Coast Care Convalescent Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to follow the facility's policy regarding advance directive's (AD, a written document that indicates to health care providers (HCP) who should speak on resident's behalf and what medical decisions to make if resident is unable to speak for self) and Physician Orders for Life Sustaining Treatment (POLST, written medical order from a medical doctor (MD) that indicate specific medical treatment the resident would want to receive during a medical emergency or if the resident is unable to speak for self) for three of three sampled residents (Residents 19, 37, and 43) by failing to: a. Ensure an Advance Healthcare Directive Acknowledgement form (AHCD) was filled out correctly and the POLST was signed by Resident 43's legal representative upon admission. b. Complete an AHCD for Resident 19 upon admission. c. Ensure the AHCD was filled out and the POLST was signed for Resident 37. These failures had the potential to result in conflict with Residents 19, 37, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to follow their policy for posting nurse staffing data for one of two sampled locations (lobby) by failing to: a. Post accurate hours for Certified Nurse Assistants (CNA) on 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024. b. Post nurse staffing information at the beginning of the shift on 10/23/2024 in the lobby, an area readily accessible by everyone. These failures had the potential to result in posting inaccurate nursing hours and nurse staffing information that could affect the quality of care given to the residents. Findings: a. During a concurrent interview and record review on 10/25/2024 at 9:51 AM with the Director of Staff Development (DSD), the facility's Staffing and Nursing Hours (SNH) and Nursing Staffing Assignment and Sign-in Sheet (NSASS) dated 10/15/2024, 10/16/2024, 10/17/2024, 10/18/2024, 10/19/2024, and 10/23/2024 were reviewed. The DSD stated the DSD is responsible for posting the SNH in the nursing station and lobby. The DSD stated the number of CNAs who worked…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure two of two sampled residents (Residents 38 and 43) on psychotherapeutic drugs (any drug capable of affecting mood, emotions, and behavior) were free from unnecessary medication by failing to: a. Identify specific target symptoms for Resident 43 on Seroquel (medication used to treat schizophrenia [a serious mental disorder in which people interpret reality abnormally]) 50 milligrams (mg, unit of measurement) for schizophrenia manifested by hearing voices and responding to internal stimuli and attempted to perform gradual dose reduction (GDR-stepwise tapering of a dose) for the use of Paroxetine HCL (Paxil, medication used to treat depression [persistent low mood or loss of interest]) 30 mg daily for depression. b. Ensure Resident 38 had GDR for Lexapro (antidepressant drug) 10 mg since 2021, and Zyprexa (antipsychotic drug) 5 mg every 12 hours since 2023 and the target symptom for Zyprexa was specific. These failures had the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for one of one sampled ice machine (IM) by failing to: a. Follow the manufacturer's recommendations for interior cleaning and sanitizing of the Manitowoc IM when moderate amounts of black and yellow substances were observed in the internal components of the Manitowoc IM around the sides of the ice dicer and on the water outlet. The contaminated ice was distributed to 40 residents before breakfast on 10/22/2024. b. Ensure the Manitowoc was deeply cleaned weekly and cleaned monthly as indicated by the cleaning log. These failures had the potential to result in residents to develop water borne illnesses from contaminated ice. Findings: During a concurrent observation and interview on 10/22/2024 at 9:30 AM with the Dietary Supervisor (DS) in the kitchen, the Manitowoc IM was observed to have yellow liquid when a napkin test was performed on the IM. Upon closer inspection, black substances were observed on the sides of the ice dicer and in the water outlet. The DS stated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect for one of one sampled resident (Resident 14). Certified Nursing Assistant 2 (CNA 2) was standing over the resident while assisting with lunch. This failure had the potential to affect Resident 14's self-esteem and self-worth. Findings: During a review of Resident 14's admission Record (AR), the AR indicated Resident 14 was readmitted to the facility on [DATE] with diagnoses that included encephalopathy (disturbance of brain function) and muscle weakness. During a review of Resident 14's History and Physical (H&P) dated 4/2/2024, the H&P indicated Resident 14 did not have the capacity to understand and make decisions. During a review of Resident 14's Nutritional Assessment (NA), dated 4/4/2024, the NA indicated Resident 14's eating ability was categorized as a feeder (a person who is fed by an assistant during meals) and Resident 14 needed assistance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for one of one sampled resident (Resident 30) by failing to ensure the resident's call light was within reach and appropriate to the resident's physical ability. This deficient practice had the potential for Resident 30 not to receive necessary care or services and placed the resident at high risk for fall. Findings: During a review of Resident 30's admission Record (AR), the AR indicated Resident 30 was admitted to the facility on [DATE] with diagnoses that included hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following unspecified cerebrovascular disease (includes all disorders in which an area of the brain is temporarily or permanently affected by bleeding or lack of blood flow) affecting right dominant side. During a review of Resident 30's untitled Care Plan (CP), revised on 4/29/2024, the CP indicated Resident 30 was at risk for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II recommended specialized add-on services that were appropriate to resident's condition were included into Resident 38's assessment, care planning, and transitions of care for one of two sampled residents (Resident 38). This deficient practice placed Resident 38 at risk of not getting the appropriate specialized care needed for the well- being of the resident. Findings: During a review of Resident 38's admission Record (AR), the AR indicated the facility readmitted Resident 38 on 9/12/24, with diagnoses that included chronic obstructive pulmonary disease (COPD-progressive lung disease that makes it hard to breathe) and schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behaviors). During a review of Resident 38's PASRR Level II individualized determination report dated 9/20/24, the report indicated mental health rehabilitation activities and psychotherapy /counselling were recommended specialized add-on services needed by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to create a care plan (CP) for one of one sampled resident (Resident 25) when Resident 25 had a 10% weight loss within three months. This failure had the potential to result in Resident 25 to develop further weight loss. Findings: During a review of Resident 25's admission Record (AR), the AR indicated Resident 25 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis that included major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities). During a review of Resident 25's history and physical (H&P, formal document of a medical provider's examination of a patient) dated 9/30/2024, the H&P indicated Resident 25 had the ability to understand and make decisions. During a review of Resident 25's Weekly Weights Monitoring (WWM) dated 10/4/2024, the WWM indicated Resident 25 weighed 116 lbs. on 10/4/2024, 113 lbs. on 10/11/2024, 113 lbs. on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to provide a communication board and/or other functional communication system to a non English speaking resident (Resident 24) for one of one sampled resident. This deficient practice placed Resident 24 at risk for miscommunication and delayed care. Findings: During a review of Resident 24's admission Record (AR), the AR indicated the facility readmitted the resident on 8/9/24, with diagnoses that included diabetes mellitus (DM-a disorder characterized by difficulty in blood sugar control) and dementia (a progressive decline in mental abilities). During a review of Resident 24's Care Plan (CP) titled, Communication Deficit related to Language Barrier dated 8/9/24, the CP indicated Resident 24 would be able to communicate needs daily using a communication device (unspecified). During an observation and concurrent interview on 10/22/24 at 4:10 p.m., Resident 24 was lying on her back in bed and awake. Resident 24 only speaks and understand Vietnamese language. The Director of Staff Development (DSD) was present in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to attempt to use appropriate alternative interventions prior to the installation of side rails for one of one sampled resident (Resident 13). This failure had the potential for Resident 13 to be at risk for entrapment (when a resident can get caught by the head, neck, chest, or other body parts in the tight spaces around the bedrail) and physical injuries. Findings: During a review of Resident 13's admission Record (AR), the AR indicated Resident 13 was originally admitted to the facility on [DATE], and readmitted on [DATE] with diagnoses that included morbid obesity (having too much body fat), schizophrenia (a serious mental disorder in which people interpret reality abnormally), and major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities). During a review of Resident 13's Order Summary Report (OSR) dated 9/4/2024, the OSR indicated an order for bilateral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one of one sampled resident (Resident 23). Licensed Vocational Nurse 1 (LVN 1) did not explain the medication and its purpose to Resident 23 during a medication pass, in accordance with the facility's Policy and Procedure (P&P) on Medication and Treatment Administration This failure resulted in Resident 23 being uninformed about the resident's medication and had the potential for medication error. Findings: During a review of Resident 23's admission Record (AR), the AR indicated Resident 23 was readmitted to the facility on [DATE] with diagnoses that included Parkinson's Disease (disease that affects the brain that produces symptoms that include muscle rigidity, tremors, and changes in speech and balance) and muscle weakness. During a review of Resident 23's Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 8/15/2024, the MDS indicated Resident 23 was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure medications were secured and stored in the medication cart in Station One for one of one sampled resident (Resident 34). This failure had the potential to result in missing medications or medication diversion (illegal distribution or abuse of medications for purposes not intended by the prescriber) for Resident 34. Findings: During a review of Resident 34's admission Record (AR), the AR indicated Resident 34 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder (MDD, a mental health condition that causes persistently low or depressed mood and a loss of interest in activities), attention and concentration deficit, and anxiety. During a review of Resident 34's History and Physical (H&P) dated 3/14/2024, the H&P indicated Resident 34 had the ability to understand and make decisions. During a review of Resident 34's Order Summary Report (OSR) dated 3/13/2024, the OSR indicated Resident 34 had an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to attempt the use of alternatives to bed rails before its installation, for three of four sampled residents (Residents 11, 33 and 37). These deficient practices placed Residents 11, 33 and 37 at risk for entrapment and injury from the use of bed rails. Findings: 1. During a review of Resident 11's admission Record, the record indicated the resident was readmitted to the facility on [DATE], with diagnoses that included diabetes mellitus (a chronic disease that occurs when the pancreas [an organ located in the abdomen] does not produce enough insulin [hormone that regulates blood sugar] or when the body cannot effectively use the insulin it produces) and Chronic Obstructive Pulmonary Disease ([COPD] a group of lung diseases that block airflow and make it difficult to breathe). During a concurrent observation and interview with Resident 11 on 11/7/23 at 9:30 a.m., Resident 11 was lying on her back in bed with half- length bed rails up on both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (Residents 11,17 and 42) on psychotropic drugs (any drug capable of affecting the mood, emotions, and behavior) were free from unnecessary medication by failing to: 1. Attempt a Gradual Dose Reduction (GDR- tapering of a dose) of Aripiprazole ([antipsychotic drug] drug use to treat psychosis [severe mental disorders that cause abnormal thinking and perceptions]) 30 milligrams (mg-unit of measurement) for Resident 17. 2. Attempt GDR of Temazepam 15 mg ([sedative-hypnotic drug] a class of drugs used to induce and/or maintain sleep) for Resident 11. 3. Ensure Ativan was ordered to treat a specific condition documented in the clinical record for Resident 42. 4. Ensure Ativan was administered to treat a specific behavior for Resident 42. These deficient practices placed Residents 11, 17 and 42 at risk for adverse drug reaction. Findings: 1. During a review of Resident 17's admission Record, the record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure fall preventive measures were implemented for one of four sampled residents (Resident 37). Resident 37's bed was not positioned at the lowest position. This deficient practice had the potential for injury, accidents or fall to Resident 37. Findings: During a review of Resident 37's admission Record, the admission record indicated the facility readmitted the resident in 2/6/23, with diagnoses that included cerebral infarction (type of ischemic [deficient supply of blood] stroke [sudden death of brain cells in a localized area due to inadequate blood flow] resulting from a blockage in the blood vessels supplying blood to the brain). During a review of Resident 37's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 8/25/23, the MDS indicated the resident had moderate impaired cognition (ability to understand). The MDS indicated Resident 37 required extensive assistance (resident involved in activity,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure gastrostomy (a tube inserted through the abdomen wall and into the stomach used for feeding or drainage) tube feeding was provided in accordance with the physician's order, for one of one sampled resident (Resident 41). This deficient practice had the potential to result in weight loss for Resident 41. Findings: During a review of Resident 41's admission Record, the admission record indicated the facility readmitted the resident on 4/8/22, with diagnoses that included cerebral infarction (stroke) and gastrostomy. During a review of Resident 41's care plan titled, Gastrostomy Tube Feeding dated 4/8/22, the care plan interventions included to provide gastrostomy feeding as ordered. During a review of Resident 41's Minimum Data Set (MDS - a standardized assessment and care planning tool) dated 10/13/23, the MDS indicated the resident was not able to express ideas and sometimes understand others. The MDS indicated Resident 41 was dependent in all activities of daily living including eating, oral hygiene,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to conduct staff competency for three of three facility staff. This deficient practice had the potential to affect resident care. Findings: During a review of the facility's staff competency on 11/9/23 at 3:55 p.m., the facility's staff competency indicated the following: a. Certified Nursing Assistant 3 had no annual competency skills assessment. b. Restorative Nursing Assistant 1 had competency assessment completed on 9/14/23. c. Certified Nursing Assistant 4 had no annual competency assessment. During an interview with the Director of Staff Development (DSD) on 11/9/23 at 4:02 p.m., the DSD confirmed the above finding and stated competency assessments were to be completed upon hire, annually and as needed when there were reports of the staff not being competent with job specific skills. During a review of the facility's undated Policy and Procedure titled Performance Evaluation, the P&P indicated employees shall be evaluated initially at the end of their 90-day probationary period, and once in every year and as necessary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to conduct and document one of one facility-wide assessment of staffing resources, necessary to care for the residents. This deficient practice had the potential to not meet the staffing needs of the facility. Findings: During a concurrent review of the facility's document titled Facility Assessment dated 10/26/23 and interview with the facility's Administrator (ADM) on 11/9/23 at 9:20 a.m., the facility assessment did not indicate that the staffing resources was completed. The ADM stated the facility assessment on staffing resources was not completed. The ADM stated the facility assessment needed to be complete to be able to ensure the resources necessary to provide the care and services for the residents residing at the facility. During a review of the facility's document titled Facility Assessment dated 10/26/2023, indicated the facility will identify the type of staff members or other health care professionals, and health care professionals that are needed to provide support and care for the residents.