Alliance Health at Coleman

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to post on a daily basis the required nurse staffing information that included the actual hours worked by licensed and unlicensed nursing staff for three days. Specifically, the facility failed post the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift that should also reflect any staff absences on that shift due to call-outs and illness.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.