Coal Creek Post Acute & Assisted Living

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination; and, -Ensure safe and appropriate storage of food items in the main kitchen walk-in refrigerator.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents had the right to a dignified existence for four (#3, #28, #72 and #73) of 24 residents out of 36 sample residents reviewed. Specifically, the facility failed to:-Speak with Resident #3, Resident #28, Resident #72 and Resident #73 respectfully while providing care to the residents; and,-Ensure residents were not discussed by staff in areas where the conversations could be overheard by others.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of two units. Specifically, the facility failed to ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care for Resident #65, Resident #62 and Resident #29, who were on enhanced barrier precautions (EBP).

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure accurate medical records were kept for one (#28) of five residents out of 36 sample residents reviewed. Specifically, the facility failed to maintain accurate records for Resident #28 of pain reassessments and foley catheter care in the electronic medical record (EMR).

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two (#29 and #62) of five residents reviewed for immunizations out of 36 sample residents. Specifically, the facility failed to offer Resident #29 and Resident #62 the COVID-19 vaccination.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident environment was free from accident hazards and adequate supervision was provided for one (#3) of three residents reviewed out of nine sample residents. Resident #3 was admitted to the facility on [DATE] for rehabilitation after surgery on her back. Upon admission, the resident was assessed for fall risk and was identified as a high risk for falls. However, the baseline care plan, initiated on 10/11/24, failed to identify the resident was at risk for falls and person-centered interventions were not put in place to prevent falls for Resident #3. On 10/12/24 Resident #3 sustained a fall which resulted in a laceration to her head and required transportation to the emergency department for further evaluation and staples to close the laceration.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that professional standards of practice were followed during medication administration for two (#9 and #8) of three residents out of nine sample residents. Specifically, the facility failed to ensure Resident #9 and Resident #8 received medications as scheduled according to the physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#4) of three residents out of nine sample residents were free of significant medication errors. Specifically, the facility failed to ensure Resident #4 was administered his Parkinson's medication per the physician orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to promote and maintain resident dignity by providing care in a dignified, respectful and individualized manner for three (#1, #5 and #6) of three residents out of 12 sample residents. Specifically, the facility failed to: -Ensure Resident #1 and Resident #6 were treated with dignity and respect when they asked for care assistance; and, -Ensure Resident #5, a resident with a diagnosis of Alzheimer's disease, was provided a dignified experience of receiving sufficient care to maintain good personal health and hygiene.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were treated with dignity and respect for two (#12 and #133) of five residents reviewed for dignity and respect out of 18 sample residents. Specifically, the facility failed to: -Ensure Resident #12 was assisted during meal times in a dignified manner; and, -Ensure Resident #133 was treated with dignity and respect when she requested a cup of coffee.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents who entered the facility with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (#12) of five residents reviewed for range of motion out of 18 sample residents. Specifically, the facility failed to ensure Resident #12 was assessed for a restorative program for her contracted right hand.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received respiratory treatment as ordered for two (#137 and #191) of five residents reviewed for supplemental oxygen use out of 18 sample residents. Specifically, the facility failed to obtain a physician's order for the administration of oxygen for Resident #137 and Resident #191.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured and labeled in accordance with accepted professional standards for two of two medication storage rooms. Specifically, the facility failed to: -Ensure medication storage refrigerators were within acceptable parameters for proper medication storage; -Ensure medication storage refrigerator temperatures were monitored and documented consistently; -Ensure a Schedule IV controlled medication was properly stored in a locked, permanently affixed compartment in the medication storage refrigerator; and, -Ensure expired medications were properly disposed of.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received and the facility provided food that accommodated resident preferences for one (#12) of three residents reviewed for food preferences out of 18 sample residents. Specifically, the facility failed to ensure Resident #4 was provided with a vegetarian diet per her preference.

Inspectors wroteBased on observations and staff interviews, the facility failed to establish and 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 for two (#3, and #9) of five residents out of 18 sample residents. Specifically, the facility failed to ensure transmission-based precautions were implemented for Resident #3 and #9.

Inspectors wroteBased on observations, interviews, and record review; the facility failed to honor resident choices for six ( #243, #246, #27, #29, #93, and #193 ) out of 25 resident's reviewed for self-determination. Specifically, the facility failed to ensure Residents #243,#246, #27, #29, #93, and #193 received showers according to their choice of frequency.

Inspectors wroteBased on record review and interviews the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to ensure enough staff were available to adequately care for the resident as residents felt and expressed their activities of daily living (ADLs) of toileting assistance, transferring, showers, and overall call light response, were met and addressed in a timely manner. -Cross-reference F561, failure to honor resident ' s choice regarding showers. I. Resident interviews Resident #194 was interviewed on 11/19/19 at 9:40 a.m. She said she often had to wait 20 to 30 minutes to use the restroom after putting on her call light. Resident #5 was interviewed on 11/19/19 at 10:19 a.m. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#102) resident of three residents reviewed for dignity out of 24 sample residents. Specifically, the facility failed to: -Address resident in her preferred way; and -Provide Resident #102 with a dignified dining experience in her room while she was eating lunch. I. Resident #102 A. Resident status Resident #102, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), pertinent diagnoses included lumbar fracture, multiple rib fractures and dementia without behaviors. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan for one (# 97) resident out of three sample residents was reviewed and revised by the interdisciplinary team. Specifically, the facility failed to ensure Resident #97's care plan was updated with new risks and interventions after resident's fall on 11/18/19.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two (#40 and #20) residents reviewed of five sample residents received treatment and care in accordance with professional standards of practice out of 24 sample residents. Specifically, the facility failed to: -Routinely monitor the surgical incision on the back, and timely communicate changes in incision to the physician for Resident #40. Resident developed purulent drainage from the wound and was sent to the emergency room for evaluation; and, -Complete skin assessments timely, and to monitor bruising and abrasions for Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide respiratory care and services in accordance with professional standards of practice, for one (#195) of one resident reviewed for supplemental oxygen use out of 25 sample residents. Specifically, the facility failed to: -Ensure staff followed current physician's order for use of oxygen; -Obtain orders to establish parameters to maintain acceptable oxygen levels; -Obtain orders to establish why the resident required oxygen to include liter flow rate when Resident #195 was below the appropriate saturation levels; -Ensure the care plan included specific oxygen use instructions for staff to follow; and, -Ensure the resident maintained safe oxygen saturation levels.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#97) of five residents reviewed out of 25 sample residents were reviewed by interdisciplinary team after pharmacy submitted monthly recommendations. Specifically, the facility failed to: -Timely communicate/deliver all pharmacy recommendations to the physician for review, and -Follow up with the physician regarding the pharmacist recommendations for Resident #97. I. Resident #97 A. Resident status Resident #97, age [AGE], was admitted on [DATE]. According to the November 2019 computerized physician orders (CPO), the diagnoses included dementia with behavioral disturbance, paraplegia, anxiety disorder, major depressive disorder, and insomnia. The minimum data set (MDS) assessment for the resident was not completed. Resident ' s brief interview for mental status (BIMS) score was not conducted. [...]