Inspection Reports for Coral Desert Rehabilitation and Care
1490 East Foremaster Drive, Saint George, UT, 84790
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% better than Utah average
Utah average: 7.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration and drug regimen monitoring in the facility.
Findings
The facility failed to ensure that a resident's right to self-administer medications was clinically evaluated and documented, and did not ensure adequate monitoring of a resident's hypnotic medication use, specifically the documentation of hours of sleep.
Deficiencies (2)
The interdisciplinary team did not determine that resident 108's right to self-administer medications was clinically appropriate; resident had medication stored bedside without evaluation.
Resident 46 was prescribed a hypnotic medication but was not monitored for hours of sleep each night as required.
Report Facts
Residents sampled: 37
Residents affected: 1
Residents affected: 1
Medication dosage: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Interviewed regarding medication self-administration assessment and monitoring |
| Director of Nursing | Director of Nursing | Interviewed regarding policies on self-administration assessment and medication monitoring |
Inspection Report
Routine
Deficiencies: 11
Date: Dec 15, 2022
Visit Reason
The inspection was a routine survey conducted to assess compliance with Medicare and Medicaid requirements, including comprehensive care plans, ADL care, nutrition/hydration, respiratory care, medication management, infection control, and life safety code compliance.
Findings
The facility was found to have multiple deficiencies related to comprehensive care plans, ADL care, nutrition and hydration, respiratory care, medication errors, labeling and storage of drugs, infection control, and life safety code violations. Immediate corrective actions were taken for all cited deficiencies, and plans of correction were submitted.
Deficiencies (11)
Failure to develop and implement comprehensive, person-centered care plans for residents, including measurable objectives and interventions.
Failure to provide necessary assistance with activities of daily living, including feeding assistance for residents who required it.
Failure to maintain acceptable nutritional and hydration status for residents, including timely interventions for weight loss.
Failure to ensure residents fed by enteral means received appropriate treatment and services to restore oral eating skills and prevent complications.
Failure to provide respiratory care consistent with professional standards, including oxygen orders and treatment plans.
Failure to ensure medication error rates were below 5 percent; observed medication errors including expired medications.
Failure to properly label and store drugs and biologicals, including expiration dates and secure storage.
Failure to maintain accurate and accessible resident medical records, including laboratory reports and documentation of care.
Failure to maintain food safety standards, including proper storage and discard of food items past use-by dates.
Failure to maintain infection prevention and control program, including hand hygiene and use of personal protective equipment.
Life safety code violation: use of extension cords and power strips not compliant with NFPA standards.
Report Facts
Sampled residents: 19
Medication error rate: 6.67
Weight loss: 37.5
Weight loss: 20.72
Number of smoke compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Observed medication errors and failure to use hand hygiene during medication pass |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding CNA duties, medication administration, and infection control |
| Registered Nurse (RN) 1 | Registered Nurse | Interviewed regarding medication orders and insulin pen management |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding weight loss interventions and laboratory orders |
| Registered Dietitian (RD) | Registered Dietitian | Interviewed regarding nutrition monitoring and supplementation |
| Licensed Practical Nurse (LPN) 1 | Licensed Practical Nurse | Observed medication administration and expiration date checks |
| Infection Preventionist (IP) | Infection Preventionist | Interviewed regarding infection control practices |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, food safety, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop and implement comprehensive care plans for residents, inadequate assistance with activities of daily living such as feeding, failure to maintain residents' nutritional status, improper management of feeding tubes, lack of physician orders for oxygen therapy, medication errors including administration of expired medications and failure to follow medication parameters, improper labeling and storage of medications, incomplete laboratory records, food safety violations, and lapses in infection prevention and control practices.
Deficiencies (10)
Failed to develop and implement a comprehensive, person-centered care plan including measurable objectives and timeframes for residents requiring feeding assistance and oxygen therapy.
Did not provide necessary one-on-one feeding assistance to a resident unable to feed herself.
Did not ensure residents maintained acceptable nutritional status; a resident experienced significant weight loss without timely interventions.
Feeding tube was not infusing at the prescribed infusion rate and family changed the rate without notifying the facility.
Residents requiring oxygen therapy did not have physician orders for oxygen; oxygen tubing was not labeled or changed as required.
Administered narcotic medication within two hours of an antianxiety medication contrary to physician orders.
Medications were not labeled or stored properly; medication cart was left unlocked and medications were left unattended; expired medications were administered.
Laboratory reports were not filed in residents' medical records and were not readily accessible.
Food items in storage were open to air and some were past use-by dates, violating food safety standards.
Staff failed to use hand hygiene during medication pass; medications were touched with ungloved hands and placed back into medication packs.
Report Facts
Weight loss: 37.5
Medication error rate: 6.67
Medication administration timing: 2
Tube feeding rate: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed not using hand hygiene during medication pass and administering expired medications. |
| CNA 1 | Certified Nurses Assistant | Observed not assisting resident 143 with one-on-one feeding despite orders. |
| Director of Nursing | Director of Nursing | Provided interviews regarding expectations for care, medication administration, and infection control. |
| Assistant Director of Nursing | Assistant Director of Nursing | Provided interviews regarding resident care and laboratory record management. |
| Registered Dietician | Registered Dietician | Provided interview regarding nutritional assessments and supplementation. |
| RN 1 | Registered Nurse | Interviewed about oxygen therapy orders and medication labeling. |
| Infection Preventionist | Infection Preventionist | Interviewed about hand hygiene expectations. |
| Dietary Manager | Dietary Manager | Interviewed about food storage and handling practices. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 6, 2021
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Coral Desert Rehabilitation and Care, summarizing the findings of a survey completed on 2021-05-06.
Findings
No health deficiencies were found during the survey.
Viewing
Loading inspection reports...
