and Administrator all stated that it was the responsibility of the staff to ensure privacy, and failure to do so was a dignity and privacy issue. The facility's policy on dignity and resident rights emphasized the importance of maintaining privacy by closing doors or using curtains as appropriate.
Failure to Update Care Plan After Resident Burn Incident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident who experienced a coffee spill resulting in a second-degree burn. The resident, an elderly male with diagnoses including syncope, venous insufficiency, diabetes, and dementia, was cognitively intact and required assistance with various activities of daily living. Despite the incident being documented and medical interventions being ordered, such as monitoring for new symptoms and applying Silvadene cream, the care plan did not include measures to address the risk of injury from hot liquids. Interviews with facility staff, including the MDS nurse, ADON, DON, and Administrator, revealed that the MDS nurse was responsible for updating care plans during morning meetings. However, the coffee spill incident was not added to the resident's care plan, which was acknowledged as an oversight. The facility had previously identified issues with care plan accuracy and consistency during an internal survey, and the MDS nurse was placed on a performance improvement plan, but the deficiency persisted.
Failure to Update Oxygen Order for Resident
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident, leading to a deficiency in care. The resident, a female with a history of hypertensive heart disease, heart failure, essential hypertension, Alzheimer's disease, and cerebellar stroke syndrome, was observed not using oxygen despite having an order for continuous oxygen therapy. The resident's care plan indicated a resolved date for her shortness of breath, yet the order for continuous oxygen remained active. Observations and interviews revealed that the resident was not using oxygen and did not appear to be in respiratory distress. A CNA and an LVN confirmed that the resident did not require continuous oxygen and that the order should have been updated to reflect her current needs. The LVN acknowledged that it was the nurse's responsibility to ensure the accuracy of the resident's orders, and the DON emphasized the importance of following physician orders to prevent potential harm. The facility's policies on oxygen therapy and medication management were not adhered to, as evidenced by the failure to update the resident's oxygen order and the incorrect documentation on the medication administration record. The administrator and DON both recognized the oversight and the potential risk to the resident if she had needed oxygen and was not receiving it. The deficiency highlights a lapse in the facility's process for ensuring accurate and up-to-date medical orders for residents.
Failure to Ensure Timely Physician Visits for New Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician at least once every 30 days for the first 90 days after admission. Specifically, Resident #245, a female with chronic obstructive pulmonary disease, neurocognitive disorder with Lewy bodies, and an aneurysm of the ascending aorta, was not seen by a physician within the first 30 days of her admission. The resident was admitted on a date not specified in the report, and the physician's progress notes indicated that she was seen on July 16, 2024, which was beyond the required timeframe. Interviews with facility staff, including the Assistant Director of Nursing (ADON), Director of Nursing (DON), Administrator, and Medical Director, revealed a lack of communication and monitoring to ensure compliance with the physician visit requirement. The ADON and DON acknowledged the responsibility of the nursing staff to notify the physician of new admissions, while the Medical Director admitted to relying on staff to inform him of residents needing initial visits. The failure to perform the initial visit within the required timeframe was attributed to a breakdown in this process, as noted by the Medical Director.
Failure to Follow Nasal Spray Administration Protocol
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate administration of medications for a resident diagnosed with COPD. The resident, who had a moderately impaired cognition, was prescribed Flunisolide Solution nasal spray to be administered twice daily. However, during an observation, LVN A administered the nasal spray without instructing the resident to blow her nose beforehand, which is contrary to the manufacturer's instructions and the facility's policy. This oversight was acknowledged by LVN A, who admitted to not considering the step as the resident was eating at the time. Interviews with the Director of Nursing (DON), the Pharmacist Consultant, and the Administrator confirmed that the standard procedure was not followed. All parties agreed that it was important for the resident to blow her nose prior to the administration of the nasal spray to ensure the medication's effectiveness. The facility's policy and the manufacturer's guidelines both emphasize the necessity of clearing the nasal passages before administering the spray. Despite regular oversight by the DON and monthly visits by the Pharmacist Consultant, this issue had not been previously identified.
Failure to Adhere to Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of blood pressure medications. The resident, a female with a history of hypertensive heart disease, heart failure, essential hypertension, Alzheimer's disease, and cerebellar stroke syndrome, was administered amlodipine and losartan outside of the ordered blood pressure parameters on multiple occasions. The medication administration record indicated that these medications were given despite the resident's blood pressure readings being below the specified thresholds. On three separate dates, the resident's blood pressure was recorded below the parameters set for the administration of amlodipine and losartan. Despite this, the medications were administered, as evidenced by check marks on the medication administration record. Interviews with staff, including a medication aide, a registered nurse, the Director of Nursing (DON), and the Administrator, confirmed that the medications should not have been given under these circumstances, as it posed a risk of further lowering the resident's blood pressure. The facility's policy on medication administration and management requires adherence to physician's orders, including the correct patient, drug, dose, time, route, charting, results, and reason. The staff involved acknowledged their responsibility in ensuring medications are administered as ordered and recognized the risk posed to the resident by administering the medications outside the prescribed parameters. The deficiency highlights a failure in following established medication administration protocols, which could lead to adverse health outcomes for the resident.
Failure to Monitor Keppra Levels for Resident with Seizure Disorder
Penalty
Summary
The facility failed to ensure that laboratory services were obtained to meet the needs of a resident with a seizure disorder. The resident, a male with cognitive impairment and a history of seizures, was prescribed Levetiracetam (Keppra) to manage his condition. The comprehensive care plan required that the Keppra levels be monitored and reported to the medical doctor. However, the facility did not adhere to the order for Keppra levels to be drawn every three months, as the last level was drawn on 07/22/2024, with the previous one on 12/17/2023. Interviews revealed that the nurses were responsible for entering new orders into the computer system, but a change in the order to draw Keppra levels every six months was not properly communicated or documented. The Assistant Director of Nursing (ADON) acknowledged the importance of drawing labs to ensure medication was at a therapeutic level. The Director of Nursing (DON) admitted there was no lab tracking system in place, and the nurses were responsible for processing orders. The Administrator confirmed that nurses were responsible for ensuring laboratory levels were drawn to prescribe the appropriate medication amount.
Expired Food Handler Certificate in Dietary Staff
Penalty
Summary
The facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service, specifically for one out of seven dietary staff members. The deficiency was identified when it was discovered that Cook E's food handler certificate had expired, and the facility did not ensure that it was renewed. The Dietary Manager, who was responsible for ensuring staff completed their food handler certificate training upon hire and every two years, was unsure why Cook E had not completed the necessary training. Despite the expiration of the certificate, Cook E continued to work her assigned schedule. Interviews with the Dietary Manager and the Administrator revealed that the facility relied on staff to ensure their trainings were up to date, which led to the oversight. The Administrator expected the Dietary Manager to ensure that dietary staff had their food handler certificates within 30 days of hire and before they expired. The facility's policy required all personnel involved in food preparation, handling, or serving to obtain a food handler certification from a Texas Department of State Health Services approved provider, valid for two years. The failure to maintain current certification could potentially put residents at risk for foodborne illness and cross-contamination.
Incomplete Documentation of Medication Refusal
Penalty
Summary
The facility failed to ensure complete and accurate documentation of medical records for a resident who refused medication. Specifically, a Licensed Vocational Nurse (LVN) did not document the notification of a physician when a resident refused to take Lasix, a medication used to treat swelling. The resident, a male with a diagnosis of COPD, had a care plan that included interventions for medication refusal, such as educating the resident on potential complications and re-offering the medication. Despite these interventions, the LVN did not document the notification of the Nurse Practitioner about the refusal, which was confirmed during interviews with the LVN and the Nurse Practitioner. The Director of Nursing (DON) and the Administrator acknowledged the importance of documenting such refusals to ensure the care team is informed and can provide appropriate care. The facility's policy requires that any withheld medication be documented, and the attending physician notified. However, the LVN failed to adhere to this policy, which could potentially put the resident at risk for complications related to his COPD. The DON stated that daily reviews are conducted to monitor documentation, but no issues had been noticed previously.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate effectively with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. This deficiency was identified for two residents, who were at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. Specifically, the facility did not obtain the most recent updated hospice plan of care and hospice medication record for one resident, and failed to maintain another resident's hospice binder containing essential information related to hospice services. For Resident #10, the facility did not have the most recent hospice plan of care or medication record in the resident's electronic medical record or hospice binder. The hospice documents were expected to be hand-delivered monthly by the hospice company, but there was a lack of clarity and responsibility regarding who was to ensure these documents were updated and available at the facility. Interviews with hospice staff revealed that there was confusion about the process, and the facility's medical records staff confirmed that the last update received was outdated. Similarly, for Resident #6, the hospice binder was missing critical documents such as the physician certification, care plan, medication list, and hospice election form. Hospice staff indicated that updates were supposed to be delivered during visits or meetings, but the facility's staff reported never receiving the necessary paperwork. The facility's administration acknowledged that it was ultimately their responsibility to ensure hospice documents were up to date, and the lack of updated documents could lead to medication errors.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Kountze
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mill Creek | 7.7 mi | ★★★★★ | 7 | 0 |
| Silsbee Oaks Health Care Llp | 9 mi | ★★★★★ | 9 | 0 |
| Paradigm At The Pines | 10.1 mi | ★★★★★ | 18 | 1 |
| Village Creek Rehabilitation And Nursing Center | 10.3 mi | ★★★★★ | 16 | 3 |
| Jefferson Nursing And Rehabilitation Center | 19.1 mi | ★★★★★ | 0 | 0 |
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