Alliance Health at Coleman

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure proper treatment was provided to maintain hearing abilities for two Residents (#4 and #18) out of a total sample of 17 residents, increasing the risk of both Residents for impaired communication abilities.Specifically, the facility failed to:1.Follow-up with Resident #4's Physician relative to the Audiologist's recommendation for ear wax removal, so that the Resident's hearing could be adequately assessed when the Resident exhibited decreased responsiveness.2.Obtain a hearing device for Resident #18 when the Audiologist recommended replacement of the right hearing aid, after the Resident's right hearing aid was lost during a hospitalization. Findings include:1.Resident #4 was admitted to the facility in December 2020 with diagnoses including age-related cognitive decline. Review of Resident #4's Physician orders initiated 12/4/20, indicated: Audiology Consult as needed. Review of the Minimum Data Set (MDS) Assessment, dated…

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 observations, interviews, and record reviews, the facility failed to provide trauma-informed care for one Resident (#33) out of a total sample of 17 residents.Specifically, the facility failed to recognize Resident #33's past history of sexual abuse and identify triggers (psychological stimuli that prompt recall of a previous traumatic event, even if the stimulus itself is not traumatic or frightening), placing the Resident at risk for re-traumatization. Findings include:Review of the facility policy titled Trauma Informed Care Program effective 11/21/19 and revised 8/1/25, indicated but was not limited to the following:-Policy:>To provide holistic, culturally sensitive, trauma-informed care in accordance with professional standards to our residents who are trauma survivors.>To account for the resident's experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident and optimize psychosocial well-being.-Purpose: To ensure the delivery of care and services,…

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 observations, interviews, and record reviews, the facility failed to ensure that two Residents (#35 and #38) out of a total sample of 17 residents were free from physical restraint. Specifically, the facility failed to ensure Resident #35's and #38's wheelchair brakes were not locked when both Residents required the use of a wheelchair for mobility and were attempting to move, resulting in the Resident's freedom of movement or activity being inhibited.Findings include:Review of the facility's policy titled Physical Restraint Policy, undated, indicated the following:-It was the facility's policy that physical restraint would only be utilized when they are required to treat a resident's medical symptoms.-Physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. a. Resident #38 was admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services related to activities of daily living (ADL) care for one Resident (#9), out of a total sample of 17 residents.Specifically, for Resident #9, the facility failed to:1. provide assistance to the Resident with applying his/her dentures when the Resident verbalized the need for his/her dentures before the breakfast meal, resulting in the Resident coughing and vomiting during the meal due to inability to chew his/her food.2. assist/encourage the Resident to use his/her back brace when he/she was out of bed.3. ensure that the Resident's hearing aids were in place every morning as required. Findings include: Resident #9 was admitted to the facility in February 2023 with diagnoses including Spinal Stenosis, Low Back Pain, Memory Deficit, and Conductive Hearing Loss. Review of the Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #9:-was moderately cognitively impaired as evidenced…

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, record review, and interview, the facility failed to provide appropriate treatment and services related to an indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine outside the body) for one Resident (#8), out of 2 applicable residents reviewed for catheter care, out of a total sample of 17 residents.Specifically, for Resident #8, the facility staff failed to obtain Physician orders relative to the Foley (type of indwelling urinary catheter) catheter and balloon size, putting the Resident at risk for indwelling urinary catheter complications. Findings include: Review of the facility policy titled Urinary Catheter Monitoring and Documentation, revised 9/1/16, indicated:-The Charge Nurse will inform the Director of Nursing (DON) and Quality Assurance Department of all residents in the facility who have catheters, any residents who are admitted with catheters and any new orders for catheterization.-The Quality Assurance Department will examine the charts of…

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 policy review, observation, and interview, the facility failed to ensure medications were appropriately stored in two out of two medication carts. Specifically, the facility staff failed to store topical medications separately from oral medications. Findings include: Review of the facility's policy, titled Medication Storage in the Facility, dated 2017, indicated the following: -Procedure: Orally administered medications are kept separate from externally used medications and treatments such as suppositories, ointments, creams, etc. 1. During an observation of the East Medication Cart, on 4/14/23 at 8:45 A.M., with Nurse #2, the surveyor observed a small basket in the top drawer of the cart that had multiple individual packets of Hydrocortisone cream (steroid for external use), several packets of lubricant (used to insert suppositories), and several packets of thickener (oral agent used to thicken liquids). All of these items were stored together in the same basket. Nurse #2 said she did not know the items could not be stored together. 2. During an observation of the [NAME]…

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 record review, and interview, the facility failed to provide Physician notification on status changes for three Residents (#18, #6 and #8) out of a total sample of 13 residents. Specifically, 1. For Resident #18, the facility staff failed to notify the Physician of an abnormal high finger stick blood sugar level (FSBS: a measurement of sugar in the blood) result. 2. For Resident #6, the facility staff failed to notify the Physician that one dose of Heparin (blood thinning medication used to prevent blood clots) was not administered as ordered. 3. For Resident #8, the facility staff failed to report the presence of pressure ulcers noted on admission to the Physician, delaying care and treatment. Findings include: 1. Resident #18 was admitted to the facility in September 2022 with a diagnosis of Diabetes Mellitus (a chronic condition that affects the way the body processes blood sugar). Review of the American Diabetes Association Blood Glucose Testing and Monitoring guidelines, copyright 1995-2023…

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 assistive devices for one Resident (#17) out of a total sample of 13 total residents, to aid in preventing an injury/accident. Specifically, the facility failed to ensure its staff provided leg rests on a wheelchair to support the Resident's legs during transport, resulting in the Resident's right foot getting caught under the wheelchair while the chair was being pushed by staff. Findings include: Resident #17 was admitted to the facility in April 2019 with a diagnosis of Dementia. Review of Resident #17's Activities of Daily Living (ADLs) and Mobility Care Plan, dated 11/8/22 and reviewed 1/31/23, included the following: - The Resident was able to self propel short distances in his/her wheelchair with staff cueing and direction. - Do not use foot pedals on chair, it prevents self-ambulation in the wheelchair. Review of the Resident's Cognitive Deficit Care Plan, dated 1/26/23, indicated the following: - Gain the Resident's attention prior to hands-on care. - Explain in simple terms what to expect,…

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, record review, and policy review, the facility failed to ensure its staff provided timely pain management interventions for one Resident (#6) out of a total sample of 13 Residents. Specifically, the facility staff failed to respond to the Resident calls for assistance and provide Physician ordered scheduled pain medication in a timely manner. Findings include: Review of the facility's policy, titled Preparation and General guidelines: Equipment and Supplies for Administering Medications, dated 2017, indicated that medications were to be administered within 60 minutes of scheduled time . Resident #6 was admitted to the facility in April 2021 with a diagnosis of unilateral (one sided) primary Osteoarthritis (condition where flexible tissue at the ends of bones gradually wears down and worsens over time) of the left hip. Review of the clinical record indicated Resident #6 was hospitalized after falling at the facility on 4/5/23 where he/she sustained a left hip fracture and required hospitalization to repair the hip. Further review of the clinical…

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 record review, observation, and interview, the facility and its staff failed to ensure that the medication pass had an error rate of less than 5%. Two out of two nurses observed failed to administer medications as ordered, for two out of seven Residents (#22 and #15) observed. The medication error rate was calculated at 10.34 % with 29 opportunities for error. Findings include: 1. On [DATE] at 4:09 P.M., the surveyor observed Nurse #1 prepare the following medication (along with other prescribed medications) for Resident #22: -Celecoxib (antidepressant) 100 milligrams (mg), the expiration date observed on the medication card was [DATE]. During an interview on [DATE] at 4:14 P.M., the surveyor intervened prior to Nurse #1 administering the medication. The surveyor asked Nurse #1 what her process was for medication administration. Nurse #1 said she checked the Resident for identification, then checked the Physician order against the medication card, and checked the expiration date. When Nurse #1 checked…

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 record review and interview, the facility failed to ensure one Resident (#6) out of a total sample of 13 residents was free of a significant medication error. Specifically, facility staff failed to implement necessary action when Heparin (blood thinning medication used to prevent the development of blood clots) that was ordered by the Physician to be administered every 12 hours, was omitted from the Resident's medication administration, resulting in a missed dose and increasing the risk for development of blood clots. Findings include: Review of facility's Medication Policy titled Preparation and General Guidelines, dated 2017, indicated: - Medications are administered in accordance with written guidelines of the Prescriber. - The Charge Nurse reports equipment and supply deficiencies to the Director of Nursing (DON). - If a medication is withheld, refused, or not available, the Physician is notified. - Nursing documents the notification and Physician's response. Resident #6 was admitted to the facility…

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.