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)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Utah average
Utah average: 7.9 deficiencies/year
Deficiencies per year
24
18
12
6
0
Inspection Report
Routine
Deficiencies: 2
Date: Nov 21, 2024
Visit Reason
The inspection was conducted to assess compliance with medication administration and monitoring regulations, including residents' rights to self-administer medications and ensuring drug regimens are free from unnecessary drugs.
Findings
The facility failed to ensure that a resident's right to self-administer medications was clinically evaluated and documented. Additionally, the facility did not adequately monitor a resident's use of a hypnotic medication, as required documentation of sleep hours was missing.
Deficiencies (2)
F 0554: The facility did not ensure the interdisciplinary team determined that a resident's right to self-administer medications was clinically appropriate. One resident had medication stored bedside without evaluation for safe self-administration.
F 0757: The facility did not ensure each resident's drug regimen was free from unnecessary drugs and failed to monitor a resident's sleep hours while taking a hypnotic medication.
Report Facts
Sampled residents: 37
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) 1 | Interviewed regarding medication self-administration and monitoring practices | |
| Director of Nursing (DON) | Interviewed regarding policies on self-administration assessments and medication monitoring |
Inspection Report
Annual Inspection
Deficiencies: 13
Date: Dec 15, 2022
Visit Reason
The annual inspection was conducted to assess compliance with Medicare and Medicaid requirements, including comprehensive care plans, ADL care, nutrition and 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 planning, ADL assistance, nutrition and hydration interventions, respiratory care, medication errors, infection control, and life safety code violations. Immediate corrective actions were implemented and plans of correction were accepted.
Deficiencies (13)
F 656 Comprehensive Care Plan: The facility failed to develop and implement a comprehensive, person-centered care plan for residents requiring one-on-one feeding assistance and oxygen therapy, affecting residents 91, 103, and 143.
F 677 ADL Care for Dependent Residents: The facility did not provide necessary assistance with activities of daily living, including feeding assistance for resident 143.
F 692 Nutrition/Hydration Status Maintenance: The facility failed to ensure timely and appropriate interventions for a resident with significant weight loss, resident 18.
F 693 Tube Feeding Management: The facility failed to ensure enteral feeding was administered at the prescribed infusion rate for resident 17.
F 695 Respiratory/Tracheostomy Care and Suctioning: The facility failed to provide oxygen therapy as ordered for residents 91 and 103.
F 757 Drug Regimen Free from Unnecessary Drugs: The facility failed to ensure residents were free from unnecessary drugs and medication errors, including expired medications for resident 148 and inappropriate narcotic administration for resident 18.
F 759 Free of Medication Error Rates 5 Percent or More: The facility had a medication error rate of 6.67% with two expired medications administered to resident 148.
F 761 Label/Store Drugs and Biologicals: The facility failed to properly store and secure medications, including unlocked medication carts and expired medications for residents 9, 17, 100, and 148.
F 775 Lab Reports in Record: The facility failed to file dated laboratory reports in residents' medical records for residents 97 and 103.
F 812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to maintain food safety standards, including storing food past use-by dates and unsealed food items.
F 842 Resident Records - Identifiable Information: The facility failed to maintain complete, accurate, and accessible medical records, including missing neurological checks and incomplete documentation for resident 97.
F 880 Infection Prevention & Control: The facility failed to maintain an effective infection prevention and control program, including failure to use hand hygiene during medication pass for resident 9.
K 920 Electrical Equipment - Power Cords and Extension Cords: The facility used extension cords improperly in patient care areas, violating NFPA 70 standards.
Report Facts
Medication error rate: 6.67
Weight loss: 37.5
Medication opportunities observed: 30
Residents sampled: 19
Smoke compartments affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurses Assistant | Interviewed regarding feeding assistance and report documentation for resident 143. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding CNA duties, medication administration, and infection control. |
| LPN 1 | Licensed Practical Nurse | Observed medication administration and interviewed regarding medication errors and feeding rate verification. |
| RN 1 | Registered Nurse | Interviewed regarding oxygen orders, medication administration, and resident assessments. |
| ADON | Assistant Director of Nursing | Interviewed regarding weight loss interventions and feeding tube management. |
| RD | Registered Dietician | Interviewed regarding nutrition assessments and weight monitoring. |
| IP | Infection Preventionist | Interviewed regarding infection control practices and hand hygiene compliance. |
Inspection Report
Annual Inspection
Deficiencies: 11
Date: Dec 15, 2022
Visit Reason
Annual inspection survey conducted to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including care planning, feeding assistance, respiratory care, medication management, infection control, laboratory record keeping, and food safety. Several residents did not receive care consistent with their needs and physician orders, and medication errors and expired medications were identified.
Deficiencies (11)
F 0656: The facility failed to develop and implement comprehensive care plans with measurable objectives for residents, including oxygen use and feeding assistance for 3 of 19 sampled residents.
F 0677: The facility did not provide one-on-one feeding assistance to a resident who required it, resulting in inadequate support during meals.
F 0692: The facility did not ensure timely and appropriate interventions for a resident experiencing significant weight loss over 76 days.
F 0693: A resident's tube feeding was not infusing at the prescribed rate, and staff failed to properly monitor and document feeding rates.
F 0695: Residents requiring oxygen therapy did not have physician orders for oxygen, and oxygen tubing was not changed or labeled as required.
F 0757: The facility administered narcotics within two hours of antianxiety medication, violating prescribed medication parameters.
F 0761: Medications and biologicals were not properly labeled, stored securely, or dated, including expired medications and insulin pens without dates.
F 0761: Medication carts were left unlocked and medications were left unattended, increasing risk of medication errors or misuse.
F 0775: Laboratory reports were not consistently filed in residents' medical records and were not readily accessible for review.
F 0812: Food items in storage and refrigeration were open to air and some were past use-by dates, compromising food safety standards.
F 0880: Staff failed to maintain infection prevention and control practices, including inadequate hand hygiene during medication administration and improper handling of medications.
Report Facts
Medication error rate: 6.67
Weight loss: 37.5
Medication administration timing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 1 | Licensed Practical Nurse | Observed medication administration errors, improper hand hygiene, and handling of expired medications |
| DON | Director of Nursing | Provided interviews regarding care expectations, medication administration, and infection control |
| ADON | Assistant Director of Nursing | Provided interviews regarding laboratory results management and resident care |
| RN 1 | Registered Nurse | Interviewed about oxygen orders and medication storage |
| CNA 1 | Certified Nurses Assistant | Interviewed regarding feeding assistance and resident care |
| RD | Registered Dietician | Interviewed about nutritional assessments and supplementation |
| DM | Dietary Manager | Interviewed about food storage and handling practices |
| IP | Infection Preventionist | Interviewed about hand hygiene expectations |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 6, 2021
Visit Reason
Annual inspection of Coral Desert Rehabilitation and Care facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
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