cms_AL
Data source: Big Local News · About: big-local-datasette
8,867 rows
This data as json, copyable, CSV (advanced)
Suggested facets: inspection_date (date), filedate (date)
| Link | rowid ▼ | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 1 | BURNS NURSING HOME, INC. | 15009 | 701 MONROE STREET NW | RUSSELLVILLE | AL | 35653 | 2018-08-01 | 880 | D | 0 | 1 | XRXN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of a facility policy titled Infection Prevention and Control Program/Plan, the facility failed to ensure a Certified Nursing Assistant (CNA) performed hand hygiene between removing a pair of soiled gloves and re-gloving during incontinence care. This affected Resident Identifier (RI) #12, one of one resident observed during incontinence care. Findings include: RI #12 was readmitted to the facility on [DATE]. Review of RI #12's quarterly Minimum Data Set assessment, with an Assessment Reference Date of 7/02/18, revealed RI #12 had severely impaired cognition and required extensive assistance of one person for toileting and personal hygiene needs. RI #12 was always incontinent of both bowel and bladder. A facility policy titled, Infection Prevention and Control Program/Plan, revised (MONTH) (YEAR), revealed: Policy: It is the policy of this facility to establish and 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. Policy Explanation and Compliance Guidelines: . 4. Hand Hygiene Protocol: a. All staff shall wash their hands . after PPE (personal protective equipment) removal . Incontinence care for RI #12 was observed on 07/31/18 at 04:17 PM. Incontinence care was performed by Employee Identifier (EI)#3 and EI#4, both CNAs. During the care, while cleaning RI#12's bottom, EI#3 had stool on her glove. EI#3 removed the soiled glove and put on a new pair without doing hand hygiene. When EI#3 was finished wiping RI #12, she changed gloves again and did not do hand hygiene. An interview conducted with EI#3 on 07/31/18 at 04:35 PM. EI#3 was asked what should be done between removing soiled gloves and putting on a new pair. EI#3 replied, use germ x (sanitizer). EI#3 was asked if she did that every time she changed her gloved during t… | 2020-09-01 |
| 2 | 2 | BURNS NURSING HOME, INC. | 15009 | 701 MONROE STREET NW | RUSSELLVILLE | AL | 35653 | 2019-08-21 | 554 | D | 0 | 1 | HHU111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review and review of facility policies titled, MEDICATION ADMINISTRATION BY MOUTH and Self-Administration of Medication, the facility failed to ensure a licensed nurse remained with Resident Identifier (RI) #32, who had not been assessed for self-administration of medication, during the administration of [MEDICATION NAME] during medication pass observation on 08/21/19. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of a facility policy titled, MEDICATION ADMINISTRATION BY MOUTH, with a REVISED DATE: 09/18/2014, documented: .9. The nurse will remain with resident/patient until medications are taken. A review of a facility policy titled, Self-Administration of Medication, with Date Implemented: (MONTH) (YEAR), revealed: .1.an assessment is conducted by the interdisciplinary team and results of the assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. 2. As part of the interdisciplinary team, a physician order [REDACTED]. The care plan must reflect resident self-administration and storage arrangements for such medications. RI #32 was admitted to the facility on [DATE]. A review of RI #32's medical record revealed no order for self-administration of any medications, no self-administration assessment form and no care plan for self-administration of medication. On 08/21/19 at 7:56 a.m., during medication pass observation, the surveyor observed Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), mix RI #32's [MEDICATION NAME] in four ounces of water in a plastic cup and deliver it RI #32's bedside, along with other medications. EI #1 administered all medications except [MEDICATION NAME]. Surveyor observed EI #1 instruct RI #32 to drink his [MEDICATION NAME]. EI #1 then left RI #32's bedside and entered the bathroom to wash her hand… | 2020-09-01 |
| 3 | 3 | BURNS NURSING HOME, INC. | 15009 | 701 MONROE STREET NW | RUSSELLVILLE | AL | 35653 | 2019-08-21 | 880 | D | 0 | 1 | HHU111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, medical record review and review of Potter and Perry, Fundamentals of Nursing, Ninth Edition, the facility failed to ensure a licensed nurse: 1. cleaned Resident Identifier (RI) #32's nasal spray prior to recapping, 2. removed gloves and washed hands and applied clean gloves after administering RI #32's inhaler prior to administering his/her nasal spray, 3. cleaned RI #32's inhaler prior to recapping, 4. cleaned RI #32's [MEDICATION NAME] syringe prior to placing it back in a plastic sleeve, and 5. cleaned and dried RI #32's nebulizer mask and reservoir prior to storing it in a plastic bag. This affected RI #32, one of four residents observed during medication pass observation and one of two nurses observed. Findings Included: A review of of Potter and Perry, Fundamentals of Nursing, Ninth Edition, Chapter 29, Infection Prevention and Control, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .When an object comes in contact with an infectious or potentially infectious material, it is contaminated .Reusable objects need to be cleaned thoroughly before reuse . RI #32 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 08/21/19 at 7:56 a.m., during medication pass observation, Employee Identifier (EI) #1, Licensed Practical Nurse (LPN), was observed administering RI #32's inhaler while wearing gloves. She then proceeded to administer RI #32's nasal spray while wearing those same gloves. EI #1 also recapped RI #32's nasal spray and inhaler without wiping or rinsing them off and returned a syringe used to administer RI #32's sublingual [MEDICATION NAME] back into a plastic sleeve without rinsing it prior to storing it in the medication cart. EI #1 was then observed returning RI #32's nebulizer mask and tubing back into a plastic bag without emptying the residue, rinsing and drying the reservoir. On 08/21/19 at 1:31 p.m., an interview was cond… | 2020-09-01 |
| 4 | 4 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 241 | D | 0 | 1 | 0F3P11 | Based on observations, interviews and review of a facility policy titled Promoting /Maintaining Resident Dignity, the facility failed to ensure staff knocked on residents' doors prior to entering the residents room. This was observed on three of four days of the survey, affected Room Locator (RL) #1, RL #2, RL #3, RL #4, RI #5 and affected two of three units in the facility. Findings Include: A review of a facility policy titled Promoting /Maintaining Resident Dignity, with a revision date of 8/15/15 documented the following: POLICY: It is the practice of this facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect. Compliance Guidelines: .11. Respect the resident's living space, personal possessions. Knock on door prior to entering room . On 4/3/17 at 7:00 p.m., the surveyor observed Employee Identifier (EI) #10 walk into RL #1, then walk into RL #2, and then walk into RL #3 without knocking. On 4/4/17 at 12:05 p.m., the surveyor observed EI #11 walk into RL #4 without knocking. On 4/5/2017 at 11:05 a.m., the surveyor was conducting a resident interview with EI #5 and observed a staff member enter RL #5 without knocking. On 4/6/17 at 2:10 p.m., an interview was conducted with EI #11, a Registered Nurse (RN). EI #11 was asked if she remembered entering RL #4 without knocking. EI #11 replied, yes. EI #11 was asked how was she trained to enter a resident's room. EI #11 replied, to knock first. EI #11 was asked what was the facility's policy on entering a residents room. EI #11 replied, to knock first. On 4/6/17 at 3:15 p.m., an interview was conducted with EI #10, a Certified Nursing Assistant (CNA). EI #10 was asked how she was trained as a CNA to enter a resident's room. EI #10 replied, to knock then wait for them to give permission to come in. EI #10 was asked what was the facility's policy on how to enter a resident's room. EI #10 replied, to knock and wait for permission to come in. The surveyor asked EI #10 what type of issue was … | 2020-09-01 |
| 5 | 5 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 253 | D | 0 | 1 | 0F3P11 | Based on observations, interview and review of a facility document titled Cart List, the facility failed to ensure a plaster like substance was not hanging from the dining room ceiling on three of four days of the survey. This had the potential to affect 13 of 74 residents who eat meals in the dining room. Findings Include: On 4/4/17 at 8:07 a.m., and 12:35 p.m., the surveyor observed a plaster like substance hanging from the ceiling in the dining room. At 12:35 p.m., the surveyor observed a resident sitting under the ceiling where the plaster was hanging. On 4/5/17 at 4:00 p.m., the surveyor observed the plaster continued to hang from the ceiling. On 4/6/17 at 2:00 p.m., an interview was conducted with EI (Employee Identifier)#7, a maintenance staff member. EI #7 was asked what was hanging from the ceiling in the dining room. EI #7 replied, plaster ceiling flaking. EI #7 was asked why was it hanging. EI #7 replied, moisture being absorbed into the plaster. EI #7 was asked what was the facility's policy on the up keep of the ceiling. EI #7 replied, remove flakes of plaster and patch it. EI #7 was asked when were rounds last made on observing the ceiling. EI #7 replied, daily and a couple times a day. EI #7 was asked what was the potential harm when there was plaster hanging from the ceiling and a resident was sitting under the hanging plaster. EI #7 replied, worst harm would be plaster falling into the food. | 2020-09-01 |
| 6 | 6 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 278 | D | 0 | 1 | 0F3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure: 1) Resident Identifier (RI) #2's height was coded on RI #2's 2/25/16, Initial Minimum Data Set (MDS) assessment, 2) RI #4's height and [MEDICAL TREATMENT] status was coded on RI #4's 7/22/16, Significant Change MDS assessment, and 3) RI #5's catheter was coded on RI #5's 10/21/16, Annual MDS assessment. These deficient practices affected RI # 2, RI #4 and RI #5, three of 15 residents whose MDS assessments were reviewed. Findings Include: 1) RI #2 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #2's Admission Assessment, dated 2/15/16, revealed RI #2 had an admission height of 64 inches. A review of RI #2's Initial MDS assessment with an Assessment Reference Date (ARD) of 2/25/16, revealed RI #2's height was not captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with EI (Employee Identifier) #8, the MDS Coordinator. The surveyor asked EI #8 should there be a weight and height on the MDS. EI #8 replied, Yes. That is asked on all of them. The surveyor asked EI #8 was RI #2's height coded on RI #2's Admission MDS assessment dated [DATE]. EI #8 said RI #2's height was not on the MDS. EI #8 said the area had 0's and she did not know why. The surveyor asked EI #8 should RI #2's height be on the MDS. EI #8 replied, Yes Ma'am. The surveyor asked EI #8 was RI #2's 2/25/16 MDS assessment an accurate assessment. EI #8 said no, it would not be accurate without the height being on it. 2) RI #4 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #4's [MEDICAL TREATMENT]/[MEDICAL CONDITION] care plan, no date, revealed RI #4 started [MEDICAL TREATMENT] 8/2014. A review of RI #4's Significant Change MDS assessment with an ARD of 7/22/16, revealed RI #4's height nor [MEDICAL TREATMENT] status was captured during this assessment period. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview wit… | 2020-09-01 |
| 7 | 7 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 279 | D | 0 | 1 | 0F3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, the facility failed to ensure care plans were developed for Oxygen usage for Resident Identifier (RI) #9 and RI #17. This affected two of 15 sampled residents whose plans of care were reviewed. Findings Include: 1) Resident Identifier (RI) #9 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/5/17 revealed under Section O: Special Treatments, Procedures, and Programs for Respiratory Treatment, RI #9 was using Oxygen during this assessment period. A review of RI #9's (MONTH) physician's orders [REDACTED]. . O2 (oxygen) @ (at) 4L(liter)/min (minute) via (by way of) NC (nasal cannula) A review of RI #9's care plans revealed that RI #9 did not have an Oxygen care plan. On 4/6/17 at 1:49 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, the MDS Coordinator. The surveyor asked EI #8 was RI #9 using Oxygen. EI #8 said she thought RI #9 was put on Oxygen. The surveyor asked EI #8 if RI #9 had a care plan for the Oxygen usage. EI #8 replied, No Ma'am. The surveyor asked EI #8 should RI #9 have a care plan for the Oxygen usage. EI #8 replied, yes. 2) RI #17 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly MDS assessment with an ARD of 2/9/17, revealed RI #17 was receiving Oxygen during this assessment period. On 4/3/17 at 5:22 p.m., during the initial tour of the facility, RI #17 was observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/4/17 at 4:41 p.m., RI #17 was again observed with the Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/5/17 at 2:42 p.m., RI #17's Oxygen remained at 2 Liters per minute by way of a nasal cannula/Concentrator. On 4/6/17 at 8:22 a.m., RI #17 was again observed with Oxygen on at 2 Liters per minute by way of a nasal cannula/Concentrato… | 2020-09-01 |
| 8 | 8 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 281 | D | 0 | 1 | 0F3P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of Potter and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a licensed nurse, Employee Identifier (EI) #9, did not crush Resident Identifier (RI) #16's 9:00 a.m. medications together on 4/22/16. This deficient practice affected RI #16, one of two residents observed for Gastrostomy tube medication administration, and EI #9, one of three medication nurses observed during the medication pass. The facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, dated 4/3/2017, documented nine residents in the facility with tube feedings. Findings Include: A review of Potter and Perry's FUNDAMENTALS OF NURSING, Ninth Edition, with a copyright date of (YEAR), page 636, Unit V, Foundations for Nursing Practice documented: . 16. b. Do not mix medications together; administer each separately . RI #16 was originally admitted to the facility on [DATE]. The most recent Quarterly Minimum Data Set assessment with an Assessment Reference Date of 2/1/17, assessed RI #16 as having short and long term memory problems with severely impaired cognitive skills for daily decision making. This assessment also indicated RI #16 had a feeding tube during the assessment period. RI #16's (MONTH) (YEAR) physician's orders [REDACTED].#16's PEG (percutaneous gastrostomy) tube at 9:00 a.m. daily. On 4/4/17 at 8:50 a.m., the surveyor observed EI #9 crush all of the above medications together and poured the crushed medications into a medication cup. EI #9 poured 10 cc's (cubic centimeters) of water into RI #16's syringe then poured the crushed medications into the syringe. On 4/6/17 at 1:23 p.m., the surveyor conducted an interview with EI #9. The surveyor read back the observation of the medication pass done for RI #16 on 4/3/17, and asked EI #9 how should crushed medications be prepared. EI #9 replied, Separately. The surveyor asked EI #9 why did she crush RI #16's medications together. EI #9 said it wa… | 2020-09-01 |
| 9 | 9 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 356 | C | 0 | 1 | 0F3P11 | Based on observations, interview and review of a facility policy titled Nursing Staff Posting Sheet, the facility failed to ensure the daily staffing form for the nursing home was documented with the hours worked on the form for four of four days of the survey. This had the potential to affect all 74 residents who reside in the facility. Findings Include: A review of a facility policy titled Nursing Staff Posting Sheet with a revision date of 6/27/2016 revealed the following: POLICY: . Policy Explanation and Compliance Guidelines: 1. The nursing staffing information will contain the following information: . d. The total number and actual hours worked by the following staff: . 2. The facility will post the nurse staffing total number at the beginning of each shift . On 4/3/17 at 4:55 p.m., the staffing form for the nursing home was observed for the day and the evening shift and did not have the hours worked documented on the form. On 4/4/17 at 8:00 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/4/17 at 4:30 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/5/17 at 8:40 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/5/17 at 3:25 p.m., the staffing form for the nursing home was observed for the evening shift and did not have the hours worked documented on the form. On 4/6/17 at 8:20 a.m., the staffing form for the nursing home was observed for the day shift and did not have the hours worked documented on the form. On 4/6/17 an interview was conducted with Employee Identifier (EI) #1, Clinical Coordinator. EI #1 was asked who was responsible for filling out the daily staffing form. EI #1 replied, she was responsible to fill it out during the week. EI #1 was asked if she filled out the form for all four days of the survey. EI #1 replied, yes. EI … | 2020-09-01 |
| 10 | 10 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2017-04-06 | 371 | F | 0 | 1 | 0F3P11 | Based on record reviews, observations, interviews and a review of facility policies titled Food And Supply Storage Procedures, Cleaning and Sanitizing Flatware, Trayline/Taste/Temperature Record, Product Labeling and Dating, and review of a document titled 'Menu Week, the facility failed to ensure: 1. chicken wings, beef burgers and fish patties were sealed in a box in the freezer, 2. chocolate icing in a container in dry storage was sealed, 3. dented cans were not stored with regular cans, 4. a mighty shake in the cooler had not expired, 5. utensils in a canister were not wet and the staff did not wrap the utensil while wet, 6. milk temperatures were taken and recorded on the temperature guide sheet, 7. a jar of jelly was labeled with an open and use by date and stored in the refrigerator, and 8. pimentos in the refrigerator were labeled with an open and use by date. Finding Include 1) A review of a facility policy titled Food and Supply Storage Procedures with a reviewed date of 7/16/16 revealed: POLICY: . Frozen Storage .Wrap food tightly to prevent freezer burn . On 4/3/17 at 4:55 p.m., the surveyor along with the Dietician, Employee Identifier (EI) #3, toured the freezer. The surveyor observed a box of beef burgers, fish patties and chicken wings opened in a box. The plastic in each box was opened and not sealed. On 4/6/17 at 10:00 a.m., the surveyor conducted an interview with EI #3. EI #3 was asked what food items were in the freezer in a box and not sealed. EI #3 replied, chicken wing pieces, fried chicken patties and fish patties. EI #3 was asked who was responsible for making sure food items were sealed after use. EI #3 replied, the staff and maybe the dietary coordinator's job was to go back and check. EI #3 was asked when should food items be sealed. EI #3 replied, soon as possible. EI #3 was asked why were the food items left opened. EI #3 replied, they had a catering job and someone just threw it in there. EI #3 was asked what was the facility's policy on leaving food items opened in the freezer. EI… | 2020-09-01 |
| 11 | 11 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2018-06-07 | 656 | D | 0 | 1 | FTJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure an individualized care plan was developed to address Resident Identifier (RI) #12's use of side rails. This affected one of 16 sampled residents for whom care plans were reviewed. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #4, the Minimum Data Set/ Care Plan Coordinator, was interviewed on 6/07/18 at 4:18 PM. EI #4 said the purpose of a resident's care plans was to ensure you know everything the resident needs, including all care needs. She explained the approaches should reflect the personal choices, likes, dislikes, diagnoses, and care areas for each resident. EI #4 said all care plans should be patient centered. When asked if RI #12's care plans were individualized for the use of side rails, EI #4 said, no not for… | 2020-09-01 |
| 12 | 12 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2018-06-07 | 700 | E | 0 | 1 | FTJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure Resident Identifier (RI) #12 was assessed to determine the need for side rails and the risk of entrapment prior to utilizing two upper side rails. Further the facility failed to obtain informed consent prior to applying side rails for RI #12. This affected RI #12 one of one resident sampled for siderail use but had the potential to affect 28 of 64 total residents in the facility identified by staff as using side rails. Findings include: RI #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #12's Quarterly Minimum Data Set Assessment, with an Assessment Reference Date of 03/22/2018, indicated RI #12 had short and long term memory impairment and severely impaired cognitive skills for daily decision making. This assessment also documented RI #12 as totally dependent on staff for bed mobility and transfers. RI #12's comprehensive care plans included a care plan for Falls, with a modify date of 01/11/2018. This care plan included an intervention for . 2. SIDE RAILS RAISED x (times) . The care plan did not specify the number or size of siderails to be used. On 6/6/18 at 9:30 AM RI #12 was observed in bed with 1/4 (quarter) side rails up times two. Employee Idenifiter (EI) #3, Registered Nurse (RN), was interviewed on 6/07/18 at 3:43 PM. When asked what purpose RI #12's side rails served, EI #3 said they were for safety. When asked which siderails should be used, EI #3 said the top ones, but was unsure what size rails should be used. EI #3 said the care plan should reflect the size of siderails and which ones to use, but after reviewing RI #12's care plans, said they did not reflect that. EI #3 also confirmed RI #12 was not able to use the side rails. When asked if she could provide evidence the resident was assessed to determine the risk of entrapment, EI #3 said she could provide a fall risk assessment, but it did not address entrapment, only confusion and falls. When asked if residents should be… | 2020-09-01 |
| 13 | 13 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2018-06-07 | 812 | F | 0 | 1 | FTJ211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of the facility policy titled . SUBJECT: Food and Supply Storage Procedures and review of the (YEAR) Food Code, the facility failed to ensure: 1.) a dented can of pineapple chunks was removed from stock rotation; 2.) Glucerna TF was not stored past the manufacturer's use by date; and 3.) raw chicken was not stored directly over coed/prepared pork tenderloins. These failures had the potential to affect all 60 residents receiving meals from the dietary department. Findings include: Review of the undated facility policy titled . SUBJECT: Food and Supply Storage Procedures revealed the following: . POLICY: Dry Storage * . Remove Dented Cans and place in dented can area for credit and discard. * Remove from storage any items for which the expiration date has expired. * . Store cooked meat above raw meat. On [DATE] at 8:38 AM a can of pineapple chunks was observed on a shelf in the dry storage area in rotation for use. The can had a large dent on the bottom, side of can. The dry storage area also had two cases of expired tube feeding formula (Glucerna 1.2 Cal). The cases had a manufacturer's use by date of [DATE]. On [DATE] at 8:49 AM a rack containing trays of cooked pork tenderloins and raw chicken was observed in the walk-in cooler. The rack had a plastic tray with cooked pork tenderloins, and on each of the three shelves above the cooked pork were sheet pan of raw chicken breasts with blood-colored juices on the pans. Employee Identifier (EI) #1, Dietary staff, confirmed the raw chicken was stored over top of the cooked pork and said raw items should not be stored over cooked items because it could cause contamination.- EI #2, the Dietitian, was interviewed on [DATE] at 8:29 AM. EI #2 said it was important to ensure canned food items did not have dents because of the possibility of the seal being compromised. EI #2 also stated items should be checked on an ongoing basis for use by dates. EI #2 said t… | 2020-09-01 |
| 14 | 14 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2018-06-07 | 880 | D | 0 | 1 | FTJ211 | Based on observations, interviews and review of a facility policy titled, Gloving, the facility failed to ensure a licensed staff member wore gloves when administering a subcutaneous injection to Resident Identifier (RI) #7 on 6/06/2018. This affected one of three residents observed for subcutaneous injections during medication administration observations. Findings include: Review of a facility policy titled: Gloving, with an effective date of 8/2005 revealed: . I. Indications [NAME] To reduce the possibility that personnel will become infected with microorganisms, to reduce the likelihood that personnel will transmit their own endogenous microbial flora to resident . II. [NAME] All employees who come in direct contact with blood or body fluids are to wear gloves . B. Gloves should be worn for any procedure requiring aseptic technique. On 6/06/18 at 4:32 PM, Employee Identifier (EI) #6, Licensed Practical Nurse (LPN), was observed administering a subcutaneous injection to RI #7. EI #6 did not wear any gloves for the administration of the injection. EI #6 was interviewed on 6/07/18 at 3:39 PM. When asked what the facility's policy indicated about when gloves should be worn, EI #6 was unsure; however, after reviewing the policy, EI #6 said gloves should be worn anytime a procedure requires aseptic technique. EI #6 said gloves should be worn when administering a subcutaneous injection to prevent cross contamination. | 2020-09-01 |
| 15 | 15 | COOSA VALLEY HEALTHCARE CENTER | 15010 | 260 WEST WALNUT STREET | SYLACAUGA | AL | 35150 | 2019-06-13 | 880 | D | 0 | 1 | DC4511 | Based on observations, interviews, and review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, the facility failed to ensure: 1) a licensed nurse did not place Resident Identifier (RI) #53's medication on the over bed table, then into her pocket, prior to placing the medication back into the medication cart; and 2) a licensed nurse washed her hands prior to preparing RI #31's medications. These failures affected RI #s 31 and 53, two of five residents, and two of four nurses, observed during medication administration observations. Findings Include: 1) On 6/12/19 at 4:34 p.m., during medication administration observations, Employee Identifier (EI) #3, a Licensed Practical Nurse, removed medication (eye drops) from the medication cart, placed the medication on RI #53's overbed table, then stored the medication in her pocket while administering other medications. EI #3 then returned to the medication cart and placed the eye drops back inside. A phone interview was conducted on 6/13/19 at 11:42 a.m. with EI #3. EI #3 was asked, what should be done before laying medication and supplies on the resident's overbed table. EI #3 stated, Usually it's cleaned off and I put a paper towel there. EI #3 was asked, did you do that yesterday. EI #3 stated, No ma'am. EI #3 was asked, after administering RI #53's eye drops, what did she do with them. EI # 3 stated, I put them in my pocket, then returned them to the med (medication) cart. EI #3 said she was not supposed to store things in her pocket because it could become contaminated. 2) A review of the facility's policy titled, PREPARATION AND GENERAL GUIDELINES, effective (MONTH) (YEAR), revealed: . MEDICATION ADMINISTRATION-GENERAL GUIDELINES Procedures . [NAME] Preparation . 2) Handwashing and Hand Sanitation : The person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: * before beginning a medication pass * prior to handling any medication . On 6/13/19 at 8:23 a.m., EI #4, a Licensed Practical Nurse, left the m… | 2020-09-01 |
| 16 | 16 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2017-03-16 | 315 | D | 0 | 1 | WKAI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and a review of a facility policy titled: Hand Hygiene and Incontinent/Perineal Care, the facility failed to ensure incontinent care was provided for RI (Resident Indentifer) #4, a resident with a current Urinary Tract Infection in a manner to prevent cross contamination. On 03/15/17, Employee Identifier (EI) #3/staff Certified Nursing Assistant (CNA), failed to remove soiled gloves and wash her hands when providing incontinent care for RI #4. The CNA repeatedly touched the resident's bottle of peri-wash, the barrier skim cream, the privacy curtain and the residents clean brief while wearing soiled gloves. This affected RI #4, one of one sampled residents observed for incontinent care. Findings Include: A facility policy titled: Hand Hygiene . with an Effective Date: 5/15/2008 .3. Perform hand hygiene: a. before and after having direct contact with patients . A facility policy titled: INCONTINENT/PERINEAL CARE . with a revised date of 2-2016 . PURPOSE: To maintain cleanliness, promote comfort, prevent infection . RI #4 was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. RI #4's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/16/17, documented RI #4 as incontinent for bowel and bladder. A facility document titled: .URINALYSIS . with a date of 03/03/17 documented . PROTEIN 2+ H (HIGH) . BLOOD 2+ H . RBC (Red Blood Cells) 11-20 H .WBC ([NAME] Blood Cells) 20-50 H BACTERIA 4+ H . [MEDICATION NAME] DS (Double Strength) one PO (by mouth) BID (twice a day) x (times) 7. Culture. A document titled: MICROBIOLOGY . with a date of 03/06/17 . Urine Culture Final Organism 1. ESCHERICHIA COLI ESBL COLONY COUNT >100,000 colonies/ml (milliters). During an observation of incontinent care for RI #4 on 03/15/17, at 4:25 p.m., EI #3 CNA was observed repeatedly touching RI #4's bottle of peri-wash with the same gloves used to provide the incontinent care. EI #3 failed to remove the s… | 2020-09-01 |
| 17 | 17 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2017-03-16 | 363 | E | 0 | 1 | WKAI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a facility document titled MENU w (with)/DIETS the facility failed to ensure 1/2 cup of the roasted vegetables were served at lunch on 3/15/17, as indicated on the lunch menu. This affected Resident Indentifer (RI) #8, one of eight sampled residents whose meals were observed on 3/15/17 and had the potential to effect 40 of 50 residents receiving meals from the kitchen. Findings Include: Resident Identifier (RI) #8 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility document titled MENU w/DIETS for 3/15/17 documented .noon day 18 .ALTERNATE . REGULAR .1/2 c (cup) Roasted Vegetables .MECHANICAL SOFT .Roasted Vegetables . On 3-15-17 at 11:45 a.m., the surveyor observed kitchen staff plating food. When plating the roasted vegetables the staff used kitchen tongs to serve the Roasted Vegetables. On 3-15-17 at 12:11 p.m., during the lunch meal, RI # 8's was served roasted vegetables. On 3-15-17 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 8. EI # 8 was asked about the roasted vegetables being served with tongs during lunch on 3-15-17 when the menu called for 1/2 cup. EI #8 replied the staff should have used a scoop or ladle and it couldn't be measured accurately using tongs. | 2020-09-01 |
| 18 | 18 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2017-03-16 | 371 | F | 0 | 1 | WKAI11 | Based on observation, interview and facility policies titled PRODUCTION, PURCHASING, STORAGE, KITCHEN HOOD CLEANING AND MECHANICAL AREA, ROOF AND GROUNDS the facility failed to ensure the following: 1. Boiled eggs were not stored in the refrigerator past the 3 day, use by date. 2. A pan of Jello was not stored past the use by date of 3-12-17. 3. Jello, oranges and pudding were not observed uncovered and undated in the refrigerator. 4. Meat balls, sloppy Joe meat and Corn on the Cobb were not stored in the freezer past the use by date. 5. Roast Beef was not stored in the freezer without a use by date. 6. Diced tomatoes, Swiss cheese and Pepper Jack cheese were not stored in the refrigerator past the use by date. 7. A pipe above the stove was free of a dust like substance. 8. A portion of the ceiling in the kitchen was free of a dark drown substance. This was observed during the initial tour of the facility on 3-14-17 and 3-15-17 and affected 49 of 49 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled PRODUCTION, PURCHASING, STORAGE with a revised date of 1/16, documented the following: POLICIES: All food, non-food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption . PR[NAME]EDURES; .The words .Use-by should precede the date .foods past the use-by . date should be discarded .Cover, label and date unused portions and open packages .Frozen STORAGE .Food stored frozen should be kept no longer than 3 months for quality purposes .Discard food past the use-by or expiration date . A review of a policy titled KITCHEN HOOD CLEANING effective 1/1/99 documented the following: .Kitchen Hood Cleaning .A licensed service contractor will clean as necessary the kitchen hood system every six (6) months . A review of a facility document check titled MECHANICAL AREA, ROOF AND GROUNDS .CHECKLIST documented the following: .Check the roof monthly, Report any prob… | 2020-09-01 |
| 19 | 19 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2017-03-16 | 425 | E | 0 | 1 | WKAI11 | Based on a review of a facility documents titled: MEDICATION DESTRUCTION RECORD. and interviews the facility failed to ensure there were three signatures for the drug destruction of Narcotics. This affected six of 12 drug destruction documents reviewed to include March, (YEAR), April, (YEAR) and (MONTH) (YEAR). Findings Include: On 03/16/17, at 8:50 p.m. during a review of facility documents titled: MEDICATION DESTRUCTION RECORD . CONTROLLED SUBSTANCES the surveyor observed 2 signatures for 2 documents dated 03/16/16, 2 documents for (MONTH) (YEAR), one with one signature, and 2 documents dated 01/16/17, with 2 signatures. An interview was conducted on 03/16/17, at 11:00 a.m. with Employee Identifier (EI) #1 Pharmacy Consultant. EI #1 was asked to review the 6 documents for the drug destruction for Narcotics and tell the surveyor how many signatures he observed for the destruction by flushing of Narcotics. EI #1 replied, 5 of the sheets dated 01/16/17 had 2 signatures, (MONTH) (YEAR) had one document with 2 signatures and another with only one signature and 2 documents for (MONTH) (YEAR) had only 2 signatures. EI #1 was asked how many signatures should be on each of the documents. EI #1 replied, 3 signatures. He was asked why there were 2 instead of 3. EI #1 stated, I don't know why. EI #1 was asked what the potential for harm was if 3 people were not present and destroyed Narcotics. He replied, it could be a potential for someone not destroying the medications. Drug diversion possibility. A second interview was conducted on 03/16/17, at 11:15 a.m. with EI #2 Registered Nurse. She was asked to review the 6 documents for the destruction of the Narcotics and tell the surveyor how many signatures she observed. EI #2 replied, 2 documents for (MONTH) 16, (YEAR) had 2 signatures, 2 documents for (MONTH) (YEAR) one included 2 signatures and one document had one signature and 2 documents for (MONTH) (YEAR) had 2 signatures. EI #2 was asked how many signatures should be on the destruction of Narcotics. She stated, 3 Signa… | 2020-09-01 |
| 20 | 20 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2017-03-16 | 441 | E | 0 | 1 | WKAI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and a review of facility policy's titled: Laundry, Hand Hygiene, and Cleaning of Glucose Meter, the facility failed to ensure the following: 1) Clothing items were free of a brown substance after being washed with other resident clothing items. This affected 19 residents receiving laundry services through the facility. 2) Employee Identifier (EI) #3 Certified Nursing Assistant (CNA) removed her soiled gloves and washed her hands while providing incontinent care for Resident Identifier (RI) #4. 3) EI #7 Licensed Practical Nurse (LPN) cleaned the glucometer after checking RI #9's blood sugar. This affected one of one observation of a finger stick during the medication pass on 03/15/17. Findings Include: 1) A review of a facility policy titled, Laundry with a revised date of 05/2011 revealed the following: .Policy: Laundry will be handled in a safe manner .Procedure: .7. The department responsible for ensuring the proper handling . or cleaning of all laundry is Environmental Services. On 03/15/2017 at 9:05 a.m., an observation was made of wet/damp clothing items in a barrel with a pair of black sweat pants with a brown substance. EI #4, Environmental Service Supervisor was asked to observe the clothing item. EI #4 was asked what did the substance look like. EI #4 replied, feces. EI #4 was asked were the clothing inside of the barrel with the black sweat pants already washed. EI #4 replied yes ma'am. EI #4 was asked how were items with visible soiled areas such as feces to be handled in the laundry. EI #4 explained if laundry staff washed items with visible feces they would separate them from other resident clothing items. EI #4 was asked why should visibly soiled clothing items with feces be washed separately from other resident clothing items. EI #4 replied because it would contaminate the rest of the laundry. EI #4 was asked what was the potential harm in washing clothing items with visible substance such as fec… | 2020-09-01 |
| 21 | 21 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2018-05-03 | 550 | D | 0 | 1 | VXOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review and review of a facility policy titled, Care of Urinary Catheter, the facility failed to ensure Resident Identifier (RI) #29's Foley catheter bag was in a privacy bag and not visible from the hallway on 05/02/18. This deficient practice affected RI #29, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Care of Urinary Catheter, with an effective date of 12/09/04, and a revision date of 1/12, documented: . PR[NAME]EDURE: . 10. Assure the drainage bag is placed in a privacy bag. RI #29 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. RI #29's Foley catheter care plan, with a problem onset date of 03/10/10, documented the following approach: . * privacy bag . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/09/18, assessed RI #29 as having an indwelling catheter. RI #29's (MONTH) (YEAR) Physician order [REDACTED].> . 16 french 10 cc (cubic centimeter) foley catheter to dependent drainage. Dx. (diagnoses) [MEDICAL CONDITION] bladder s/t (secondary to) spinal cord injury . Privacy bag . On 05/01/18 at 4:15 p.m., RI #29's Foley urinary catheter bag was observed uncovered, attached to the left bed rail, and was visible from the hallway. On 05/01/18 at 5:44 p.m., RI #29's Foley urinary catheter bag remained uncovered and visible to anyone walking past RI #29's room. At this time, the surveyor conducted an interview with Employee Identifier (EI) #3, RI #29's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #3 how should a resident's Foley catheter be when the resident was in bed. EI #3 said the Foley catheter should be attached to the bed frame. When asked should the Foley catheter bag be visible to any one walking past the resident's room, EI #3 said no. EI #3 said the Foley catheter bag should be on the opposite side of the door (bed) or cover… | 2020-09-01 |
| 22 | 22 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2018-05-03 | 812 | F | 0 | 1 | VXOM11 | Based on observations, interviews, and a review of a facility policy titled, Ice Handling of Ice Scoops and the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: (1) the ice scoop was not stored on top of the ice machine, on three of four days of the survey; (2) a dark brown colored dust like substance was not on the pipes above the deep fryer, on three of four days of the survey; (3) dust was not on the pipes above the conventional oven, on three of four days of the survey; and (4) the meat slicer did not have food debris on it, on three of fours days of the survey. These deficient practices had the potential to affect all 44 residents receiving meals from the dietary department. Findings Include: (1) A review of an undated facility policy titled, Ice Handling/Cleaning of Ice Scoops, documented: POLICY: . Ice scoops are to be maintained in sanitary conditions in an effort to prevent the spread of infection. PR[NAME]EDURE: . 5. The ice scoop(s) in dietary shall be sanitized each day and placed next to the ice machine in a covered container . On 05/01/18 at 10:21 a.m., the surveyor observed a dietary staff member removing ice from the ice machine. The staff member was using a large blue colored ice scoop. When finished with removing ice from the cooler, the staff member placed the ice scoop on top of the ice machine. The ice scoop was not stored in any type of covering. On 05/02/18 at 8:58 a.m., the surveyor observed the large ice scoop to remain on top of the ice machine, not stored in any type of covering. On 05/03/18 at 8:27 a.m., the large ice scoop was again observed by the surveyor to be laying uncovered on top of the ice machine. On 05/03/18 at 8:28 a.m., the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6 how should the ice scoops be stored. EI #6 said the ice scoop should be stored up out of the bin. The surveyor asked EI #6 should the ice scoop be stored on to… | 2020-09-01 |
| 23 | 23 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2018-05-03 | 814 | F | 0 | 1 | VXOM11 | Based on observation and interview, the facility failed to ensure the above ground grease receptacle did not have grease and leaves on top of the receptacle, and on the ground in front of the receptacle. This was observed on 04/30/18, during the initial tour of the facility. This has the potential to affect all 45 residents residing at the facility. Findings Include: On 04/30/18 at 4:35 p.m., the surveyor observed the above ground grease receptacle. There were leaves and grease observed on top of the grease receptacle, and on the area on the ground in front of the grease receptacle. At this time, the surveyor conducted an interview with Employee Identifier (EI) #6, the Food Service Director. The surveyor asked EI #6, what did she see on the top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said it looked like leaves and grease to her. The surveyor asked EI #6 what was there a potential for when grease and leaves were left on top of the grease receptacle, and on the ground in front of the grease receptacle. EI #6 said the grease and leaves could attract pest. | 2020-09-01 |
| 24 | 24 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2018-05-03 | 880 | D | 0 | 1 | VXOM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and review of facility policies titled, Medication Administration and nebulizer use, the facility failed to ensure: 1) licensed staff did not place Resident Identifier (RI) #21's container of eye drops in her pocket after instilling the drops; this was observed on 05/01/18; 2) licensed staff did not place a container of glucometer strips in her pocket, remove them to check a finger stick blood sugar for RI #146, return them to her pocket and place the container on the medication cart; this was observed on 05/01/18; and 3) RI #3's nebulizer mask was stored in a covering on two of four days of the survey. These deficient practices affected RI # 3, one of two residents observed with nebulizer masks, RI #21 one of one resident observed receiving eye drop medication; and RI #146, one of one residents observed receiving nebulizer medication. Findings Include: (1) A review of a facility policy titled Medication Administration, with an updated date of 06/12, revealed: . PR[NAME]EDURE: . 7. Return medication to medication cart and store according to the facility policy. RI #21 was readmitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A review of RI #21's (MONTH) (YEAR) Physician order [REDACTED].> .1/29/18 ARTIFICIAL TEARS - INSTILL 2 DROPS TO EACH EYE 5 x (times)/DAY . On 05/01/18 at 10:15 a. m., Employee Identifier (EI) #4, Registered Nurse (RN) was observed administering medications to RI #21. EI #4 gave the medications by mouth then placed the eye drop bottle and the breathing treatment vial in her uniform pocket. EI #4 washed her hands, removed the eye drop bottle from her pocket and put on gloves. EI #4 instilled the eye drops then put the eye drop bottle back in her pocket after taking her gloves off. EI #4 washed her hands and removed the breathing treatment medication from her pocket, put on gloves and administered the medication. EI #4 removed her gloves and washed her han… | 2020-09-01 |
| 25 | 25 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2019-06-06 | 812 | F | 0 | 1 | 3PTZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility Policy Titled, Food Storage, the facility failed to ensure that expired food items and undated food items were not present in the food storage area and walk-in cooler during the initial tour of the kitchen. Further, the facility failed to ensure expired Juven was not stored in a cabinet at the nurse's station. This deficient practice had the potential to affect 45 out of 45 residents who received meals from the kitchen. Findings include: Review of a facility policy titled, Food Storage with no date, revealed the following: . 2. Stock is rotated with each delivery to ensure freshness . c.) Stock should be dated . 7. Leftover food . clearly labeled, and dated . On [DATE] at 03:08 PM during the initial tour of the kitchen, observations of the dry storage area revealed the following items: - a container of graham crumbles prepared on [DATE] with a use by date of [DATE] - 1 bag of almonds opened ,[DATE], not labeled with a use by date - 2 out of 4 bags of almonds stamped with a best by date of [DATE] - a bag of macaroni opened and tied closed in a box with no open or use by date noted on the bag or box - one open box of Juven therapeutic nutrition powder with 9 packets inside, as well as 2 full boxes of 30 packets each, all with use by dates of [DATE] - 2 additional closed cases of Juven therapeutic nutrition powder with use by date of [DATE] - eight two-packs of baby food peaches with an expiration date of [DATE], (YEAR) - 3 individual cups of baby food sweet potato with no expiration stamp on the packs - one [MEDICATION NAME] bottle (one liter) for tube feed which had a use before (MONTH) 1, 2019 date stamped on the bottle On [DATE] at 03:39 PM an observation of the walk in freezer revealed frozen sweet peas and frozen breaded cod squares were in an open, clear plastic bag in a box, with no open or use by date noted. On [DATE] at 03:45 PM an observation of the walk in cooler to the right r… | 2020-09-01 |
| 26 | 26 | HIGHLANDS HEALTH AND REHAB | 15012 | 380 WOODS COVE ROAD | SCOTTSBORO | AL | 35768 | 2019-06-06 | 880 | D | 0 | 1 | 3PTZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record reviews and review of facility policies titled, Universal Precautions and Hand Hygiene, the facility failed to ensure: 1) a licensed nurse washed her hands when removing gloves after obtaining Resident Identifier (RI) # 9's fingerstick blood sugar (FSBS) and before leaving RI #9's room to return to the medication cart. Further, the nurse failed to use a barrier when laying an insulin syringe with RI #9's insulin and alcohol wipe on the bathroom sink; and 2) a licensed nurse did not place a medication cup containing medication for RI #23 inside another medication cup containing the remainder of RI #23's medication. Further, the nurse did not use a barrier before placing RI #23's Salonpas patches and [MEDICATION NAME] on the top of the medication cart, computer and a shelf in RI #23's room. These deficient practices affected RI #9 and RI #23, two of four residents and two of three nurses observed during medication pass observations. Findings Include: 1) A review of a facility policy titled, Hand Hygiene, Last Revised: 02/2019, documented: .B. Indications for hand washing and hand antisepsis .3. Perform hand hygiene: a. before and after having direct contact with patients; b. after removing gloves; before handling an invasive device (regardless of whether or not gloves are used) for patient care; .f. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient; . A review of a facility policy titled, Universal Precautions, Last Revised: 02/2019, revealed: .[NAME] Hand Washing .3. Hands should be sanitized immediately after gloves are removed. B. 1. Gloves should be worn for touching blood and body fluids, . 1.) RI #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 06/05/19 at 5:04 p.m., the surveyor observed Employee Identifier (EI) #7, Registered Nurse (RN), during medication pass for RI #9. The surveyor observed EI #7, RN, ob… | 2020-09-01 |
| 27 | 27 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2019-01-24 | 812 | F | 0 | 1 | TMYV11 | Based on observations, interviews, and review of facility policies titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT, and, FOOD FROM OUTSIDE SOURCES, the facility failed to ensure: 1. vents located above the tray line were clean and not full of dust particles; and 2. foods being brought in from outside the facility were properly labeled and were discarded after expiration. These failures had the potential to effect 62 of 74 residents in the facility, who received meals from the kitchen. Findings include: 1. A facility policy titled, SANITARY CONDITIONS OF THE FOOD SERVICE DEPARTMENT revised 2/15, revealed, POLICY: Facilities and equipment used in the preparation and serving of food provided to residents are safe and sanitary. PR[NAME]EDURE: 1. The facility is arranged so contact with contaminated sources . is unlikely to occur. On 01/23/19 at 11:33 a.m. , while watching the tray line, a large vent above where the tray line was being conducted, was observed to be full of gray dust-like particles. On 01/24/19 at 09:52 a.m. an interview was conducted with Employee identifier (EI) #3, Dietary Manager. EI #3 was asked, who is responsible for cleaning the vents in the kitchen. EI #3 replied, maintenance does it. EI #3 was asked, how often are they cleaned. EI #3 replied, he cleans them, usually once a month. EI #3 was asked if she noticed a lot of dust in the vent located above the tray line yesterday. EI #3 replied, yes. EI #3 was asked, what is the potential concern for a vent, located above where the tray line is, being full of dust. EI #3 replied, particles could get in the food. 2. A facility policy titled, FOOD FROM OUTSIDE SOURCES, revised 10/17, revealed, POLICY: The facility procures food based on the current menu from sources approved or considered satisfactory by federal, state or local authorities. Food that is brought to residents from family, visitors or volunteers is handled in a safe and sanitary manner. PR[NAME]EDURE: . 4. a. ii. Refrigerated foods are labeled with the date and time of storage… | 2020-09-01 |
| 28 | 28 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2019-01-24 | 880 | D | 0 | 1 | TMYV11 | Based on observation, interviews, and review of a facility policy titled, Standard Precautions, the facility failed to ensure a Laundry Aide did not allow clean towels, sheets, and wash cloths touch her dress on her upper body when removing these items from the second dryer and during folding. Further, the Laundry Aide did not wash her hands after putting soiled laundry in the small washing machine, prior to putting on another pair of gloves. This had the potential to affect 23 of 74 residents in the facility. Findings Include: A review of a facility policy titled, Standard Precautions, with a revised date of 12/2009, revealed: .1. Hand Hygiene a. Wash hands after touching .contaminated items, whether or not gloves or worn . On 01/24/19 at 08:43 a.m., the surveyor observed the laundry room in the facility. The surveyor observed Employee Identifier (EI) #1, a Laundry Aide, remove the following clean items (for station 1 residents) from the second dryer: 4 sheets and 4 pads. The items touched her personal dress on the upper body area. The surveyor observed EI #1 fold the 4 sheets and 4 pads and touched her personal dress on her upper body area. On 01/24/19 at 08:53 a.m., the surveyor observed EI #1 put on a disposable apron and gloves. EI #1 removed the soiled towels, wash cloths, and sheets from the gray linen container for station 1 residents. EI#1 placed the soiled items in the small washing machine, started the washing machine to wash the clothes, removed her gloves (EI #1 did not wash hands), put on gloves, and rolled the gray linen container to the outside of the soiled utility room. An interview was conducted on 01/24/19 at 11:23 a.m. with EI #1, a Laundry Aide. EI #1 was asked when you took the 4 sheets and 4 pads from the second dryer for station 1 residents and started folding these items, did the clean laundry items touch your dress on your upper body. EI#1 stated she did not intend for the clothes to touch her dress, but should have put on an apron. EI #1 was asked if clean clothes being removed from a … | 2020-09-01 |
| 29 | 29 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 636 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interview with staff and review of a facility policy titled ADMINISTRATIVE POLICY, the facility failed to ensure Resident Identifier (RI) #285's fall risk assessment was completed upon admission. This deficient practice affected one of one residents investigated for falls. Findings Include: A review of a facility policy titled, ADMINISTRATIVE POLICY with a revised date of 10/2013 documented the following: . PURPOSE: Residents are assessed, . to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 6:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/2018 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when he/she was trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers that there is always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's fall risk assessment dated [DATE] was reviewed on the computer and observed to be blank. The surveyor asked for a copy of the fall risk assessment. Emp… | 2020-09-01 |
| 30 | 30 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 656 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and a review of a facility policy titled Care Plans the facility failed to ensure a care plan was developed for fall prevention on resident identifier (RI) #285. This deficient practice affected one of 18 sampled residents whose Care Plans (CP) were reviewed. Findings Include: A review of a facility policy titled Care Plans with a revised date of 09/2009 documented the following: . PURPOSE: Plans of Care are developed by the interdisciplinary team, to coordinate and communicate the plan of care for the resident. STANDARD: According to federal regulations, the facility develops a comprehensive plan of care for each resident . to meet a resident's medical, nursing and mental/psychosocial needs . PR[NAME]ESS: I. Entry Record a) . assessment must be completed on every admission . no later that the entry date Plus 14 calendar days . II. a) The comprehensive assessment is completed no later that 14 days of admission . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating cognition was severely impaired. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/18 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers the… | 2020-09-01 |
| 31 | 31 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 676 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, medical record review, and a review of Fundamentals of Nursing Chapter 28 the facility failed to ensure palm guards were applied to Resident Identifier (RI) #32's hands as directed by physician's orders [REDACTED].#32 with a call bell he/she could activate if assistance is needed. These deficient practices affected one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of (YEAR) Chapter 28 Immobility, page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles, and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's (MONTH) (YEAR) Physician order [REDACTED]. On 01/24/18 at 10:05 AM, RI #32's call button was secured to the gown. RI #32 was asked if he/she could push the call button. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. RI #32 was observed not having palm guards in his/her hands. On 01/24/18 at 12:30 PM, RI #32 was observed not having palm guards in his/her hands. On 01/25/18 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse (RN) Unit Manager to RI #32's room asses… | 2020-09-01 |
| 32 | 32 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 684 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review, review of a facility policy titled Monthly Physician's Orders and review of a facility policy titled Pressure Ulcers the facility failed to ensure licensed staff provided as needed (PRN) Medication as ordered for constipation for Resident Identifier (RI) #77 and further failed to ensure RI #32 was turned and repositioned every two hours as care planned. These deficient practices affected two of 18 residents sampled. Findings include: 1. Review of the facility policy titled Monthly Physician's Orders with an effective date of 2/1/2004 revealed the following: . PURPOSE: To provide a documented review of the medical plan of care for each resident on a monthly basis by the physician. Resident #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #77's Admission MDS (Minimum Data Set) assessment with an Assessment Reference Date of 12/26/17 revealed a BIMS (Brief Interview for Mental Status) score of 13 which indicated intact cognition. On 01/24/18 at 04:13 PM RI #77 told the surveyor about having to take stool softeners at times because of constipation. RI #77 said, I ask for them about every three days. On 01/25/18 at 05:26 PM RI #77 told the surveyor about having gone three, maybe four consecutive days without having a bowel movement (BM). RI #77 said, About one time a week they have to pull it (BM) out. RI #77's (MONTH) (YEAR) Physicians orders documented: . Order Date . 12/19/17 . [MEDICATION NAME] SODIUM 100 MG (milligram) SOFTGEL- GIVE ONE SOFTGEL BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . 12/19/17 POLYETHYLENE [MEDICATION NAME] 3350 POWD- (powder) GIVE 17GM (gram) BY MOUTH DAILY AS NEEDED FOR CONSTIPATION . Review of RI #77's (MONTH) (YEAR) Bowel Report and DAILY BM (Bowel Movement) MONITORING SHEET revealed four consecutive days Resident #77 did not have a Bowel Movement, 1/12/18, 1/13/18, 1/14/18, and 1/15/18. Review of RI #77's (MONTH) (YEAR) Medicati… | 2020-09-01 |
| 33 | 33 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 688 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of Physician order's, review of Fundamentals of Nursing and staff interview the facility failed to ensure Resident Identifier (RI) #32's hand splints were in place to prevent decreased ROM. This deficient practice was observed on three of four days of the survey for one of one residents sampled for rehabilitation and restorative. Findings Include: A review of Potter and Perry Fundamentals of Nursing with a copyright of (YEAR) Chapter 28 Immobility page 408 and 414 documented: . Nurses intervene to maintain maximum Range of Motion (ROM) in unaffected joints and . collaborate with physical therapists to design interventions to strengthen affected muscles and joints . Fingers and Thumb. The ROM in the fingers and thumb enables a patient to perform Activities of Daily Living (ADLs) and activities requiring fine-motor skills . Resident Identifier (RI) #32 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #32's annual Minimum Data Set (MDS) with an Assessment Reference Date of 01/01/2018 revealed RI #32's Brief Interview for Mental Status (BIMS) score of 15, indicating intact. cognition. Section G of the MDS, for Functional Status documented RI #32 was totally dependent on staff for all activities of daily living (ADL) and Range of Motion (ROM) upper extremity impairment on both sides. A review of RI #32's (MONTH) (YEAR) Physician order [REDACTED]. On 01/24/2018 at 10:05 AM, RI #32's call button was observed secured to his/her gown. RI #32 was asked if he/she could push the call button. RI #32 responded he/she could not push the call button and he/she did not know he/she had one. RI #32 attempted to push the call button but could not due to bilateral contractures to hands. Bilateral hands observed with no palm guards. On 01/24/2018 at 12:30 PM, RI #32 was observed without palm guards in bilateral hands. On 01/25/2018 03:30 PM, the surveyor and Employee Identifier (EI) #3 Registered Nurse… | 2020-09-01 |
| 34 | 34 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2018-01-25 | 689 | D | 0 | 1 | I9JH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of a facility policy titled Resident Assessment Instrument the facility failed to ensure a resident admitted to the facility was assessed for falls and a fall prevention care plan was in place prior to the resident sustaining a fall on 12/20/17. This deficient practice affected Resident Identifier (RI) #285, one of one sampled resident investigated for falls. Findings Include: A review of a facility policy titled Resident Assessment Instrument with a revised date of 10/2013 documented . PURPOSE: Residents are assessed, using a comprehensive assessment process, in order to identify care needs and to develop a plan of care. STANDARD: According to federal regulations, the facility conducts initially . a comprehensive, accurate . assessment of each resident's functional capacity . RI #285 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #285's 14 day assessment Minimum Data Set (MDS) with an Assessment Reference Date of 12/28/2017 revealed RI #285's Brief Interview for Mental Status score of 7, indicating severely impaired cognition. Section G of the MDS, documented RI #285 required two plus person physical assist with transfers. On 01/24/2018 at 06:00 PM, RI #285 told the surveyor he/she had a fall on 01/19/18 when going to the bathroom with one staff member assisting him/her. RI #285 said he/she hurt his right side and hit his/her upper right forehead. He/she said he/she had pain to the right side of his/her abdominal area. RI #285 said an X-ray was done. RI #285 said he/she had tennis shoes on and the nurse took him/her by wheelchair into the bathroom and when trying to get back into the wheelchair from the toilet he/she fell . RI #285 said he/she was told there were no fractures. RI #285 said usually with his/her transfers there was always two staff members, but this time there was only one staff member. On 01/25/2018 at 08:30 AM, RI #285's Fall Risk assessment dated [DA… | 2020-09-01 |
| 35 | 35 | EASTVIEW REHABILITATION & HEALTHCARE CENTER | 15014 | 7755 FOURTH AVENUE SOUTH | BIRMINGHAM | AL | 35206 | 2020-02-20 | 880 | D | 0 | 1 | C4NW11 | Based on observation, interviews, record review, and review of a facility policy titled Standard Precautions, the facility failed to ensure a Licensed Nurse washed her hands after she administered an eye drop medication to Resident Identifier (RI) #24, removed her gloves, and prior to administering RI #24's oral medications. This affected one of three nurses and one of three residents observed during medication pass. Findings Include: A review of a facility policy titled Standard Precautions, with a revised date of 9/2010, revealed . Standard Precautions will be used in the care of all residents . POLICY INTERPRETATION AND IMPLEMENTATION: 1. Hand Hygiene. b. Wash hands immediately after gloves are removed. and when otherwise indicated to avoid transfer of microorganisms to other residents or environments. On 2/20/20 at 8:30 a.m., the surveyor observed Employee Identifier (EI) #1, a Registered Nurse (RN), during medication administration pass. EI #1 gave an eye drop medication to RI #24's right and left eyes, removed her gloves, and did not wash her hands or use hand sanitizer prior to administering RI #24's oral medications. On 2/20/20 at 10:30 a.m., the surveyor conducted an interview with EI #1. EI #1 was asked, what she should have done after administering an eye drop medication to RI #24, removing her gloves, and prior to administering RI #24's oral medications. EI #1 stated she should have removed her gloves and washed her hands. EI #1 was asked why she had not wash her hands or used hand sanitizer. EI #1 stated, she forgot. EI #1 was asked, what does the facility Hand Washing Policy state should be done after giving a resident an eye drop medication and removing gloves. EI #1 stated, go directly and wash hands. EI #1 stated, hands should be washed before patient care, after patient care, after removing gloves, before applying gloves and in between residents. EI #1 was asked, what would be the concern if a Licensed Nurse did not wash or sanitize her hands after she gave an eye drop medication, removed her gl… | 2020-09-01 |
| 36 | 36 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2017-03-09 | 225 | E | 0 | 1 | VTS511 | Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure all employees considered for potential hire were screened to include reference checks before being allowed to work in the facility. This affected three of six employee files reviewed. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: .3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers . d. Background, reference . check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked about documentation of reference checks for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. When asked where she documented the date and time of the reference check, EI #4 replied, she did not document the date and time, and only documented the reference check was okay. When as… | 2020-09-01 |
| 37 | 37 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2017-03-09 | 226 | E | 0 | 1 | VTS511 | Based on interview, review of employee files, and the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, the facility failed to ensure the abuse policy was fully implemented for the element of Screening, to include reference checks of all potential employees prior to hire. Three of six employee files reviewed did not include reference checks. This deficient practice had the potential to affect all 88 residents residing in the facility. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 3/6/2017 indicated the facility had a total of 88 residents. Findings include: Review of the facility policy titled Policy and Procedure Abuse, Neglect, Exploitation And Reporting Abuse, with a revised date of 12/1/2016 revealed the following: .Compliance Guidelines: . 3. Screening-Facility will screen potential employees for a history of abuse, neglect or mistreating residents. This includes attempting to obtain information from previous employers and/or current employers, .d. reference .check should be conducted on employees prior to or at the time of employment, . EI (Employee Identifier) #1 LPN (Licensed Practical Nurse), was hired at the facility on 10/12/2016. EI #2 CNA (Certified Nursing Assistant) was hired at the facility on 10/21/2016. A review of EI #1 and #2's employee files revealed there was not any documentation that references had been checked or investigated. On 3/8/2017 at 3:40 p.m. EI #4, ADON (Assistant Director of Nursing), responsible for reference checks on nursing staff, was asked about the facility policy for checking references prior to hire. EI #4 said, all employees should have a reference check prior to being hired. When asked where the documentation of reference checks was for EI #1 and #2, EI #4 said, she usually documented beside the reference listed on the application, but she failed to document those. EI #3, a House Keeper was hired at the facility on 10/31/2016. Review of EI #3's file revealed there was not any documentation that referen… | 2020-09-01 |
| 38 | 38 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 577 | C | 0 | 1 | K9LV11 | Based on observations, interview, and a review of a facility policy titled, MEGA RULE REVIEW TOOL, the facility failed to ensure postings for the local and state ombudsman included an electronic mailing address. This was observed on one of three survey days and had the potential to affect all ninety-eight residents that reside in the facility. Findings Include: A review of an undated facility document titled, MEGA RULE REVIEW TOOL, revealed: . Resident Rights . Furnish a list of names, addresses (mailing and email), and telephone numbers of all pertinent State regulatory and information agencies, resident advocacy groups . the State Long-Term Care Ombudsman program . An observation was made on 4/17/18 at 2:57 PM of the Ombudsman poster in the main lobby and on the east wing. The posters did not have the Ombudsman's email address listed. An observation was made on 4/17/18 at 5:15 PM of three posters with the Ombudsman's information. The Ombudsman's email address was not listed in the information. An interview was conducted with EI (Employee Identifier) #3, the Social Services designee, on 4/19/18 at 12:34 PM. EI #3 was asked who was responsible for ensuring contact information posted in the facility was complete and she answered, Me. EI #3 was asked what postings should be available to the residents and visitors. EI #3 answered, We have to have the local and state ombudsman, the elder abuse neglect exploitation hotline, and complaint hotline. EI #3 was asked what should those postings include. EI #3 answered, Name, address, email address, and phone number. EI #3 was asked had all of those requirements been included on the posters in the facility during the survey. EI #3 answered, Not the email address. EI #3 was asked what was the concern of posted contact information not including an email address. EI #3 answered, If they couldn't reach them on the phone, they may be able to reach them via email. | 2020-09-01 |
| 39 | 39 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 641 | D | 0 | 1 | K9LV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, a review of the medical record, and a review of a facility policy titled, Conducting an Accurate Resident Assessment, the facility failed to ensure side rails were coded accurately on RI (Resident Identifier) #45's Quarterly MDS (Minimum Data Set) dated 3/2/18. This affected RI #45, one of twenty-three residents whose MDS assessments were reviewed. Findings Include: A review of an undated facility policy titled, Conducting an Accurate Resident Assessment, revealed: Policy: The purpose of this policy is to assure that all residents receive an accurate assessment, reflective of the resident's status at the time of the assessment, by staff qualified to assess relevant care areas. Accuracy of Assessments means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial status . Policy Explanation and Compliance Guidelines: . 7. A registered nurse will sign and certify that the assessment/correction request is completed. Each individual who completes a portion of the assessment will sign and certify the accuracy of that portion of the assessment. A review of the medical record for RI #45 revealed a re-admission date of [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE] revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . An interview was conducted with EI (Employee Identifier) #4, the LPN (Licensed Practical Nurse)/MDS Coordinator, on 4/19/18 at 3:54 PM. EI #4 was asked who was responsible for ensuring restraints were coded correctly. EI #4 answered, Me. EI #4 was asked why did RI #45 use bed rails. EI #… | 2020-09-01 |
| 40 | 40 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 700 | D | 0 | 1 | K9LV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, and a review of a facility policy titled, BED RAILS, the facility failed to ensure a bed rail assessment was completed prior to use of bed rails for RI (Resident Identifier) #45. This affected RI #45, one of three residents sampled for bed rail use. Findings Include: A review of an undated facility policy titled, BED RAILS revealed: Policy: The facility must ensure that residents treatment and care in accordance with professional standards if (of) practice, the comprehensive person-centered care plan, and the resident's choices. Policy Explanation and Compliance Guidelines: . 2. If a bed or side rail is used, the facility must ensure correct installation, use and maintenance of bed rails, including but not limited to the following elements: a. Assess the resident for risk of entrapment from bed rails prior to installation. 7. The facility will conduct ongoing assessments to evaluate risks and assure the bed rails is used to meet the residents' needs. A review of the medical record for RI #45 revealed a re-admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated [DATE], revealed RI #45 used bed rails as a restraint daily. A review of a physician's orders [REDACTED]. 1/2 (half) side rail in place for T&P (Turning and Positioning) . A review of RI #45's care plan, with a next review date of 6/8/18, revealed: Problem/Need . REQUIRES limited to Total ASSISTANCE WITH ADLs (Activities of Daily Living) . Approaches . siderails in place for safety & (and) T&P . A review of the medical record revealed no bed rail assessment was completed for RI #45. An interview was conducted with EI (Employee Identifier) #1, a LPN (Licensed Practical Nurse), on 4/19/18 at 12:26 PM. EI #1 was asked who was responsible for ensuring bed rail assessments were completed. EI #1 answered that he did them when residents were admitted to the facility. EI #1 was asked who was responsible for the assessm… | 2020-09-01 |
| 41 | 41 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 730 | C | 0 | 1 | K9LV11 | Based on record reviews, an interview, and a review of a facility policy titled, IN-SERVICE TRAINING POLICY, the facility failed to ensure evidence could be provided for four CNAs (Certified Nursing Assistants) receiving 12 hours of mandatory annual training. This was observed in four of four CNA training records reviewed. Findings Include: A review of an undated facility policy titled, IN-SERVICE TRAINING POLICY, revealed: Employees will receive training (in-service) according to (Name of Facility) INCs (Incorporation's) requirements, and state and federal requirements. Procedure . D The facility will provide at least 12 hours of in-service training annually to include dementia & (and) abuse training. A review of inservice sign-in sheets provided to the surveyor revealed four CNAs names had been highlighted. However, there were no documented start/end times or number of hours for the in-services that were provided. There was no evidence of how many in-service hours the CNA's had obtained. An interview was conducted with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing), on 4/19/18 at 1:16 PM. EI #7 was asked who was responsible for ensuring CNAs received 12 hours of continuing education each year. EI #7 answered, I am. EI #7 was asked who was responsible for ensuring CNAs received training to include abuse and dementia care and she stated she was responsible. EI #7 was asked had CNAs received training to include abuse and dementia care and she answered, Yes. EI #7 was asked if she could provide evidence of the number of hours of training the CNAs had received and she answered, No. EI #7 was asked what was the facility's policy regarding annual training for CNAs. EI #7 answered, That they should receive 12 hours of inservice training per calendar year. EI #7 was asked what was the concern of not being able to verify CNAs had received 12 hours of training. EI #7 answered, I would not be able to prove that they got the training. | 2020-09-01 |
| 42 | 42 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 732 | C | 0 | 1 | K9LV11 | Based on observations, an interview, and a review of a facility policy titled, Nurse Staffing Posting Information the facility failed to ensure staffing hours were posted for shifts worked on two of three survey days. This had the potential to affect all ninety-eight residents residing in the facility. Findings Include: A review of a facility policy titled, Nurse Staffing Posting, with a copyright date of (YEAR), revealed: . Policy: It is the policy of this facility to make staffing information readily available in a readable format to resident and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis and will contain the following information: . d. The total number and the actual hours worked by the following categories of licensed and unlicensed staff directly responsible for resident care per shift: i. Registered Nurses ii. Licensed Practical Nurses/Licensed Vocational Nurses iii. Certified Nurse Aides. An observation was made on 4/17/18 at 2:57 PM of a dry erase board at the center nurse's station. The following shifts were identified: 10:30 PM-7:00 AM; 6:30 AM-3:00 PM; and 2:30 PM-11:00 PM. The names of staff were on the board according to the shifts to be worked, but there were no hours posted for the 10:30 PM-7:00 AM shift. An observation was made on 4/17/18 at 4:52 PM of the dry erase board. The posting of hours worked for 10:30 PM-7:00 AM and 6:30 AM-3:00 PM shifts was not completed. An observation was made on 4/18/18 at 11:46 AM of the board where staffing was to be posted. There were no hours documented as worked on the board for the 10:30 PM-7:00 AM shift at that time. An observation was made on 4/18/18 at 4:48 PM of the staff posting board. There were no entries for hours worked for any of these shifts: 10:30 PM-7:00 AM, 6:30 AM-3:00 PM, and 2:30 PM-11:00 PM shifts. An interview was conducted on 4/18/18 at 4:57 PM with EI (Employee Identifier) #7, the ADON (Assistant Director of Nursing). EI #7 was asked who was res… | 2020-09-01 |
| 43 | 43 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 812 | F | 0 | 1 | K9LV11 | Based on observations, interviews, and a review of the facility's policy and procedure titled, HANDWASHING the facility failed to ensure EI (Employee Identifier) #9, a dietary worker, performed hand washing when going from the dirty dish washing area to the clean dish washing area and when storing clean dishes after working in the dirty dish area. This was observed on one of three survey days and had the potential to affect all ninety-seven residents receiving meals from the kitchen. Findings Include: A review of an undated facility policy titled, HANDWASHING revealed: Policy: Staff will wash hands as frequently as needed throughout the day following proper hand washing procedures . 1. When to Wash Hands: . After handling soiled equipment or utensils. After engaging in other activities that contaminate the hands. On 04/18/18 at 03:00 PM, an observation of the dish washing process was made. EI #9 entered into the dish washing area. EI #9 was observed to place dirty dishes into the dish rack, then placed the dirty dishes into the dish washer and without washing his hands pulled clean dishes out of dish washer. EI #9 continued to load dirty dishes into the dish racks and move to the clean dish area and pick up clean dishes and took them to the storage area in the kitchen. EI #9 was never observed washing his hands in between movement from dirty to clean areas. EI #9 left the washing area and on return, stopped and tied his shoe, then continued into the clean dish area and never washed his hands. An interview was conducted with dietary worker, EI #9 on 04/18/18 at 4:38 PM. EI #9 was asked what was the facility policy for dish washing. EI #9 replied the dirty dishes had to be run through the dish washer and the clean dishes could not be put back with the dirty dishes because that was cross contamination. EI #9 also said he had to wash his hands when he touched the dirty dishes before he could touch the clean dishes. EI #9 was asked if he had followed the facility policy while washing dishes that day. EI #9 replied, no… | 2020-09-01 |
| 44 | 44 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2018-04-19 | 842 | D | 0 | 1 | K9LV11 | Based on medical record review, interviews, and a review of a facility policy titled, Incident and Accident Report, the facility failed to ensure an incident/accident report regarding a fall RI (Resident Identifier) #45 sustained on 2/14/18 was done. This affected RI #45, one of two residents sampled for falls. Findings Include: A review of an undated facility policy titled, Incident and Accident Report, revealed: Purpose: Incident and accident reports are filled out to study the cause of an accident or incident and to take corrective action. Policy: The incident and accident form is to be filled out immediately by LPN (Licensed Practical Nurse) Charge Nurse, department head or supervisor when notified of an injury or accident. Procedure: [NAME] If an incident or accident occurs: . 4. If the incident involved a resident, chart the information required including: Sponsor (who and when Notified) Time the physician was notified Resident vital signs . During the review of the fall reports, the surveyor was made aware by the facility RI #45 had a fall on 2/14/18. A review of RI #45's medical record revealed no incident/accident report for the fall sustained on 2/14/18. An interview was conducted with EI (Employee Identifier) #6, a LPN (Licensed Practical Nurse), on 4/19/18 at 3:33 PM. EI #6 was asked who was responsible for documenting resident information in the medical record and she answered, The Nurse. EI #6 was asked who should have documented the fall RI #45 had on 2/14/18. EI #6 answered, The Nurse that responded. EI #6 was asked who was the nurse that responded and she answered, Me, I was the Nurse. EI #6 was asked why was this not done. EI #6 answered, I had started it and had a medical emergency and had to leave the facility. EI #6 was asked what she documented prior to leaving. EI #6 answered she had documented everything except for the notification part and she had not gotten the witness statement. EI #6 was asked where was that documentation. EI #6 answered, We think it must have gotten lost. EI #6 was as… | 2020-09-01 |
| 45 | 45 | PLANTATION MANOR NURSING HOME | 15015 | 6450 OLD TUSCALOOSA HIGHWAY P O BOX 97 | MC CALLA | AL | 35111 | 2019-05-02 | 695 | D | 0 | 1 | X13O11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policies titled, Oxygen Concentrator and Oxygen Administration, facility failed to ensure Resident #54's nasal cannula tubing was labeled with a date and the tubing connecting the concentrator with the water bottle were not out of date. This had a potential to affect of one of three residents observed receiving oxygen therapy. Findings include: A review of the facility's policy titled, OXYGEN CONCENTRATOR, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: 5. Care of the Concentrator . c. i. Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. .iii. If applicable, change nebulizer tubing and delivery devices every seventy-two hours. A review of the facility titled, Oxygen Administration, with no effective date, revealed: . Policy Explanation and Compliance Guidelines: . 5. d. If applicable, change nebulizer tubing and delivery devices every 72 hours and as needed if they become soiled or contaminated . RI# 54 was admitted to facility on 10/13/17 and readmitted on [DATE] with [DIAGNOSES REDACTED].>[MEDICAL CONDITION], acute and chronic [MEDICAL CONDITION] with hypercapnia, acute and chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], and obstructive sleep apnea. On 04/30/19 at 09:56 am, the Surveyor observed Resident # 54 with oxygen, per nasal cannula, with no date on the nasal cannula tubing. The tubing connecting the concentrator and water bottle, dated 2/11/19, was handwritten on the tubing. The water bottle was dated 4/26/19. On 04/30/19 at 12:04 pm, the Surveyor observed Resident # 54 with oxygen per nasal cannula, with no date on the cannula tubing and a date of 2/11/19 was handwritten on the tubing connecting the concentrator and the water bottle. On 05/01/19 at 04:19 pm, the Surveyor observed Resident # 54 with oxygen in use by nasal cannula. No date was written on the nasal cannula tubing or the tubing connecting … | 2020-09-01 |
| 46 | 46 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2017-06-01 | 371 | F | 0 | 1 | QJHS11 | Based on observations, review of the facility's policy titled: Food Cooking and Serving Temperatures dated (MONTH) 25, 2012, review of the 2013 Food Code and interviews with facility staff, the facility failed to ensure: 1. The thermometer was calibrated correctly prior to taking food temperatures on the tray line. 2. Monitored all foods on the tray line. 3. No use by dates on frozen shakes. 4. No dish racks were stored on the floor in the dish washing area. 5. Dishware (sectioned plates) were free of food debris, chips and stains. 1. Thermometer Calibration A facility policy titled: Food Cooking and Serving Temperatures with an effective date of 5/25/2012 revealed: . PURPOSE: Safe and sanitary food handling practices include effective control of food temperatures, in order to prevent food borne illnesses. STANDARD: According to federal regulations, food should be prepared according to tested recipes; .utilizing correct methods to conserve nutritive value and retain quality, .; and should be served attractively at proper temperatures. PR[NAME]ESS: . III. General Guidelines: a. A calibrated thermometer should be used for taking food temperatures. The final bullet under General Guidelines states,[NAME]center of food items . The 2013 Food Code revealed: 4-201.11 Good Repair and Calibration. (B) FOOD TEMPERATURE MEASURING DEVICES shall be calibrated in accordance with manufacturer's specifications as necessary to ensure their accuracy . On 5/31/2017 at 10:45 AM, an observation was made during the calibration of the thermometers. The thermometer was placed inside a cup filled with ice only and no water. On 6/1/2017 at 10:55 AM, an interview was conducted with EI #4, Certified Dietary Manager (CDM). EI #4 was asked what was the standardized methods for thermometer calibration. EI #4 said, to use ice and water. EI #4 was asked why did the cook fail to follow the standardized method on 5/31/2017. EI #4 said, carelessness. EI #4 was asked how did this affect the accuracy of the food temperatures. EI #4 said, if the thermo… | 2020-09-01 |
| 47 | 47 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2017-06-01 | 441 | D | 0 | 1 | QJHS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with facility staff and review of a facility policy titled, Infection Prevention & (and) Control and Potter and Perry, Fundamentals of Nursing. The facility failed to ensure a licensed staff member did not place her ungloved fingers inside a medication cup during medication pass. This affected one of ten residents observed during medication pass. A facility policy titled: Infection Prevention & Control Section: General Infection Prevention .with an effective date of (MONTH) 1, 2009 revealed: PURPOSE: To provide guidelines to employees . that will aid in the prevention of the transmission of infections . Potter and Perry, Fundamental of Nursing, Ninth Edition, Copyright (YEAR), Unit V (five), page 448 revealed: . NURSING KNOWLEDGE BASE . The meticulous of specific infection prevention practices reduces the risk of cross-contamination and transmission of infection . An unsampled resident was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/31/2017 at 4:30 PM, Employee Identifier (EI) #5, License Practical Nurse (LPN) placed her ungloved fingers inside a medication cup to pick it up. She placed four medications inside the cup and provided the medication to the unsampled resident. On 5/31/2017 an interview was conducted with EI #5, LPN. EI #5 was asked how did she pick up the medication cup when preparing medications for the unsampled resident. EI #5 said, she placed her fingers inside the cup. EI #5 was asked how should a medication cup be picked up. EI #5 said, from the bottom. EI #5 was asked should ungloved fingers be placed inside the medication cup when picking the cup up. EI #5 said, never. EI #5 was asked what was the potential harm to a resident when ungloved fingers are placed inside a medication cup. EI #5 said, transfer of bacteria. On 6/1/2017 at 8:33 AM, an interview was conducted with EI #6, LPN/Infection Control. EI #6 was asked how should a licensed nurse retrieve a medication… | 2020-09-01 |
| 48 | 48 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 656 | D | 0 | 1 | OEFS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review and a review of the facility's policy and procedure titled, Person Centered Care Plans, the facility failed to ensure staff developed a comprehensive care plan for a regular diet with nectar thickened liquids. This deficient practice affected RI (Resident Identifier) #24, 1 of 29 sampled residents. Findings Include: Review of the facility's policy titled Person Centered Care Plans dated (MONTH) (YEAR) states, PURPOSE: Person centered care plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches approaches and goals of the resident,,,. RI #24 was readmitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. On 7/18/18 at 8:00 AM an observation of RI 24's tray was made with EI # 4, Certified Nursing Assistant (CNA) present. EI #4 stated the resident was on nectar thickened liquids but did not know why. On 7/18/18 at 8:42 AM, RI #24's chart was reviewed with EI #2, Registered Nurse (RN) Supervisor of East I. The surveyor asked EI #2 what diet RI #24 was currently receiving according to physician's orders [REDACTED].#2 stated that from the 7/10/18 orders and readmission, the resident is on a regular diet with nectar thickened liquids. On 7/18/18 at 9:08 AM, an interview was conducted with EI #3, the Certified Dietary Manager (CDM). The surveyor asked what diet was the resident on when he was readmitted on [DATE]. EI #3 reviewed a dietary Communication Form dated 7/17/18 and said that she got a communication form from EI #2, the RN Unit Manager, putting RI #24 on a regular diet with nectar thick liquids. 07/19/18 09:38 AM an interview was conducted with EI #13, the MDS/Minimum Data Set Coordinator, The surveyor asked who is responsible for the care plan for diet changes. EI #13 stated, it is the unit manager or the person taking that order off. The surveyor asked where the care plan was for RI #24's diet for … | 2020-09-01 |
| 49 | 49 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 658 | D | 0 | 1 | OEFS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, review of Potter and Perry's Fundamentals of Nursing, Ninth Edition and a facility policy titled Medication Administration Guidelines, the facility failed to ensure licensed nursing staff, Employee Identifier (EI) #14, followed Resident Identifier (RI) #25's Physician order [REDACTED]. This deficient practice affected RI #25, one resident observed receiving eye drops. Finding Include: 1. A review of Potter and Perry's Fundamentals of Nursing, ninth edition, with a copyright date of (YEAR), Chapter 23, Legal Implications in Nursing Practice, page 311, documented: . Health Care Providers' Orders . Nurses follow health care providers' orders unless they believe that the orders are in error . RI #25 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record for RI #25 revealed the following Physician order [REDACTED]. . REFRESH [MEDICATION NAME] 1% EYE DROPS INSTILL TWO DROPS IN BOTH EYES THREE TIMES A DAY FOR DRY EYES, ARTIFICIAL TEARS --- (HOUSE ST[NAME]K) GIVE 1 DROP OU (BOTH EYES) AT BEDTIME NIGHTLY . On 7/18/18 at 9:00 a.m., during the Medication Administration Observation, the surveyor observed EI #14, the medication nurse administer Artificial Tears, two drops in each eye of RI #25. The medications were reconciled by the surveyor via (by way of) RI #25's Physician order [REDACTED]. The physicians's orders revealed EI #25 had not followed the physician orders [REDACTED].#25. The eye drops which were ordered and scheduled for this time (9:00 a.m.) were REFRESH [MEDICATION NAME] 1% EYE DROPS. On 07/18/18 10:56 AM, the surveyor conducted an interview with EI #14. The surveyor asked EI #14 if she administered RI #25 Artificial Tears 2 drops (gtts) in ou (both eyes), or Refresh [MEDICATION NAME] 1% eye gtts. EI #14 said she did not give RI #25 the Refresh eye drops. EI #14 said she has never given RI #25 gel eye drops(Refresh [MEDICATION NAME] 1… | 2020-09-01 |
| 50 | 50 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 661 | D | 0 | 1 | OEFS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and a review of the facility's policy titled, Discharge Summary and Plan of Care, the facility failed to ensure licensed staff completed a discharge summary for RI (Resident Identifier) #113's discharge from the facility. This was evident during the review of 1 of 4 discharges. Findings Include: The facility's policy titled Discharge Summary and Plan of Care dated 11/28/16 states: Purpose: Appropriate discharge planning and communication of necessary information to the continuing care provider, after discharge of a resident/guest from the facility, help the new care provider understand the resident/guests goals and needs. The process in this policy includes what the dscharge smmary should include which is: *A recapitulation of the residentguest's stay *A final summary of the resident/guest's status at the time of discharge *A post discharge plan of care developed with the resident/guest and his/her family which will assist the resident/guest to adjust to his/her new living environment . Medical review review conducted for RI # 113 revealed this resident was admitted to the facility on [DATE] and was discharged from the facility on 5/24/18. An interview was conducted with Employee Identifier (EI) #6, LPN/Licensed Practical Nurse, Charge nurse on 07/19/18 12:15 PM. The surveyor asked where the discharge summary was for RI #113. EI #6, stated, there was no d/c summary for RI #113. The policy and procedure regarding discharge summaries was referenced with EI #6, and asked if the resident should have a discharge summary. EI #6 stated, Yes. When EI #6 was asked if the discharge summary policy and procedure was followed, EI #6 stated, No. | 2020-09-01 |
| 51 | 51 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 687 | D | 0 | 1 | OEFS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to ensure the nails of Resident Identifiers (RI) #3 and #31 were maintained in a trimmed condition. This affected two of five sampled residents for whom an observation of the feet and toes was made. Findings included: The facility policy titled, Nail Care dated (MONTH) 1, 2010, cites the purpose as: Routine nail care helps reduce the potential for infection, prevents intrusion of the nail into the skin, prevents possible injuries and promotes a feeling of well being for the resident. The standard specifies: Nail care is a routine part of grooming each day. Foot care should be provided as a part of a tub or shower bath. The policy further recommends .a Podiatrist provides foot care for residents with Diabetes or [MEDICAL CONDITION] . 1) RI #3 has resided in the facility since 11/06/17, with [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 07/12/18, identified RI #3 as cognitively intact. The care plan related to Activities of Daily Living for RI #3, (dated 11/07/17) included, Nail care as needed. During an interview on 07/17/18 at 8:44 AM, the surveyor questioned RI #3 about the care of his/her feet. In response, RI #3 removed his/her shoes. The toenails on RI #3's left foot were long, particularly the great toe, which extended approximately 1/2 beyond the end of the toe. When questioned further, RI #3 explained he/she had been on the list to see the facility podiatrist for nearly a year, and had made numerous requests for podiatry assistance. On 07/18/18 at 5:05 PM, the facility Administrator, Employee Identifier (EI) #1 accompanied the Surveyor to RI #3's room, and viewed his/her feet. When asked, EI #1 stated it was the nurses' responsibility to ensure each resident's toe nails were trimmed. EI #1 then affirmed the nails on the resident's left foot (particularly the great toe) were in need of a tri… | 2020-09-01 |
| 52 | 52 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 755 | D | 0 | 1 | OEFS11 | Based on observations of medication storage on 3 of 5 units, and review of the facility's policy titled Medication Storage, Storage of Medications and Biologicals, the facility failed to ensure that medications that were expired were not available for use. Expired medications were located on one of the three units observed. Findings include: Review of a facility policy titled Medication Storage, Storage of Medications and Biologicals, Policy 3.1, 03/11 states: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier . Procedures 11. Outdated, contaminated or deterioriated medications and those in containers that are cracked, soiled, or without secure clusures are removed from stock, disposed of according to procedures for medications disposal . During an observation on 7/18/18 at 2:39 PM, with EI #9, a Licensed Practical Nurse (LPN), of the rehab. medication storage room, two vials of flu vaccine were observed. These two vials had expiration dates of 6/22/18. During an interview with EI #9, on 7/18/18 at 2:43 PM, she was asked who is responsible for removing expired medications. EI #9 said, any of the nurses (could remove expired medications). When asked if there is a potential for harm for administering expired medications, EI #9 responded by saying, they could have a reaction. When asked if expired medications should be in the refrigerator, EI #9 said, no. | 2020-09-01 |
| 53 | 53 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2018-07-19 | 880 | D | 0 | 1 | OEFS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and a review of the facility policies titled Hand Hygiene, Blood Glucose/PT/INR Machine Cleaning Guidelines, and Using Gloves, this facility failed to ensure that infection control practices were utilized to prevent the spread of infection. This deficient practice had the potential to affect 3 of 3 residents, RI #'s 57, 49 and 313. Findings include: A review of the facility's policy Infection Prevention & Control Manual, Policy Title: Hand Hygiene, effective date (MONTH) 1, (YEAR), Purpose: To provide guidelines to employees for proper and appropriate hand washing techniques that will aide in the prevention of the transmission of infections. Standard: Hand washing should be performed between procedures with resident/guest(s) based upon the principle that all blood, body fluids, secretions, excretions (except sweat), non-intact skin, and mucus membranes may contain transmissible infectious agents. III. Hand Hygiene Hand hygiene continues to be the primary means of preventing the transmission of infections. The following is a list of some situations that require hand hygiene. * .before and after direct residnet/guest contact . Before and after perfoerming any invasive procedure (e.g. fingerstick blood sampling). A facility policy titled, Using Gloves dated (MONTH) 1, 2009 revealed, Standard: Gloves should be worn when . possibly infectious materials are anticipated. A facility document titled Blood Blucose/PT/INR Machine Cleaning Guidelines with a revision date of 11/5/11 included the following: 3. Don first pair of gloves, do procedure, place glucometer on contaminated towel/surface. 4. Wash hands and put on a second pair of gloves. 5. Clean glucometer with disinfectant wipe, place on clean surface . EI (Employee Idenntifier) #7 Licensed Practical Nurse (LPN), was observed during the medication pass observation on 7/17/18 at 3:39 PM. 1. At 3:45 PM, EI #7 performed a finger stick blood sugar (FSBS) on RI #57. … | 2020-09-01 |
| 54 | 54 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 580 | D | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled, Change in Medical Condition of Resident/Guest(s), the facility failed to ensure Resident Identifier (RI) #272's family/responsible party was notified of a new order written on 4/19/19, for [MEDICATION NAME] DR (Delayed Release) 125 MG (milligrams) sprinkle by mouth at hour of sleep. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Change in Medical Condition of Resident/Guest (s), with an effective date of 11/28/2016 revealed the following: .STANDARD: Notification . legal representative, or interested family member, should occur promptly, according to federal regulations, when there is a change in the resident/guest (s) condition, . *A need to alter treatment . to commence a new form of treatment . RI #272 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #272 Physician order [REDACTED]. The orders also included an order for [REDACTED]. On 8/29/19 5:52 p.m., the surveyor conducted an interview with Employee Identifier (EI) #3, Registered Nurse Unit Manager/Supervisor. The surveyor asked EI #3 was there an order for [REDACTED].#3 how could she verify that an order had been given. EI #3 stated what she had been told by this company was that you do not have to have a written order, you can put verbal orders directly into the computer. The surveyor asked EI #3 when did the physician write the order. EI #3 stated she did not know why the physician did not hand write the order. The surveyor asked EI #3 was this a usual practice. EI #3 stated, not generally. The surveyor asked was the family/responsible party notified of the new order. EI #3 stated it did not look like they were notified. The surveyor asked EI #3 where would the evident be that family was notified if there were evident. EI #3 stated in the nurses notes. The surveyor asked EI #3 was there evident in the nurses notes. EI #3 stated t… | 2020-09-01 |
| 55 | 55 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 602 | E | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and a review of a facility policy titled, Abuse Prevention, the facility failed to ensure resident narcotic medications were not missing. This deficient practice affected RI #87, #48, #222, #223 and #224, five of five residents who were investigated for missing narcotic medication. Findings Include: A review of a facility policy titled Abuse Prevention, with an effective date of [DATE] , revealed: The following are definitions of specific types of abuse: . D) Misappropriation of Resident/ . Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's . belongings or money without the resident's consent . (1) RI #87 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A review of RI #87's (MONTH) 2019 Medication Administration Record [REDACTED]. [DATE] 6:35 pm, an interview with Employee Identifier (EI) #15, Licensed Practical Nurse(LPN) Charge Nurse was conducted. EI #15 was asked was she familiar with RI #87. EI #15 said yes. EI #15 was asked when she worked on [DATE] did RI #87 complain of pain during her shift. EI #15 said RI #87 sometimes would, he/ she would say his/ her head hurt or he/ she hurt all over. EI #15 was asked when was the last time she had to give RI #87 pain medication. EI #15 said she did not remember, hospice started the medication and she may have given pain medication one time. EI #15 was asked what was the narcotic. EI #15 said it was [MEDICATION NAME]. EI #15 was asked was RI #87 presently on this drug. EI #15 said no, it was stopped. EI #15 was asked what, if any, did RI #87 take for pain since the [MEDICATION NAME] had been stopped. EI #15 said if RI#87 needed pain medication, RI #87 will take a Tylenol. EI #15 was asked how did she know RI #87 was missing pain medication. EI #15 said because she fussed about it everyday, because she had to count that many pills every day; hospice sent a lot of narcotics so on that… | 2020-09-01 |
| 56 | 56 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 658 | D | 1 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Medication Orders, the facility failed to ensure Resident Identifier (RI) # 272 received additional [MEDICATION NAME] for three days, as ordered. This deficient practice affected RI #272, one of 25 sampled residents. Finding Include: A facility policy title: Medication Policies Prescriber Medication Orders dated 03/11 revealed the following, Policy Medications are administered only upon the clear, complete, and signed order of a person lawfully authorized to prescribe. Procedures 1. Elements of the Medication Order . (4) Time or frequency of administration. RI #272 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. The Physician order [REDACTED].#272, with an order start date of 4/24/19 and a stop date of 4/26/19. The order was to give [MEDICATION NAME] 20 MG (milligram) tablet- take one tablet everyday at noon for three days. On 8/29/19 at 5:52 p.m., the surveyor conducted an interview with Employee Identifier #3, Register Nurse (RN) Unit Manager. The surveyor asked EI #3 was RI #272 admitted to the facility on [MEDICATION NAME] 20 M[NAME] EI #3 stated yes, they were admitted on [MEDICATION NAME] 20 MG daily. The surveyor asked EI #3 when was the RI #272 discharged from the facility. EI #3 stated it looked like he/she was discharged on [DATE]. The surveyor asked EI #3 did he/she receive the [MEDICATION NAME] the entire time he/she was at the facility. EI #3 stated yes they (nursing) were signing off that he/she got the [MEDICATION NAME]. The surveyor asked EI #3 was there a new order for additional [MEDICATION NAME] 20 MG to be started on 4/24/19 and given for three days. EI #3 stated, give [MEDICATION NAME] 20 MG tablet by mouth at noon daily times three days in addition to morning dose. The surveyor asked EI #3 why was there a new order for the additional [MEDICATION NAME] 20 MG on 4/24/19 to be given one everyday at noon for three days. EI #3 stated sh… | 2020-09-01 |
| 57 | 57 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-08-29 | 695 | D | 0 | 1 | 39OM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, record review and review of a facility policy titled, Oxygen Administration , the facility failed to ensure oxygen masks and distilled water bottles were dated. This deficient practice had the potential to effect Resident Identifier (RI) #105, RI #274 and RI #275, three of three residents observed for oxygen therapy. Findings Include: A review of the facility policy titled, Oxygen Administration, effective date 12/08/2005, revealed, . Process: . 11. Cannula's and masks should be changed weekly . 14. O2 cannula/mask should be stored in a plastic bag when not in use. 1) RI #105 was re-admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. Physician Orders included an order, dated of 7/24/19, for O2 (Oxygen) at 2 L/M (Liter per Minutes) via NC (Nasal Cannula) as needed for SOB (Shortness of Breath). A care plan, dated 8/6/19, included, . Administer oxygen therapy as ordered. On 8/27/19 at 4:02 p.m., the surveyor observed RI #105's NC tubing and distilled water bottle on the oxygen concentrator were not dated. On 8/29/19 at 7:50 a.m., a second observation was made of the NC tubing and the distilled water bottle on the oxygen concentrator not dated 2) RI #274 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Physician's Orders included Oxygen at 2 L/M via nasal cannula, dated 8/22/19. A care plan included Administer oxygen therapy as ordered , dated 8/23/19. On 8/27/19 at 0:00 a.m., the surveyor observed RI #274's NC tubing and the distilled water bottle on the oxygen concentrator were not dated. On 8/27/19 at 3:27 p.m., during a second observation the surveyor observed that the NC tubing and distilled water on the oxygen concentrator were not dated. On 8/28/19 at 9:06 a.m., during a third observation the surveyor observed that the NC tubing and the distilled water bottle on the oxygen concentrator were not dated. 3) RI #275 was admitted to the facility on [DATE]. A [DIAGNOSES REDACTED]. A Phy… | 2020-09-01 |
| 58 | 58 | ATHENS HEALTH AND REHABILITATION LLC | 15016 | 611 WEST MARKET STREET | ATHENS | AL | 35611 | 2019-12-19 | 656 | D | 1 | 0 | QVJE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, a review of RI (Resident Identifier) #1's medical record, RI #1's Resident Incident Report, and the facility's policy titled, Person Centered Care Plans, the facility failed to ensure RI #1's care plan for a fall mat beside the bed was consistently implemented. This deficient practice affected RI #1, one of three sampled residents reviewed for falls. Findings Include: A review of a facility policy titled, Person Centered Care Plans, with an effective date of 8/15/18, documented: PURPOSE: Person centered plans of care are developed by the interdisciplinary team, to coordinate and communicate care approaches and goals of the resident/guest, consistent with the resident/guest(s) rights. STANDARD: . According to federal regulations, the facility develops a comprehensive person centered plan of care for each resident/guest that includes measurable objectives and timetables to meet a resident/guest(s) medical, nursing and mental/psychosocial needs that are identified in the comprehensive assessment . PR[NAME]ESS: I.(f) .will ensure care plan intervention(s) are entered into Care Guide ADLs/Intervention in the electronic medical record that are considered outside of routine care. This will provide the CNA with individualized information needed to meet the resident's care needs. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 9/27/19, indicated RI #1 was cognitively intact, with a BIMS(Brief Interview for Mental Status) score of 14. RI #1's Resident Incident Report, prepared by EI (Employee Identifier) #1, RN (Registered Nurse), DON (Director of Nursing Services), indicated on 11/30/19 at 8:35 p.m., CNAs (Certified Nursing Assistants) EI #2 and E#3 called the nurse to the resident's room. The resident was lying on his/her left side, on the floor, beside the bed. RI #1's care plan titled, Potential for Falls: r/t … | 2020-09-01 |
| 59 | 59 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 600 | J | 1 | 0 | KDKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #1, RI #2's medical record, RI #3's medical record, the facility's policy titled OPS300 Abuse Prohibition and the facility's investigative file, the facility failed to ensure RI #2 and RI #3 were free from abuse perpetrated by RI #1, a resident who resides on the Homestead Memory Care (Dementia) Unit. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1, a resident identified as being physically aggressive toward others, struck RI #2 with no warning or provocation and physical abuse did occur. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the evening shift on 2/20/2019, around supper time, the intervention of 1:1 supervision/oversight was not implemented and RI #1 was found by staff standing over RI #2, punching RI #2 in the head. This deficient practice affected RI #2 and RI #3, two of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F600. Findings include: The facility's policy titled, OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . POLICY Genesis HealthCare Cen… | 2020-09-01 |
| 60 | 60 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 607 | K | 1 | 0 | KDKT11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record review and review of the facility's policy titled OPS300 Abuse ProhibitionAbuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure a Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) reported an allegation of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not reported timely to the State Survey Agency (Reporting); 3) protect Resident Identifier (RI) #2 and potentially other residents from abuse perpetrated by RI #1 (Protection); and 4) investigate an allegation of physical abuse (Investigation). On 4/19/2018 at approximately 4:45 PM, loud voices were heard in the hallway near room [ROOM NUMBER] on the Memory Care Unit. Staff responded and found RI #5 and RI #1 in a physical altercation; they were striking each other with their fists. On 11/23/2018 around 6:45 PM, RI #1 and RI #4 were found on the floor in RI #4's room. RI #4 said RI #1 entered his/her room, uninvited, used the bathroom and then tried to lay down in the empty bed. RI #4 tried to remove RI #1 and both residents fell to the floor. RI #1 sustained superficial scratches to the neck/chest, a skin tear to the right forearm and a torn t-shirt. On 12/16/2018 at approximately 6:55 PM, RI #1 and RI #3 were discovered on the floor in the residents' room. RI #3 had a cracked tooth and RI #1 had minor scratches on his/her right arm. On 1/25/2019 at 3:05 PM, RI #1 was ambulating in the hallway and bleeding from injuries to the right hand. There were three lacerations across the resident's knuckles. The trail of blood was followed and the staff observed RI #3 in his/her wheelchair bleeding from the lower lip, with a possible broken tooth. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility co… | 2020-09-01 |
| 61 | 61 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 609 | J | 1 | 0 | KDKT11 | > Based on interviews and review of the facility's policy titled OPS Abuse Prohibition the Licensed Practical Nurse (LPN) and the Director of Nursing Service (DNS) failed to report an allegation of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, this allegation of abuse was not timely reported to the Alabama State Survey Agency. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the LPN, she informed the DNS; however, she was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/27/2019 at 6:46 PM, the Alabama State Survey Agency received a facility reported allegation of physical abuse involving RI #1 and RI #2 that occurred on 2/20/2019 at 7:00 PM. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F609. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 5.1 Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin, or misappropriation of patient property is to tell the abuser to stop immediately and report the incident to h… | 2020-09-01 |
| 62 | 62 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 610 | J | 1 | 0 | KDKT11 | > Based on interviews and review of the facility's policy titled OPS300 Abuse Prohibition, the facility failed to immedately investigate an allegation of physical abuse perpetrated by Resident Identifier (RI) #1, a cognitively impaired resident who resides on the facility's Homestead Memory Care (Dementia) Unit. During the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed Resident Identifier (RI) #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the Director of Nursing Service (DNS); however, she was told to not document anything that the DNS, would take care of everything in the morning. There was no documentation or investigation of this allegation of physical abuse until 2/27/2019. This deficient practice affected RI #1 and RI #2, two of five sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who reside on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings of immediate jeopardy in the area of Freedom from Abuse, Neglect, and Exploitation, F610. Findings include: Refer to F600 The facility's policy titled OPS300 Abuse Prohibition with a revision date of 7/1/2018, documented . PR[NAME]ESS 1. The Center Executive Director, or designee, is responsible for operationalizing policies and procedures that prohibit abuse . 6.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 6.7.1 whether abuse or neglect occurred and to what extent; 6.7.2 clinical examination for signs of injuries, if indicated; 6.7.3 causative factors; and 6.7.4 interventions to prevent further injury. 6.8 The investigation wil… | 2020-09-01 |
| 63 | 63 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 725 | K | 1 | 0 | KDKT11 | > Based on interviews, review of the facility's policy titled OPS138 Staffing/Center Plan, the Facility's Assessment Tool, the facility's daily census, staffing and assignment report, the facility failed to ensure sufficient staff was assigned to work during the evening shift on 2/20/2019 on the Homestead Memory Care (Dementia) Unit. The facility had determined the staffing needs for the evening shift was one direct care staff per nine residents. The daily census for the Dementia Unit for 2/20/2019 was 34, which indicated two direct care staff were assigned to care for 11 residents and one direct care staff was assigned to care for 12 residents. During the evening shift on 2/20/2019 around supper time, Resident Identifier (RI) #1, a resident identified as being physically aggressive towards others, was found by staff standing over RI #2, punching RI #2 in the head. RI #1 had previously been identified to physically abuse RI #2 on 2/15/2019. After this physical altercation, RI #1 was to be placed on 1:1 until discharge from the facility. This intervention was not implemented, thus RI #1 was found again physically abusing RI #2, five days later. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the Administrator, Director of Nursing Service and Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Nursing Services, F725. Findings include: The facility's policy titled OPS138 Staffing/Center Plan with a revision date of 9/1/2013, documented POLICY Genesis HealthCare Centers will provide qualified and appropriate staffing levels to meet the needs of the patient population. The staffing plan will include all shifts, seven days per week. PURPOSE To assure that appropriate staf… | 2020-09-01 |
| 64 | 64 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2019-03-02 | 835 | K | 1 | 0 | KDKT11 | > Based on interview and review of the Center Nurse Executive's job description, the Center Nurse Executive (CNE), also known as the Director of Nursing Service (DNS), responsible for the overall operations associated with direct patient care, failed to ensure staff was provided written education on when and how to provide 1:1 supervision of Resident Identifier (RI) #1 and further failed to ensure the 1:1 supervision was implemented from 2/15/2019 until 2/21/2019. On 2/15/2019 at 7:45 PM, RI #1 and RI #2 were ambulating in the hallway towards each other, when RI #1 struck RI #2 with his/her right fist on RI #2's chin. The facility concluded RI #1 struck RI #2 with no warning or provocation. Beginning 2/15/2019 until 2/21/2019, RI #1 was to be provided 1:1 supervision/oversight during the resident's waking hours. However, during the 2:00 PM to 10:00 PM shift on 2/20/2019, around supper time, staff observed RI #1 standing over RI #2 in RI #2's room, punching RI #2 in the head. RI #1 was sweating and his/her knuckles were red. According to the Licensed Practical Nurse (LPN), she informed the DNS and was told to not document anything that she, the DNS, would take care of everything in the morning. On 2/21/2019, RI #1 was discharged to a local Geri-Psychiatric setting. During interview on 2/28/2019, Employee Identifier (EI) #2 stated she now realized that she should have provided written education and had the staff to document that the 1:1 supervision intervention was being implemented for RI #1. This deficient practice affected RI #2, one of five sampled residents reviewed for resident to resident altercations; and placed RI #2 in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining residents who resided on the facility's Homestead Memory Care (Dementia) Unit. On 3/1/2019 at 3:40 PM, the facility's Administrator (Center Executive Director), Director of Nursing Service (Center Nurse Executive) and Director of Clinical Services were notified of the findings o… | 2020-09-01 |
| 65 | 65 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 580 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review and review of a facility policy titled Change in Condition: Notification of the facility failed to contact Resident Identifier (RI) # 24's resident representative when his/her diet was changed to pureed in August 2019. This affected 1 of 20 sampled residents. Findings Include: A review of policy titled Change in Condition: Notification of, with an effective date of 11/28/16, documented: .A Center must immediately inform the patient's Health Care Decision Maker (HCDM) where there is:.A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment. RI # 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI # 24 also had a [DIAGNOSES REDACTED]. A review of RI # 24's diet orders documented the following: 8/13/19.Resident's diet downgraded to pureed due to coughing when eating. Resident appearing at times to have trouble swallowing regular tray. Speech Therapy (ST) was alerted and to see resident. On 03/02/20 at 2:53 p.m. the Surveyor reviewed RI # 24's medical record. A Speech Therapy Initial Evaluation for therapy dates 8/2/19 through 8/31/19 documented the following: . Patient/Caregiver Education = Family/caregiver expressed understanding of evaluation and agreement with goals and treatment plan; Does patient/family agree w/ (with) Diet Recommendation? = Yes. On 3/2/20 at 9:38 a.m. an interview was completed with Employee Identifier (EI) # 3, Speech Therapist. EI # 3 stated she had RI # 24 on her case load on and off in 2019 for swallowing and cognitive problems. EI # 3 was asked what type of diet she recommended for RI # 24. EI # 3 stated she recommended a pureed diet in August of 2019 and RI #24 received that diet after the recommendation. A follow-up telephone interview was completed with EI # 3, Speech Therapist, on 3/2/20 at 2:47 p.m. EI # 3 was asked if she contacted RI #… | 2020-09-01 |
| 66 | 66 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 732 | C | 1 | 1 | LZCS11 | > Based on observation and interview, the facility failed to ensure Nurse Staffing information was posted on Saturday, 2/29/20, when the survey team entered the building. This was observed on 2/29/20 and had the potential to affect all 92 residents residing in the facility, as well as family and visitors in the facility. Findings include: On 2/29/20 at 1:00 p.m., the survey team entered the facility and observed the Nurse Staffing information posted; the posting was dated for the previous day, 2/28/20, instead of for the current date and shift. On 3/03/20 at 3:17 p.m., Employee Identifier (EI) # 6, Licensed Practical Nurse (LPN), was interviewed. EI # 6 was asked who was responsible for ensuring Nurse Staffing information was posted daily on the weekends. EI # 6 said the first hall nurse was responsible. EI # 6 further stated she had been the nurse working on the 1st hall on 2/29/20. When asked if she had posted the Nurse Staffing information that day, EI # 6 said no, she forgot. EI # 6 said she should have posted the staffing information for 2/29/20 that morning. EI # 6 was asked the purpose of posting the Nurse Staffing information daily in the facility. EI # 6 said it should be posted because it shows the public how many people are working, shows the number of employees in the building, as well as the number of residents. | 2020-09-01 |
| 67 | 67 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 756 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, review of the consultant pharmacist's February 2020 Medication Regimen Review reports, and review of policies titled 9.1 Medication Regimen Review and 3.8 [MEDICAL CONDITION] Medication Use, the facility failed to ensure the consultant pharmacist identified concerns during the February 2020 medication review with Resident Identifier (RI) #24's [MEDICATION NAME], an antipsychotic medication, that was ordered on [DATE] without adequate justification for use. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 9.1 Medication Regimen Review, dated 11/28/16, revealed the following: .PROCEDURE . 1.1 The drug regimen of each skilled nursing facility resident must be reviewed at least once a month by a licensed pharmacist. Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/16, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was previously discontinued on 11/02/2018. Further, review of RI #24's current comprehensive car… | 2020-09-01 |
| 68 | 68 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 758 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews, and review of the facility's policy titled [MEDICAL CONDITION] Medication Use, the facility failed to ensure Resident Identifier (RI) #24 was not given [MEDICATION NAME], an antipsychotic medication, without a [DIAGNOSES REDACTED]. This affected RI #24, one of six sampled residents reviewed for unnecessary medications. Findings include: Review of the policy titled 3.8 [MEDICAL CONDITION] Medication Use, revised 11/28/2016, revealed the following: POLICY This Policy 3.8 sets forth procedures relating to [MEDICAL CONDITION] medication use. DEFINITION A [MEDICAL CONDITION] drug is any medication that affects brain activities associated with mental processes and behavior, PROCEDURE . 3. [MEDICAL CONDITION] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use. . 8. Antipsychotic medications used to treat Behavioral or Psychological Symptoms of Dementia (BPSD) must be clinically indicated, be supported by an adequate rationale for use, and may not be used for a behavior with an unidentified cause. RI #24 was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of hospital records indicated RI #24 was transferred to the hospital on [DATE] due to complaints of chest pain, where he/she remained overnight until readmitted to the facility on [DATE]. Review of RI #24's current physician orders [REDACTED]. However, review of RI #24's order history, revealed RI #24 had not received [MEDICATION NAME] since the order was discontinued on 11/02/18. Further, review of RI #24's current comprehensive care plans revealed no care plan addressing any behaviors. RI #24's January and February 2020 Medication Administration Record [REDACTED]. A telephone interview was completed on 3/2/20 at 3:37 p.m. with Employee Identifier (EI) # 7, Nurse Practitioner. EI # 7 was asked if she was aware RI #24 was readmitted to the facility on [DATE]… | 2020-09-01 |
| 69 | 69 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 812 | F | 1 | 1 | LZCS11 | > Based on observations, interviews and a review of a facility policy titled, Food Storage: Cold Foods, the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler, and 2. food items were labeled with a received date or use by date prior to storage in the walk-in cooler/reach-in freezer. These failures had the potential to affect 89 residents receiving meals from the kitchen out of 92 total residents residing in the facility. Findings Include: The facility policy titled, Food Storage: Cold Foods, with a revised date of 4/2018, included . Procedures . 5. All foods will be stored . labeled and date, and arranged . to prevent cross contamination . On 02/29/20 at 01:18 p.m., the surveyor observed food items in the walk-in cooler. There was one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one container of Prepared Yellow Salad Mustard with an opened date of 12/25/19 and labeled with a use by date of 01/25/20, and one bag of turkey with an open date of 02/15/20 and labeled with a use by date of 02/25/20. On 02/29/20 at 01:31 p.m., the surveyor observed food items in the reach-in freezer. The following items were observed: one bag of Spinach with an open date of 0[DATE] and no use by date, one bag of pepperoni slices with no open date and a use by date of 12/09/20, and one unopened roll of Ground Turkey with a received date of 12/13/19 and labeled with a use by date of 01/13/19. On 03/02/20 at 09:08 a.m., the surveyor conducted an interview with EI (Employee Identifier) #1, the Lunch Cook. The surveyor asked EI #1, what does a use by date mean. EI #1 stated, use it by that date or throw it away the next day. The surveyor asked EI #1 why the following items were observed in the walk-in cooler on 02/29/20 at 01:18 p.m.: one container of Sliced Peaches with no prepared date or use by date, one container of Strawberries prepared on 0[DATE] and labeled with a use by date of 01/30/20, one… | 2020-09-01 |
| 70 | 70 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2020-03-03 | 842 | D | 1 | 1 | LZCS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interview and review of a facility policy titled Medication: Administration: General, the facility failed to ensure nursing staff documented administration of Resident Identifier (RI) #24's [MEDICATION NAME] on 01/28/20 and 01/30/20 on the Medication Administration Record (MAR). This affected 1 of 20 sampled residents whose MARs were reviewed. Findings Include: A review of a facility policy titled Medication: Administration: General, revised [DATE], documented: .11. Document: 11.1 Administration of medication on Medication Administration Record (MAR). RI # 24 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. RI #24's physician's orders [REDACTED]. A review of RI # 24's Narcotic Record for January 2020 documented one dose of [MEDICATION NAME] was taken out on 1/28/20 and another on 1/30/20. However, review of RI # 24's January 2020 MAR did not reflect [MEDICATION NAME] was administered on [DATE] or 1/30/20. On 3/1/20 at 5:00 p.m., an interview was conducted with Employee Identifier (EI) # 5, the Licensed Practical Nurse (LPN) that signed out the [MEDICATION NAME] on 1/28/20. EI # 5 was asked if she gave RI # 24 a [MEDICATION NAME] on 1/28/20. EI # 5 stated yes, it was documented on the narcotic book that she had signed one out. EI # 5 was asked if she marked the MAR when the [MEDICATION NAME] was given on 1/28/20. EI # 5 stated no, she forgot, but she should have signed it off on the MAR as adminsitered. EI # 5 was asked why she should mark it on the MAR. EI # 5 stated the next shift needed to know what was given. EI # 5 was asked how many doses of the [MEDICATION NAME] RI # 24 received. EI # 5 stated a total of two doses: one on 1/28/20 at 6:00 p.m. and one on 1/30/20 at 12:00 p.m. EI # 5 stated she did not give the the dose on 1/30/20. EI # 5 was asked if the nurse from 1/30/20 marked on the MAR that the [MEDICATION NAME] was given. EI # 5 stated no. An interview was completed with EI # 4, Register… | 2020-09-01 |
| 71 | 71 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2018-03-29 | 600 | D | 1 | 1 | OSF111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews, and a review of the facility policy titled, Abuse Prohibition, the facility failed to ensure two residents were free from an incident of abuse. This affected RI (Resident Identifier) #s 94 and 2, two of twenty-five sampled residents. Findings Include: A review of the facility policy titled, Abuse Prohibition, with a revision date of 11/28/17, revealed: . POLICY . (name of HealthCare Company) will prohibit abuse, . Federal Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish. Instances of abuse of all patients, irrespective of any mental or physical condition cause physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse includes hitting, slapping, pinching, kicking, . A review of two investigative summaries dated 1/19/18, revealed that on 1/13/18, RI #54 was observed to strike RI #2 and RI #94 with an open hand and sustained a skin tear to his/her hand. RI #54 struck RI #s 2 and 94 while urging the to Come on, let's go home. The Center Conclusion indicated under current definitions, (RI #54, the aggressor) acted in a deliberate manner in striking RI #2 and RI #94. The center's Abuse Coordinator concluded there was no evidence of physical harm as a result of the event. In the absence of physical harm, the Center concluded that physical abuse did not occur. A review of RI #54's Medical Record revealed the resident was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a Quarterly MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 2/15/18, revealed RI #54 had a BIMS (Brief Interview for Mental Status) score of 4 out of a possible 15. … | 2020-09-01 |
| 72 | 72 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2018-03-29 | 812 | F | 0 | 1 | OSF111 | Based on observations, an interview, review of the facility's policies and procedures titled, 4.0 Cleaning Standards and 4.7 Food Handling, along with a review of a facility document titled, Weekly Cleaning List, the facility failed to ensure: 1. the meal cart covers were sanitized prior to use and 2. chicken was thawed completely submerged in running water. This had the potential to affect all 92 residents who received meals from the kitchen. Findings Include: 1. A review of the facility's policy and procedure titled, 4.0 Cleaning Standards, with a revision date of 12/1/15, revealed: POLICY Written cleaning procedures are used to clean all equipment/areas in the Food and Nutrition Services Department. PURPOSE To ensure all food service equipment and areas are clean and sanitary. CART WASHING (HAND METHOD) WHEN: After Use . A review of a facility document titled, Weekly Cleaning List-(Name of facility), dated (YEAR)-2018, revealed: 1) Food Carts and Bun Rack Covers-Wiped Down after every shift break, lunch, and dinner . Monthly Cleaning List-(Name of facility), 1) Food Racks and Bun Covers-sprayed down with sanitizer and pressure washed, air-dried and brought back into facility . 2. A review of the facility's policy and procedure titled, 4.7 Food Handling, with a revision date of 11/28/17, revealed: POLICY Foods are stored, prepared and served in a safe and sanitary manner. PURPOSE To prevent bacterial contamination and the possible spread of infection. Food Safety During Meal Preparation and Service . 8. Frozen foods are thawed in the refrigerator and not at room temperature. Foods can be thawed if completely submerged under fast running cold water of at least 70 (circle representing degrees) F (Fahrenheit) or below. On 3/29/18 at 9:29 a.m., an observation was made of the kitchen. An observation was made of frozen pieces of chicken thawing in a sink under running water. Only the portion of the chicken the water was pouring directly onto was being wet. There was no submersion of the pieces of frozen chicken. A se… | 2020-09-01 |
| 73 | 73 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2018-03-29 | 880 | D | 0 | 1 | OSF111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and the review of facility policies, Waste Management, Medication Administration, Hand Hygiene, Glucose Meter, and Cleaning and Disinfecting, the facility failed to ensure: 1. medications were not placed on an unclean surface for RI (Resident Identifier) #22 and RI #55, 2. a glucose monitor was not placed on an unclean surface for RI #55 and then used for the resident, 3. hands were washed during medication administration, 4. gloves were used when handling the enteral infusion administration set, 5. a Gastrostomy tube infusion administration set was not covered with a unclean plastic cover and 6. a nurse did not dispose of a used glucose test strip in a trash can after use for RI #55 in his/her room. This affected RI #22, and RI #55, two of eleven residents observed during medication administration. Findings Include: A review of a facility policy and procedure, titled, Hand Hygiene with a revision date of 11/28/17, revealed: . POLICY Adherence to hand hygiene practices is maintained by all Center personnel. PR[NAME]ESS 1. Perform hand hygiene 1.1 Before patient care; . 1.4 After patient care; 1.5 After contact with patient's environment . A review of a facility policy and procedure titled, Cleaning and Disinfecting, with a revision date of 11/28/17, revealed: . PURPOSE To prevent infectious spread from items or environment to patients and/or staff. To ensure reusable medical equipment is cleaned and disinfected appropriately. PRACTICE STANDARDS . 5. Clean environmental surfaces, . using Environmental Protection (EPA) registered disinfectant . A review of a facility policy and procedure titled, Glucose Meter with a revision date of 5/15/17, revealed: .Glucose Meter 1. Gather equipment: . 2. Disinfect meter before and after each . use. A review of a facility policy and procedure titled, Waste Management, with a revision date of 10/31/16, revealed: . POLICY The Center's waste disposal system inclu… | 2020-09-01 |
| 74 | 74 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2018-12-13 | 656 | D | 0 | 1 | D9RW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to ensure Resident Identifier (RI) #46's electrical outlets were blocked as specified on his/her care plan. This affected one of 22 residents for whom care plans were reviewed. Findings include: RI # 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #46's Annual MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 10/19/18, revealed RI # 46 had severely impaired cognitive skills and he/she required limited assistance from staff for all Activities of Daily Living. Review of RI #46 's comprehensive care plans revealed an intervention dated 1/26/18 for the following: . Provide (RI #46) with a barrier free environment; electric outlets blocked, walls free of removable items because (RI #46) runs (his/her) hands up and down walls as (he/she) walks about all areas . On 12/11/18 at 10:36 AM , RI #46 was observed in bed pulling the plug out of the outlet and and plugging it back in five times. On 12/11/18 at 3:54 PM, RI #46 was again observed plugging his/her radio in and unplugging it from the wall outlet above his/her bed four times. During an interview with Employee Identifier (EI) #3, the Recreational Director, on 12/13/18 at 3:15 PM, EI #3 said she had reviewed RI #46's care plan in 7/2018. She explained the previous Recreational Director had initiated the intervention to block the electrical outlets, but she left it in place when she reviewed the care plan. EI #3 and the surveyor then went to RI #46's room. After viewing the electrical outlets, EI #3 stated the electrical outlets/plugs were not blocked as specified on the care plan. | 2020-09-01 |
| 75 | 75 | MERRY WOOD LODGE | 15019 | P O BOX 130 | ELMORE | AL | 36025 | 2018-12-13 | 689 | E | 0 | 1 | D9RW11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the Material Safety Data Sheet (MSDS) for a bottle of shampoo, the facilty failed to ensure: 1) Resident Identifier (RI) #46 was not observed repeatedly plugging and unplugging an electrical cord within reach of his/her bed; and 2) RI #21, a cognitively impaired resident, did not have access to a bottle of shampoo, that posed the risk for eye irritation and was identified as potentially harmful if swallowed. On 12/13/18, RI #21 was observed applying the shampoo to another resident's hair (RI #54) during an activity being held in the secure/dementia unit. These failures affected one of 22 sampled residents with electrical outlets in their rooms, and had the potential to affect all 33 residents residing on the secure unit. Findings include: 1) RI # 46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #46's Annual MDS (Minimum Data Set) assessment, with an ARD (Assessment Reference Date) of 10/19/18, revealed RI # 46 had severely impaired cognitive skills and he/she required limited assistance from staff for all Activities of Daily Living. Review of RI #46 's comprehensive care plans revealed an intervention dated 1/26/18 for the following: . Provide (RI #46) with a barrier free environment; electric outlets blocked, walls free of removable items because (RI #46) runs (his/her) hands up and down walls as (he/she) walks about all areas . On 12/11/18 at 10:36 AM , RI #46 was observed in bed pulling the plug out of the outlet and and plugging it back in five times. On 12/11/18 at 3:54 PM, RI #46 was again observed plugging his/her radio in and unplugging it from the wall outlet above his/her bed four times. On 12/13/18 at 10:39 AM, Employee Identifier (EI) #1, a Certified Nursing Assistant (CNA), stated he had been working with RI # 46 for over ten years. EI #1 also stated RI #46 plugs and unplugs his/her radio all the time. On 12/13/18 at 10:54 AM, EI #2… | 2020-09-01 |
| 76 | 76 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2017-03-16 | 314 | D | 0 | 1 | 4ZQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record reviews and a review of a facility document titled, Hand Hygiene Table, the facility failed to ensure Employee Identifier (EI) #1, a Registered Nurse (RN) washed her hands and changed gloves after cleaning the wound of Resident Identifier (RI) #3 and before continuing with RI #3's wound care. EI #1 further failed to ensure she washed her hands and changed gloves when she performed wound care on RI #10's multiple wounds. This deficient practice affected RI #3 and RI #10, two of three residents observed for wound care. Findings Include: A review of an undated facility document titled, Hand Hygiene Table, revealed hand hygiene should be performed using .Either Antimicrobial Soap and Water or Alcohol Based Hand Rub . After handling items potentially contaminated with blood, body fluids, secretions, or excretions . When during resident care, moving from a contaminated body site to a clean site . 1) RI #3 was admitted to the facility on [DATE]. RI #3's physician orders [REDACTED]. On 3/15/2017 at 11:46 a.m., EI #1, the RN/Wound Care Nurse, was observed performing wound care on the Stage 2 pressure ulcer on RI #3's sacrum. EI #1 washed her hands and applied gloves then removed the dirty dressing from RI #3's sacrum. EI #1 then ungloved and washed her hands and applied clean gloves. EI #1 then cleansed the wound with saline soaked gauze. EI #1 did not change gloves and wash hands after cleaning the wound. EI #1 then proceeded to cut the [MEDICATION NAME] gauze with sterile scissors and transferred it to the wound using sterile tweezers and secured it in place using gloved fingers; then covered the wound with the [MEDICATION NAME] Border dressing. On 3/16/2017 at 2:33 p.m. and interview was conducted with EI #1, the RN who performed the wound care on RI #3. EI #1 was asked when should gloves be changed and hands washed during wound care. EI #1 responded, prior to touching the old dressing, prior to clea… | 2020-09-01 |
| 77 | 77 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2017-03-16 | 367 | D | 0 | 1 | 4ZQH11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review and review of the facility's policy titled, Therapeutic Diets, the facility failed to ensure Resident Identifier (RI) #3 received a regular mechanical soft diet for breakfast and lunch on 3/15/2017. This affected RI #3, one of 14 sampled residents observed for meals. The facility's Resident Census and Conditions of Residents form, dated 3/14/2017, indicated 40 residents in the facility received mechanically altered diets. Findings Include: The facility's policy dated (MONTH) 2014 titled, Therapeutic Diets, documented Policy Statement It is the center policy to provide therapeutic diets in accordance with physician orders [REDACTED].>RI #3 was admitted to the facility on [DATE]. A review of RI #3's Annual Minimum Data Set with an Assessment Reference Date (ARD) of 9/13/2016, identified RI #3 as being cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. RI #3 was assessed as being independent with eating after set-up. RI #3's care plan titled Resident is at nutritional risk . with a problem onset date of 9/13/2016 last reviewed 3/7/2017 had an approach of . Diet as ordered . RI #3's (MONTH) (YEAR) Physician order [REDACTED].#3 was ordered a regular with mechanical soft diet. On 3/15/2017 at 8:20 a.m., during the breakfast meal observation, RI #3's plate contained two whole sausage patties. RI #3 consumed all of the oatmeal and half of the biscuit provided on the tray, but did not eat the sausage patties. On 3/15/2017 at 12:21 p.m., during the lunch meal observation, RI #3's plate contained two pieces of fried chicken, a whole thigh and leg. RI #3 consumed half of the chicken noodle soup, half of the roll provided, but did not eat the fried chicken. RI #3 explained to the surveyor that he/she had his/her top teeth pulled in (MONTH) (YEAR), and it hurt his/her gums to eat hard foods, so he/she did not eat the fried chicken. An interview was conducted with Employee… | 2020-09-01 |
| 78 | 78 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2017-03-16 | 371 | F | 0 | 1 | 4ZQH11 | Based on observations, interview, and review of the facility's policies titled Receiving and Food and Supply Storage Procedures, the facility failed to ensure: 1) food items were properly labeled with the item name and use by date and were discarded once the use by date was exceeded; and 2) chicken was thawed in the walk-in cooler in a manner to prevent cross contamination. These failures had the potential to affect all residents receiving meals from the kitchen. The facility's Resident Census and Condition of Residents form, dated 03/14/2017, indicated 144 residents resided in the facility. Findings include: 1) Review of the facility policy titled Receiving, dated 05/2014, revealed the following: . Action Steps . 6. All food items will be appropriately labeled and dated either through manufacturer packaging or staff notation. 7. All food items will be stored in a manner that insures appropriate and timely utilization based on the principles of first in - first out . During the initial tour of the kitchen on 03/14/2017 at 2:00 p.m., the following items were observed in the walk-in cooler: - two plastic containers of soup not labeled with an item name - chopped ham (identified by the Dietary Manager) not labeled with an item name - Bologna labeled with a use by date of 03/07/2017 - another container of Bologna with a use by date of 03/11/2017 - Vegetable soup labeled with a use by date of 03/12/2017 - Turkey labeled with a use by date of 03/11/2017 - Sausage for mechanical soft and puree diets with no use by date On 03/15/2017 at 11:28 a.m. three pans of jello were observed in the cooler with a use by date of 03/14/2017. Employee Identifier (EI) #4, the Dietary Manager, was interviewed on 03/16/2017 at 2:45 p.m EI #4 said food should be labeled upon placement into the cooler with the date received, open date, use by date, and what the item is. EI #4 said if items were not labeled with the use by date you would not know when it should be discarded. EI #4 also explained items past their use by dates should be discar… | 2020-09-01 |
| 79 | 79 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2017-03-16 | 441 | D | 0 | 1 | 4ZQH11 | Based on observation, interview, and review of a document titled Hand Hygiene Table, the facility failed to ensure staff wore gloves when changing dirty bed linens. Further, staff did not wash hands or change gloves prior to handling the clean linens. This deficient practice was observed during one of one observation of staff changing dirty linens. Findings include: Review of the facility's undated document titled Hand Hygiene Table revealed staff should either use antimicrobial soap and water or an alcohol based hand rub before and after handling clean or soiled linens. On 03/15/2017 at 8:50 a.m., Employee Identifier (EI) #11, a Certified Nursing Assistant (CNA), was observed changing bed linens in Resident Identifier (RI) #14's room. EI #11 did not wear any gloves to remove the soiled linens from the bed and was observed holding the linens against her clothing. EI #11 then replaced the soiled linens with clean linens without washing her hands or applying gloves. EI #11, the CNA, was interviewed on 03/15/2017 at 2:45 p.m EI #11 said they strip resident beds on Mondays, Wednesdays, and Fridays. EI #11 agreed she did not wear gloves when changing the linens, but said she had never been told she had to. EI #11 was then asked when she should wash hands when changing bed linens. She stated she used hand sanitizer after she made the bed with clean linens, but said she had not cleaned her hands after she took the dirty linens off or put the clean ones on. EI #11 said she should wash her hands to avoid transferring anything to the clean linens. EI #2, the Infection Control Nurse, was interviewed on 03/16/2017 at 3:00 p.m EI #2 explained staff should wear gloves when changing bed linens to prevent the spread of infection. She also stated staff should wash hands before and after handling the linens. She said it was important for staff to wash hands after handling dirty linens, before touching the clean ones, to prevent transferring germs from the dirty to the clean. | 2020-09-01 |
| 80 | 80 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2019-05-09 | 609 | D | 1 | 1 | HQGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, medical record reviews, review of facility policies titled, ABUSE, NEGLECT AND EXPLOITATION and REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION and review of a document titled, Alabama Department of Public Health Online Incident Reporting System, the facility failed to timely report 13 allegations of abuse to the State Agency after the incidents occurred. This affected 14 of 71 facility reported incidents that were reviewed and affected Resident Identifier's (RI) #434, #74, #79, #47, #8, #69, #115, #22, #21, #104, #46, #38, #109, #70 and two unsampled, discharged residents. Findings Include: A review of the facility policy titled ABUSE, NEGLECT AND EXPLOITATION, with no date, revealed the following: .The facility must: .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: a. Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, . A review of the facility's policy titled, REPORTING ALLEGATIONS OF ABUSE, NEGLECT AND EXPLOITATION, with no date, documented: Policy: It is the policy of this facility to report all allegations of abuse/neglect/exploitation to appropriate agencies in accordance with current state and federal regulations. Review of the Alabama Department of Public Health Online Incident Reporting System, revealed the following: 1) An incident of mistreatment was reported by a Certified Nursing Assistant (CNA), regarding another CNA being abnormally rough with Resident Identifier (RI) #434 on 04/25/2019 at 10:30 AM. This incident was not reported to the State Agency until 04/25/2019 at 3:29 PM. 2) An incident of verbal abuse was reported occurring on 01/12/2019 at 6:57 PM where RI #79 was fussing at other residents and staff and RI #74 threatened to kill RI #79. … | 2020-09-01 |
| 81 | 81 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2019-05-09 | 761 | D | 0 | 1 | HQGM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of a facility policies titled, STORAGE OF MEDICATIONS AND BIOLOGICALS and CONTROLLED MEDICATION STORAGE, observations and interviews, the facility failed to ensure: 1. the A Wing medication storage room / cabinet did not contain expired medications, including five unopened bags of normal saline intravenous fluids, along with eight other medication including creams, ointments, gel, liquid and tablets and 2. the Medication Cart for the 600 hall did not include a medication (narcotic) labeled with an unreadable expiration (discard) date. This affected one of two medication rooms observed and one of four medication carts observed. Findings include 1. A review of the facility's policy titled, 3.1: STORAGE OF MEDICATIONS AND BIOLOGICALS, with a date of 3/11, revealed: . Procedure . 11. Outdated, contaminated, or deteriorated medications and . are removed from stock, disposed of according to procedures for medication disposal, . The Surveyor reviewed another facility policy titled, 4.3: Disposal of Medication Non-Controlled Medication Destruction, with a date of 3/11, . Policy . expired medications, .are destroyed or disposed of per federal/state regulations. On 05/08/19 at 04:29 pm, the Surveyor observed, with Employee Identifier (EI) # 5, the A Wing Medication Storage Room. Observations were made of the following items: One of the lower cabinets contained a paper bag with expired intravenous fluids (see the expiration dates below). The Surveyor observed with EI# 5, a total of five unopened bags of normal saline 0.9 Sodium Chloride injection, labeled for a resident,t one bag with an expiration of [DATE] (YEAR), one bag with an expiration date of (MONTH) (YEAR) and three bags with an expiration date of (MONTH) (YEAR). The Surveyor also observed, with EI# 5, an upper cabinet containing the following: 1. one opened bottle of Icy Hot Arthritis pain relief lotion 5.5 ounces with a handwritten first name on it, expired 6/14; 2. one open… | 2020-09-01 |
| 82 | 82 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2019-05-09 | 880 | D | 0 | 1 | HQGM11 | Based on observation, interviews and a review of a facility policy titled, Infection Prevention and Control Program, the facility failed to ensure EI (Employee Identifier) #4 folding laundry, did not allow the laundry to touch the floor or her clothing. This affected 1 of 1 laundry staff observed folding clean laundry. Findings include: A facility policy titled, Infection Prevention and Control Program, date implemented, 11/28/17, revealed, Policy: It is a policy of this facility to establish and 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. Policy Explanation and Compliance Guidelines: .10. Linens: a. Laundry and direct care staff shall handle, store, process and transport linens so as to prevent spread of infection. d. Never place linen on floor . An observation was made on 05/09/19 at 10:11 a.m. of the laundry area. EI #4 was observed folding sheets, gowns, and under pads. Two sheets were observed touching the floor while being folded. Multiple sheets, gowns and under pads were observed touching EI #4 's clothing as he/she folded. On 05/09/19 at 10:38 AM, an interview was conducted with EI #4 , laundry staff. EI #4 was asked, should laundry touch your clothing while folding. EI #4 replied, she did not think so. EI #4 was asked, should the laundry touch the floor while folding. EI #4 replied, no. EI #4 was asked, did the laundry touch her clothing, or the floor, when she was folding clothes. EI #4 replied, if so, it was by accident, the fans were blowing everywhere. EI #4 was asked, where was that load of laundry going, that she was folding. EI #4 replied, each wing, it was divided up. EI #4 was asked, what was the potential concern of the laundry touching she clothing or touching the floor. EI #4 replied, it would be considered dirty. On 05/09/19 at 10:48 AM, an interview was conducted with EI #3 Assistant Director Of Nursing (ADON)/ Infection Co… | 2020-09-01 |
| 83 | 83 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 584 | D | 0 | 1 | YKK111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and review of a facility policy titled, Resident Rights Policy, the facility failed to ensure RL (Room Locator) 1-4 were free of scrapes, gashes, cracks, and missing paint on the walls. The facility further failed to ensure Resident Identifier (RI) #'s 15, 31 and 93's rooms did not have deep scrapes, dents, and missing paint on the walls, and RI #31's arm rests on his/her wheel chair were not torn. This affected three of 111 rooms in the facility, and affected one of 10 wheelchairs observed during the survey. Findings Include: (1) A review of a facility policy titled, Resident Rights Policy, with a revised date of 12/19/16, revealed the following: . Safe environment. The resident has a right to a . comfortable and Homelike environment . On 05/08/18 at 4:57 p.m., the surveyor observed in RL #1, on the A and B side of the room, walls with deep punctures in the sheetrock, and a brown stain in the ceiling on the B side of the room. On 05/08/18 at 5:12 p.m., the surveyor observed in RL #2, on the A and B side of the room, walls with gashes and holes in sheetrock. On 05/08/18 at 5:30 p.m., the surveyor observed in RL #3, the ceiling had cracked plaster and brown stain on the left side. On 05/09/18 at 8:36 a.m., the surveyor observed in RL #4, chipped paint on the walls on both the A and B sides of the room. Behind the head board on the A side of the room there was a hole in the wall. In the bath room, in the middle of the wall, was chipped paint and there was a hole in the wall in the corner behind the dresser on the B side of the room. On 05/10/18 at 5:45 p.m., the surveyor toured rooms in the facility with Employee Identifier (EI) #19, the Maintenance Director and observed the same issues previously documented. On 05/10/18 at 6:10 p.m., the surveyor conducted an interview with EI #19. EI #19 was asked when touring with the surveyor, did he observe in RL #'s 1-4 scrapes, holes, gashes, cracks and missing paint on t… | 2020-09-01 |
| 84 | 84 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 641 | D | 0 | 1 | YKK111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Resident Identifier (RI) #89's Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/27/18, was coded correctly under urinary continence for RI #89's use of a Foley catheter. Findings Include: RI #89 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a Quarterly MDS dated [DATE], revealed RI #89 was coded as always continent. On 05/08/18 at 5:00 p.m., RI #89 was observed in bed. A Foley catheter was observed hanging to the left side of the bed contained in a privacy bag. On 05/10/18 at 1:50 p.m., an interview was conducted with Employee Identifier (EI) #4, a Registered Nurse (RN)/MDS Coordinator. EI #4 was asked if RI #89 had a Foley catheter. EI #4 replied, yes. EI #4 was asked, when was RI #89's Foley catheter ordered. EI #4 replied she was not sure, RI #89 had it a long time. EI #4 was asked how should the urinary continence section on the 03/27/18, MDS be coded. EI #4 replied, Foley catheter and not rated which was a 9. EI #4 was asked in the under urinary continence section, it was coded as 0 always continent, would that assessment be accurate. EI #4 replied, no. EI #4 was asked what was the risk of the MDS not being coded accurately. EI #4 replied, some one may not realize the resident had a Foley catheter. | 2020-09-01 |
| 85 | 85 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 686 | D | 0 | 1 | YKK111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to ensure: (1) Resident Identifier (RI) #53, a resident at risk for developing pressure ulcers, intervention to have his/her feet elevated off the mattress, and to wear heel protectors while in bed was implemented. This was observed on two of three days of the survey; and (2) RI #15 and RI #93, residents at risk of developing pressure ulcers, had cushion on the oxygen tubing behind their ears. This was observed on two of three days of the survey. These deficient practices affected RI #53, one of three residents sampled for pressure ulcers, and RI #15 and RI #93, two of three sampled residents using oxygen: Findings Include: (1) RI #53 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. RI #53's Pressure Ulcer care plan, with a Problem Onset date of 06/14/17, documented: . Approaches . * Apply heel protects to feet while in bed and float heels . A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/21/18, identified RI #53 as being at risk for pressures ulcers. On 05/09/18 at 10:32 a.m., the surveyor observed the Treatment Nurse, Employee Identifier (EI) #11, prepare to provide wound care to the top of a toe on RI #53's right foot. RI #53's feet were on the mattress and no heel protectors were worn at this time. On 05/10/18 at 8:01 a.m., the surveyor observed RI #53's bare feet on the mattress, with no heel protectors on. On 05/10/18 at 2:30 p.m., the surveyor conducted an interview with EI #12, RI #53's assigned Certified Nursing Assistant (CNA). The surveyor asked EI #12 how should RI #53's feet be when he/she was in bed. EI #12 said they should be elevated on pillows so RI #53's heels would not rub on the bed and get a pressure sore on them. The surveyor asked EI #12, according to RI #53's plan of care, what should be on RI #53's feet. EI #12 said heel protectors. When asked what was the rationale for RI #53 having… | 2020-09-01 |
| 86 | 86 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 812 | F | 0 | 1 | YKK111 | Based on observations, interviews and review of facility policies titled, Equipment, Food Storage: Dry Goods, Service Line Checklist, Food: Preparation, and Staff Attire and review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure: 1) a stored blender was free of debris; 2) food items in the dry storage area was sealed; 3) temperatures of all food items on the trayline were taken; and 4) dietary workers hair was completely enclosed in their hairnets and strains of loose hair was not on the back of a dietary worker's shirt. This had the potential to affect 131 of 132 residents who received meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Equipment, with a revised date of 09/17, revealed: Policy Statement All food service equipment will be clean, sanitary . Procedures . 3. All food contact equipment will be cleaned and sanitized after every use. A review of the (YEAR) Food Code, revealed: . 4-701.10 Food Contact Surfaces . Equipment Food-Contact Surfaces . shall be SANITIZED. 4-702.11 Before use After Cleaning. FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED Before Use after cleaning. On 05/08/18 at 4:57 p.m., the surveyor observed powdered sugar and icing located on the bowl holder and on the back plate of the mixer. The mixer was stored away under a plastic covering to be used again. There was chocolate icing on the bag that covered the mixer. On 5/10/18 at 1:13 p.m., an interview was conducted with (Employee Identifier) EI #23, a Dietary Aide. EI #23 was asked what did she see on the mixer on 05/08/18. EI #23 replied, powdered sugar. EI #23 was asked was it put away for next use. EI #23 replied, yes ma'am. EI #23 was asked, who was responsible for making sure equipment was clean before covering it up. EI #23 replied, the last person who used it. EI #23 was asked why was it important that equipment was clean when putting it away. EI #23 replied, everything was suppose to be sanitized. EI #23 … | 2020-09-01 |
| 87 | 87 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 814 | F | 0 | 1 | YKK111 | Based on observation, interview and a review of the (YEAR) Food Code U.S. (United States) Public Health Service FDA (Food and Drug Administration), the facility failed to ensure the dumpster lid was closed. This was observed on 05/10/18. This has the potential to affect all 132 residents residing in the facility. Findings Include: A review of the (YEAR) Food Code, revealed: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnables used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors or covers. On 05/08/18 at 5:09 p.m., the surveyor along with (Employee Identifier) EI #23, a dietary aide, toured the outside area of the kitchen. The first dumpster had the lid completely open. The second one had an one inch gap between the lids. On 05/10/18 at 1:03 p.m., an interview was conducted with EI #23. EI #23 was asked what did she observe when going out to the dumpster. EI #23 replied, the first dumpster lid was open. EI #23 was asked what did she observe about the second dumpster. EI #23 replied, it had a space between the lids. EI #23 was asked who was responsible for keeping the dumpster lids closed. EI #23 replied, the first dumpster, the kitchen. EI #23 was asked what did the facility's policy say regarding the dumpster. EI #23 replied, they were suppose to be closed after each use. EI #23 was asked what was the potential harm when the dumpster lid was not closed. EI #23 replied, a racoon or something could get in the dumpster. | 2020-09-01 |
| 88 | 88 | HATLEY HEALTH CARE INC | 15023 | 300 MEDICAL CENTER DRIVE | CLANTON | AL | 35045 | 2018-05-10 | 880 | D | 0 | 1 | YKK111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of a facility policy titled, Incontinent & (and) Catheter Care, the facility failed to ensure a Certified Nursing Assistant (CNA) washed her hands during glove changes while performing incontinent care for Resident Identifier (RI) #123. This was observed on 05/09/18, and affected RI #123, one of one residents observed for incontinence care. Findings Include: A review of a facility policy titled, INCONTINENT & CATHETER CARE, with a revised date of 04/06/10 revealed: . IV. COMPLETION 1. Wash hands and change gloves as deemed necessary during the procedure to prevent the spread of infection. RI #123 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 05/09/18 at 9:05 a.m., Employee Identifier (EI) #5, a CNA was observed performing incontinent care for RI #123. EI #5 gathered the supplies washed her hands and put on gloves. EI #5 positioned RI #123, loosened the brief and wiped the perineal area of RI #123. EI #5 removed her gloves, picked up a clean brief and put on clean gloves. EI #5 rolled RI #123 to the right side and cleaned the buttock area. EI #5 placed the clean brief under RI #123, and applied moisture barrier cream. EI #5 removed her gloves and put on clean gloves. EI #5 placed a clean pad under RI #123. EI #5 did not wash her hands between glove changes. On 05/10/18 at 8:35 a.m., an interview was conducted with EI #5. EI #5 was asked what was the policy on washing hands during incontinent care. EI #5 replied, wash hands before and after resident care and between glove changes. EI #5 was asked, what should be done when gloves are removed. EI #5 replied, wash hands or use sanitizer. EI #5 was asked if she washed her hands between glove changes. EI #5 replied, no. EI #5 was asked what was the risk when removing gloves during incontinent care and not washing hands. EI #5 replied, cross contamination. On 05/10/18 at 1:20 p.m., an interview was conducted with EI #3,… | 2020-09-01 |
| 89 | 89 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2020-02-13 | 550 | D | 0 | 1 | SQ2Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review and review of a facility policy titled, Urinary Catheter Care, the facility failed to ensure Resident Identifier (RI) #84's Foley catheter bag was in a privacy bag and not visible from the hallway on 02/11/20. This deficient practice affected RI #84, one of one resident sampled with a Foley catheter. Findings Include: A review of a facility policy titled, Urinary Catheter Care, with an effective date of 01/16/14, and a supersedes date of 11/01/01, documented: . PR[NAME]ESS: . i) . Bags should be covered to provide privacy. RI #84 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/22/19, assessed RI #84 as having an indwelling catheter. On 02/11/20 at 10:16 a.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 12:50 p.m., RI #84's Foley urinary catheter bag was observed uncovered, attached to the left lower side of bed. The bag contained clear yellow urine that was visible from the hallway. On 02/11/20 at 3:39 p.m., the surveyor conducted an interview with Employee Identifier (EI) #8, RI #84's assigned Registered Nurse (RN). EI #8 stated RI #84's Foley catheter bag was not in a privacy bag when she began her shift at 10:00 a.m. EI #8 was asked if the Foley catheter should have had a privacy bag. EI #8 said yes. The surveyor asked EI #8 what was the concern when a resident's Foley catheter bag was not covered. EI #8 replied, invasion of the resident's privacy. On 02/13/20 at 02:04 p.m., the surveyor conducted an interview with EI #10, RN/DON (Director of Nursing). The surveyor asked EI #10 who was responsible for ensuring the Foley catheter bag was covered with a privacy cover for each resident. EI #10 said all clinical staff that are assigned to that… | 2020-09-01 |
| 90 | 90 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2020-02-13 | 812 | F | 1 | 1 | SQ2Q11 | > Based on observations, interviews, review of the (YEAR) Food and Drug Administration (FDA) Food Code, and review of the facility's policies titled, General Food Preparation and Handling, General Sanitation of Kitchen, Food Storage, Cleaning Dishes/Dish Machine, Cleaning Instructions: Ovens, Cleaning Instructions: Floors, Tables and Chairs, and Cleaning Instructions: Refrigerators, the facility failed to ensure: 1) seven items in the reach in cooler were discarded on the used by date, 2) the floors in the dry food storeroom were clean from rodent droppings, underneath the shelving, 3) there was not a white substance on a pan observed on the clean rack, 4) open food items in the walk-in freezer were sealed, 5) the interior of the walk-in cooler was clean and dry, 6) the convection oven did not have a heavy build-up of dark black residue inside the oven, 7) a pole with chipping, flaking paint was not hanging directly beside and above a food preparation area, and 8) a frying pan did not have a non-stick coating peeling off. This had the potential to affect 149 of 149 residents receiving meals from the kitchen. Findings include: 1.) A review of a facility policy titled, Food Storage with a date of 2013, revealed: . Procedure: . 13. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. On 02/11/20 at 08:48 a.m., Employee Identifier (EI) #1, the Dietary Cook, accompanied the surveyor during the initial tour of the kitchen. In the reach-in refrigerator, the surveyor and EI #1 observed the following: (1) two full pans of leftover mechanical soft meatballs-cooked labeled with a use by date of 2/10/20; (2) leftover cooked carrots labeled with a… | 2020-09-01 |
| 91 | 91 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2020-02-13 | 880 | D | 0 | 1 | SQ2Q11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed hands or used hand sanitizer after administering Resident Identifier (RI) #213's nebulizer treatment and placing a garbage bag in the medication cart garbage can, prior to reentering RI #213's room to clean RI #213's facemask; and 2) a Certified Nursing Assistant (CNA) washed hands or used hand sanitizer after she emptied RI #105's urinal, prior to exiting RI #105's room. This affected one of four residents observed during medication administration pass and one of one sampled resident for whom a CNA was observed emptying a urinal. Findings Include: A review of a facility policy titled Hand Hygiene, with a date of 7/30/2016, revealed . Hand Hygiene procedures include the use of alcohol-based hand rubs . and handwashing with soap and water . Always perform hand hygiene in the following situations . Before exiting the patient's care area after touching the patient or the patient's immediate environment . after glove removal . 1) RI #213 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/13/20 at 9:04 a.m., the surveyor observed Employee Identifier (EI) #7, a LPN, during medication administration pass for RI #213. EI #7 gave RI #213's nebulizer treatment and placed a plastic garbage bag in the medication cart garbage can. EI #7 did not wash or sanitize her hands prior to reentering RI #213's room. EI #7 then cleaned RI #213's facemask attached to the nebulizer machine, removed her gloves, and did not wash or sanitize her hands prior to exiting RI #213's room. On 2/13/20 at 9:56 a.m., the surveyor conducted an interview with EI #7, a LPN. EI #7 was asked what she should have done after she started RI #213's nebulizer treatment, placed a plastic garbage bag in the medication cart garbage can, and prior to reentering RI #213's room. EI #7 stated sh… | 2020-09-01 |
| 92 | 92 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2018-02-15 | 554 | D | 0 | 1 | EZGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and review of a facility policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, the facility failed to ensure Resident #293 was assessed for self-administering nebulizer treatments. This affected one of one resident reviewed for self administration. Findings include: Review of the facility's policy titled RESIDENT SELF ADMINISTRATION OF MEDICATION, updated 10/31/2017, revealed the following: POLICY: Each resident who desires to self-administer medication may be permitted to do so if Facility Interdisciplinary Care-Plan Team has determined that the practice would be safe for the resident and other residents of the facility. 1. The medication self-administration assessment is conducted by the interdisciplinary team . 2. The results of the interdisciplinary team assessment are recorded on the Self-Administration Assessment Form, which is placed in the resident's medical record. Resident #293 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #293's (MONTH) (YEAR) physician's orders [REDACTED]. There were no orders listed indicating Resident #293 could self-administer medications or nebulizer treatments. Review of Resident #293's comprehensive care plans revealed no care plan or approaches addressing self-administration of medications. On 02/14/18 at 9:26 AM, Resident #293 was observed receiving a nebulizer treatment. No staff were present in the room at the time. Resident #293 reached over and turned the machine off while the surveyor was speaking with the spouse; visible nebulizer solution remained in the nebulizer cup. Employee Identifier (EI) #1, Registered Nurse, was interviewed on 02/15/18 at 05:26 PM. When asked which residents she had that could self-administer nebulizer treatments, EI #1 referred to a list she had, and said Resident #293 was one of the ones she had that was able to self-administer nebulizer treatments. EI #1 explained she put the medica… | 2020-09-01 |
| 93 | 93 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2018-02-15 | 690 | D | 0 | 1 | EZGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of incontinent care on 02/14/18, medical record review, staff interviews, and review of facility policies titled Urinary Catheter Care, and a facility document titled Perineal/Catheter Care, the facility failed to ensure the Certified Nursing Assistant (CNA) properly cleaned Resident #33's catheter tubing. Further, the CNA failed to clean Resident #33's perineal area of fecal matter, prior to the completion of care. These failures were observed during one of one catheter and incontinence care observations. Findings Include: A review of a facility policy titled: Urinary Catheter Care with an effective date of (MONTH) 16, 2014 documented: . PURPOSE: Urinary catheter care helps to prevent urinary tract infection . PR[NAME]ESS: . II. Catheter Care . c) Wash the catheter itself by holding on to the catheter at the insertion site; wash with one stroke downward . A review of a facility document titled: . Perineal/Catheter Care . with a date of 12/18/16 documented: . CATHETER CARE . 2 . Gently . to expose meatus . A review of RI #33's Quarterly Minimum Data Set with an assessment reference date of 11/22/17 revealed RI #33 was severely impaired in cognition, incontinent of bowel and dependent upon staff for hygiene. A review of the hospital DISCHARGE SUMMARY dated 01/04/2018 documented: . DISCHARGE Diagnosis: [REDACTED]. RI #33 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/2018 at 5:45 p.m., Certified Nursing Assistant, Employee Identifier (EI) #7 provided incontinent care for RI #33. The resident rolled his/her self to left side and EI #7 wiped the buttock area three times front to back, using a clean wash cloth with each wipe. Bowel movement was visible on each wash cloth used. RI #33 had a foley catheter in place. EI #7 then cleaned the catheter tubing toward the residents perineum. RI #33 rolled onto his/her back. Without changing the soiled gloves or washing her hands, EI #7 then placed a clean … | 2020-09-01 |
| 94 | 94 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2018-02-15 | 803 | D | 0 | 1 | EZGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews, and review of the facility's policy titled FOOD PREFERENCES, the facility failed to ensure Resident #117 was served foods in accordance with his/her assessed preferences. This affected one of 132 residents for whom meals were observed. Findings include: Review of the facility's undated policy titled FOOD PREFERENCES revealed the following: POLICY: Information will be gathered upon admission to inform the dietary department of the resident/patient's food preferences and diet history. PR[NAME]EDURE: 1. Interview the resident for the following information: . *Food preferences, intolerances, allergies [REDACTED]. Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/14/18 at 12:00 PM, Resident #117 was observed eating the lunch meal. Resident #117 said he/she was not supposed to get any fried foods but did so today. The tray card on Resident #117's lunch tray listed fried foods as a dislike. Resident #117's family member (also present) stated he/she could not eat the fried french fries or fried macaroni bites the facility had provided on the tray. On 02/14/18 at 12:20 PM, Employee Identifier (EI) #3, Certified Nursing Assistant, was asked who was responsible for making sure residents received items in accordance with their likes/dislikes. EI #3 stated the dietary department was responsible. EI #3 verified Resident #117 had received fried foods on his/her tray. On 02/15/18 at 06:52 PM, EI #4, the Certified Dietary Manager, explained the Dietary staff list residents' likes and dislikes on their tray tickets and keep each resident's preferences on file in the computer. When asked what system was in place to ensure the items listed on the tray tickets under likes and dislikes were honored, EI #4 said the cooks or person plating the trays read the tickets. EI #4 explained dietary staff were supposed to look at the preferences and, if a resident had a dislike listed, they… | 2020-09-01 |
| 95 | 95 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2018-02-15 | 812 | F | 0 | 1 | EZGG11 | Based on observations, interview of the Certified Dietary Manager (CDM), Employee Identifier (EI) #4, and a record review of the Food Code U.S. Public Health Service (USPHS) and FDA (Food and Drug Administration) 2013, the facility failed to assure: 1. adequate immersion time for food preparation equipment sanitized in hot water which measured 175 degrees Fahrenheit (3-compartment sink). 2. effective cleaning/sanitizing of utensils and equipment to prevent the potential growth of foodborne organisms, a. assure dinnerware, sectional plates, was cleaned to sight/touch (machine dishwashing) and air dried, b. assure equipment, a Tea Urn/spigot a non Time/Temperature control for safety, was cleaned every 24 hours. The spigot was observed with a brown solid build-up, 3. the dishmachine, which sanitizes with chemical, maintained chemical efficacy, by testing, monitoring/documenting the concentration prior to use, These failures had the potential to affect all 132 residents receiving meals from the facility's kitchen. Findings include: 1. Review of the 2013 Food Code by the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 4-7 SANITIZING OF EQUIPMENT AND UTENSILS METHODS 4-703.11 Hot Water and Chemical: After being cleaned .shall be SANITIZED in: (A) Hot water manual operation by immersion for a least 30 seconds and as specified under . 02/13/2018 @7:00 PM, manual dishwashing (pots/pans) was observed. Water in 3rd sink (sanitizing) temperature was measured by the CDM (EI #4), to be 175 degrees F. The employee was observed to dip a washed pot in and out of the hot water, while holding the handle. (For sanitizing, item must remain in hot water 170 or above and less than 180 degrees F. for 30 seconds.) After the above observation, the CDM (EI #4), was asked, why staff failed to leave the item in the hot water for 30 seconds. The CDM responded by saying she could not answer but knows better. 2. (a) Review of the 2013 Food Code by the United States Public Health Ser… | 2020-09-01 |
| 96 | 96 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2018-02-15 | 880 | D | 0 | 1 | EZGG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of incontinent care on 02/14/2018 and medication administration on 02/13/2018, a review of the facility's policy's titled Urinary Catheter Care and Hand Hygiene, as well as staff interviews, the facility failed to ensure: 1) A Licensed Practical Nurse (LPN) did not place her ungloved fingers inside medication crush pouches to empty the crushed medications for administration of Resident #58's medications: [REDACTED] 2) A Certified Nursing Assistant (CNA) failed to wash her hands after removing soiled gloves and before putting on clean gloves during the provision of incontinence care. The CNA then touched clean items, including linens and Resident Identifier (RI) #33's clean brief and gown. These failures affected one of four nurses observed during medication pass observations and one of one incontinent care observations, involving RI #58 and RI #33. Findings Include: A review of Potter and Perry, Ninth Edition: FUNDAMENTALS OF NURSING Chapter 32 Medication Administration, page 656, documented: . (1) . Do not touch medication with fingers. (2) To prepare unit-dose tablets . place tablet . directly into medicine cup . A review of a facility policy titled: Hand Hygiene with a date of 07/30/16 documented: . 2. Indications for Hand Hygiene Always perform hand hygiene in the following situations: . After glove removal . 1) RI #58 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #58's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date of 12/11/17 revealed RI #58 was severely impaired in cognition (with a Brief Interview for Mental Status score of 4 of a possible 15). On 02/13/18 at 7:10 p.m., LPN/Employee Identifier (EI) #6 administered medication to RI #58. EI #6 placed [MEDICATION NAME] 20 milligram (1 tablet) in a crush pouch and crushed the medication. EI #6 opened the pouch with her ungloved fingers and emptied the medication into a medication cup. EI #6 placed [MEDICATION N… | 2020-09-01 |
| 97 | 97 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2019-03-20 | 812 | F | 0 | 1 | ITMZ11 | Based on observation, interview and review of facility policies titled, FOOD STORAGE, CLEANING DISHES/DISH MACHINE AND CLEANING INSTRUCTIONS OVEN, the facility failed to ensure: 1. a plastic bag of riblets in the refrigerator was labeled with a date and use by date, 2. staff air dried sectional plates; and 3. the main baking oven was free of a thick black substance. This had the potential to affect 128 of 128 residents receiving meals from the kitchen. Findings Include: A review of a facility policy titled, FOOD STORAGE, with a 2013 date revealed: PR[NAME]EDURE: . 14. Refrigerated Food Storage: . f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates . A facility policy titled, CLEANING DISHES/DISH MACHINE with a 2013 date revealed: PR[NAME]EDURE: . 9. Allow the dishes to air dry on the dish racks. A facility policy titled, CLEANING INSTRUCTIONS: OVENS with a (YEAR) date revealed: Policy: Ovens will be cleaned as needed . Spills and food particles will be removed after each use. 1. On 3/18/19 4:56 PM a plastic double sealed bag, labeled riblets, was observed in the walk in refrigerator. No date or use by date was on the bag. The surveyor asked Employee Identifier (EI) #3, Dietary Manager what was in the bag. EI #3 replied, riblets. EI #3 was asked where was the date or use by date. EI #3 replied, it did not have one. EI #3 was asked if the riblets should be labeled with the use by date. EI #3 replied, yes. EI #3 was then asked why should it have a use by date. EI #3 replied because it was opened, so you will know when it was opened and it does not make anyone sick. 2. On 3/18/19 at 5:55 PM, the surveyor observed, during tray line, a divided plate with water on the inside of the plate in two sections. EI # 3 stated she observed the water on the inside of the divided plate in two compartments as well. EI # 3 was asked should there be water droplets on the plate. EI # 3 replied, no, it should be air dried com… | 2020-09-01 |
| 98 | 98 | SENIOR REHAB & RECOVERY AT LIMESTONE HEALTH FACILI | 15024 | 1600 WEST HOBBS STREET | ATHENS | AL | 35611 | 2019-03-20 | 880 | D | 0 | 1 | ITMZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, Dressing - Clean, the facility failed to ensure staff gloves were removed and hand hygiene was performed after cleaning a sacral wound and before applying ointment and touching other parts of the resident's body, pillow, blanket and bed remote. This affected Resident Identifier (RI) #65, one of 2 residents observed for wound care. Findings include: A facility policy titled, Dressings-Clean, with an effective date of (MONTH) 1, 2001, revealed: . Process: . 13. Remove gloves and wash hands. A facility policy titled, Hand Washing, with an effective date of (MONTH) 1, 2001, revealed: . Standard: Hand washing should be performed between procedures with residents. RI #65 was readmitted to the facility on [DATE] with two sacral ulcers. [DIAGNOSES REDACTED]. Review of the resident's physician's orders [REDACTED]. On 03/19/19 at 10:14 am, the surveyor observed pressure ulcer care provided by Employee Identifier(EI) #2, the facility Certified Registered Nurse Practitioner, and EI #4 Registered Nurse/Wound Nurse, to RI #65. EI #2 was observed to remove the dressing to the sacral area and discarded it into the trash container. She then discarded the gloves into the trash container, washed her hands in the bathroom sink and applied new gloves. EI #4 stated this was a new wound area from around the (MONTH) 15 th, 2019. EI #2 cleaned the sacral area wound with normal saline applied to folded gauze handed to her by EI # 4. EI#2 then wiped the wound on the sacral area with the gauze. EI #2 proceeded to touched the resident on the gown with the same gloved hand. EI #2 applied [MEDICATION NAME] powder mixed with Venalex ointment from a medicine cup with a Q-tip. After applying the ointment EI #2 then touched RI #65's pillow under the resident's head, the resident's arm and then the blanket lying on the bed, pulling it up over RI #65's, wearing the same soiled gloves. EI #2 picked up the bed… | 2020-09-01 |
| 99 | 99 | WETUMPKA HEALTH AND REHABILITATION, LLC | 15027 | 1825 HOLTVILLE ROAD | WETUMPKA | AL | 36092 | 2017-02-23 | 325 | D | 0 | 1 | 6GSS11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and a review of a facility policy titled Therapeutic Supplements, the facility failed to ensure RI (Resident Identifier) # 14 a resident at risk for weight loss received a magic cup as ordered with the lunch and dinner meal on 2/22/17. This affected one of 12 sampled residents who were observed for meals on 2/22/17. Findings Include: A review of a facility policy titled, Therapeutic Supplements with an effective date of (MONTH) 13, 2013 documented the following: .PURPOSE: Residents may require supplementation of their meal plan in order to attain or maintain acceptable parameters of nutrition . RI #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #14's weight change history documented the following: .9/6/16 Weight 89lbs (pounds) 10/4/2016 Weight 94lbs, 11/10/2016 Weight 94lbs, 12/10/2016 Weight 90lbs, 1/3/2017 Weight 90lbs, 2/7/2017 Weight 97lbs and 02/14/2017 Weight 96lbs. A review of RI #14's Departmental Notes documented the following: .2-15-2017 RD NOTE REVIEWED. MAGIC CUP ADDED AT LUNCH AND DINNER AS RESIDENT WILL ALLOW . A review of RI # 14's Physician order [REDACTED].MAGIC CUP WITH LUNCH AND DINNER AS RESIDENT WILL ALLOW . Meal observations: On 2/22/17 at 11:25 a.m. RI #14's lunch meal was observed. RI #14 received a pureed meal to include ham, cabbage, butterbeans, cornbread and pie. No magic cup was observed on the tray. The meal was completed at 11:50 a.m. On 2/22/17 at 5:00 p.m. RI #14's dinner meal was observed. RI #14 received a pureed meal to include potatoes/gravy, meat, okra, bread and dessert. No magic cup was observed on the tray. The meal was completed at 5:30 p.m. On 2/23/17 at 9:50 a.m., an interview was conducted with EI (Employee Identifier) # 3, Dietary Manager. EI #3 was asked if RI #14 was supposed to receive a magic cup with lunch and dinner. EI #3 responded as of (MONTH) 15th according to the medical order. EI #3 was asked why the magic cup was … | 2020-09-01 |
| 100 | 100 | WETUMPKA HEALTH AND REHABILITATION, LLC | 15027 | 1825 HOLTVILLE ROAD | WETUMPKA | AL | 36092 | 2017-02-23 | 371 | F | 0 | 1 | 6GSS11 | Based on observations, interviews, record reviews and a review of facility policies titled Food Receipts and Storage and Food Cooking and Serving Temperatures, the facility failed to ensure a can was not dented, a can was labeled in dry storage and milk temperatures were written down on the menu daily. This had the potential to affect 115 of 116 residents who receive meals from the kitchen. Findings Include: 1) A review of a facility policy titled, Food Receipt and Storage with an effective date: of (MONTH) 21, 2013 revealed: .PR[NAME]ESS I. Receiving Foods: .b. all items delivered should be checked as follows: Cans are intact, free of dents, . II. Storage of Foods: .f. Place dented .cans .in a separate area . On 2/21/2017 at 2:05 p.m., the surveyor along with the dietary manager toured the dry storage area in the kitchen. The surveyor observed a six pound can of pineapple tidbits with a dent at the top and bottom of the can. On 2/23/2017 at 9:01 a.m., the surveyor conducted an interview with (Employee Identifier ) EI #3, dietary manager. EI #3 was asked what can in dry storage was dented. EI #3 replied, pears and changed her answer to pineapple tidbits. EI #3 was asked where was the can dented at. EI #3 replied, on the side. EI #3 was asked what was the facility policy on dented cans. EI #3 replied, place in the dented cans location. EI #3 was asked where was the can located in dry storage. EI #3 replied, in with regular cans. EI #3 was asked who was responsible for removing dented can from the regular can area. EI #3 replied, she was and staff. EI #3 was asked why was the dented can in with regular cans. EI #3 replied, it was overlooked. EI #3 was asked why should dented can foods not be cooked. EI #3 replied, an infection control issue, it can mess up what was inside and they can not use something once air gets inside. On 2/23/2017 at 9:33 a.m., an interview was conducted with EI #4, dietary aide. EI #4 was asked who was responsible for putting supply items away. EI #4 replied, he was and another worker. EI #4… | 2020-09-01 |
Advanced export
JSON shape: default, array, newline-delimited
CREATE TABLE [cms_AL] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );