Coral Cove Post Acute

In the surveyor’s words

From the most serious findings on record at Coral Cove Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Apr 23, 2021

  Based on observation, interview, and record review, the facility failed to: 1. Monitor all exit doors and ensure the wander guard system ([Resident Monitoring System] a device that alarms when residents attempt to elope [leaving the facility without permission] or wander [to move aimlessly from place to place] from a safe environment) was working properly on all exit doors for five of eight sampled residents (Resident 14, Resident 15, Resident 16, Resident 17, and Resident 18) with elopement and wandering risk. 2. Ensure one of eight sampled residents (Resident 14) at risk for elopement received supervision. […]

• Immediate jeopardy, widespreadF925Apr 23, 2021

  Based on observation, interview and record review, the facility failed to maintain an effective pest control program to prevent and eradicate (destroy) gnats (small long legged flying insects) infestation (presence of an unusually large number) throughout the facility for 84 of 84 residents who were eating food and drinking in their room. This deficient practice resulted in the presence multiple gnats observed in the residents' rooms, food items, curtains, bed, blankets, bathrooms, shower rooms, hallway walls, food trays left in the hallways, and kitchen. […]

• Immediate jeopardy, patternF755Jun 29, 2023

  Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to prevent adverse events for three of six sampled residents (Residents 1, 2, and 3) and failed to accurately document medication administration for six of six sampled residents (Residents 1, 2, 3, 4, 5, 6) out of 48 residents receiving narcotic medications. The facility failed to: 1. Ensure Resident 1, who was prescribed Hydrocodone-Acetaminophen ([Norco] an opioid [medication used to treat moderate to severe pain]) did not receive excessive doses of the medication. 2. […]

• Immediate jeopardy, patternF688Mar 30, 2023

  Based on observation, interview, and record review, the facility failed to provide appropriate treatment and services to maintain, increase, or to prevent further decrease in range of motion [(ROM) a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints, that over time becomes irreversible] for five of six sampled residents (Residents 1, 7, 15, 26, and 32). The facility failed to: 1. Ensure a Restorative Nursing Aide [(RNA) nursing aide program that helps residents maintain their function and joint mobility) services were provided by a certified restorative nursing aides to all eligible residents in the facility from 3/11/2022 to 3/31/2023. 2. […]

• Immediate jeopardy, patternF919Jul 13, 2021

  Based on observation, interview and record review, the facility failed to ensure the call light system was operable with visual and audible in all of the residents' rooms, bathrooms, and at the nursing stations, to alert and relay the residents' needs to the staff for 19 of 19 residents (Residents 5, 10, 11, 14, 21, 23, 26, 43, 47, 52, 53, 63, 77, 80, 81, 83, 88, 89, and 98) with a universe of 94, and had the potential to affect all the residents who resided in the facility. During a review of the facility's Resident Census and Conditions of Residents (CMS 672 form) completed by the facility, the CMS 672 indicated the facility had 60 residents occasionally or frequently were incontinent (inability to control) of bladder; 68 residents occasionally or frequently were incontinent of bowel;… […]