Coastal Post Acute

Inspectors wroteBased on interview and record review, the facility failed to provide supervision for one of 14 residents (Resident 1) who was at risk for leaving the facility (elopement) when Resident 1 went out of the facility premises without the facility's knowledge on [DATE]. This failure resulted in Resident 1 leaving the facility unattended and Resident 1 being found by a bystander face down and unresponsive at a bus stop. The bystander called 911 (universal emergency number) and EMS (Emergency Medical Services, a system that provides emergency medical care) responded and resuscitated Resident 1. Resident 1 was transferred to an acute care hospital where Resident 1 expired on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary conditions were maintained in the food and nutrition services when: 1. One plastic spatula (a kitchen utensil with a wide, flat blade used for mixing spreading, lifting, and removing food) had burned handle and brownish color; 2. Nine pieces of large sized steel pan trays with a blackish colored substance on all the edges; 3. Several black colored dots were trapped in the bug light trap and was not clean as needed; and 4. Staff did not check the expiration date of the test strip prior to using. These failures had the potential to cause food contamination and illness for 69 out of 70 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control measures when: 1. Resident 26's nasal cannula (flexible tubing inserted into the nostrils and attached to an oxygen [a colorless and odorless gas that people need to breathe] was hanging and expose on the resident side rails; 2. Staff did not perform handwashing/hand hygiene before and after gloving; 3a. Enhanced barrier precautions signage was not posted on the door for one resident; b. One staff member did not disinfect cap of medication bottle appropriately; and 4. The Physical Therapy Assistant (PTA) hanged the foley catheter bag on his cargo pants pocket. These failures had the potential to result in the transmission and spread of infection throughout the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dignity and privacy was upheld for two of four sampled residents (Resident 121 and Resident 226 ) when Resident 121 and Resident 226 foley catheter (a thin, flexible tube inserted into the bladder through the urethra to drain urine) drain bags were left uncovered. This failure had the potential for adverse effects on the psychosocial well-being and health of Resident 121 and Resident 226.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to protect resident's rights to confidentiality of protected health information (PHI, any information in the medical record that can be used to identify an individual and that was created, used, or disclosed in the course of providing a health care service such as diagnosis or treatment)for one of 18 residents (Resident 7) when Registered Nurse D (RN D) left the computer screen on and unattended on top of the medication storage cart. This deficient practice had the potential to compromise the resident's privacy and confidentiality.

Inspectors wroteBased on interview and record review, the facility failed to ensure the PASARR (a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) Level 1 assessment was coded accurately for one of five sampled residents (Resident 6) reviewed for PASARR. This failure had the potential for having residents that were not appropriate in the facility and for Resident 6 not to receive the appropriate services.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted and given according to the physician's orders for two of seven sampled residents (Resident 51 and 66). Controlled medications were signed out of the Controlled Drug Record (CDR, an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) as administered to the residents; Controlled medications were documented on the MAR as administered to the residents but not signed out of the CDR. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) for proper labeling and storage of medications when food was stored on two of four medication storage carts. This deficient practice had the potential to cause cross contamination that could affect the residents.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure that the facility environment remains free of accident hazards when the temperatures of hot water at the sinks of Room AA and Room BB were at 127 degrees Fahrenheit (F, temperature scale) and 130 F. This failure placed the residents and staff at risk for accidental burns.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to implement infection control practices when: 1. Certified Nursing Assistant A (CNA A) placed soiled linen and towels on the restroom floor in Resident 1's room and carried the soiled linen and towels out of Resident 1's room and in the hallway; and 2. CNA B cleansed Resident 2, then carried a bag of used incontinent brief and soiled towels with gloved hands, walked out of Resident 2 ' s room and in the hallway. These failures had the potential to spread infection in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Medicare Non-Coverage (NOMNC, notice informing the resident that Medicare covered services will end) was issued in a timely manner for one of three sampled residents (Resident 1). This failure had the potential to compromise the residents' right to appeal (apply for reversal of) the decision to discontinue Medicare covered services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was stored and/or prepared under sanitary conditions when: 1. There was a crusty white substance on several areas of the ice machine; and 2. Kitchen staff did not follow manufacturer's instructions when testing the kitchen surface sanitizer (solution used to kill microorganisms on kitchen surfaces). These failures had the potential to cause foodborne illness (illness caused by contaminated food) for 66 out of 66 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their pest control program was effective when there were several fruit flies (small flying insects that have the potential to contaminate food) in the kitchen, even though the kitchen had recently been treated for fruit flies. The presence of pests in the kitchen had the potential to result in foodborne illness (illness caused by contaminated food) for 66 out of 66 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the temperature (temp) in one of two medication refrigerators (Ref #2) was maintained within acceptable range from 36 to 46 degrees Fahrenheit (ºF) as per the manufacturers' and the facility's guidelines. Ref #2 had out-of-range temp readings 4 times in June 2023, and 23 out of 47 times in July 2023, without any documented action taken by the staff to correct the out-of-range temps. Exposing medications to out-of-range temps, such as too hot or cold, can cause them to become unstable and even degrade, posing a risk of negative side effects and decreasing their effectiveness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food palatability was maintained, when six of 17 sampled residents (Residents 11, 41, 12, 269, 270 and 6) complained about the taste of the food being served. This failure had the potential to result in decreased food intake and weight loss, compromising the resident's nutritional status.

Inspectors wroteBased an interview, and record review, the facility failed to ensure the dignity of one of 17 sampled residents (Resident 317), when certified nursing assistant G (CNA G) did not use proper technique in modestly covering Resident 317's unclothed lower body. This failure was against the resident's right to dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 35) had been informed about having an advance directive (legal form directing their wishes about their healthcare, whether from them or a named individual on their behalf), when no documentation was found about advance directive. This failure had the potential to result with inability to make medical decisions and could lead to the delivery of unnecessary or inappropriate medical services.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1. one of 17 sampled residents (Resident 35) or their responsible party (RP, person who is accountable in making decision on behalf of the resident) received a notice of transfer and discharged to the general acute care hospital (GACH) and 2. the State Long-Term Care Ombudsman (Ombudsman, an advocate for residents in the nursing homes) office was not notified about two of 17 residents (Residents 35 and 317) transfer to the GACH. These failures had the potential of not providing the residents and/or their RPs with an access to an advocate who could inform them of their rights.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the Minimum Data Set (MDS, an assessment tool) for one of 17 sampled residents (Resident 52). Failure to accurately assess the resident had the potential to compromise the facility's ability to provide resident-centered care plan interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards and facility policy and procedures for three of 17 sampled residents (Residents 7, 20, and 41), when: 1. Licensed Vocational Nurse (LVN) C failed notify the physician when Resident 7 refused his diabetic medication 8 times in June and 12 times in July 2023; 2. For Resident 41, LVN E administered 13 units of insulin (medication to lower blood sugar) while the order indicated to give 6 units, and informed the physician after he administered it; 3. For Resident 20, 72 hour alert charting was not completed post fall. These failures had the potential to cause complications of the residents' medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities for one of 17 sampled residents (Resident 52). This failure had the potential to negatively affect the resident's overall well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor, evaluate and managed residents behavior for one of 11 sampled residents (Resident 24), when Resident 24 had episodes of shaking her side rails when in bed. The failure had the potential for Resident 24, not attaining her highest well-being and caused discomforts to her roommate Resident 41.

Inspectors wroteBased on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted and given according to the physician's orders for two of two sampled residents (Residents 2 and 267). Controlled medications were signed out of the Controlled Drug Record (CDR, or an inventory sheet that keeps record of the usage of controlled medications) but not documented on the Medication Administration Record (MAR) as administered to the residents; furthermore, there were no physician's orders for the administrations. The failure resulted in inaccurate accountability and had the potential for misuse or diversion (illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) of controlled medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medication regimen for one of 17 sampled residents (Resident 57) was free from unnecessary medications. Resident 57 had been receiving Reglan (metoclopramide; medication to treat nausea and vomiting) exceeding 12 weeks duration, as specified by the manufacturer, without a risk/benefit (R/B) assessment. This had the potential for the resident to experience side effects, specifically tardive dyskinesia (an involuntary movement disorder that causes a range of repetitive muscle movements in the face, neck, arms and legs) from prolonged use.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 17 sampled residents (Resident 35) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behaviors) when Resident 35 received Remeron (generic name: mirtazepine, an antidepressant medication) for poor appetite related to depression without staff consistently monitoring for his meal intakes. The failure resulted in inadequate monitoring for the effectiveness of the medication.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure refuse (any disposable materials, which includes recyclable and non-recyclable materials) was stored properly when one out of four dumpsters was overfilled and the lid was not closed. This failure had the potential to attract insects, rodents, and other pests to the facility.

Inspectors wroteBased on observation, interview, and record review, licensed vocational nurse A (LVN A) failed to perform hand hygiene during wound treatment for one of two sampled residents (Resident 6). This failure had the potential to cause infection or other complications to Resident 6's wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute food safely when: 1. refrigerator #1 had torn, dirty gaskets and racks with peeling coating and rust; 2. refrigerator #2 had torn, dirty gaskets; racks with rust; and a discolored pork roast; and 3. freezer #2 had torn, dirty gaskets; racks with peeling coating and rust; and poultry and salmon with freezer burn These failures had the potential to cause food borne illness to a highly susceptible population of 75 residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services were provided to prevent accidents or harm for five of 20 sampled residents, when: 1) There was no bolster (cushion for support) in Resident 39's bed and the bed level was raised. 2) A neurological assessment was not completed after seven unwitnessed falls for Resident 19 and the alarming devices were non-functional and not in place for Resident 19. 3) There were fire hazard items placed on three residents room light (Residents 23, 36 and 45). These failures had the potential to place residents at risk for accidental burns, repeated falls, injury, or even death.

Inspectors wroteBased on observation and interview, the facility failed to promote resident's dignity when three certified nursing assistants (CNAs) were standing while assisting with meals for four of eight residents (Resident 6, Resident 11, Resident 15 and Resident 39) reviewed, which had the potential to decrease residents' self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Residents 25 and 44) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying them that Part A coverage is being terminated and providing information on how to file an appeal of that decision). This failure had the potential to prevent the residents from filing a timely appeal of the decision to discharge from Medicare Part A services.

Inspectors wroteBased on interview and record review, the facility failed to provide restorative nursing assistant (RNA) services (exercise program intended to improve or maintain level of function) as ordered for two of 18 sampled residents (9 and 44). This failure had the potential to result in a decline in the residents functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care of an intravenous (IV, within a vein) site dressing and accurate measurement of arm circumference and external length catheter were completed as per physician orders for one (Resident 66) of one resident reviewed with IV catheters, which had the potential to result to IV complication.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis (the clinical purification of blood as a substitute for normal function of the kidney) communication record were completed, for one of one resident receiving dialysis (21). This failure had a potential to put Resident 21 at risk in developing undetected, potentially life-threatening complications related to dialysis treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate indication, behavioral and adverse/side-effects monitoring for one of 20 sampled residents (Resident 122) related to use of Seroquel (treats mental/mood disorder), which had the potential to result to adverse drug reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Alprazolam (anti-anxiety) for one of 20 sampled residents (Resident 122) was limited to 14 days, which had the potential to cause adverse drug reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1) resident medications were sufficiently labeled; 2) unused narcotics were disposed of; and 3) discontinued narcotics were secured. This failure had the potential to result in the accidental administration of a wrong medication to the wrong resident and/or drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide plateguard (stainless steel food guard to secure food spill) during lunch meal for one of seven residents (Resident 61) reviewed with adaptive devices, which had the potential to affect resident's ability to complete self-feeding task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when used lancets (a spring-loaded device that contains a needle) were stored in an unlocked freezer in an unlocked biohazardous waste storage area. This failure had the potential to expose the residents to infectious disease. During an observation of the biohazardous waste storage area with the associate director of nursing (ADON) and the van driver (VD) on 6/24/19 at 8:45 a.m., the door to the storage area was unlocked. A freezer used to contain biohazardous waste was also unlocked. Thirteen lancets and caps (lancet covers) were scattered on the bottom of the freezer. During a concurrent interview, both the ADON and VD confirmed the observations. [...]