Coffman Nursing Home

Inspectors wroteBased on record review, interviews, and observations, it was determined that the facility failed to ensure that meals were delivered to residents at an appropriate and palatable temperature. This deficient practice has the potential to affect all residents who receive meals from the facility's kitchen.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store and prepare food in accordance with professional standards and guidelines. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide a home-like environment for residents. This was evident in three of the three hallways reviewed for the environment.

Inspectors wroteBased on a record review, observations, and interviews, it was determined that the facility failed to serve residents meals according to a predetermined menu that reflected their preferences. This was evident in four out of four dining observations during the survey.

Inspectors wroteBased on observations, review of policies and medical records, and interviews it was determined that the facility failed to ensure staff maintained standard and enhanced barrier precautions (EBP) while providing care; and failed to ensure the infection prevention and control policies and procedures were reviewed and revised at least annually. This was found to be evident for 3 (Resident # 3, #37 and #29) out of 40 residents included in the sample.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately recorded. This was evident for 1 (#8) of 5 residents reviewed for unnecessary medications and 1 (#40) of 2 residents reviewed for the Preadmission Screening and Resident Review (PASSR) screening.

Inspectors wroteBased on interviews and a review of medical records, it was determined that the facility failed to ensure an interdisciplinary team (IDT) care plan meeting was conducted for a resident. This was evident for one Resident (#48) who was reviewed for care planning.

Inspectors wroteBased on review of medical records and complaint 316958, and interviews it was determined that the facility failed to ensure a resident received care in accordance with professional standards of practice. This was found to be evident for one (Resident #23) of five residents reviewed for unnecessary medication.

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to ensure the residents were free from unnecessary antibiotics. This was found to be evident for one (Resident #54) out of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure that drugs and biologicals were stored in areas that are secure against unauthorized access. This was evident in 2 (the 200 hall and the 300 hall) out of 3 rooms being used to store medications, as observed during the completion of the medication storage and labeling task for the annual recertification survey.

Inspectors wroteBased on a record review, observation, and interviews, it was determined that the facility failed to provide an assistive device for eating to a Resident. This was evident in one of four dining observations during the survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to maintain the daily posted staffing information in a readily accessible format. This practice has the potential to affect all residents.

Inspectors wroteBased on complaint, review of the facility policies and a closed medical record, as well as staff interviews, it was determined that the facility staff failed to immediately notify a resident's physician and responsible party when a resident had fallen and received an injury. This was evident for 1 (Resident #6) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on observation, interview and review of relevant documentation, it was determined that the facility failed 1) to ensure that clean dishes were stored in a manner to prevent contamination; 2) maintain a cleaning schedule for the ice machine 3) ensure bulk food items were labeled and dated and 4) failed to ensure the temperature of the nourishment refrigerator was monitored. These practices have the potential to affect all the residents in the facility.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to implement an effective infection control program and facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease by 1) failing to store insulin pens and glucometers in a way that reduced the risk of bloodborne pathogen exposure, 2) failing to have a process in place to screen and educate visitors regarding infection control procedures for visiting, 3) failing to review and update Infection Prevention and Control policies and procedures on an annual basis. 4) failing to follow hand hygiene procedures during medication administration, 5) failing to properly store resident care equipment, and 6) failing to ensure daily COVID symptom assessments were being completed. [...]

Inspectors wroteBased on review of facility records and interview with staff, it was determined that the facility staff failed to provide residents/representatives with a Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) for 1 (#291) of 3 residents reviewed for Beneficiary Protection Notification.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure their residents were free of abuse. This was evident during the annual survey and has the potential to affect all residents.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to establish when to report suspicion of a crime and mandated time frames to report those suspicions. This was evident during the annual survey and has the potential to affect all residents.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that staff identified injuries of unknown origin and reported them to the state survey and certification agency. This was found to be evident for 2 ( #22, #16) of 31 residents reviewed during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility 1) failed to include the required statement of the resident's appeal rights and contact information in the written notice of transfer, 2) failed to notify the resident/representative of the reason for the transfer, and 3) failed to notify the resident representative in writing of a transfer/discharge. This was evident for 1 (#30) of 1 resident reviewed for hospitalization.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that a Preadmission Screening and Resident Review level II (PASARR II) referral was completed for a resident who was newly diagnosed with a mental illness while living in the nursing home. This was evident for 1 (#25) of 14 residents reviewed during annual survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility failed to develop a care plan to address a resident's needs related to activities. This was found to be evident for 1 (#9) of 3 residents reviewed for activities.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff who evaluate care plans failed to revise the interdisciplinary care plans to reveal accurate approaches. This was evident for 1 (#30) of 1 resident reviewed for pressure ulcers.

Inspectors wroteBased on review of observation, interviews, and review of medical records and activity staff documentation, it was determined that the facility failed to ensure that each resident received an ongoing program to support their choice of activities. This was found to be evident for 2 (#9, #16) of 3 residents reviewed for activities during the survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that staff completed the controlled drug count at the change of shift as evidenced by documentation by nursing staff that the count had been completed prior to the end of the shift. This was found to be evident for 1 out of 3 controlled substance log books reviewed.

Inspectors wroteBased on medication administration observation, medical record review and staff interview, it was determined that the facility staff failed to ensure a medication error rate of less than 5 percent for 1 (#18) of 3 residents observed with 28 medication administration opportunities resulting in an error rate of 6.9 % by 1 of 2 certified nursing assistants.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to store medications in a locked container and limit access to those medications as evidenced by a medicine cart left unlocked and unsupervised with topical medications and the keys to the cart in a cup sitting on top of the cart. This was evident for 1 of 3 medicine carts observed during the survey.

Inspectors wroteBased on observation, record review, and resident and staff interview, it was determined that the facility failed to serve meals and beverages at an appetizing temperature as evidenced by resident complaints that the food and coffee were served cold when they eat in their rooms. This was evident for 2 (#31 and #10) of 14 residents screened for dining concerns.

Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to develop effective plans of correction (PoC) to correct previously cited deficiencies. This has the potential to affect all residents.

Inspectors wroteBased on review of the facility assessment and interview, it was determined that the facility had failed to ensure the assessment had been reviewed at least annual. This deficient practice has the potential to affect all residents in the facility.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to develop comprehensive COVID-19 vaccination policies and procedures to ensure that all staff were fully vaccinated by failing to implement 1) include a date of implementation on the policy and to clearly define who the vaccination policy pertained to, 2) include a process for ensuring the implementation of additional precautions for all staff who were not yet fully vaccinated or who a medical or nonmedical exemption, 3) a process by which all facility staff would have their COVID-19 vaccination information collected, secured, and tracked and to include any booster doses, 4) a hiring process for ensuring that all staff hired were fully vaccinated with COVID-19, 5) a process for medical and non-medical exemptions, for the COVID-19 vaccination, that have been requested and granted to ensure that all required [...]

Inspectors wroteBased on observations and staff interview, it was determined the facility failed to provide housekeeping and maintenance services necessary to keep the resident's environment clean and in good repair. This was evident on 3 of 3 hallways.

Inspectors wrote3) On 12/7/18, a review of Resident #4's medical record revealed that, on 11/14/18 at 11:00 PM, in a progress note, the nurse documented that the resident was on an antibiotic for a MRSA (methicillin resistant staphylococcus aureus) infection in a scalp wound. Review of Resident #4's November 2018 MAR documented that, from 11/14/18 to 11/24/18, Resident #4 took the antibiotic medication, Bactrim DS twice a day for a MRSA infection. Review of Resident #4's quarterly MDS assessment, with an ARD of 11/19/18, Section I, diagnosis, revealed the MDS assessment failed to capture the wound infection diagnosis. Continued review of Resident #4's November 2018 MAR revealed documentation that the resident received the medication Lovastatin 20 mg, by mouth every day for hyperlipidemia (high cholesterol). [...]

Inspectors wrote6) On 12/4/18 at 11:14 AM, observation of Resident #4 revealed the resident was using oxygen. On 12/6/18, review of Resident #4's December 2018 Respiratory Administration History record revealed a 4/4/15 physician's order for Oxygen via nasal cannula, may titrate to keep SPO2 (saturation of peripheral oxygen) above 90%, check SP02 every shift while in use every shift which was documented as being administered every shift from 12/1/18 through 12/6/18, days. Review of Resident #4's quarterly assessment dated [DATE], documented diagnoses that included dependence on supplemental oxygen. Review of Resident #4's care plans failed to reveal that a comprehensive care plan had been developed to address Resident #4's respiratory status and use of oxygen. On 12/7/18 at 12:59 PM, the Director of Nurses was made aware of these findings. [...]

Inspectors wrote4) Resident #24's medical record was reviewed on 12/10/18 at 12:58 PM. The resident had a physician's order for Amitriptyline 10 mg (milligrams) at bedtime for insomnia, which was decreased on 8/25/18, from 25 mg at bedtime. The resident had a plan of care for insomnia, which included the intervention 'Administer medications: Amitriptyline 25 mg every night at bedtime'. The Evaluation note, dated 9/18/18, indicated Care Plan reviewed and current. The plan of care was not updated to reflect the dosage change of the resident's Amitriptyline, nor did the plan evaluate the resident's progress or lack of progress toward reaching his/her goal. Staff #1 was made aware of these findings on 12/10/18 at approximately 2:30 PM. [...]

Inspectors wroteBased on surveyor observation, interviews with staff and review of resident and facility records, it was determined that the facility failed to have an effective quality assessment and assurance program by failing to implement plans of action to correct quality deficiencies identified during the prior annual quality indicator survey.

Inspectors wroteBased on surveyor observation, it was determined that the facility staff failed to treat each resident with respect and dignity by failing to accommodate the dining needs of all residents seated together at a meal in a timely manner. This was evident for 2 (#6 and #7) of 4 residents seated together during breakfast service.

Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to notify the physician and resident's representative timely of a residents injury. This was evident for 1 (#6) of 18 residents reviewed during the investigative phase of the survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to document what preparation and orientation was given to a resident to ensure an orderly transfer to an acute care facility. This was evident for 1 (#37) of 1 resident reviewed for hospitalization.

Inspectors wroteBased on observation, medical record review, and family and staff interview, it was determined the facility failed to render care in accordance with the resident's care plan and failed to apply an ordered treatment. This was evident for 1 (#7) of 2 residents reviewed for positioning/mobility.

Inspectors wroteBased on observation, family interview, medical record review and staff interview, it was determined that the facility failed to ensure that residents with a limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 1 (#7) of 2 residents reviewed for mobility.

Inspectors wroteBased on observation, staff interview and record review, it was determined that the facility staff 1) failed to ensure the maintenance of bedrails, 2) failed to ensure that resident bed rail assessments were kept in the resident's medical record, 3) failed to ensure that resident's bed rail assessment information included attempts at using alternatives to bed rails, including how the alternatives did not meet the resident's medical or safety need or were inappropriate and 4) failed to reveal ongoing assessment to assure that the bed rail is used to meet the resident's needs. This was evident for 1 (#16) of 1 residents reviewed for accidents.

Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs by failing to assure a medication had a clear dosage regimen. This was evident for 1 (#35) of 7 residents reviewed for unnecessary medication.

Inspectors wroteBased on observation and medical record review, it was determined the facility failed to keep accurate medical records as evidenced by professional nursing staff signing off that a treatment was performed when it was observed not to be done. This was evident for 1 (#7) of 2 residents reviewed for mobility.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (#37) of 1 resident reviewed for hospitalization.