Coal Creek Post Acute & Assisted Living

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Have exits that are accessible at all times.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

A complaint survey, prompted by #CO37382, #CO37463, #CO38068, #CO38075 and #CO38077 was conducted on 11/13/24. Three deficiencies were cited. Based 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. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.sevier, St. Louis Missouri, page 606-607, retrieved on 11/21/24, It read in pertinent part, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked.. Based 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.Findings include:I. Professional reference According to the carbidopa/levodopa dosing instructions, retrieved from https://www.goodrx.com/carbidopa-levodopa/dosage on 11/21/24, "A combination of two medications: carbidopa and levodopa. Levodopa replaces dopamine, which improves symptoms of Parkinson' s disease. And carbidopa helps levodopa stick around longer in the body."If you miss a dose of carbidopa/levodopa, take the medication as soon as you remember. But if you remember when you' re already close to taking your next dose, skip the missed one."Don' t take more than one carbidopa/levodopa dose at a time. Doubling up on doses can be dangerous and lead to more side effects, such as movement problems and mood changes.. Based 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 10/11/24 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. Findings include:I. Facility policy and procedureThe Fall Management policy, reviewed September 2012, was provided by the nursing home administrator (NHA) on 11/13/24. The policy revealed the facility would ide..

A survey prompted by complaint #CO38449 was completed on 11/13/24. One deficiency was cited. Based 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 10/11/24 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. Findings include:I. Facility policy and procedureThe Fall Management policy, reviewed September 2012, was provided by the nursing home administrator (NHA) on 11/13/24. The policy revealed the facility would identify each resident who was at risk for falls, would plan the care and implement interventions to manage falls. Residents who were at risk for falls, would have interventions to manage falls. The facility would manage falls by providing an environment that was free from potential hazards.II. Fall investigationThe 10/12/24 fall investigation for Resident #3 was provided by the NHA on 11/13/24 at 11:00 a.m.Review of the fall investigation revealed Resident #3 was found on the floor near her bathroom. The resident said she walked to the hallway and asked for help but "the girl told me to do it myself." The resident returned to her room where she later was found on the floor with a laceration to her head. Resident #3 was transported to the emergency department for further evaluation.The investigation included an interview with certified nurse aide (CNA) #2 who said she assisted Resident #3 to the bathroom and back to her room. CNA #2' s written statement indicated Resident #3 continued to say that she was going to fall while CNA #2 was..

A complaint survey, prompted by #CO36978, #CO36979 and #CO36981 was conducted on 8/26/24 to 8/27/24. One deficiency was cited. Based 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.Findings included:I. Facility policyThe Dignity policy, revised February 2021, was provided by the corporate nurse consultant (CNC) on 8/27/24 at 11:10 a.m. It read in pertinent part, "Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem."Residents are treated with dignity and respect at all times. The facility culture supports dignity and respect for residents by honoring resident goals, choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident' s facility stay."Individual needs and preferences of the resident are identified through the assessment process.Residents may exercise their rights without interference, coercion, discrimination or reprisal from any person or entity associated with this facility."When assisting with care, residents are supported in exercising their rights. For example, residents are; groomed as they wish to be groomed (hairstyles, nails, facial hair)."The Resident Rights policy, revised December 2016, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, "Employees shall treat all residents with kindness, respect and dignity. The residents' rights include a dignified experience."The Activities of Daily Living (ADL), Supporting policy, dated 2001, was provided by the CNC on 8/27/24 at 11:10 a.m. It read in pertinent part, "Residents who are unable to carry out a..