A list of the most recent deficiencies for Coffman Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-26 | 2022-06-10 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-04-26 | 2022-06-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-26 | 2022-06-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-26 | 2022-06-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-04-26 | 2022-06-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-26 | 2022-06-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-26 | 2022-06-10 | N |
| Provide activities to meet all resident's needs. | Health | 2022-04-26 | 2022-06-10 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-26 | 2022-06-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-26 | 2022-06-10 | N |
| 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. | Health | 2022-04-26 | 2022-06-10 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-04-26 | 2022-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-26 | 2022-06-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-04-26 | 2022-06-10 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-04-26 | 2022-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-26 | 2022-06-10 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-26 | 2022-06-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-04-21 | 2022-05-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-21 | 2022-05-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-21 | 2022-05-23 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-04-21 | 2022-05-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-21 | 2022-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-12-10 | 2019-02-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-12-10 | 2019-02-03 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-12-10 | 2019-02-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-12-10 | 2019-02-03 | N |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2018-12-10 | 2019-02-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-12-10 | 2019-02-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-12-10 | 2019-02-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-12-10 | 2019-02-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-12-10 | 2019-02-03 | N |
| 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. | Health | 2018-12-10 | 2019-02-03 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-12-10 | 2019-02-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-12-10 | 2019-02-03 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-12-10 | 2019-02-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-12-10 | 2019-02-03 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2018-12-11 | 2019-01-25 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-11 | 2019-01-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-12-11 | 2018-12-11 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-08-16 | 2017-09-18 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-16 | 2017-09-18 | N |
| Give notice to the resident before a room or roommate change. | Health | 2017-08-16 | 2017-09-18 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-16 | 2017-09-18 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-08-16 | 2017-09-18 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-08-16 | 2017-09-18 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-08-16 | 2017-09-18 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-16 | 2017-09-18 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2017-08-16 | 2017-09-18 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-16 | 2017-09-18 | N |
