Coral Desert Rehabilitation and Care

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 37 sampled residents, a resident had a medication stored on the bed side table and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 108. Findings included: Resident 108 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spinal stenosis lumbar region, type two diabetes mellitus, cognitive communication deficit, anxiety disorder, mood affective disorder, scoliosis, and fall on same level. On 11/19/24 at 8:56 AM, an observation was conducted of resident 108's room. A bottle of AREDS 2 eye vitamin and mineral supplement was observed on resident 108's bedside table. Resident 108's medical record was reviewed on 11/19/24 through 11/21/24. An admission Minimum Data Set…

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 did not ensure that each resident's drug regimen was free from unnecessary drugs and was provided adequate monitoring of those drugs. Specifically, for 1 out of 37 sampled residents, a resident taking a medication used as a hypnotic was not monitored for the number of hours of sleep each night. Resident Identifier: 46. Findings included: Resident 46 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, displaced midcervical fracture of right femur, depression, and chronic kidney disease. Resident 46's medical record was reviewed on 11/18/24 through 11/21/24. A physician's order dated 11/2/24, documented Hydroxyzine HCL [hydrochloride] Oral Tablet 25 MG [milligrams] Give 1 tablet by mouth at bedtime for Sleep. There were no physician's orders located for staff to monitor for the amount of sleep resident 46 obtained each night. The Medication Administration Record (MAR) and Treatment Administration Record were reviewed 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 30 medication opportunities, on 12/14/22, revealed 2 medication errors which resulted in a 6.67% medication error rate. Specifically, for 1 out of 19 sampled residents, a resident received two expired medications. Resident identifier: 148. Findings included: Resident 148 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. On 12/14/22 at 7:34 AM, Licensed Practical Nurse (LPN) 1 was observed to administer PreserVision AREDS 2 tablets with an expiration date of 3/31/22 and Centrum Adult Multivitamin 1 tablet with an expiration date of 4/30/22 to resident 148. On 12/14/22 at 7:40 AM, an interview was conducted with LPN 1. LPN 1 stated the medications came from the resident's hospice company. LPN 1 stated it was the responsibility of the admitting nurse to verify that the medications were not expired and each nurse should check the expiration…

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 and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart, the medication cart was left unlocked when unattended, and expired medications were administered. Resident identifiers: 9, 17, 100, and 148. Findings included: 1. On 12/14/22 at 7:09 AM, Licensed Practical Nurse (LPN) 1 was observed to enter resident 9's room and leave the medication cart for the 100 hallway unlocked with medications unattended on top of the medication cart. 2. On 12/14/22 at 7:34 AM, LPN 1 was observed to administer PreserVision AREDS 2 tablets with an expiration date of 3/31/22, and Centrum Adult Multivitamin 1 tablet with an expiration date of 4/30/22, to resident 148. LPN 1 was immediately interviewed and stated the medications came from the resident's hospice…

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 and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, food items in the dry storage room, refrigerator, and freezer were open to air and food items in the refrigerator were past the use by date. Findings included: On 12/12/22 at 1:40 PM, an initial walk-through of the kitchen was conducted. In the walk-in refrigerator a container of cottage cheese was observed with a use by date of 12/7/22. The date written on the top of the container was 12/10/22. Additionally, in the walk-in freezer, a box of uncooked bacon strips was open to air. In the walk-in freezer, a box of pizza dough with a use by date of 12/7/22 was observed. A box with frozen tortillas and a box of sausage links were also observed to be open to air. In the dry food storage room, a package of spaghetti noodles was observed to be unsealed and open to air. On 12/15/22 at approximately 11:00 AM, a second walk-through of the kitchen was conducted. In the walk-in refrigerator, a container of cottage…

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, it was determined that the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff did not use hand hygiene (HH) during medication pass, a medication was touched with an ungloved hand and placed back in the medication pack for future use, and medication was touched after no HH was used and administered to a resident. Resident identifier: 9 Findings included: 1. On 12/14/22, an observation was made of Licensed Practical Nurse (LPN) 1. LPN 1 did not use HH prior to beginning medication pass. LPN 1 deposited 2 pills into the medication cup which held previously dispensed medications for resident 9. LPN 1 took her ungloved right hand and placed it into the medication cup to retrieve one of the medications. The medication was then placed back into the medication pack 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident consistent with the resident's rights that includes measurable objectives and timeframe's to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Specifically, for 3 out of 19 sampled residents, a resident who required one on one feeding assistance was not receiving that assistance, and two residents who required oxygen did not have the use of oxygen included in the comprehensive care plan. Resident identifiers: 91, 103, and 143. Findings included: 1. Resident 91 was admitted to the facility on [DATE] with diagnoses which included displaced intertrochanteric fracture of left femur, other intraarticular fracture of lower end of left radius, history of falling, chronic obstructive pulmonary disease, dehydration, nutritional anemia, hypertension, and hyperlipidemia. On 12/13/22 at 11:49 AM, 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 did not provide a resident who was unable to carry out activities of daily living the necessary services to maintain good grooming and personal hygiene. Specifically, for 1 out of 19 sampled residents, a resident was not provided one on one feeding assistance. Resident identifier: 143. Findings included: Resident 143 was admitted to the facility on [DATE] with diagnoses which included traumatic subdural hemorrhage with loss of consciousness, hemiplegia and hemipareses affecting right dominant side, displaced supracondylar fracture of right humerus, and history of falling. On 12/12/22 at 3:30 PM, an interview was conducted with resident 143's family member. The family member stated the staff did not cut up resident 143's food. The family member stated resident 143 could only use her left arm, which was her non-dominant arm, since her stroke and broken right arm. The family member stated if he was not at the facility to help resident 143, she would…

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 did not ensure that residents maintained acceptable parameters of nutritional status. Specifically, for 1 out of 19 sampled residents, a resident with weight loss did not receive timely and appropriate interventions. Resident identifier: 18. Findings included: Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dependence on ventilator, unspecified intracranial injury, epilepsy, type II diabetes hemiplegia and hemipareses on left non-dominant side, dysphagia, and anxiety. On 12/15/22, resident 18's medical record was reviewed. On 9/29/22, the Weight Summary revealed a weight of 181 pounds. On 12/14/22, the Weight Summary revealed a weight of 143.5 pounds. [Note: This was a 37.5 pound weight loss, 20.72 percent weight loss in 76 days.] A care plan dated 8/11/22 revealed, At risk for potential nutrition problem per inadequate oral intake, fluid deficit. A goal developed…

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 did not ensure that a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications. Specifically, for 1 out of 19 sampled residents, a resident's tube feeding was not infusing at the prescribed infusion rate. Resident identifier: 17. Findings included: Resident 17 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure with hypoxia, tracheostomy, dependence on ventilator, dysphagia, cognitive communication deficit, chronic diastolic congestive heart failure, essential hypertension, rheumatoid arthritis, major depressive disorder, and need for assistance with personal care. On 12/12/22 at 4:12 PM, an observation was made of resident 17 lying asleep in bed with a family member (FM) in the room. Resident 17's tube feeding (TF) was infusing at 75 milliliters an hour (ml/hr) with 40 ml/hr of water flush. On the TF bag…

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 that residents who need respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, for 2 out of 19 sampled residents, residents who required oxygen did not have a physician's order for oxygen. Resident identifiers: 91 and 103. Findings included: 1. Resident 91 was admitted to the facility on [DATE] with diagnoses that included displaced intertrochanteric fracture of left femur, other intraarticular fracture of lower end of left radius, history of falling, chronic obstructive pulmonary disease, dehydration, nutritional anemia, hypertension, and hyperlipidemia. On 12/13/22 at 11:49 AM, an interview was conducted with resident 91. Resident 91 was observed wearing oxygen with the nasal cannula properly placed. An observation was made that the oxygen tubing had no information as to when it was last…

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 did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 19 sampled residents, the facility administered a narcotic within two hours of an antianxiety medication which was outside of the physician ordered parameters. Resident identifier: 18. Findings included: Resident 18 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included dependence on ventilator, unspecified intracranial injury, epilepsy, type II diabetes hemiplegia and hemiparesis on left non-dominant side, dysphagia, and anxiety. On 12/15/22, resident 18's medical record review 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 interview and record review, the facility did not file laboratory reports that were dated and contained the name and address of the testing laboratory in the residents' clinical record. Specifically, for 2 out of 19 sampled residents, results of laboratory (lab) tests were not in the residents medical record and were not readily accessible. Resident identifiers: 97 and 103. Findings included: 1. Resident 97 was admitted to the facility on [DATE] with diagnoses that included fracture of left femur, presence of artificial hip joint, abnormalities of gait, muscle weakness, acute kidney failure, thrombocytopenia, hypertension, rheumatoid arthritis, benign prostatic hyperplasia, and insomnia. Resident 97 was transferred to the hospital on [DATE], for altered mental status. A review of the hospital discharge documents revealed that resident 97 had a urinary tract infection (UTI). The discharge document also revealed that resident 97 had a urinalysis (UA) and urine culture. Resident 97 was given a written…

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.