Coral Desert Rehabilitation and Care

In the surveyor’s words

From the most serious findings on record at Coral Desert Rehabilitation and Care, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF759Dec 15, 2022

  Based on observation and interview, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 30 medication opportunities, on 12/14/22, revealed 2 medication errors which resulted in a 6.67% medication error rate. Specifically, for 1 out of 19 sampled residents, a resident received two expired medications. Resident identifier: 148. Findings included: Resident 148 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease. On 12/14/22 at 7:34 AM, Licensed Practical Nurse (LPN) 1 was observed to administer PreserVision AREDS 2 tablets with an expiration date of 3/31/22 and Centrum Adult Multivitamin 1 tablet with an expiration date of 4/30/22 to resident 148. […]

• No harm, potential for more than minimal, patternF761Dec 15, 2022

  Based on observation and interview, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with accepted professional principles, included the accessory and cautionary instructions and the expiration date when applicable, and were stored in locked compartments. Specifically, observations were made of medications left unattended on top of the medication cart, the medication cart was left unlocked when unattended, and expired medications were administered. Resident identifiers: 9, 17, 100, and 148. Findings included: 1. On 12/14/22 at 7:09 AM, Licensed Practical Nurse (LPN) 1 was observed to enter resident 9's room and leave the medication cart for the 100 hallway unlocked with medications unattended on top of the medication cart. 2. […]

• No harm, potential for more than minimal, patternF812Dec 15, 2022

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards of food service safety. Specifically, food items in the dry storage room, refrigerator, and freezer were open to air and food items in the refrigerator were past the use by date. Findings included: On 12/12/22 at 1:40 PM, an initial walk-through of the kitchen was conducted. In the walk-in refrigerator a container of cottage cheese was observed with a use by date of 12/7/22. The date written on the top of the container was 12/10/22. Additionally, in the walk-in freezer, a box of uncooked bacon strips was open to air. In the walk-in freezer, a box of pizza dough with a use by date of 12/7/22 was observed. […]

• No harm, potential for more than minimal, patternF880Dec 15, 2022

  Based on observation, interview, and record review, it was determined that the facility did not 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. Specifically, staff did not use hand hygiene (HH) during medication pass, a medication was touched with an ungloved hand and placed back in the medication pack for future use, and medication was touched after no HH was used and administered to a resident. Resident identifier: 9 Findings included: 1. On 12/14/22, an observation was made of Licensed Practical Nurse (LPN) 1. LPN 1 did not use HH prior to beginning medication pass. […]

• No harm, potential for more than minimal, isolatedF554Nov 21, 2024

  Based on observation, interview, and record review, the facility did not ensure that the interdisciplinary team had determined that the resident's right to self administer medications was clinically appropriate. Specifically, for 1 out of 37 sampled residents, a resident had a medication stored on the bed side table and the resident had not been evaluated to determine if they were safe to self administer medications. Resident identifier: 108. Findings included: Resident 108 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spinal stenosis lumbar region, type two diabetes mellitus, cognitive communication deficit, anxiety disorder, mood affective disorder, scoliosis, and fall on same level. […]