cms_AL
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| Link | rowid | facility_name ▼ | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1710 | 1710 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2018-02-08 | 761 | D | 0 | 1 | 2NI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of a facility policy titled, Diabetes - Insulin Injections, the facility failed to ensure Resident Identifier (RI) #19's vial of insulin contained an opened date on the vial and box containing RI #19's insulin. This deficient practice affected RI #19, one of 15 sampled residents. Findings Include: A review of a facility policy titled, Diabetes - Insulin Injections with a Revised date of 02.01.15, revealed: .Procedure [NAME] Procedure to prepare the insulin for an injection. .4. When opening new vial of insulin - the date opened should be documented on the vial and the box with an indelible pen. 5. Open vials of insulin should be replaced within 28 days of being opened, or according to manufacturer's guidelines whichever comes first. RI #19 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 8:21 a.m. during medication pass observation, Employee Identifier (EI) #3, Licensed Practical Nurse (LPN), was observed administering medications to RI #19. EI #3 took a box containing [MEDICATION NAME]from her medication cart, took out vial of insulin and drew up 44 units of [MEDICATION NAME] in a syringe. There was no opened date observed on the box or on the vial of insulin. On [DATE] at 2:15 p.m., an interview was conducted with EI #3, LPN. EI #3 was asked, what should be done when a box of insulin is opened. EI #3 said, she should date and initial the box and vial of insulin. EI #3 was asked, did the box and/or vial of [MEDICATION NAME] for RI #19 have a opened date on it. EI #3 replied, no. EI #3 was asked, was the policy for insulin followed since RI #19's box or vial did not have an opened date. EI #3 answered, no. EI #3 was asked, what was the concern with no opened date being on the insulin. EI #3 said, it could be expired, because it should be used within 28 days of the opened date. | 2020-09-01 |
| 1711 | 1711 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2018-02-08 | 842 | D | 0 | 1 | 2NI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record reviews and review of a facility policy titled, ALABAMA Advance Directives - Do Not Resuscitate Orders - DNR, the facility failed to ensure DNR - Do Not Resuscitate Consent forms were completed for Resident Identifier (RI) #12, RI #36, and RI #49. This deficient practice affected RI #12, RI #36 and RI #49, three of four residents sampled with Do Not Resuscitate orders. Findings Include: A review of a facility policy titled, ALABAMA Advance Directives - Do Not Resuscitate Orders - DNR with a Revised date 04/01/03, revealed: .1. The Attending Physician determines, to a reasonable degree of medical certainty, that (a) the resident is unable to understand, appreciate, and direct his or her medical treatment, and (b) the resident has no hope of regaining such ability; 2. Two physicians, one of whom is the Attending Physician and one of whom is qualified and experienced in making such diagnosis, have personally examined the resident and have diagnosed and certified in the medical record that the resident has a Terminal Illness or Injury or is in a state of Permanent Unconsciousness; . 1. RI #12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #12's medical record revealed a DNR - Do Not Resuscitate Consent form dated 9/30/16. The form did not contain pertinent information regarding RI #12's terminal diagnosis, signs and symptoms or competence status. 2. RI #36 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #36's medical record revealed a DNR - Do Not Resuscitate Consent form dated 3/27/17. The form did not contain RI #36's name, terminal diagnosis, signs and symptoms or competence status. 3. RI #49 was readmitted [DATE] with [DIAGNOSES REDACTED]. A review of RI #49's medical record revealed a DNR - Do Not Resuscitate Consent form dated 11/7/17. The form did not contain RI #49's terminal diagnosis, signs and symptoms or competence status. On 02/08/18 at … | 2020-09-01 |
| 1712 | 1712 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2018-02-08 | 880 | D | 0 | 1 | 2NI011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility policies titled, Standard Precautions, Personal Protective Equipment - Gloves Usage, Handwashing - Hand Hygiene and Catheter - Care - Suprapubic, the facility failed to ensure: 1. Licensed Practical Nurse (LPN) cleaned her stethoscope and pulse oximeter after obtaining vital signs for RI #19, 2. an LPN washed her hands after removing her gloves when cleaning RI #30's glucometer and putting on a clean pair of gloves, 3. an LPN did not touch the paper towel dispenser handle after washing her hands and prior to applying clean gloves during administration of RI #49's medications via gastrostomy tube and and LPN cleaned a stethoscope before and/or after using the stethoscope to auscultate RI #49's gastrostomy tube placement, and 4. a Certified Nursing Assistant (CNA) did not place a garbage bag containing items used during catheter care for RI #51 on the floor in RI #51's room. These deficient practices affected two of two nurses observed during medication pass observations and one of one CNA observed during catheter care. Findings Include: A review of a facility policy titled, Standard Precautions with an Effective date of 11.01.09 revealed: Policy Standard Precautions will be used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Procedure 1. Standard Precautions shall apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. .Standard precautions include the following practices: .1. Hand hygiene .d. Wash hands after removing gloves . 2. Gloves .g. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash h… | 2020-09-01 |
| 1713 | 1713 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2016-12-01 | 156 | C | 0 | 1 | 6HH811 | Based on interviews record review and observations, the facility failed to ensure the residents had access to the current Ombudsman information provided to the facility by the State Ombudsman Agency. This had the potential to affected all 65 residents and visitors in the facility. Findings include: The Ombudsman poster posted on the bulletin boards on both units in the facility provided the name of an Ombudsman that no longer worked as a State Ombudsman. The surveyor called to notify the Ombudsmen office of the current survey in progress and ask for the person identified on the poster. The secretary stated she was no longer with that office assigned to the facility. The surveyor was given the name of the current Ombudsman assigned to the facility. The Social Worker (Employee Indentifer) EI #9, was interviewed on 11/30/16 at 3:00 PM, and asked who was responsible for updating the Ombudsman posters to ensure the accuracy of information for the residents. EI #9 stated, That would be me. EI #9 was asked who is the current Ombudsman assigned to the facility. EI #9 was able to identify the current Ombudsman. The surveyor asked whose name was posted on the bulletin boards for the residents to notify if they need to discuss something with the Ombudsman? EI #9 replied the former Ombudsman name. EI #9 and surveyor checked the name on both Bulletin Boards. EI #9 stated she was responsible for following up with the Ombudsman office to ensure the information was current for the residents. | 2020-09-01 |
| 3521 | 3521 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2015-10-01 | 253 | C | 0 | 1 | NOUU11 | Based on observation, record review and interview the facility failed to maintain RL's (Room Locater's) #'s 1 - 37 free of scuffed and scraped areas on room walls and doors. This was observed on 3 days of the survey and affected 2 units in the facility. Findings Include: A review of a policy titled Daily Maintenance Compliance Rounds dated 02/01/07 documented the following: .Policy Routine inspection of buildings .shall be made to ensure that all property is inspected not less than once every three months .These inspections shall serve as a basis for scheduling, painting, caulking, equipment repairs or replacement and other repair work as needed .These inspections shall focus on providing a safe, comfortable and home-like environment for all residents . The following observations were made of the general environment of the building: On 9/29/15 between 9:15AM and 9:30AM, 9/30/15 between 8:30AM and 10:30AM and 10/1/15 at 9:00AM RL# 1, 21, 22, 23, 24, 25, 26, 27 and 28 were observed to have scuffed and scrapped areas on the entry room doors and bathroom doors. On 9/29/15 at 10:00AM, 9/30/15 at 10:45AM and 10/1/15 at 9:00AM RL # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 36 and 37 were observed to have scuffed areas on the entry door to the rooms. A hand rail in need of repair and the entry door to the unit was observed to have scuffed and scrapped areas. On 9/29/15 at 9:15AM, 9/30/15 at 9:00AM and 10/1/15 at 10:00AM RL # 29, 30, 31, 32, 33, 34 and 35 were observed to have scuffed areas on the entry door to the resident rooms and to the walls on the inside of the rooms. An interview was conducted with EI (Employee Identifier) # 10, Maintenance staff on 10/1/15 at 10:30 AM. EI # 10 was asked if the rooms observed need to be replaced/repaired. EI # 10 stated yes painting or repaired. EI # 10 was asked what could be done to repair the hand rail. EI # 10 stated either sanding or replacement of the rail. EI # 10 was asked how do you know when to make repairs in the building. EI # 10 stated through the… | 2019-03-01 |
| 3522 | 3522 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2015-10-01 | 315 | D | 0 | 1 | NOUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure: 1) A Certified Nursing Assistant (CNA) performed foley catheter care to Resident Identifier (RI) #2, a resident with a history of Urinary Tract Infections [MEDICAL CONDITION] in a manner in which to decrease risks for UTIs. The CNA wiped from the end of the catheter toward the insertion site. This was observed on 9/29/15 during an observation of foley catheter care. This affected 1 observation of foley catheter care. 2) A CNA performed incontinent care to RI #9, a resident with a history of UTI's in a manner in which to decrease the risks for UTI's. The CNA touched the resident with soiled gloves after performing incontinent care. This was observed on 9/30/15 during an observation of incontinent care. This affected one of one observation of incontinent care and one of one observation of foley catheter care. Findings Include: 1) A review of a facility policy titled Catheter Care - Male with a revised date 1/23/09 revealed Purpose To keep meatus and surrounding area clean and bacteria free and to decrease incidence of infection .Procedure .6. Use wet washcloth by circling around meatus with downward stroke toward the end of tubing . RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of a laboratory report dated 4/19/15 revealed urine .Bacteria 3+ . A review of RI # 2's most recent Minimum Data Set with an Assessment Reference date of 4/29/15 revealed Urinary Tract Infection [MEDICAL CONDITION] Last 30 days . On 9/29/15 EI #1 CNA was observed performing foley catheter care on RI #2. EI #1 removed the brief then cleaned the foley first. Using a wipe EI #1 cleaned from the end of the tubing towards the urethral opening. On 9/29/15 at 3:50 PM an interview was conducted with EI #1, she was asked how was she taught to wipe during foley care. EI #1 replied up, she was then asked what she meant by up. EI #1 replied foam the tip of the pen… | 2019-03-01 |
| 3523 | 3523 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2015-10-01 | 328 | D | 0 | 1 | NOUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure an oxygen order was obtained for Resident Identifier (RI) #3. RI #3 was observed with oxygen in place at 2 liter/minute on 2 days of the survey. This affected 1 of 2 residents observed for oxygen use. Findings Include: A facility policy titled, Oxygen - Administration with with a revised date of 02.01.15 documented Purpose To provide guidelines for safe oxygen administration. Policy Oxygen therapy is administered as ordered by the physician. RI #3 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's Physician order [REDACTED]. No Oxygen order was documented on the current orders. A review of RI #3's most recent Significant Change Minimum Data Set (MDS) with and Assessment Reference Date (ARD) of 06/23/2015 documented RI #3 as having a Brief Interview for Mental Status (BIMS) score of 15 which indicted RI # 3 was cognitively intact. Section I documented a [DIAGNOSES REDACTED]. During the initial tour on 09/29/2015 at 9:30 AM an oxygen concentrator with nasal cannula tubing was observed in RI #3's room. RI #3 was not in the room at this time. On 09/29/2015 at 2:00 PM RI #3 was observed in the room with oxygen in use per nasal cannula at 2 liter/minute. On 09/30/2015 at 2:30 PM RI #3 was observed sitting on the bed with oxygen in use per nasal cannula at 2 liters/minute. The surveyor asked RI #3 if he/she used oxygen a lot. RI #3 replied oh yes off and on. RI #3 was asked how long he/she had used oxygen. He/She replied a long time, ever since I've been here. During an interview on 09/30/15, at 3:00 PM with Employee Identifier (EI) #7 a Registered Nurse Supervisor. EI # 7 was asked if RI #3 used oxygen. EI #7 stated, Yes as needed. EI #7 was asked to review RI #3's Physician order [REDACTED].#3 should have a Physician order [REDACTED].#7 was asked what the potential for harm would be if a resident did not have a Physician Order. EI … | 2019-03-01 |
| 3524 | 3524 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2015-10-01 | 371 | F | 0 | 1 | NOUU11 | Based on observation, interview and record review 1) the facility failed to ensure a box of grapes and a bag of frozen chicken in the refrigerator were dated. This was observed during the initial tour of the kitchen. 2) the facility failed to ensure a dietary staff member did not place the hub of the thermometer into the food while checking the temperatures of the food items on the tray line. The staff member failed to clean the food off of the hub of the thermometer and continued to check the temperatures of other food items. This had the potential to affect 60 residents receiving food/meals from the kitchen. Findings Include: A facility policy titled, Storage of Food - Supplies Policy No.DPP 608 with a revised date of 12.01.13 documented Purpose To maintain high quality and prevent spoilage and contamination. Policy .Refrigerated items should be covered, labeled and dated . On 09/29/15 at 9:10 AM during the initial tour of the facility's kitchen the surveyor was unable to identify an open date or use by date for a box of grapes observed in the refrigerator. Employee Identifier (EI) #4 the Dietary Manager who was with the surveyor was also unable to identify a date on the grapes. Furthermore, in another refrigerator a bag of frozen chicken was observed without an open date or use by date. The surveyor asked EI #4 if the frozen chicken had an open date or use by date. EI #4 looked for a date and was unable to find a date. On 09/30/15 at 10:35 AM EI #5 a dietary cook was observed checking the temperatures of food items on the tray line. EI #5 placed the thermometer in the barbeque chicken and the hub of the thermometer touched the chicken. She cleaned the gauge of the thermometer but did not clean the hub of the thermometer. She continued to check the green beans, baked chicken and puree chicken. EI #5 touched the puree chicken with the hub of the thermometer. She continued to check the mashed potatoes, puree green beans and chopped barbeque chicken. EI #5 was asked if there were any cold items to be served. She o… | 2019-03-01 |
| 3525 | 3525 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2015-10-01 | 441 | D | 0 | 1 | NOUU11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure: 1) a Certified Nursing Assistant (CNA) did not touch three bedside cabinet drawers and then touch clean items with the same soiled gloves she had on while performing foley catheter care to Resident Identifier (RI) #2; and 2) a CNA did not touch RI #9, a clean pad and linens with same soiled gloves she had on to provide incontinent care to RI #9. This was observed during one observation of foley catheter care on 9/29/15 and incontinent care on 9/30/15. This affected one of one observation of foley catheter care and one of one observation of incontinent care. Findings Include: 1) A review of a facility policy titled Catheter Care - Male with a revised date 01/23/09 revealed Procedure .2. Take equipment to bedside .6. Use wet washcloth by circling around meatus with downward stroke toward end of tubing .9. Discard gloves . RI #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/29/15 at 3:40 PM Employee Identifier (EI) #1, CNA was observed performing foley catheter care on RI #2. EI #1 was observed removing the brief then she used the first wipe and cleaned from the end of the catheter tubing toward the urethral opening. EI #1 then turned RI #2 to the right side to clean the buttocks. She cleaned the stool from RI #2 using three wipes then reached into each drawer of the bedside cabinet with the same soiled gloves. The surveyor asked what was she looking for; she replied wipes. She then removed her gloves washed her hands and left the room to retrieve more wipes. EI #1 returned to the room washed her hands donned gloves and completed the foley catheter care to RI #2. On 9/29/15 at 3:50 PM an interview was conducted with EI #1, she was asked how was she taught to wipe during foley care. EI #1 replied up, she was then asked what she meant by up. EI #1 replied from the tip of the penis to the catheter end. EI #1 was asked how did she wipe, she… | 2019-03-01 |
| 4783 | 4783 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2014-10-09 | 164 | D | 0 | 1 | PMSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review,observations and interviews the facility failed to ensure that a licensed staff member closed the door and pulled the privacy curtain when administering medications to UR (Un-sampled Resident ) #1 and RI (Resident Identifier) #5 during the medication administration pass on 10/08/2014. This affected 1 of 3 nurses observed during the medication administration pass. Findings Include: UR #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of UR #1's most recent Annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/05/2014 revealed that UR #1 had severely impaired cognitive skills for daily decision making. A review of a facility document titled,Residents These are YOUR Rights not dated revealed: You have the right to be treated with dignity, privacy, respect, and to live in a safe, clean,comfortable and homelike environment .You have the right to privacy including accommodations, medical treatment . A review of UR#1's physician's orders [REDACTED].[MEDICATION NAME] Caplet 100mg (milligrams) Give 1 capsule by mouth once a day, Thera-M Caplet Give 1 Caplet by mouth once a day . [MEDICATION NAME] Tablet 25mg Give 1/2 Tablet by mouth twice a day, [MEDICATION NAME] Sodium Extended Capsule 100 mg Give 1 tablet by mouth 3 times a day, [MEDICATION NAME] Tablet 15 mg Give 1 Tablet by mouth once a day .[MEDICATION NAME] ([MEDICATION NAME]) Tablet 75mg Give 1 Tablet by mouth twice daily, [MEDICATION NAME] Tablet 64.8 mg Give 1 tablet by mouth twice daily, [MEDICATION NAME] Tablet 1 gm (gram) Give 1 Tablet by mouth twice daily . On 10/08/2014 at 8:10 AM, EI #3 ,LPN (Licensed Practical Nurse) was observed by the surveyor placing the above medications in a medication cup. EI#3 entered UR #1's room with the medications,explained that she would be administering medications to UR #1 and gave the medications to the resident. UR#1's roommate was in the room. EI #3 did not pull the privacy curtai… | 2018-03-01 |
| 4784 | 4784 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2014-10-09 | 441 | D | 0 | 1 | PMSI11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and interviews, the facility failed to ensure that a licensed staff member washed her hands or changed her gloves after cleaning the wound of UR (Unsampled Resident) #2 and before touching the measuring device and clean dressing. This occurred on 10/8/14 while performing the wound care of UR #2. This affected 1 of 1 residents observed during the provision of wound care. Findings Include: UR #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. UR #2's most recent Significant Change MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/26/2014 revealed that UR #2 had a BIMS (Brief Interview for Mental Status) score of 12 which indicated the resident was moderately impaired for daily decision making. The MDS also indicated the resident was at risk of developing pressure ulcers. A review of UR #2's care plan with a problem onset date of 10/01/2014 revealed: Problem/Need I have two stage two pressure ulcers to my bil (bilateral) inner buttocks .Approaches .Provide my tx (treatment) as ordered . A review of a facility policy titled, Skin & (and) Wound Care Protocol Pressure Ulcer Treatment Open Pressure Ulcers with a revised date of 03/03/14 revealed: .9. Cleanse wound . 10. Wash hands with soap and water. 11. Measure pressure ulcer . 12. Wash hands with soap and water. 13. Apply clean gloves. 14 Apply appropriate dressing . On 10/8/14 at 9:20 AM, EI (Employee Identifier) #2, LPN (Licensed Practical Nurse) was observed providing wound care for UR #2. EI #2 washed her hands, donned gloves and cleaned the Stage 2 wound to UR #2's left buttock. EI #2 then dried the wound, measured the wound, applied a barrier wipe around the wound and then applied the dressing to the wound; all without washing her hands or changing her gloves. EI #2 then repeated the same steps for the Stage 2 wound located on UR #2's right buttock. On 10/8/14 at 9:45 AM, an interview was conducted with EI #2, LPN. … | 2018-03-01 |
| 5885 | 5885 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2013-10-23 | 253 | B | 0 | 1 | KRH811 | Based on observation, interviews and record review the facility failed to maintain Room Locator (RL) #1 in a manner to prevent a build up of dust and cobwebs. This was observed on 2 of 3 days of the survey. This had the potential to affect all residents who consumed their meals in RL #1. Findings Include: A review of the facility's policy titled Room - Dining Room with an effective date of 08/01/2006 documented Purpose To provide a clean and sanitary dining room for residents. Policy The dining room should be cleaned after each meal by the Housekeeping Department . Responsibility The Dietary Director is responsible for monitoring the cleanliness of the dining room(s) and notifying the Administrator of necessary cleaning. On 10/21/2013 at 5:05 PM during the evening meal, the surveyor made an observation of RL #1. The surveyor observed a table with 4 residents eating their evening meal beside a window and the outside exit door. Two other table areas in RL #1 were also being used by other residents to consume their evening meal. The surveyor observed brown dust on the air conditioner under the window, dust and cobwebs along the frame of the window and the outside exit doorframe. Surveyor observed a combination of dust and cobwebs in the 4 corners of the glass sections on the outside exit door. Cobwebs were also observed between the wall and the television located in the back of the Dining Room. At 5:35 PM, another group of residents (4 residents) were served their meal in RL #1. The areas were not cleaned before they were served. On 10/22/2013 at 7:30 AM during the breakfast meal, the surveyor made an observation of RL #1. The surveyor observed residents eating their breakfast at the table beside the window and the outside exit door as well as two other table areas. The surveyor observed the same unclean areas as observed during the 10/21/2013 observation made at 5:05 PM and 5:35 PM. On 10/22/2013 at 8:25 AM, the surveyor and Employee Identifier (EI) # 1 Director of Environmental Services made an observation of RL #… | 2017-01-01 |
| 5886 | 5886 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2013-10-23 | 325 | D | 0 | 1 | KRH811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview the facility failed to ensure RI (Resident Identifier) #7, a resident with weight loss, received an ordered supplement on 10/22/2013. This affected 1 of 2 residents sampled for weight loss. Findings include: RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of RI #7's Quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 10/14/2013, revealed RI #7 suffered both short and long term memory problems and severely impaired cognition. Further review revealed RI #7 was totally dependent on staff for eating, requiring a one-person physical assist and received a mechanically altered therapeutic diet. Review of the October 2013 Physician Orders revealed an order dated 09/05/2012 for the following: .MILKSHAKES BID (twice a day) B/T (between) MEALS AT 9 AM AND 2 PM . RI #7's Physician order [REDACTED].#2 Registered Nurse (RN)/Unit Manager indicating she had reviewed the physician's orders [REDACTED]. Review of the PHYSICIAN'S TELEPHONE ORDERS for RI #7 dated 10/07/2013 revealed an order for [REDACTED]. Review of RI #7's Care Plan for .Problem Onset: 05/12/2011 . ALTERATION IN NUTRITION . MECHANICALLY ALTERED/ THERAPEUTIC DIET . revealed the following approach: . * PROVIDE MY SNACKS/SUPPLEMENTS TO ME AS ORDERED. Review of RI #7's Departmental Notes prepared by Employee Identifier (EI) # 4, Registered Dietician, revealed the following: .10/22/2013 5:30 PM . Role: Dietary . Progress Note: .Wt (weight) down gradually x (times) 6mos (months) . Wt down gradually x past 2wks (weeks) . Diet: .Milkshakes BID b/t meals @ 9/2 (at 9 AM and 2 PM) . Ensure and milkshakes in place for extra cals/prot (calories and protein) needed for wt stability . Review of the facility's policy titled Nourishment - Supplemental Feedings, with a revision date of 06/01/02 revealed the following: . Purpose To provide proper nutritional intervention to the resident .with nutritional or d… | 2017-01-01 |
| 5887 | 5887 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2013-10-23 | 328 | D | 0 | 1 | KRH811 | **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) #9's oxygen (O2) was delivered at 2 liters a minute by concentrator as ordered by the physician. This was observed 2 of 3 days of the survey. This affected 1 of 2 sampled residents for specialized care. Findings Include: A review of the facility policy titled Oxygen Therapy with a Revised date of 04/01/2002 and 04/01/2006 documented . Policy Oxygen therapy is administered only as ordered by the physician or as an emergency measure until an order can be obtained. The physician's order shall specify the rate of flow of oxygen. Resident Identifier (RI) # 9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/24/2013 identified RI #9 as a resident receiving oxygen treatment. A review of RI #9's Physician Orders for the month of October 2013 revealed .02/2L (liters) MIN (minutes) VIA (by) NC (nasal cannula) PER CONCENTRATOR . RI #9's Physician Orders were signed by Employee Identifier (EI) #2 Registered Nurse (RN)/Unit Manager indicating she had reviewed the Physician's Orders. On 10/21/2013 at 5:00 PM, the surveyor observed RI #9 in the Dining Room eating her evening meal without receiving her oxygen treatment. RI #9 remained in the Dining Room until 5:26 PM without O2 in place. On 10/22/2013 at 3:15 PM, the surveyor observed RI #9 sitting at the Nursing Station with the nasal cannula in her nostrils and the tubing connected to an oxygen concentrator. The surveyor observed the concentrator turned off. RI #9 remained at the Nursing Station. At 4:20 PM, the surveyor asked Employee Identifier (EI) #2, RN/Unit Manager, to observe EI #9's concentrator which was still turned off. EI #2 stated the nurse should have turned it back on after lunch. When the surveyor asked EI #2 if the resident had been without it since lunch, EI #2 stated sh… | 2017-01-01 |
| 6965 | 6965 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2012-11-01 | 164 | D | 0 | 1 | H2S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure nursing staff maintained privacy of a resident's medical record by leaving a resident's MAR (Medication Administration Record) open unattended during medication pass. This was observed on 1 of 2 units during medication pass on RI (Resident Identifier) #16, one of 14 sampled residents. Findings include: On 10/30/12 at 4:10 PM, EI #8 (LPN-Licensed Practical Nurse) was observed preparing medications on the medication cart for RI #16. She then entered RI #16's room to administer the medications. EI #8 left the MAR indicated [REDACTED]. RI #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #16's Significant Change MDS (Minimum Data Set), dated 10/06/12, indicated the resident had a BIMS (Brief Interview for Mental Status) score of 5, indicating the resident was cognitively impaired. On 10/31/12 at 10:05 AM, EI #10 (RN-Registered Nurse) was interviewed and asked how should MARS be maintained during medication pass. She stated to make sure no resident name or information on resident was showing. The MAR indicated [REDACTED]. She was asked why and EI #10 stated that it would be breaking HIPAA (Health Insurance Portability and Accountability Act) law. She stated that anyone could walk up and see the information and that it was a privacy issue. At 2:10 PM on 10/31/12, EI #11 (LPN) was interviewed and asked how should MARS be maintained during medication pass. She stated the MAR indicated [REDACTED]. She was asked why and EI #11 stated it was to keep the resident's privacy so that people could not see what kind of medications the resident takes. A review of MEDICATION GUIDE for the Long-Term Care Nurse, 6th Edition, page 68, indicated, .9. Remember to protect confidentiality of patient records, including the MAR book. The nurse should flip the MAR pages face down when the book is unattended. | 2015-11-01 |
| 6966 | 6966 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2012-11-01 | 241 | D | 0 | 1 | H2S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure residents were fed in a manner to preserve their dignity by standing to feed the residents. This affected two residents on the east wing, RI (Resident Identifier) #13 and URI (Unsampled Resident Identifier) #1. 1) RI (Resident Identifier) #13 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his most recent MDS (Minimum Data Set), with an Assessment Reference Date of 09/06/2012, RI #13 required total assistance of one person for eating. On 10/31/2012 at 11:35 AM RI #13 was observed lying in bed being fed by EI (Employee Identifier) #1, RN (Registered Nurse) Supervisor. RI #13's bed was observed to be elevated. EI #1 was observed to be standing next to the bed feeding RI #13. On 11/01/2012 at 1:18 PM, EI #1 was interviewed. EI #1 was asked what she had been taught about how to feed residents. EI #1 stated she gets everything together at the same time. She then sits with the resident at all times, making sure the resident has his/her clothing protector on. She makes sure the resident has at least three beverages of choice and that they have whatever their tray card says they are supposed to have. She stated that she sits at eye level with the resident and she makes sure they know what they are eating. EI #1 was asked why would she sit to feed a resident. EI #1 stated to be at eye level with the resident. EI #1 was asked why wouldn't you stand to feed a resident. EI #1 stated I don't want to be looking down at my residents. 2) URI (Unsampled Resident Identifier) #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her most recent MDS (Minimum Data Set) with an Assessment Reference Date of 10/12/2012, URI #1 required extensive assistance of one person with eating. On 10/31/2012 at 11:35 AM URI #1 was observed lying in bed being fed by EI (Employee Identifier) #2, COTA (Certified Occupational Therapist Assistant). URI #1… | 2015-11-01 |
| 6967 | 6967 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2012-11-01 | 371 | F | 0 | 1 | H2S811 | The facility failed to ensure meals were prepared in a sanitary manner by: 1. Affixing a thaw date and a use by date on a box of thawed mighty shakes that were stored in the refrigerator, 2. Handling clean metal bowls, lids and utensils without touching the areas where residents food would be placed. 3. Touching rolls with bare hands while plating residents food. This had the potential to affect 62 of 62 residents who were served food from the Dietary Department. Findings include: 1. The facility Policy/Procedure for, Milkshake Protocol, with a revision date of 7/26/ 11, indicated, Policy to thaw, date and use milkshakes within appropriate time frame. Procedure 1. Milkshakes are to arrive from vendor frozen and be stored in freezer until needed for use.3. The date milkshakes are put in refrigerator to thaw is to be written on each individual milkshake carton. This is to be identified as the thaw date. 4. The milkshake is to be disposed of 14 days after thawing, this is to be identified as the use by date. A use by date is to be written on each individual milkshake carton also. During the initial tour of the Dietary Department, a box of mixed sized Mighty Shakes were stored in the refrigerator. The container (cardboard box) was dated 10/16/12. When Employee Identifier (EI) #6 was asked if there was a thaw date or use by date she replied , All its got is 10/16- the day they came in. There were no other dates found therefore EI #6 discarded the shakes. In an interview on 11/1/12 at 8:15, EI #5 was asked when the Mighty Shakes were supposed to be dated. She replied the should be dated when they come in, when they are taken out of the freezer- the thaw date and the use by date- 14 days after the thaw date. 2. On 10/31/12 at 10:45 AM, during the tray line observation, the EI # 4 was observed to be removing the clean bowls, lids and utensils from the clean area of the dishwashing area. She was noted to be holding the lids with her hands and touching the food side of the lids and also the bowls. She was also noted to hav… | 2015-11-01 |
| 6968 | 6968 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2012-11-01 | 441 | D | 0 | 1 | H2S811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to ensure professional nursing staff: 1) Cleaned a glucometer after use; 2) Wiped the top of an open insulin vial prior to drawing up insulin, and 3) Washed hands in a manner to prevent cross-contamination. This was observed on two nurses observed and three of nine residents observed during medication pass. Findings include: 1) On 10/30/12 at 3:47 PM, EI (Employee Identifier) #8 (LPN-Licensed Practical Nurse) was observed during medication pass. She gathered the supplies for a blood glucose check on RI (Resident Identifier) #1. A small clear plastic box was located next to the sink in RI #1's room. The plastic box contained a glucometer and lancets. EI #8 obtained blood glucose from RI #1 and placed the glucometer back into the clear plastic box without cleaning or disinfecting the glucometer. EI #8 stated that all residents who get a blood glucose have an individual glucometer. RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's quarterly MDS (Minimum Data Set), dated 9/02/12, revealed he required total assistance with all ADLs (Activities of Daily Living) and was incontinent of bowel and bladder. RI #1's November 2012 Physician order [REDACTED]. On 10/31/12 at 10:05 AM, EI #10 (RN-Registered Nurse) was interviewed and asked when should glucometer be cleaned/disinfected. She stated it should be cleaned after each use. EI #10 was asked who was responsible for cleaning the glucometer and she stated each charge nurse working the medication cart. She indicated that night shift checks the meter and cleans it but the day shift nurse also cleans it. EI #10 was asked what was the potential for harm if the glucometer was not cleaned. She stated the glucometer may not get an accurate reading and there was no telling what could have landed on it. EI #10 stated each individual has their own glucometer and has to be cleaned after each use. … | 2015-11-01 |
| 7024 | 7024 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2012-10-10 | 225 | D | 1 | 0 | 77Q311 | Based on interviews, record review and review of a facility policy titled Abuse Prevention Program Identification & Investigation of Resident Incidents & Accidents the facility failed to report an allegation of sexual abuse to the Alabama State Agency within 24 hours. This deficient practice affected two sampled residents (RI #1) and RI #2. Findings Included: Review of a facility policy titled, Abuse Prevention Program Identification & Investigation of Resident Incidents & Accidents effective 01/01/04, revised 04/05/11, documented, Procedure Subject: Investigation, Reporting Obligations, and Response to the Results of Investigations I. Investigation and Reporting Steps A. Notify the Administrator their designee and/or supervisor of any unusual situation in the facility, whether reportable or not. The Administrator/designee shall notify the appropriate state agency no later than 24 hours of the alleged occurrence . The facility submitted a 24 hour report to the Alabama State Agency on September 26, 2012. In this report the facility documents, .On 9/26/12 C.N.A (CNA #3) .came to the administrator to talk about residents (RI #1 and RI #2). On 9/26/12 (CNA #3) told the administrator that (RI #2) alleged that (RI #1) molested her on 9/14/12. CNA #3 stated she did not report the incident to the administrator previously because there did not seem to be any evidence that RI#1 touched RI#2. At this point, administrator told (CNA #3) that no one had reported that RI #2 said molested and this constitutes an allegation of abuse. During an interview with the Administrator on 10/6/12 at 2:20PM the Administrator was asked what would you consider it to be if a resident says he or she has molested me, regardless of the resident's cognitive status. The Administrator stated if it's alleged, it's an allegation. The surveyor asked the Administrator what prompted her to report the allegation of 9/14/12. The Administrator stated when I received new information from CNA #3 that the resident said help help he molested me. On 10/01/12 at … | 2015-10-01 |
| 8029 | 8029 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 371 | F | 0 | 1 | RB2U11 | Based on observation, interviews and record review, the facility failed to ensure: 1) staff stored luncheon meat in a securely sealed container in the reach-in refrigerator; 2) milk was discarded after it had reached the manufacturer's recommended "use-by" date; and 3) staff sanitized kitchen cookware and utensils processed through the three-compartment sink. This had the potential to affect all 79 residents for whom meals were prepared and served at the time of this survey. Findings included: 1) A tour of the kitchen was conducted on 11/01/11 at 5:45 PM. At this time, a double bagged package of sliced bologna was stored in reach-in refrigerator #2. Neither of the two zip lock bags were sealed, exposing the contents to air and potential contaminants. On 11/03/11 at 9:15 AM, the Consultant Dietitian (Employee Identifier/EI #3) was interviewed. EI #3 acknowledged the storage concern and stated she had discarded the bologna. EI #3 stated it had been seven days since the meat had been opened, and according to the Food Code, it was time for disposal. 2) A one-gallon container of fat free milk was stored in the #1 Victory reach-in refrigerator. The stamped "use-by" date was 10/31/11 (expired). The same gallon of milk remained in the refrigerator on the following day, 11/02/11 at 10:50 AM. 3) On 11/01/11 at 6:10 PM, EI #12, a Dietary Aide, was finishing up with the washing of cookware and utensils in the three compartment sink. EI #12 explained the final rinse sink contained a chemical sanitizer (quaternary ammonia). However, the monitoring record contained no documentation of the chemical concentration. At the surveyor's request, EI #12 tested the final rinse water. No reading was detected on the test strip despite attempts with three test strips, and the addition of more chemical from the sink dispenser. EI #12 stated the concentration should register 300 parts per million on the test strip. When asked what she should do if the test strip did not register a chemical concentration, EI #12 stated did not know. When aske… | 2014-11-01 |
| 8030 | 8030 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 315 | E | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to obtain a [DIAGNOSES REDACTED].#5 and RI #9. This affected two of four residents sampled with the use of a Foley Catheter, on two of two residential units. The facility further failed to ensure Employee Identifier (EI) #7 (Certified Nursing Assistant) provided incontinence care to RI #7, in a manner to prevent a potential development of a Urinary Tract Infection [MEDICAL CONDITION]. This affected RI #7, a resident with a history of UTIs, one of two residents observed during incontinence care. Findings Include: 1. RI #9 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of RI #9's Annual Minimum Data Set ((MDS) dated [DATE] revealed RI #9 had short and long term memory loss and had moderately impaired cognitive skills for daily decision-making. The MDS also documented RI #9 required total assistance with toileting and hygiene. The MDS indicated RI #9 was incontinent of bowel and bladder. A review of RI #9's "Physician Orders" for November 2011 revealed the following: "...Date 10/25/11...Orders...INDWELLING CATHETER #16...DISCONTINUED WHEN SKIN IRITATION (IRRITATION) IS HEALED..." A review of the facility's "Departmental Notes," dated 10/25/11 revealed the following: "...Res (resident) inner thighs are noted to be very excoreated (excoriated), this is an ongoing problem...writer fax (name of physician) requesting an indwelling cath, (catheter)...2:30 PM...new order received...inserted indwelling cath #16, res tolerated procedure well, urine yellow and clear draining to bag at bed side..." A review of the facility's "Nursing Home Progress Note," dated 10/26/11 revealed the following: "...Other: inner right thigh small areas x (time) 2 of excoriation Tx (treatment) in process-cath was placed yesterday. ...Plan: ...New Orders DC (discontinue) cath when area healed..." On 11/02/11 at 3:50 PM, during an interview with Employee… | 2014-11-01 |
| 8031 | 8031 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 281 | D | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews with staff, the facility failed to clarify physicians' orders whether Resident Identifier (RI) #5, was to receive an in and out catheter or an indwelling catheter. The facility also failed to clarify orders for supplemental bolus tube feedings for RI #7 when oral food intake was suboptimal. This affected two of 14 sampled residents. Findings included: "Fundamentals of Nursing," 7th edition, by Potter & Perry specifies on page 419, the following regarding Physicians' Orders: "The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients. Therefore all orders must be assessed, and if one is found to be erroneous or harmful, further clarification from the physician is necessary... The supervising nurse should help resolve the questionable order. A medical consultant may be called in to help clarify the appropriateness or inappropriateness of the order." 1) RI #5 has resided in the facility since 09/07/11, with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment of 09/15/11, identified RI #5 as cognitively intact, with a Brief Interview for Mental Status score of 14 out of a possible 15 total. This MDS documented the presence of an intermittent catheter. physician's orders [REDACTED]. Staff to assist." Subsequent orders dated 09/12/11, specified: "Indwelling urinary cath #16 Fr (French). Change q month & prn (as needed)/occlusion." Both orders were included on the 11/01/11 signed Physician order [REDACTED]. On 11/02/11 at 9:50 AM, the resident was observed in bed, with a Foley catheter in place. On 11/02/11 at 5:45 PM, the Registered Nurse (RN) Unit Manager, Employee Identifier/EI #5, was interviewed about the conflicting catheter orders. EI #5 confirmed she had checked the physician's orders [REDACTED]. EI #5 was asked if the resident could have both types of cathe… | 2014-11-01 |
| 8032 | 8032 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 431 | D | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure Employee Identifier (EI #8) (Licensed Practical Nurse) did not leave the medication cart unlocked, unattended and out of visual sight. This affected one of two medication carts. Findings Include: A review of the facility's policy and procedure titled "Medications - Storage of," with an effective date of 06/10/04 revealed the following: "...Procedure: "...4. Compartments containing drugs and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended..." 1. RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #18's current Quarter Minimum Data Set ((MDS) dated [DATE] revealed RI #18 had short and long term memory loss and had moderately impaired cognitive skills for daily decision-making. On 11/02/11 at 9:35 AM, the surveyor observed Employee Identifier (EI) #8 during medication pass. The following observations were made: EI #8 pulled the following medications for administration for RI #19: Lamictal 100 mg, Flomax 0.4 mg, Lortab 500 mg, Levetracetam 500 mg, Glimeripride 2 mg, Aspirin Enteric Coated 81 mg, Norvasc 2.5 mg, Colace 100 mg and Exelon 4.6 mg/24 hr patch. At 9:50 AM, EI #8 entered RI #18's room. The medication cart was positioned in the doorway, with drawers facing inward and the cart was unlocked. After EI #8 entered the room, her back was turned to the cart and the medication cart was not in EI #8's visual sight. At 11/02/11 at 9:45 AM, the surveyor asked what was the policy and procedure for leaving the medication cart unlocked and unattended. EI #8 stated the cart should be locked. The surveyor asked what did she (EI #8) do with the medication cart. EI #8 stated that the medication cart was locked. The surveyor asked when did she (EI #8) lock the cart. EI #8 stated when she brought the Exelon patch back, the old one that she had removed from RI #18. The surveyo… | 2014-11-01 |
| 8033 | 8033 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 332 | D | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the medication error rate was less than 5 % (percent). The medication error rate was 6.5 % with 46 opportunities and three errors. This affected two of 13 residents, two shifts and one of three nurses. Findings include: A review of the facility's policy and procedure titled, "Administering Medications," with a revised date of 04/01/02 revealed the following: "...Procedure...2. Medications shall be administered in a timely manner and in accordance with attending physician's written orders...6. Medications...shall be administered within one(1) hour of their prescribed time..." 1. RI #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the RI #18's current Quarterly Minimum Data Set ((MDS) dated [DATE], revealed RI #18 had short and long term memory loss and had moderately impaired cognitive skills for daily decision-making. A review of RI #18 physician's orders [REDACTED]...8/10/11...Interval Code QOD (every other day)[MEDICATION NAME] Acetate 0.1 mg (milligram) tablet, one tab (tablet) QD (every day)...Date 6/13/11...Time Code 8AM [MEDICATION NAME] Patch 4.6 mg/24 hr (hour) patch apply one patch on the skin q (every) day..." On 11/02/11 at 9:35 AM, the surveyor observed Employee Identifier (EI) #8 during medication pass. The following observations were made: EI #8 pulled the following medications for administration for RI #18: [MEDICATION NAME] 100 mg, [MEDICATION NAME] 0.4 mg, [MEDICATION NAME] 500 mg, Levetracetam 500 mg, Glimeripride 2 mg, Aspirin [MEDICATION NAME] Coated 81 mg, [MEDICATION NAME] 2.5 mg, [MEDICATION NAME] 100 mg and [MEDICATION NAME] 4.6 mg/24 hr patch. At 9:50 AM, EI #8 entered RI #18's room and proceeded to administer medications. RI #18 refused the oral medications. EI #8 then applied the [MEDICATION NAME] to RI #18's right upper chest area. At 10:08 AM, the surveyor asked what was the time frame for medication a… | 2014-11-01 |
| 8034 | 8034 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 514 | D | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to document the percentages of meal intake for Resident Identifier (RI) #7 on 13 days of September and 12 days of October, 2011. Nursing staff were therefore unaware of the need to provide bolus tube feeding for suboptimal intakes. Also, there were many omissions (no documentation) on areas on the MARs (Medication Administration Records) and the ADL (Activities of Daily Living) sheets for the documentation of the tube feedings. This affected one of 14 sampled residents. Findings Included: RI #7 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. RI #7 had a 14 Day Admission MDS dated [DATE]. The MDS identified RI #7 with a Brief Interview for Mental Status (BIMS) of 8 out of 15 for her cognition, which was moderately impaired in her daily decision skills. EI #7 was identified with requiring extensive to total dependence of one to two staff members for all her Activities of Daily living (ADL) skills. The RD (Registered Dietician) Nutritional assessment dated [DATE] identified RI #7 with "... Diet LCS (Low Concentrated Sweets) Mech SOFT (Mechanically soften) with Nectar Liquids Diet Continued Bolus feeding of [MEDICATION NAME] 1.5 240 cc (cubic centimeters) @ (at) 2 a (am) and 10 p (pm) (480 cc/ 720 cals (calories)/ 31 g (grams) Prot (Protein)/364 cc free H20/d (free water a day). Also, if Rt (Resident) consume less than 50% of meal, give 1 can bolus feeding of [MEDICATION NAME] 1.5. Flush w/ 50 cc H2O q (every) 4 Hrs. Intake 25 -50% most meals. ..." A new FEES (Fiberoptic Endoscopic Evaluation of Swallowing) was done on 09/06/11 by the Speech Therapist which now recommended "thin liquids." A new Physician's Telephone order was hand written in for RI #7 on 09/07/11 ' " D/C (Discontinue) LCS Mech soft diet with Nectar Liquids. (2) LCS mech soft diet with Thin liquids with a nosey cup." 10/28/11 at 11:14 AM, a Consultant Registered Dietitian, EI # 4 documented in RI #7's … | 2014-11-01 |
| 8035 | 8035 | ADAMS NURSING HOME | 15386 | 1555 HILLABEE STREET | ALEXANDER CITY | AL | 35010 | 2011-11-03 | 309 | D | 0 | 1 | RB2U11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to ensure the oxygen concentrator was in the 'ON' position and infusing into Resident Identifier (RI) #6 on 11/02/11. This affected one of three sampled residents with orders for oxygen infusion. Findings Included: The Facility's "Oxygen Therapy Policy and Procedures", revised 04/01/06, "... 4. b. If a nasal cannula is used, fit cannula into nostrils and hook the cannula tubing behind the ears and under the chin and slide the adjuster upward under the chin to secure. ... 5. Keep the resident as comfortable as possible and try to alleviate anxiety. 6. Observe frequently to see that: a. Resident is not anxious. b. Cannula is in proper position and tubing is not kinked, and c. Tube in the bottle is under the water level. ..." RI #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Physician order [REDACTED].@ (at) 3 L (Liters) NC (Nasal canula) Continuously ..." RI #6 had a care plan dated 10/29/11, for "I have a potential for respiratory distress related to my [DIAGNOSES REDACTED]." The approaches discussed under this care plan were: "Observe for s/s (signs and symptoms) of respiratory distress, ie (for example): cyanosis, changes in level of care, restlessness. Provide oxygen as ordered. Assess lung sounds when abnormal signs or symptoms occur. Medications as ordered per my MD .... " An observation was made of RI #6 on 11/02/11 at 11:15 AM. RI #6 was brought back from the Physical Therapy department by the Physical Therapist, Employee Identifier (EI) # 15 and the therapy director, EI #16. EI #16 followed EI #15 and RI #6 with the 02 concentrator. When they arrived in the room, EI #16 plugged the concentrator into the electrical outlet and left the room. EI #15 was still in the room with RI #6. He assisted RI #6 with getting set up for lunch, and placing her tray table up to her wheelchair. He then left the room. He did not turn her 02 concentrator on. … | 2014-11-01 |
| 740 | 740 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 557 | D | 0 | 1 | L0J811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure Employee Identifier (EI) #17, a Certified Nursing Assistant (CNA) knocked before entering Resident Identifier (RI) #77's room. This affected RI #77, one of 33 sampled residents. Findings include: RI #77 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed RI #77 was severely impaired in cognitive skills for daily decision making and dependent on staff for all Activities of Daily Living (ADLs). On 1/14/19 at 4:35 PM and 4:38 PM, EI #17, a CNA entered RI #77's room without knocking. An interview was conducted on 1/14/19 at 4:43 PM with EI #17, a CN[NAME] EI #17 was asked why should she knock before entering a resident's room. EI #17 answered for privacy and that was the resident's room. EI #17 was asked why did she just enter RI #77's room twice without knocking before entering. EI #17 answered probably because she had been in there earlier for a few minutes and thought she was continuing care. EI #17 added that she should not have done that for any reason. EI #17 was asked how she was trained regarding knocking on doors prior to entering resident rooms. EI #17 answered staff were trained before they enter a resident room to knock. EI #17 was asked what was the concern of not knocking and entering a resident's room. EI #17 answered the resident might feel violated because that environment is their home. An interview was conducted on 1/16/19 at 8:48 AM with EI #6, the Staff Development Coordinator. EI #6 was asked why it was important for staff to knock before entering a resident's room. EI #6 answered because it was the resident's home. EI #6 added staff members have to announce they were entering the resident's room and get permission to do so. EI #6 was asked what was the concern of staff entering a residents room without knocking. EI #6 answered that the residents may feel it … | 2020-09-01 |
| 741 | 741 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 661 | D | 0 | 1 | L0J811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and a review of a facility's policy titled, Discharge Summary and Plan, the facility failed to ensure a discharge summary was completed for RI (Resident Identifier) #145, who discharged from the facility on 10/17/2018. This affected one of one sampled resident reveiwed for a discharge summary. Findings include: The facility's policy titled, Discharge Summary and Plan dated 11/22/2018, revealed: Policy When a residents discharge is anticipated, a discharge summary . will be developed . General Guidelines .2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharged . RI #145 was admitted to the facility on [DATE] and discharged home on[DATE]. A review of RI #145's medical record revealed no documentation of a discharge summary. On 01/15/19 at 5:25 p.m., an interview was conducted with EI (Employee Identifier) #14, the Director of Nursing. EI #14 was given RI #145's medical record to locate the resident's discharge summary. When asked if there was a discharge summary, EI #14 replied, No. EI #14 was asked why was there no discharge summary for RI #145. EI #14 said she did not know why a discharge summary was not done for RI #145. | 2020-09-01 |
| 742 | 742 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 732 | B | 0 | 1 | L0J811 | Based on observations and interviews, the facility failed to post nurse staffing data daily prior to the beginning of each shift. This deficient practice was observed on three of five days of the survey. Finding include: On 1/12/19 at 4:52 AM, the posted Nurse Staffing data was dated 11/24/18. On 1/13/19 at 8:32 AM, the posted Nurse Staffing data was dated 1/12/19. On 1/13/19 at 5:32 PM, the posted Nurse Staffing data was not posted for the evening shift, 3:00 PM to 11:00 PM. On 1/15/19 at 3:59 PM, an interview was conducted with EI (Employee Identifier) #19, the Staffing Coordinator. EI#19 was asked who was responsible for ensuring the Nurse Staffing data was posted daily prior to each shift. EI #19 said she was responsible. When asked why the Nurse Staffing data that was posted on 1/12/19 was dated 11/24/18, EI #19 stated she thought EI #22, the Registered Nurse (RN) House Supervisor did it. On 1/16/19 at 8:42 AM, EI #22, the RN House Supervisor acknowledged that she was supposed to post the Nurse Staffing data for the 11:00 PM to 7:00 AM shift. When asked why it was not posted on 1/12/19 at 4:52 AM, EI #22 said she didn't have an answer for that. EI #22 was asked should the Nurse Staff data be posted daily. EI #22 said, yes. When asked why it was important to post Nurse Staffing data, EI #22 said, It tells you about all the nurses working, how many hours and the area. | 2020-09-01 |
| 743 | 743 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 761 | D | 0 | 1 | L0J811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of the facility's policy and and review of a facility policy titled Medication: ordering, receiving,labeling, storage, drug regiment review reporting/documenting, and destruction of controlled substances and a document titled Guidance for Using Insulin Products, the facility failed to discard expired over-the-counter medications and Insulin per the manufacturer's recommendations. This deficient practice was observed in one of three medication rooms and one of seven medication carts in the facility. Findings include: The facility's policy titled, Medication: ordering, receiving,labeling, storage, drug regiment review reporting/documenting, and destruction of controlled substances revised date [DATE], documented . Labeling, Storage and Disposition . 5. All medications will be stored per manufacturers recommendations and discarded per manufacturers recommendation . On [DATE] at 2:45 PM, the building 2 medication room was observed with Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN). Sodium [MEDICATION NAME], an over-the-counter medication taken orally to neutralize gastric acid had an expiration date of (MONTH) (YEAR) and Senna Syrup, an over-the-counter medication taken orally to treat constipation had an expiration date of (MONTH) (YEAR). EI #1 was asked how often did she check for expired meds. EI #1 replied when she removed a med from the cabinet she always checked the expiration date. When EI #1 was asked if she thought there would be a problem with giving expired meds, she replied yes. EI #1 was asked what kind of concerns would she have with administering expired meds. EI #1 said the chemicals of expired meds would break down and lessen the effects of the medicine. When asked would that be harmful for a resident, she replied yes. EI #1 was asked what type of harm/concerns would she have with administering expired meds. She said the sodium [MEDICATION NAME] would not be active in alle… | 2020-09-01 |
| 744 | 744 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 812 | F | 0 | 1 | L0J811 | Based on observation, interview and review of the facility's policy titled, Food Item Labeling/Dating, the facility failed to discard an open box of bagged eggs and failed to label a box of chicken with an open and use-by date. These failures had the potential to affect 127 of 137 residents who receive meals from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by Employee Identifier (EI ) #14, the Director of Nursing and dated 1/12/19 indicated the facility had a total of 137, 10 of which receive nutrition by way of a tube feeding. Findings include: The facility policy titled, Food Item Labeling/Dating with a revised date of 8/23/17 documented PURPOSE: To ensure that food items are properly labeled and dated to preserve quality and prevent the spread of food borne pathogens . PR[NAME]EDURE: . 4. Refrigerated and frozen items will be labeled with an OPENED-ON date, as well as appropriate USE BY date . During an observation of the walk-in freezer with EI #5, the morning baker, on 1/12/19 at 5:22 AM, there was an opened box of Tyson 1/2 diced dark and white chicken, with no open or use-by date. At 5:47 AM, there was an opened box of bagged eggs with a use-by date of 1/7/19, in the walk-in cooler. In an interview with EI #5, the morning baker, on 1/15/19 at 11:45 AM, she was asked why the box of bagged eggs has not been discarded. EI #5 said, overlooked, possibly forgotten. When asked why the opened box of chicken was not labeled with an open and use-by date, EI #5 replied, it was overlooked by staff. EI #5 was asked should items be labeled with an open and use-by date and she said yes. When asked what the harm was for not labeling items and with an open and use-by date, EI #5 stated, it could cause sickness or illness to the residents. | 2020-09-01 |
| 745 | 745 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 835 | F | 0 | 1 | L0J811 | Based on interviews, review of the Nursing Home Administrator job description, the facility's Administrator who is responsible for the overall operations of the facility, failed to ensure Certified Nursing Assistants (CNAs) received at least 12 hours of in-service training. This deficient practice affected 42 of the 53 CNAs currently employed by the facility. Findings include: Refer to F947 The facility's Nursing Home Administrator job description signed by EI (Employee Identifier) #4, the Administrator, on 11/15/18, documented General Purpose: To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and Company polices, . During an interview on 1/16/2019 at 10:55 AM, EI #4, the Administrator acknowledged she was made aware in (MONTH) (YEAR) by the Staff Development Coordinator that CNAs had not received the required education and hours within their twelve month time frame. In a follow-up interview on 1/16/19 at 4:33 PM, EI #4 stated she was responsible for ensuring CNAs received at least 12 hours of inservice training. | 2020-09-01 |
| 746 | 746 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 867 | F | 0 | 1 | L0J811 | Based on interview, review of the facility's policy titled, Quality Assurance Performance Improvement Plan, the facility failed to determine a root cause and implement a performance improvement plan when it was determined Certified Nursing Assistants (CNAs) were not provided at least 12 hours of in-service training per year. This deficient practice affected 42 of the 53 CNAs currently employed by the facility, with the potential to affect all residents currently residing in the facility. Findings include: Refer to F835 and F947 An unlabeled,undated document typed on facility letterheard documented The QAPI (Quality Assurance Performance Improvement) meeting is held on a monthly basis and is lead by the Administrator . The facility's policy titled, Quality Assurance Performance Improvement Plan with a revised date of 11/2018, documented . An effective Quality Assurance Performance Improvement (QAPI) plan at all levels of our organization is vital for success. This process will enable the identification of problem area at every level and will ensure appropriate measures are taken. Once corrective actions have been taken, monitoring and follow up will ensure that improvements are sustained . The ultimate goals of committees at all levels are to identify trends, perform root cause analyses, prioritize issues in order of importance, initiate Process Improvement Projects (PIPS) to enable an effective and sustainable solution, monitor and revised as needed . During an interview on 1/16/2019 at 10:55 AM, EI #4, the Administrator acknowledged she was made aware in (MONTH) (YEAR) by the Staff Development Coordinator that CNAs had not received the required education and hours within their twelve month time frame. When asked if she had implemented a performance improvement plan to address the lack of CNA in-service training provided by the facility, EI #4 said she had not. In an follow-up interview on 1/16/19 at 5:01 PM, EI #4 was asked did the facility implement a written plan after she was made aware of the CNAs not receiv… | 2020-09-01 |
| 747 | 747 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 880 | D | 0 | 1 | L0J811 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #42's medical record and the facility's policy titled Hand-hygiene Technique, the facility failed to ensure Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) washed or sanitized her hands prior to and after assisting with feeding of Resident Identifier (RI) #42 breakfast on 1/13/2019. This deficient practice affected RI #42, one of six residents observed for dining. Findings include: The facility's undated policy titled, Hand-hygiene Technique revealed: . General Guidelines . 2. hand washing of a minimal of 15 seconds with antimicrobial or non-antimicrobial soap and water must be performed under the following conditions: . c. Before and after eating or handling food . RI #42 was readmitted to the facility on [DATE]. On 1/13/2019 at 8:31 a.m., the surveyor observed EI #2, a CNA entered RI #42's room, sat down in a chair and without washing or sanitizing her hands, proceeded to feed RI #42 the breakfast meal. After EI #2 fed RI #42 the breakfast meal, EI #2 wiped RI #42's mouth with a towel, picked up the food tray and left RI #42's room without washing or sanitizing her hands. EI #2 then put the food try in the dining cart in the North Wing Hallway and proceeded to enter another resident's room. On 1/13/2019 at 10:00 a.m., an interview was conducted with EI #2, a CN[NAME] EI #2 was asked if she washed or sanitized her hands after she entered RI #42's room, prior to feeding the resident the breakfast meal. EI #2 stated no. EI #2 was asked if she washed her hands or sanitized her hands after she fed RI #42 the meal and before leaving the resident's room with the food tray. EI #2 stated no. EI #2 was asked why she did not wash or sanitize her hands. EI #2 stated she had ran out of hand sanitizer. EI #2 was asked what should she do before and after feeding a resident their meal. EI #2 stated that she should either wash her hands or use hand sanitizer. EI#2 was aske… | 2020-09-01 |
| 748 | 748 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-01-16 | 947 | F | 0 | 1 | L0J811 | Based on interviews, the facility's policy titled Nursing-Staff Development and an audit conducted by the facility, the facility failed to provide Certified Nursing Assistants (CNAs) with at least 12 hours of in-service training per year. This deficient practice affected 42 of the 53 CNAs currently employed by the facility, with the potential to affect all residents currently residing in the facility. Findings include: The facility's policy titled, Nursing-Staff Development dated 12/2017, documented Policy Staff Development includes the planning, coordination, provision, and management of orientation, an in-service activities for facility employees . Procedure: . 8. Nurse aides are provided no less than 12 hours of in-service education per year . On 1/15/19 at 4:12 PM, Employee Identifier (EI) #6, the Licensed Practical Nurse (LPN) Staff Development Coordinator was interviewed. EI #6 reported she had been in her current position since (MONTH) (YEAR). EI #6 acknowledged an audit was conducted on 12/6/2018 of the CNAs' in-service training hours. EI #5 stated there were only three CNAs who were current with training hours. According to EI #6, prior to 12/6/2018, the facility had no system to ensure CNAs received the required 12 hours of in-service education. A listing of the facility's CNA staff dated 12/6/18, revealed 42 of the 53 CNAs did not have the required 12-hours of training per year. Of the 53 CNAs, eight employees had been hired within the past year and three employees had received the required 12-hours of in-service education. During an interview on 1/16/2019 at 10:55 AM, EI #4, the Administrator acknowledged she was made aware in (MONTH) (YEAR) by the Staff Development Coordinator that CNAs had not received the required education and hours within their twelve month time frame. | 2020-09-01 |
| 749 | 749 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 582 | E | 1 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #313's, RI #316's and RI #317's medical and financial records, the facility's RF[CONDITION] (Resident Fund Management Service) Patient Trust Fund Policy and Procedure, the Resident AR (Accounts Receivable) Refund Policy and a complaint received by the State Survey Agency, the facility failed to refund any and all refunds due to the resident and/or the resident's representative within 30 days from the date of discharge or expiration in the facility. This deficient practice affect RI #313, RI #316 and RI #317, three of four residents sampled residents reviewed for personal funds. Findings include: The facility's RF[CONDITION] Patient Trust Fund Policy and Procedure, dated [DATE], documented . A few points to remember: . Refunds for expired residents must be complete and refunded within thirty days of date of death . The facility's Resident AR Refund Policy dated [DATE], documented PROCEDURE: [STAFFING CO] Healthcare will review all credit balances for appropriate refund, and issue refund within 30 days . 1) On [DATE], the State Survey Agency received a complaint which alleged, RI #313's representative had not received a refund of the money paid to the facility for the resident's room and board. According to the complaint, when the resident was admitted to the facility on [DATE], the representative paid $5400.00. When the resident expired in the facility on [DATE], the complainant stated he was told he would receive a refund since he paid for the entire month, but the resident only stayed in the facility for 10 days. The complainant stated the Business Office person acknowledged that a refund was due but had given many excuses as to why a refund had not been issued. The complainant stated he had been trying to get his money back since [DATE]. RI #313 was admitted to the facility on [DATE] and expired in the facility on [DATE]. RI #313's financial records indicated a check dated [DATE], in… | 2020-09-01 |
| 750 | 750 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 638 | D | 0 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of Resident Identifier (RI) #1's medical record and the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, the facility failed to ensure RI #1's Quarterly Minimum Data Set (MDS) was completed within 92 days after the previous assessment. This deficient practice affected RI #1, one of two sampled residents reviewed for overdue assessments. Findings include: Page 2-33 of Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 dated October 2019, documented . The Quarterly assessment is an OBRA (Omnibus Budget Reconciliation Act) non-comprehensive assessment for a resident that must be completed at least every 92 days following the previous OBRA assessment of any type. It is used to track a resident's status between comprehensive assessment to ensure critical indicators of gradual change in a resident's status are monitored . RI #1 was admitted to the facility on [DATE]. RI #1's Admission MDS has an assessment reference date of 8/26/2019. RI #1's next assessment was a Quarterly MDS with an assessment reference date of 12/24/2019, 120 days later after the previous assessment. On 1/16/2020 at 8:42 AM, an interview was conducted with Employee Identifier (EI) #7, the MDS Coordinator. EI #7 was asked when was RI #1's last assessment (MDS) done. EI #7 said on 8/19/2019. When asked when should RI #1's next assessment have been done, EI #7 said on 11/24/2019. EI #7 was asked when was RI #1's Quarterly MDS done. EI #7 said on 12/24/2019. When asked if the Quarterly MDS was completed within EI #7 was asked was RI #1's Quarterly MDS assessment completed 92 days following the previous assessment, EI #7 said no. EI #7 acknowledged that she was responsible for ensuring the MDS was completed timely. | 2020-09-01 |
| 751 | 751 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 684 | J | 1 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of Resident Identifier (RI) #362's medical and hospital records, the facility failed to provide treatment for [REDACTED]. On 11/30/2019 at 1:00 PM, RI #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. When EI #15 assessed the resident, the resident complained of left arm pain. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. RI #362's x-ray results were released to the facility's computerized charting system on 12/1/2019 at 11:36 PM. During a planned discharge scheduled for [DATE], RI #362 was discharged home, without notification to the resident's representative that an x-ray had been ordered or the results had been received that indicated the resident had sustained a [MEDICATION NAME] distal radius. While the facility was made aware of the resident's x-ray results, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called the physician and was asked to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. RI … | 2020-09-01 |
| 752 | 752 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 686 | D | 0 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of Resident Identifier (RI) #17's and RI #128's medical records and the facilities' policies titled Wound Care Management and Hand-Hygiene Technique, the facility failed to ensure: 1) RI #128's care plan interventions were implemented to reduce the risk of pressure ulcer development; and 2) Employee Identifier (EI) #9, the Licensed Piratical Nurse (LPN)/Treatment Nurse washed her hands between glove changes while providing wound care to RI #17. These deficient practices affected RI #17 and RI #128, two of two sampled residents reviewed for pressure ulcers. Finding include: 1) The facility's policy titled, Wound Care Management dated December 2017, documented Policy Each resident receives the care and services necessary to retain or regain optimal skin integrity to the extent possible. A plan of care is developed and implemented . RI #128 was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. RI #128's care plan titled, The resident has a history stage 4 right heel pressure ulcer r/t (related to) Immobility initiated on [DATE]19, had an intervention of . Heel protector while in bed . RI #128's care plan titled, Resident at (risk) for pressure ulcers . initiated on [DATE]19, had an intervention of . pressure relieving pad for w/c (wheelchair) . RI #128's care plan titled, The resident has limited physical mobility r/t Weakness initiated on 8/15/2019, had an intervention of Positioning: Resident to wear heel protectors with a pillow under legs to lower the risk of pressure ulcer . RI #128's AHAVA BRADEN SCALE dated 12/15/2019, indicated the resident was at risk for pressure ulcer development. The [STAFFING CO] Progress Notes for RI #128 dated 12/31/2019 5:24 PM, documented . Resident to wear heel protectors with a pillow under legs to lower the risk of pressure ulcer . On 1/15/2020 at 3:20 PM, RI #128 was observed in bed. The resident was not wearing heel protectors and there was no … | 2020-09-01 |
| 753 | 753 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 726 | L | 1 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #362's medical record, the 24 HOUR REPORT/CHANGE OF CONDITION REPORT, Contract Agency #1's FACILITY STAFFING AGREEMENT, Contract Agency #2's CLIENT AGREEMENT FOR HEALTHCARE PROFESSIONAL SERVICES and personnel files, the facility failed to train the Licensed Nurses of Contract Agency #1 and Contract Agency #2 on the facility's policies and the computerized charting system. On 11/30/2019 at 1:00 PM, RI #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. On 12/1/2019 at 11:36 PM, RI #362's x-ray results were released to the facility's computerized charting system, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. The RN, on duty and assigned to care for the resident when the x-ray results were sent to the facility, was an employee of Contract Agency #1. The RN stated she did not get the results of the x-ray for RI #362 because the fax machine was not working, and she had not been trained on where x-ray results would come. The facility's Director of Nursing (DON) stated the facility utilized licensed nurses from different agencies and they were not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. This failure led to the Ordering Physician and the resident's responsible party not being made aware of the results of the resident's x-ray. Furthermore, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home on[DATE]. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. Whe… | 2020-09-01 |
| 754 | 754 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 777 | J | 1 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of Resident Identifier (RI) #362's medical and hospital records, the facility's policy titled Clinician Notifications of Lab and Diagnostic Results and the 24 HOUR REPORT/CHANGE OF CONDITION REPORT, the facility failed to notify Employee Identifier (EI) #14, the facility's Medical Director and RI #362's Ordering/Primary Physician of the results an x-ray of the resident's left wrist and shoulder that was ordered on [DATE]. On 12/1/2019 at 11:36 PM, the facility was made aware of the results of RI #362's wrist and shoulder x-ray, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. While the facility was made aware of the resident's x-ray results, the Ordering Physician was not and the resident was discharged home from the facility on [DATE] around noon. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improving, RI #362's family member called a physician and was instructed to call an ambulance to have the resident transferred to the local hospital. RI #362 presented to the emergency room of the local hospital with mild to moderate swelling of the left wrist, minimal bruising, mild redness on the dorsal side of the wrist, and pain with attempted range of motion of the left wrist. The x-ray reports revealed the resident had sustained a Left distal radius fracture. RI #362's wrist fracture was treated with immobilization, given pain medication, and asked to follow up with an orthopedic physician for further evaluation and treatment of [REDACTED]. This deficient practice affected RI #362, one of six sampled residents reviewed for accidents and placed this resident in immediate jeopardy as it was likely to cause serious injury, harm, impairment or death. On 1/31/2020 at 9:30 PM, the Ad… | 2020-09-01 |
| 755 | 755 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 812 | F | 0 | 1 | MBZD11 | Based on observations, interviews, review of facility's policies titled, DISHWASHING PROCEDURE, DISH AND UTENSIL PROCEDURE and FOOD TEMPERATURES, and review of FOOD TEMPERATURE/SANITATION RECORD, the facility failed to ensure: 1) dishware, including silverware, plates, dome lids and trays were air dried prior to use; and 2) staff checked the temperatures of chopped hamburger and chicken prior to meal service on 1/15/2020. This had the potential to affect all residents who received meals from the kitchen. Findings include: 1) The facility's policy titled, DISHWASHING PROCEDURE, revised 11/1/2010, revealed: . 13. Air dry dishes by racking or putting on single trays lined with mesh . The facility's policy titled, DISH AND UTENSIL PROCEDURE, revised 7/1/2014, revealed: . 6. Dishes, trays and utensils shall be air dried before storage. On 1/15/2020 at 4:31 PM, while observing meal service, the surveyor observed wet silverware in a holder containing water. The surveyor also observed meal trays stacked wet. While watching staff plate meal trays, the surveyor also noted staff using wet plates and wet dome lids. On 1/15/2020 at 6:17 PM, the surveyor conducted an interview with EI #1, a Dietary Aide. EI #1 was asked what she observed in the dome lids during meal service. EI #1 replied, water. On 1/15/2020 at 6:44 PM, the surveyor conducted an interview with EI #2, Cook. EI #2 was asked what she observed during meal service. EI #2 replied, wet plates. EI #2 was asked how many she pulled off the line wet. EI #2 replied, at least ten. When asked why plates should not be wet on the tray line, EI #2 said because of bacteria. EI #2 was asked who was responsible for making sure plates were not wet on the tray line. EI #2 replied, the dish room or the manager. On 1/15/2020 at 6:50 PM, an interview was conducted with EI #3, a Dietary Aide. EI #3 was asked what was in the spoons, forks and knives in the silverware holder. EI #3 replied, she saw that they were wet. EI #3 was asked what was on the trays. EI #3 replied, water. When ask… | 2020-09-01 |
| 756 | 756 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 835 | L | 1 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of Employee Identifier (EI) #13, the Director of Nursing, the DON failed to oversee the activities of the Nursing Department when she failed to ensure the Licensed Nurses from Contract Agency #1 and Contract Agency #2 were trained on the facility's policies and procedures and the facility's computerized charting system. On 11/30/2019 at 1:00 PM, Resident Identifier (RI) #362 was found on the floor by Employee Identifier (EI) #25, a Certified Nursing Assistant. The CNA informed the Registered Nurse (RN), EI #15. After continued complaints of pain, on 12/1/2019, EI #15 called the physician and an x-ray was ordered at 3:33 PM. On 12/1/2019 at 11:36 PM, RI #362's x-ray results were released to the facility's computerized charting system, which revealed the resident had sustained a recent left [MEDICATION NAME] radius, with soft tissue swelling. The RN, on duty and assigned to care for the resident when the x-ray results were sent to the facility, was an employee of Contract Agency #1. The RN stated she did not get the results of the x-ray for RI #362 because the fax machine was not working, and she had not been trained on where x-ray results would come. The facility's Director of Nursing (DON) stated the facility utilized licensed nurses from different agencies and they were not provided the same training on the facility's computerized charting system as the licensed staff employed through the facility. This failure led to the Ordering Physician and the resident's responsible party not being made aware of the results of the resident's x-ray. Furthermore, the resident received no treatment or further evaluation of the left distal radius fracture before being discharged home on[DATE]. Once the resident arrived home, RI #362's family member noticed swelling, bruising and guarding of the left arm. The resident complained of pain when the left arm was touched. When the change in the resident's condition was not improvi… | 2020-09-01 |
| 757 | 757 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2020-02-01 | 880 | D | 0 | 1 | MBZD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of Resident Identifier (RI) #15's medical record and the facility's policy titled [STAFFING CO] [MEDICAL CONDITION] Care, the facility failed to ensure Respiratory Therapist #1 changed gloves and washed her hands during [MEDICAL CONDITION] care for RI #15. This deficient practice affected RI #15, one of one resident sampled for respiratory care. Findings include: The facility's policy titled, [STAFFING CO] [MEDICAL CONDITION] Care, with a revised date of August 2013 revealed . Clean the Removable Inner Cannula . 2. Set up supplies on sterile field. 8. Put on sterile gloves. 11. Gently remove the inner cannula . 14. Remove and discard gloves . 15. Wash hands and put on fresh gloves. Site and Stoma Care: 1. Apply clean gloves. RI #15 was admitted to the facility on [DATE], with a medical history to include a [DIAGNOSES REDACTED]. During [MEDICAL CONDITION] care on 1/16/2020 at 8:00 AM, Respiratory Therapist (RT) #1 washed her hands, applied gloves then gathered and set up supplies on the bedside table on a clean washcloth. RI #15 had a disposable inner cannula. RT #1 removed RI #15's inner cannula with her gloved left hand and placed the inner cannula in an empty gauze package. RT #1 then cleansed the [MEDICAL CONDITION] and bridge with peroxide-soaked Q-tips. RT #1 then removed the new sterile inner cannula from the package with her left hand, wearing dirty contaminated gloves, touching only the hubb portion of the cannula. RT #1 placed the inner cannula into outer cannula and locked it in place. RT #1 used both gloved hands to remove the dirty gauze drain sponge from under the bridge and placed a clean gauze drain sponge under the bridge of RI #15's trach. RT #1 wore the same gloves throughout the entire procedure and did not remove or change her gloves nor did she wash her hands. In an interview on 1/16/2020 at 8:08 AM, Respiratory Therapist (RT) #1 was asked when she should change gloves [MEDICAL COND… | 2020-09-01 |
| 758 | 758 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-02-15 | 554 | D | 1 | 0 | 9GDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, interviews and review of a facility policy titled Self-Administration of Drugs, the facility failed to ensure Resident Identifier (RI) #3 was assessed to self-administer the resident's nebulizer treatments This affected RI #3, one of one resident observed receiving a nebulizer treatment. Findings Include: Review of the facility's policy titled Self-Administration of Drugs with a revision date of 2006, documented: Policy Statement Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so. Policy Interpretation and Implementation 1. As part of their overall evaluation, the staff and practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications . RI #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #3's ASSESSMENT FOR SELF-ADMINISTRATION OF MEDICATIONS, dated 08/13/17, documented: . Can correctly state name of medication and what it is used for? . (Unable was checked) Can read print on precription (prescription) label? . (Unable was checked) Can correctly state common side-effects of each medication? . (Unable was checked) . Can administer inhalant medications with proper procedure? (No response was checked) . RI #3's (MONTH) (YEAR) physician's orders [REDACTED].> . IPRAT ([MEDICATION NAME])-ALBUT ([MEDICATION NAME]) 0.5-3(2.5) MG (Milligram)/3 ML (Milliliter) INHALE CONTENTS OF 1 VIAL BY MOUTH VIA (by way of) NEBULIZER AFTER SMOKING TID (three times a day) FOR SOB (shortness of breath) . On 02/14/18 at 4:44 p.m., the surveyor observed RI #3 sitting in a wheelchair in the doorway of the resident's room. RI #3 had a nebulizer mask on and the nebulizer treatment was infusing. RI #3 stated the nurse had just put solution in the reservoir. There was no nurse observed in RI #3's room at this time. RI #3 stated he t… | 2020-09-01 |
| 759 | 759 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-02-15 | 726 | D | 1 | 0 | 9GDJ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record review, the facility failed to ensure a Certified Nursing Assistant (CNA), Employee Identifier (EI) #4, got a qualified professional (nurse) to place Resident Identifier (RI) #9's continuous tube feeding on hold. On 02/15/18, EI #4, a CNA, not qualified to performed this nursing task, placed RI #9's continuous feeding on hold when providing incontinence care. This affected RI #9, one of one resident sampled with a continuous tube feeding. Finding Include: RI #9 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set assessment, with an Assessment Reference Date of 12/25/17, identified RI #9 as having a Feeding tube during this assessment period. RI #9's (MONTH) (YEAR) Physician Orders, documented: . [MEDICATION NAME] 1.2 CAL (calorie) LIQUID GIVE 60 ML (milliliters)/HR (hour) x (times) 23 HOURS . On 02/15/18 at 1:48 p.m., EI #4, RI #9's assigned CNA and EI #5, another CNA entered RI #9's room to check RI #9's incontinence status. RI #9 had [MEDICATION NAME] 1.2 cal infusing by way of a feeding tube pump at 60 cc's (centimeters) an hour. EI #4 placed the feeding tube pump on hold and lowered the head of RI #9's bed. After providing incontinent care to RI #9, EI #4 let the head of the bed up and turned the feeding tube pump back on. The surveyor asked EI #4 were CNAs allowed to place a feeding pump on hold. EI #4 said the CNAs could. EI #4 said the CNAs could not unplug the tube feedings. On 02/15/18 at 7:43 p.m., the surveyor conducted an interview with EI #1, the Interim Director of Nursing. The surveyor asked EI #1 should the CNAs be placing a feeding pump on hold. EI #1 said no. The surveyor asked EI #1 was this out of the scope of practice for a CN[NAME] EI #1 said yes. | 2020-09-01 |
| 760 | 760 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 584 | D | 1 | 1 | F1G011 | > Based on observations, interview and review of a facility policy titled, Environmental Services Guidelines, the facility failed to ensure a shower room did not have a stained brown film build up on the baseboards. This deficient practice affected one of three showers in the facility. Findings Include: A review of the facility's policy titled, Environmental Services Guidelines, without a date, revealed: .All horizontal surfaces such as .shower floors .will be cleaned daily with an acceptable hospital-grade disinfectant/germicide . On 07/09/19 at 9:06 a.m., the surveyor observed the North Section shower floor and baseboards had a stained brown film build up. On 07/10/19 at 9:53 a.m., the North Section shower floor and baseboards had the same stained brown film build up. On 07/11/19 at 7:37 a.m., the North Section had no changes made to the shower floor and baseboards. On 07/11/2019 at 11:39 a.m., the surveyor conducted an interview with Employee Indentifer (EI) #5, Regional Maintenance Director. The surveyor asked EI #5 what was on the North Section shower floor and baseboards. EI #5 said some build up. EI #5 said it needed a little more attention. The surveyor asked EI #5 how often were the showers supposed to be cleaned. EI #5 said daily. The surveyor asked EI #5 what were the issues with the shower floors and baseboards having a stained brown film build up. EI #5 said it was a path for infection. | 2020-09-01 |
| 761 | 761 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 641 | D | 1 | 1 | F1G011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and a review of the resident's medical record, the facility failed to accurately code Resident Identifier (RI) #140's Discharge Minimum Data Set (MDS) assessment, dated 05/10/19. This deficient practice affected RI #140, one of three residents sampled for closed record review. Findings Include: RI #140 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of RI #140's Discharge Recommendations/Arrangement form, dated 05/10/19, revealed the resident was discharged home. A review of RI #140's Discharge MDS assessment, dated 5/10/19, revealed the resident was discharged to an acute care hospital. On 07/11/19 at 4:09 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON). EI #1 was asked if the Discharge Status section of the MDS dated [DATE] was coded correctly. EI #1 said no. EI #1 was asked what was coded under the Discharge Status section . EI #1 said acute hospital. EI #1 was asked what location was RI #140 discharged to from the facility. EI #1 said home. EI #1 was asked if this was an accurate MDS assessment. EI #1 said no. | 2020-09-01 |
| 762 | 762 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 686 | E | 1 | 1 | F1G011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record review, the facility failed to ensure the treatment nurse did not use gloves from the pocket of her uniform when providing wound care to Resident Identifier (RI) #12 and #42's Stage III pressure ulcers on 07/10/19. This deficient practice affected RI #12 and 42, two of three residents observed for wound care. Findings Include: (1) RI #12 was admitted to the facility on [DATE], and readmitted on [DATE], with a [DIAGNOSES REDACTED]. RI #12's Weekly Wound Assessment revealed a pressure ulcer to his/her sacrum reopened on 04/05/19. RI #12's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 04/23/19, identified RI #12 as having a Stage III pressure ulcer during this assessment period. RI #12's (MONTH) Order Summary Report (physician's orders [REDACTED]. . wound: clean area to sacrum with cleanser. Apply [MEDICATION NAME] blue (antibacterial wound dressing) to wound and cover one time a day every Mon (Monday), Wed (Wednesday), Fri Friday) . On 07/10/19 at 10:49 a.m., the surveyor observed Employee Identifier (EI) #3, the Treatment Nurse provide wound care to RI #12's sacrum pressure ulcer. EI #3 said RI #12's Stage III pressure ulcer healed and reopened on 04/02/19. EI #3 gathered RI #12's wound supplies, removed gloves from a box on top of the treatment cart and placed the gloves in the right pocket of her uniform. EI #3 entered EI #12's room, removed a pair of gloves from her pocket, and put the gloves on. EI #3 cleaned the area to RI #12's sacrum with a wound cleanser soaked 4 x 4 gauze. EI #3 removed the gloves, washed her hands in bathroom, removed gloves from the pocket of her uniform again, put the gloves on and applied the [MEDICATION NAME] Blue dressing on top of the border dressing. EI #3 placed the clean dressing over RI #12's wound bed. (2) RI #42 was admitted to the facility on [DATE], and readmitted on [DATE] with [DIAGNOSES REDACTED]. RI #42's Weekly… | 2020-09-01 |
| 763 | 763 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 732 | C | 1 | 1 | F1G011 | > Based on observations, interviews and review of the RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the facility failed to ensure the facility name was on the Daily Nursing Staffing Form on four of four days of the survey. This had the potential to affected all 146 residents at the facility. Findings Include: A review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form revealed there were 146 residents residing in the facility during the survey. On 07/08/19 at 6:12 p.m., the surveyor observed the Daily Nursing Staffing Form for the evening shift. No facility name was on the form. On 07/09/19 at 9:42 a.m., the surveyor observed the Daily Nursing Staffing Form for the day shift. No facility name was on the form. On 07/09/19 at 8:42 a.m., the surveyor observed the Daily Nursing Staffing Form for the day shift. No facility name was on the form. On 07/11/19 at 7:50 a.m., the surveyor observed the Daily Nursing Staffing Form for the day shift. No facility name was on the form. On 07/11/19 at 10:32 a.m., the surveyor conducted an interview with Employee Identifier (EI) #4, the Staffing Coordinator. The surveyor asked EI #4 who was responsible for posting the staffing form. EI #4 said she was. When asked what information should be the form, EI #4 said she had no idea. The surveyor asked EI #4, looking at the old form and the new form, what was missing. EI #4 said the name of the facility. On 07/11/19 at 1:20 p.m., the surveyor conducted an interview with EI #1, the Director of Nursing (DON). The surveyor asked EI #1 what information should be on the Daily Nurse Staffing Form. EI #1 said the scheduled staff, the hours actually worked broken down with staff title, the census, facility name and date. The surveyor asked EI #1, looking at the staff postings for the 8 th, 9 th, 10 th and 11 th, what information was missing. EI #1 said the name of the facility. | 2020-09-01 |
| 764 | 764 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2019-07-11 | 755 | D | 1 | 1 | F1G011 | > Based on interview and review of the RECORD OF MEDICATION DISPOSAL form, the facility failed to ensure the controlled drug destruction sheets had three required signatures. This deficient practice affected one of the three months of controlled drug destruction sheets reviewed. Findings Include: A review of the RECORD OF MEDICATION DISPOSAL form revealed there were two signatures on the controlled drug destruction forms for the month of (MONTH) 2019 . On 07/11/19 at 3:59 p.m., the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse (RN) Director of Nursing (DON). EI #1 was asked how many signatures should be on the controlled drug destruction sheets. EI #1 said two nurses and the pharmacist. EI #1 was asked who was responsible for signing the controlled drug destruction sheets. EI #1 said two nurses and the pharmacist. EI #1 was asked how many signatures were on the six controlled drug sheets dated 04/24/19. EI #1 said two. | 2020-09-01 |
| 765 | 765 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 250 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of the facility's Behavior Management policy, Resident Identifier (RI) #1's medical record and staff interviews, the facility failed to ensure RI #1, a cognitively impaired resident identified as at risk for elopement, who repeatedly voiced a desire to leave the facility, was placed on a behavior management plan to address repeated wandering/exit-seeking behavior. Beginning in (MONTH) (YEAR), RI #1, a resident diagnosed with [REDACTED]. In (MONTH) (YEAR), RI #1 called a taxi to take him/her away from the facility. Then two days before RI #1 eloped from the facility, on 6/7/2017, the resident was observed cursing stating he/she had to leave this place and looking out the door. During the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge and was found a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped from[NAME]Health & Rehab Center. Staff interview revealed, RI #1's elopement could have potentially been avoided had the facility placed the resident on a behavior management plan in (MONTH) (YEAR), when the RI #1 began to voice a desire to leave the facility. This deficient practice placed RI #1, one of four sampled residents in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Medically Related Social Services, F 250. Findings include: The facility's policy with a subject title … | 2020-09-01 |
| 766 | 766 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 272 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on a review of Resident Identifier (RI) #1's medical record, www.dictionary.com and staff interviews, the facility failed to ensure RI #1's ELOPEMENT RISK ASSESSMENT indicated whether the resident was at risk of elopement. Elopement is defined as an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment. Further, the facility failed to reassess RI #1 for elopement risk when the resident voiced repeated statements about his/her desire to leave the facility. With an incomplete assessment and no behavioral interventions to redirect the resident's behavior, during the early morning hours on 6/9/2017, RI #1 eloped from the facility, without staff knowledge. RI #1 was found by a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped, without staff knowledge, from[NAME]Health & Rehab Center. Refer to F 323. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Resident Assessments, F 272. Findings include: According to www.dictionary.com, elopement is defined as . an act or instance of leaving a safe area or safe premises, done by a person with a mental disorder or cognitive impairment . RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], comp… | 2020-09-01 |
| 767 | 767 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 279 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of Resident Identifier (RI) #1's medical record and staff interviews, the facility failed to ensure a comprehensive care plan was developed with interventions on how to provide RI #1 a safe, secure environment and appropriate supervision to reduce the risk of elopement. Through staff interviews it was determined that facility staff had not identified the resident as being high risk for elopement. This resulted in no specific interventions being implemented when the resident exhibited behaviors of wanting to leave the facility. On 6/9/2017 at 5:37 AM, RI #1 was found by a bystander, who found the resident on the side of the roadway; the resident had fallen. The local fire department was notified. RI #1 complained of right shoulder pain. The resident, who was not identified as being a resident of the nursing facility was transported to the local hospital. At the local hospital, the resident was able to tell the hospital staff (his/her) son's phone number. RI #1's son was called and he stated that (his/her) father was supposed to be at the nursing home and must have eloped. RI #1's son also stated the resident has dementia and had recently been trying to leave the facility. Refer to F 323. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Comprehensive Care Plans, F 279. Findings include: RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. RI #1's ELOPEMENT RISK assessment dated [DATE], completed by EI #13, a Registered Nurse (RN) revealed RI #1 was cognitively impaired with poor decision making skills and verbally expressed the desire to go home. This assessment did not indicate whether or not… | 2020-09-01 |
| 768 | 768 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 323 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of Resident Identifier (RI) #1's medical record, the facility's investigation file, the Online Incident Reporting System Report, the Emergency Medical Technician (EMT)-Paramedic report, RI #1's hospital record and facility staff and EMT personnel interviews, the facility failed to ensure staff identified RI #1, a cognitively impaired resident with [DIAGNOSES REDACTED].#1's safety. Further, once RI #1 began making repeated verbal statements and displaying exit seeking behaviors to include calling a taxi, no safety measures and/or interventions were implemented. Thus, RI #1 exited the facility without staff knowledge during the early morning hours on 6/9/2017. The facility further failed to ensure the main lobby door and North Hall unit door were secured in a manner to prevent RI #1 from leaving the facility's premises without staff's knowledge. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of substandard quality of care at the immediate jeopardy level in the area of Quality of Care, F 323. Findings include: According to the Online Incident Reporting System Report, the facility submitted an initial report to the State Agency which documented RI #1 eloped from the facility on 6/9/2017 without staff knowledge. The report indicated RI #1 was found approximately a quarter to a half of a mile from the facility by the fire department and transported to the local hospital for evaluation. The facility began an investigation as to how RI #1 got out of the building. The Emergency Medical Technician (EMT)-Paramedic report revealed on 6/9/2017 at 5:38 AM, EMT personnel was dispatched to a nearby location for a fall victim. Once arrived to the nearb… | 2020-09-01 |
| 769 | 769 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 490 | J | 1 | 0 | 5G6H11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of the Administrator's, Director of Nursing's and Social Services' job descriptions, the Social Worker's training record and staff interviews, the facility's administrative staff failed to ensure the facility staff were trained on the completion and interpretation of the ELOPEMENT RISK ASSESSMENT. The administrative staff also failed to ensure Employee Identifier (EI) #8, the Social Worker, was trained on her responsibility in completing Elopement Risk Assessments, care plan development and the facility's behavior management program. Furthermore, the facility's administrative staff failed to ensure measures were in place to prevent a wandering resident from exiting the facility without staff knowledge. These deficient practices placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, EI #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant were notified of findings of immediate jeopardy level in the area of Administration, F 490. Findings include: Refer to F 250, F 272, F 279 and F 323 1) The facility's undated ADMINISTRATOR JOB DESCRIPTION documented SUMMARY Lead and direct the overall operation of the facility in accordance with resident needs, governing regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors . On 6/20/2017 at 4:00 AM, a State surveyor arrived at the facility's lobby door entrance and pulled on the door handle. The front door was unlocked, which allowed the surveyor to enter the facility lobby unnoticed. During the initial tour of the facility, all exit doors were checked to determine whether or not the exit door was locked or unlocked. Three exit doors were found to be unlocked. Those doors were: the front … | 2020-09-01 |
| 770 | 770 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 493 | J | 1 | 0 | 5G6H11 | > Based on a review of the Regional Nurse Consultant JOB DESCRIPTION and staff interview, the governing body of the facility failed to ensure policies were developed and implemented regarding the use of the facility's ELOPEMENT RISK ASSESSMENT. With an incomplete assessment and no behavioral interventions to redirect the resident's behavior, during the early morning hours on 6/9/2017, Resident Identifier (RI) #1, a cognitively impaired resident, eloped from the facility, without staff knowledge. RI #1 was found by a bystander one quarter to a half mile away from the facility. RI #1 had fallen on the ground and complained of pain. Emergency Medical Technicians (EMTs) responded and assessed RI #1 for injuries. Unbeknownst to the EMT personnel that RI #1 was a resident of the nearby nursing facility, RI #1 was transferred to the local hospital for further evaluation. After identification, it was discovered that RI #1 had eloped, without staff knowledge, from[NAME]Health & Rehab Center. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON), and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Governing Body, F 493. Findings include: Refer to F 272, F 279 and F 323 The Regional Nurse Consultant JOB DESCRIPTION signed by EI #18, the Regional Nurse Consultant on 4/9/2015, documented GENERAL PURPOSE OF JOB POSITION The primary purpose of the job position is to plan, organize, develop and direct the overall operation of the Nursing Services Department in accordance with current Federal, State, and local standards, guidelines, and regulations . to ensure that the highest degree of quality care is maintained at all times . ESSENTIAL JOB FUNCTIONS . * . Review, update and revise policies . * Develop and maintain . nursing policy and procedure manuals . During an … | 2020-09-01 |
| 771 | 771 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-07-21 | 520 | J | 1 | 0 | 5G6H11 | > Based on review of the facility's Quality Assessment and Assurance policy, the Quality Assurance and Performance Improvement Meeting minutes 06/29/17 . and staff interviews, the QAA committee failed to determine the root cause of Resident Identifier (RI) #1's 6/9/2017 elopement from the facility once the investigation was completed. The committee failed to develop an action plan to address the root cause of the incident and any contributing factors to prevent reoccurrence and ensure the safety of other residents remaining in the facility. This deficient practice placed RI #1, one of four sampled residents, in immediate jeopardy as it was likely to cause serious injury, harm or death. On 7/20/2017 at 5:34 PM, Employee Identifier (EI) #1, the Administrator; EI #2, the Director of Nursing (DON); and EI #18, the Regional Nurse Consultant, were notified of the findings of immediate jeopardy level in the area of Quality Assessment and Assurance, F 520. Findings include: Refer to F 250, F 272, F 279, F 323, F 490 and F 493 The facility's policy with a subject of Quality Assessment and Assurance , revised 1/15/2015, documented POLICY: The facility has an established and maintained quality assurance program. This program is governed by a committee that is responsible for identifying those issues, processes, events, risk areas and educational needs associated with quality assurance activities. This committee develops plans of action needed to correct identified areas that demonstrate needed improvement . In an interview on 7/20/2017 at 10:15 AM, EI #2, the DON stated RI #1's elopement from the facility on 6/9/2017 was discussed in a QAA on 6/29/2017. A typed document labeled Quality Assurance and Performance Improvement (QAPI) Meeting minutes 06/29/17 . documented . 2. Results of the last complaint survey conducted on 06/20-06/24/17 reviewing and reporting on the audit for the door alarms from the house supervisor and the maintenance, Social Services to report on the care plans, nurse's notes and interventions for the de… | 2020-09-01 |
| 772 | 772 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 658 | D | 1 | 0 | CDXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of Resident Identifier (RI) #1's medical record, medication error reports and FUNDAMENTAL OF NURSING NINTH EDITION, the facility failed to ensure Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN) did not administer another resident's medications to RI #1 on 8/20/2018. The facility further failed to ensure EI #5 administered only the ordered dose of [MEDICATION NAME] (Klonopin) to RI #1 on 8/20/2018. This affected RI #1, one of three sampled residents. Findings include: Chapter 32 titled Medication Administration page 626 of FUNDAMENTAL OF NURSING NINTH EDITION with a copyright date of (YEAR), documented . Standard are actions that ensure safe nursing practice . Professional standards such as Nursing: Scope and Standards of Practice apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation . RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include: [MEDICAL CONDITION], Chronic Pain, [MEDICAL CONDITION], and Pain in the right knee. RI #1's physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] (Klonopin) Tablet 0.5 MG (milligram) Give 1 tablet by mouth one time a day related to [MEDICAL CONDITION] . During an interview on 9/11/2018 at 2:23 PM, RI #1 stated on 8/20/2018, EI #5, a LPN gave (administered) him/her somebody else's medications and that he/she had also been given (administered) an additional dose of Klonopin that he/she wasn't supposed to get. RI #1 stated he/she took the additional dose of Klonopin because he/she was asleep and didn't remember that he/she had already been administered the medication by EI #5… | 2020-09-01 |
| 773 | 773 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 697 | G | 1 | 0 | CDXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, review of Resident Identifier (RI) #1's medical record, the emergency room (ER) record and a complaint received by the Alabama State Survey Agency, the facility failed to provide pain management to a resident experiencing pain. From 8/14/2018 to 8/15/2018, RI #1 was assessed as having a pain level of 9 on a scale of 0 to 10 (0 = no pain and 10 = worst pain). The ordered pain medication, [MEDICATION NAME], was not available in the facility for administration. When the medication did not arrive on 8/15/2018, RI #1 requested to be sent to the ER for pain relief. At the ER, RI #1 was administered pain medication and sent back to the facility. This deficient practice affected RI #1, one of three sampled residents reviewed for pain management. Findings include: RI #1 was admitted to the facility on [DATE]. RI #1 has a medical history to include: [MEDICAL CONDITIONS], Pain in right knee and Chronic Pain. RI #1's physician's orders [REDACTED].#1 was ordered [MEDICATION NAME] Tablet 15 MG (milligram) Give 1 tablet by mouth every 6 hours related to [MEDICAL CONDITION] . Tylenol Extra Strength Tablet 500 MG Give 2 tablet by mouth every 4 hours as needed for Pain . Page 8 of Mosby's (YEAR) NURSING DRUG REFERENCE 30TH EDITION with a copyright date of (YEAR), indicated Tylenol is an nonopioid [MEDICATION NAME] used to treat mild to moderate pain or fever. Page 811, revealed [MEDICATION NAME] is an opioid [MEDICATION NAME] used to treat moderate to severe pain. RI #1's Medication Administration Record [REDACTED]. According to the MAR, RI #1 received two Tylenol Extra Strength tablets on 8/14/2018 at 12:48 AM for a complaint of pain. During an interview on 9/11/2018 at 2:23 PM, RI #1 stated he/she had run out of [MEDICATION NAME] on 8/14/2018. According to RI #1, the facility administered him/her Tylenol instead. RI #1 stated when the [MEDICATION NAME] wasn't available on 8/15/2018, he/she asked to be sent to the ER for some pain relief… | 2020-09-01 |
| 774 | 774 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 835 | E | 1 | 0 | CDXE12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and review of the Director of Nursing (DON) and Nursing Home Administrator's job descriptions, the facility's DON, responsible for the overall operations of the Nursing Department, and the facility's Administrator, responsible for the overall operations of the facility, failed to ensure the facility implemented their submitted and accepted Plan of Correction for F 697, with an alleged correction date of 10/31/2018. This failure to implement the Plan of Correction was evident when the facility staff failed to notify pharmacy when Resident Identifier (RI) #1 and RI #5 had a seven day or less supply of routine pain medication available in the facility. This deficient practice affected RI #1 and RI #5, two of three sampled residents, with the potential to affect the remaining 96 residents currently residing in the facility receiving pain medication. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by Employee Identifier (EI) #1, the DON and dated 11/27/2018 indicated the facility had a total of 133 residents, with a total of 98 residents receiving pain medication. Findings include: Refer to F 658 and F 697 The Director of Nursing job description signed by EI #1, the DON, on 8/25/2018, documented . General Purpose: To manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs . Administrative Functions . Plan, develop, organize, implement, evaluate and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that govern the long-term care facility . In an interview on 12/12/2018 at 3:15 PM, EI #1, the DON was asked when she completed her audit on 11/19/2018, how much [MEDICATION NAME] did RI #1 have available in the facility. EI #1 replied, the resident had a seven day supp… | 2020-09-01 |
| 775 | 775 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 837 | E | 1 | 0 | CDXE12 | > Based on interviews and review of the Regional Nurse Consultant job description, the facility's governing body failed to provide oversight and monitoring to ensure the facility's Plan of Correction was implemented and the facility maintained and achieved substantial compliance. These failures affected RI #1 and RI #5, two of three sampled residents, with the potential to affect the remaining 96 residents currently residing in the facility receiving pain medication. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by Employee Identifier (EI) #1, the DON and dated 11/27/2018 indicated the facility had a total of 133 residents, with a total of 98 residents receiving pain medication. Findings include: Refer to F 658, F 697 and F 835 and F 867 The undated Regional Nurse Consultant job description documented . General Purpose: To review process and assist with the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices and governmental regulations so as to maintain excellent care of all residents' needs . Administrative Functions . Organize, develop, and direct the administration and resident care of the nursing service department . In an interview on 12/14/2018 at 10:45 AM, EI #15, the Registered Nurse (RN) Regional Consultant, was asked what her job duties consisted of. EI #15 explained she was responsible for providing support to the Director of Nursing (DON), performing audits and educations. When asked if she was involved in the development and implementation of the facility's Plan of Correction, EI #15 replied, yes for parts of it. EI #15 was asked if EI #1, the DON, should have followed the protocol as listed in the facility's Plan of Correction when she found during her audit on 11/19/2018 that RI #1 had a seven day or less supply of pain medication in the facility. EI #15 replied, Yes she should have. When asked why residents' routine medications are not being ordered in a timely manner, EI #15 answered I don't have any idea why. W… | 2020-09-01 |
| 776 | 776 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 867 | D | 1 | 0 | CDXE12 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, review of the facility's policy titled Quality Assurance Performance Improvement Plan and Resident Identifier (RI) #5's medical record, the facility failed to determine the correct root cause as to why RI #5's pain medication was not available in the facility for administration on 11/1/2018. Furthermore, the facility failed to implement an action plan that would address the facility's failure to have available pain medication for administration. This deficient practice affected RI #5, one of three sampled residents reviewed for pain medication, with the potential to affect the remaining 97 residents currently residing in the facility receiving pain medication. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by Employee Identifier (EI) #1, the DON and dated 11/27/2018 indicated the facility had a total of 133 residents, with a total of 98 residents receiving pain medication. Findings include: The facility policy titled, Quality Assurance Performance Improvement Plan with an effective of 5/1/2018, documented Plan an effective Quality Assurance Performance Improvement (QAPI) plan at all levels of our organization is vital for success. This process will enable the identification of problem areas at every level and will ensure appropriate measures are taken. Once corrective actions have been taken, monitoring and follow up will ensure that improvements are sustained . The ultimate goals of committees at all levels are to identify trends, perform root cause analyses, prioritize issues in order of importance, initiate Process Improvement Projects (PIPS) to enable an effective and sustainable solution, monitor and revise as needed . RI #5 was admitted to the facility on [DATE], with a medical history to include a [DIAGNOSES REDACTED]. RI #5's physician orders [REDACTED]. RI #5's Medication Administration Record [REDACTED]. In an interview on 12/13/2018 at 8:45 AM, EI #4, a LPN Charge Nurse was asked if RI … | 2020-09-01 |
| 777 | 777 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2018-09-27 | 880 | D | 1 | 0 | CDXE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and review of the facility's policy titled Medication Administration, the facility failed to ensure Employee Identifier (EI) #3, a Registered Nurse (RN) did not place medication into her bare hand when preparing medications for administration to Resident Identifier (RI) #1. This affected RI #1, one of three residents observed for medication administration. Findings include: The facility's policy titled, Medication Administration dated 12/2017, documented . PR[NAME]EDURE . 2. Use sanitary technique to place medications into a souffle or medication cup . During medication administration observation on 9/11/2018 at 9:17 AM, EI #3, a Registered Nurse poured Calcium Vitamin D from the bottle into her bare hand and then into a medication cup. EI #3 was also observed to punch one [MEDICATION NAME] 150 milligram capsule from the blister pack into her bare hand before placing it into a medication cup. After all medications had been prepared, EI #3 administered the medications to RI #1. In an interview on 9/12/2018 at 1:24 PM, EI #3, a RN was asked how should medications be handled during medication preparation. EI #3 replied, we are not to touch them at all. We are to pop them straight from the card into the cup or pour them straight from the bottle into the cup. When asked should she place medication into her bare hand prior to placing them into a medication cup, EI #3 said absolutely not. When asked if she poured RI #1's medication into her bare hand on 9/11/2018, EI #3 said yes. EI #3 was asked what was the concern with placing medication into her bare hands. EI #3 replied, infection control. | 2020-09-01 |
| 778 | 778 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 253 | D | 1 | 0 | J4RZ11 | > Based on observation, interview, and review of facility policy, Preventative Maintenance Program. The facility failed to maintain Room Locator (RL) #'s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11 in good repair. This was observed on two of three days of the survey and affected 11 of 124 rooms in the facility. Findings include: The facility's policy, Preventative Maintenance Program, dated 11/17/16, included the following: . the building and equipment are maintained in a safe and operable manner. The maintenance director and/or designee is responsible to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. During the initial tour on 10/17/17, between 2:30 and 3:55 p.m., RL #1 was observed to have a stained floor. RL #5's bathroom had a dirty seal around the commode (toilet) base, stains on the floor, scarring on the door, and walls needing paint. RL #10 had chipped plaster and paint on the wall behind a recliner. RL #4's bathroom had scarring on the door and walls needing paint. RL #9 had chipping in the wall behind the bed. On 10/19/17 at 4:05 p.m. the surveyor and EI #3, lead maintance person for the facility, began a tour of the building, which included RL #'s 1 through 11. At 4:15 p.m., RL #1, a bathroom, was observed to have darkened areas along the tile lines of the floor. EI #3 said the floor staining was due to age and time and the best solution is to replace the tile. When asked about the working of the ceiling vent, EI #3 said there were vent fan motors on the roof of the facility and that one vent fan may service three or four rooms. EI #3 said there were main switches for vent fans in the shower rooms. EI #3 further said some resident bathrooms had their own vent switches. EI #3 said five (vent fans) were replaced last week and they were continuing to work on this. At 4:20 p.m., RL #2's window casement was observed to have been partially repaired. EI #3 said sheetrock and mud (drywall mud) had been used in the repair and the next steps were to sand, add a second l… | 2020-09-01 |
| 779 | 779 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 364 | D | 1 | 0 | J4RZ11 | > Based on a test tray observation, interviews, and documentation to include the facility's Purpose and Objectives of the Nutrition and Food Service Department, policy for Standardized Recipes, recipe for Chicken Breast, Grilled, and Week I menu, the facility failed to ensure the chicken breast served as an alternate at lunch on 10/18/17 was seasoned and palatable. This was observed during a test tray observation on 10/18/17 and had the potential to affect any resident requesting the alternate menu for lunch on 10/18/17. Findings include: The facility's Purpose and Objectives of the Nutrition and Food Service Department, dated 2008, included: The purpose of the nutrition and food service department is to provide high quality, nutritious, palatable and attractive meals . The facility's policy for Standardized Recipes, dated 2008, included: Policy: Standardized recipes are used when preparing menu items. Procedure: . 3. Cooks are expected to use and follow the recipes provided. The facility's recipe for Chicken Breast, Grilled, dated (YEAR), included: . Ingredients Chicken, Breast, Boneless, Skinless, IQF (Individually Quick Frozen) Juice, Lemon, Onion Powder, Pepper, Black, Ground Salt, Seasoned Parsley, Dehydrated, Flaked . Method Mix lemon juice, onion powder, pepper, seasoned salt, and parsley. Dip Chicken in marinade mixture.Cook on prepared grill . The facility's Week I menu (no year specified) for Wednesday 10/18 included the following for the Lunch meal: . Alternate Grilled Chicken Patty . During the Resident Council meeting on 10/18/17 at 10:00 AM, residents complained that the Grilled Chicken Patty was tasteless and hard to swallow. A test tray was conducted with Employee Identifier (EI) #10, a Registered Dietitian and the Dietary Department Director, and EI #11, the Dietary Manager, on 10/18/17 at 12:55 p.m. to include the alternate meat for lunch, which was a Grilled Chicken Patty. EI #11 said boneless chicken breasts were used for the freshly cooked Grilled Chicken [NAME]es. The chicken appeared to hav… | 2020-09-01 |
| 2394 | 2394 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 221 | D | 0 | 1 | J4RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and a review of the facility's policy titled, Use of Restraints, the facility failed to provide medical justification for the use of a seat belt restraint for Resident Identifier (RI) #8. The facility further failed to ensure a restraint assessment was performed when the seat belt restraint was ordered for Resident Identifier (RI) #8 on 08/15/17. This had the potential to affect one of two residents reviewed for restraints. Findings Include: A review of the facility's policy titled, Use of Restraints, with a Revised date of (MONTH) 2008, revealed: . Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully. Restraints shall only be used to treat the resident's medical symptoms(s) and never for discipline or staff convenience, or for the prevention of falls. Policy Interpretation and Implementation 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body.6. Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devises, referrals, etc.) that may improve the symptoms. 19. Documentation regarding the use of restraints shall include: a. Full documentation of the episode leading to the use of the restraint. b. A description of the resident's medical symptoms . that warranted the use of restraints; c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of the physical restraint used; e. The length of ef… | 2020-04-01 |
| 2395 | 2395 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 274 | D | 0 | 1 | J4RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, medical record review and the Long-Term Care Facility Resident Assessment Instrument User's Manual the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed for Resident Identifier (RI) #7 within 14 days of the written physician orders [REDACTED]. This affected RI #7, one of three residents sampled for hospice. Findings include: A review of the Long -Term Care facility Resident Assessment Instrument User's Manual dated (MONTH) 2012 documented the following: A Significant Change Assessment is required to be performed when a .resident enrolls in a hospice program .within 14 days from the effective date of the hospice election . RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly MDS, with an Assessment Reference Date (ARD) of 8/15/2017 was the most recently completed MDS for RI #7. RI #7's Physician order [REDACTED]. Order Date: 9/01/17 Start Date: 9/01/17 Orders: admitted (admitted ) to (Name of hospice service) On 10/19/17 at 12:20 p.m., Employee Identifier (EI) #7, the MDS Coordinator, was interviewed. When asked if RI #7 was on hospice, EI #7 said, Yes. EI #7 pointed to RI #7's (MONTH) (YEAR) physician's orders [REDACTED]. EI #7 was asked if a Significant Change MDS was done for RI #7 after the resident was put on hospice, when it should have been done, and if not done, why not. EI #7 said, I just found out about it. There is one in process now. A significant change should have been done within 14 days of the hospice order. It should have been done by (MONTH) 15, (YEAR) since the order was dated (MONTH) 1, (YEAR). EI #7 further said RI #7's spouse was undecided about hospice and was going to think about it during his/her vacation. However, RI #7's spouse decided on hospice prior to leaving for vacation, so the physician wrote the order. EI #7 said he/she was not notified by either the hospice staff or the nursing home staff about this. EI #7 said normally the … | 2020-04-01 |
| 2396 | 2396 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 281 | D | 0 | 1 | J4RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, and Alabama Board of Nursing's Nurse Practice Acts, the facility failed to meet professional standards of practice by ensuring Resident Identifier (RI) #3 had a written physician's orders [REDACTED]. This affected RI #3, one of fourteen sampled residents whose diets were reviewed. Findings Include: A review of the Alabama Board Of Nursing's Nurse Practice Acts, Code Commissioner's note - 1993, revealed: .34-21-1 Definitions.a. Practice of Professional Nursing. The performance, for compensation, of any act in the care and counseling of persons or in the promotion and maintenance of health and prevention of illness and injury based upon the nursing process which includes systematic data gathering, assessment, appropriate nursing judgement and evaluation of human responses to actual or potential health problems thorough such services as case finding, health teaching, health counseling; and provision of care supportive to or restorative of life and well-being, and executing medical regimens including administering medications and treatments prescribed by a licensed . physician . RI #3 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #3's medical record revealed there was not a physician's orders [REDACTED]. A review of RI #3's discharge order from a local hospital, printed 03/15/17, revealed he/she had a diet regimen at the facility of 1800 calorie American Diabetic Association (ADA) diet with supplements. Further review of RI #3's chart revealed on 03/17/17, RI #3 was care planned for a therapeutic diet. On 10/18/17 at 8:27 a.m., the surveyor observed RI #3's breakfast. The tray card showed a regular diet with limited concentrated sweets (LCS). On 10/18/17 at 12:53 p.m., the surveyor observed RI #3's lunch. The tray card showed a regular LCS diet. An interview was conducted on 10/19/17 at 11:38 a.m. with EI #8, a Registered Nurse (RN), and the Director of… | 2020-04-01 |
| 2397 | 2397 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 372 | F | 0 | 1 | J4RZ11 | Based on observation, interview, and documentation from the facility's policy for Waste Disposal and the 2013 Food Code, the facility failed to ensure three dumpster's containing food waste were not left open and that one of five dumpster's did not have broken lids. This was observed on 10/17/17 and had the potential to affect 149 of 149 residents in the facility. Findings include: The facility's policy for Waste Disposal, dated 2008, included the following: . Procedure: . 2. Trash will be deposited into a sealed container outside the premises. The 2013 Food Code of the United States Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . shall be designed and constructed to have tight-fitting lids, doors, or covers. 5-501.110 Storing Refuse, Recyclables, and Returnable's. REFUSE, . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE . shall be kept covered: . (B) With tight-fitting lids or doors if kept outside . During the initial tour on 10/17/17 at 3:05 p.m., the two dumpster's used by the kitchen for food related waste and trash were observed. One dumpster had the top lid flap on the left side open and also had the left side door partially open. At 3:07 p.m., the dumpster used by housekeeping and the dumpster used by maintenance were observed. Both of the dumpster's contained food related trash, such as a lemonade container, drink containers, and snack wrappers. Each dumpster had one side door open. At 3:11 p.m., the dumpster used by central supply was observed to have both of the top lid flaps broken loose and not covering the dumpster. During an interview on 10/17/17 at 3:16 p.m., Employee Identifier (EI) #11, the Dietary Manager, was asked what was the problem with the dumpster's being left open. EI #11 said, Rodents and Rats and everything. | 2020-04-01 |
| 2398 | 2398 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 425 | D | 0 | 1 | J4RZ11 | Based on a review of the facility's Record of Medication Destruction, the facility's policy titled, Disposal/Destruction of Expired or Discontinued Medications and interview, the facility failed to ensure that there were two signatures on the non controlled medication destruction for the months of (MONTH) and (MONTH) (YEAR). This affected two of six months reviewed for drug destruction. A review of the facility's policy titled, Disposal/Destruction of Expired or Discontinued Medications with a Revision Date of 01/01/13, page 1, revealed: . 5. Facility should destroy non-controlled medications in the presence of a registered nurse and witnessed by one other staff member, in accordance with Facility policy or Applicable Law. A review of the drug destructions records was performed on 10/19/2017 at 3:00 p.m. It was discovered that there are 11 pages of (MONTH) (YEAR) and 15 pages of (MONTH) (YEAR) that did not have the required number of two signatures as witnesses to the drug destruction. An interview was conducted on 10/19/2017 at 4:45 p.m. with EI #8, a Registered Nurse (RN),the Director of Nursing. EI #8 was asked how many signatures are required for the non-controlled drug destruction. EI #8 replied, Two. EI #8 was asked if the months of (MONTH) and (MONTH) (YEAR) had the correct number of signatures. EI #8 replied, No. EI #8 was asked why they did not have the correct number of signatures. EI #8 replied, I'm not sure. EI #8 was asked what was the harm in not having the signatures. EI #8 replied, They could be given away or taken, and not accounted for. With one person signature, (Pharmacist) you don't have validation. | 2020-04-01 |
| 2399 | 2399 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-10-19 | 441 | E | 0 | 1 | J4RZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record review, a review of the facility's policies titled, Personal Protective Equipment - Using Gloves, Perineal Care, and Standard Precautions and a review of POTTER and PERRY'S FUNDAMENTALS OF NURSING, the facility failed to ensure: 1. A licensed nurse did not touch the medication with her fingers before loading it into Resident Identifier (RI) #15's inhaler, 2. a licensed nurse washed her hands before donning gloves and after removing gloves while administering an injection to RI #5, 3. a licensed nurse provided a barrier before placing RI #5's medical supplies on an unclean surface, 4. a Certified Nursing Assistant (CNA) removed her soiled gloves and washed her hands before leaving the room during incontinence care for RI #11, 5. a CNA washed her hands and changed her gloves after touching soiled items and before touching clean items during incontinence care on RI #11 and 6. a CNA washed her hands and changed her gloves after cleaning the front perineal area and before cleaning the buttocks during incontinence care on RI #9. This affected two of three residents and one of three nurses observed during medication administration. Further this affected two of two sampled residents observed for incontinence care. Findings Include: 1. A Review of POTTER AND PERRYS FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, page 656 revealed: . SKILL 32-1 ADMINISTERING ORAL MEDICATION -- cont'd . i. Prepare solid forms of oral medications: . Do not touch medications with fingers. RI #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 10/18/2017 at 8:38 a.m., the surveyor observed Employee Identifier (EI) #1, a Licensed Practical Nurse (LPN), place RI #15's medication into the inhaler with her bare fingers. An interview was conducted on 10/18/2017 at 8:47 a.m. with EI #1. EI #1 was asked should medications be touched with your fingers. EI #1 replied, No, never, not at all. An interview was … | 2020-04-01 |
| 2866 | 2866 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 224 | J | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review the facility failed to provide supervision for a resident who had expressed [MEDICAL CONDITION] and had been placed on suicidal precautions since the time of admission. Resident Identifier (RI) #1's Hospice Admission information documented RI #1 had a history of [REDACTED]. The facility's policy and procedure for Suicide Prevention directed the facility to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. RI #1 exited the facility in a wheelchair, unsupervised, without the knowledge of the staff for approximately one hour. RI #1 was found outside in an overturned wheelchair on the asphalt/area by a passerby. RI #1 sustained a bloody laceration of the forehead and other upper body areas of injury. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Resident Behavior and Facility Practices, F224. This deficient practice affected, RI #1, one of one sampled resident, who was known to have [MEDICAL CONDITION]. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: On [DATE], the Department of Public Health received a complaint. The complainant alleged that on [DATE] around 4:15 p.m., a resident was found by a passerby outside of the facility on the cement asking for assistance. The resident was tilted over in a wheelchair with a big knot on the head that was steadily dripping blood. Review of the facility's policy titled, Abuse and Unusual Occurrence-Prevention, revised [DATE] documented, . This facility does not permit staff, other residents, visitors, friends, . or any other individuals to mistreat, neglect or abuse residents . No resident will experience neglect or… | 2019-09-01 |
| 2867 | 2867 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 241 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview the facility failed to provide a dignified dining experience for Resident Identifier (RI) #4 by serving his lunch and dinner meals in disposable, Styrofoam dinnerware while all other residents in the dining room were served on regular chinaware. Furthermore the facility failed to provide glasses for a resident whose glasses were broken in a fall at the facility. Without the right arm on the glasses RI #1 had to adjust the glasses constantly to have adequate vision. This affected two of four sampled residents. Findings include: A review of Potter and Perry's Fundamentals of Nursing Eighth Edition, Unit 6 Psychosocial Basis for Nursing Practice, page 720 and 721 revealed: . A sense of dignity includes a person's positive self-regard, an ability to invest in and gain strength from one's own meaning in life, feeling valued by others, and how one is treated by caregivers. Attending to the patient's physical appearance promotes dignity and self-esteem. RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/09/2016 revealed RI #4 had a BIMS (Brief Interview for Mental Status) of 12 which indicated cognitively intact for daily decision making. During the initial tour on 09/20/2016 at 5:10 pm, RI #4 was observed in the dining room eating his dinner meal from disposable Styrofoam dinnerware. The plate with the food appeared to be the carry-out tray with the attached lid, and other disposable containers as well as plastic utensils. No other residents were served on disposable dinnerware. A review of the current Physician order [REDACTED]. A review of the Nurses notes for 08/19/16 at 12:15 pm .Resident also has a tendency to urinate on floor and urinate in cups; nursing staff address behaviors as behaviors arise . There is no other documentation found that addresses behaviors. On 09/26/16 at… | 2019-09-01 |
| 2868 | 2868 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 250 | J | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review the facility failed to ensure a resident admitted with suicide precautions and who had a history of [REDACTED]. RI #1 was not referred for further treatment. According to the Medical Director the facility failed to notify him for need to evaluate so services could be provided. Resident Identifier (RI) #1's, Hospice Admission information documented RI #1 had a history of [REDACTED]. The facility's policy and procedure for Suicide Prevention directed the staff to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The policy further directed the staff to contact social services to provide crisis intervention counseling for the resident such as psychological evaluation. Review of RI #1's medical record revealed, from the time the resident was placed on suicide precautions on [DATE], the social worker did not interact with RI #1 until [DATE], nine days after the order was written to place the resident on suicide precautions. The Social Worker failed to put interventions in place, and/or refer the resident to an outside agency for treatment. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Life, F250. This deficient practice affected, RI #1, one of one sampled resident, who was known to have suicidal ideations. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: The S[NAME]IAL SERVICES Job Description documented . GENERAL PURPOSE OF JOB POSITION .The primary purpose of the job position is to manage the medically related Social Services Program of the facility in accordance with federal, state and local standards, guidelines and regulations and Company policies and p… | 2019-09-01 |
| 2869 | 2869 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 278 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to accurately assess RI (Resident Identifier) #4's behaviors when eating in the dining room. This affected one of four sampled residents. Findings Include: A review of a facility document titled Behavior Assessment and Monitoring with a revision date of (MONTH) 2007 revealed: . Policy Interpretation and Implementation Assessment: 1. As part of the initial assessment, the nursing staff and Attending Physician will identify individuals with a history of . problematic behavior, or mental illness (e.g., . or [MEDICAL CONDITION]). 2. The nursing staff will identify, document, and inform the physician about an individual's . behavior . : a. Onset, duration and frequency of problematic behaviors or changes in behavior .; Monitoring: 1. If the resident is being treated for [REDACTED]. 2. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted . d. Outcomes associated with interventions. A review of RI #4's Care Plan revealed: .Problem Onset: 08/11/2016 Potential for mood/behavior due to: DX (Diagnoses) of [MEDICAL CONDITION] . Resident urinates in floor and urinates in cups . Goal and Target Date: 11/12/2016 Will not have any significant decline in . behavior through next review date. Approaches: Assess the need for psych consult if . behavior . changes . Inform physician of behavior for possible medication changes as needed . RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/09/2016 revealed RI #4 had a BIMS (Brief Interview for Mental Status) of 12 which indicated cognitively intact for daily decision making. On 09/20/2016 at 5:30 p.m., during the initial tour … | 2019-09-01 |
| 2870 | 2870 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 281 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to ensure licensed staff timed a phone order from the Physician for RI (Resident Identifier) #1 on 09/13/2016 and there was no date and time on 08/13/2016. This affected one of four charts reviewed. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.03 Conduct And Accountability. The . licensed practical nurse shall: . (15) Accept individual responsibility and accountability for accurate, complete and legible documentation related to : (a) Patient care records. RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on 8/13/16. The admission Minimal Data Set (MDS) with the assessment reference date of 8/19/16 revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since she had lower extremity deficits. A review of a Physician verbal order for Admit to Alacare Hospice for RI #1 with no date and no time. A review of a Physician phone order with a date of 09/13/2016 and no time. On 09/21/2016 at 4:50 p.m., an interview was conducted with EI (Employee Identifier) #3 LPN (Licensed Practical Nurse). EI #3 was asked what was the facility's policy on receiving Physician orders. EI #3 said have a date and time. EI #3 was asked did she document the time that the order was received. EI #3 said no. EI #3 was asked should there have been a time. EI #3 said yes. EI #3 was asked why should there be a date and time. EI #3 said to ensure that something is being taken care of in a timely manner. On 09/25/2016 at 4:00 p.m., the DON (Director of Nursing) verified that EI #3 had taken the admission order to Alacare Hospice order on 08/13/2016, and had not dated or timed the order. | 2019-09-01 |
| 2871 | 2871 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 282 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to address the exhibited behavior of RI (Resident Identifier) #4 to reflect on the CP (Care Plan). This affected one of four sampled residents. Findings Include: A review of RI #4's Care Plan revealed: .Problem Onset: 08/11/2016 Potential for mood/behavior due to: DX (Diagnoses) of [MEDICAL CONDITION] . Resident urinates in floor and urinates in cups . Goal and Target Date: 11/12/2016 Will not have any significant decline in . behavior through next review date. Approaches: Assess the need for psych consult if . behavior . changes . Inform physician of behavior for possible medication changes as needed . RI #4 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 08/09/2016 revealed RI #4 had a BIMS (Brief Interview for Mental Status) of 12 which indicated cognitively intact for daily decision making. On 09/20/2016 at 5:30 p.m., during the initial tour the dining room was observed during the dinner meal. RI #4 was sitting at a table with four other residents. RI #4 was eating off of disposable dinnerware. RI #4 was observed to be the only resident in the dining room to be eating on disposable dinnerware. A review of a facility document titled Departmental Notes with a date of 05/02/2016, . Dietary Quarterly Notes . Resident receives meals on disposable tray/utensils due to propensity to urinate in/break plates. After record review no further documentation was found regarding behaviors that necessitated the need for disposable dinnerware. On 09/23/2016 at 1:40 p.m., an interview was conducted with EI (Employee Identifier) #15 RN (Registered Nurse) CP/MDS Coordinator (Care Plan/ Minimal Data Set). EI #15 was asked how do you monitor behaviors. EI #15 said the nurses monitor them any staff member could report anything. EI #15 was asked can you tell if behaviors are monitored from RI #… | 2019-09-01 |
| 2872 | 2872 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 323 | J | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview the facility failed to provide supervision for a resident on suicide precautions and who had a history of [REDACTED].#1 exited the building unattended 0n [DATE] and sustained an unwitnessed fall with injuries. According to Resident Identifier (RI) #1's, Hospice Admission information, RI #1 had a history of [REDACTED]. The facility's policy directed staff to take preventative actions to prevent the resident from endangering self and others and to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The DON stated the facility did not conduct every 15 minute checks as outlined by policy. The facility staff members caring for Resident Identifier (RI) #1 confirmed they were unaware and did not provide the every 15 minute checks, resulting in RI #1 exiting the building unsupervised on [DATE] and sustaining an unwitnessed fall with injury that required medical attention beyond first aid. The fall resulted in injuries that included lacerations to the head, hematoma and edema to forehead, a large skin tear of the right shoulder that left the area denuded and skin tears of the right elbow and hand. In addition, the resident sustained [REDACTED]. On [DATE] at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Quality of Care, F323 (Accidents). This deficient practice affected, RI #1, one of three sampled resident, who had sustained falls. The immediate jeopardy began on [DATE], until the facility implemented immediate corrective actions. The Immediate Jeopardy was relieved onsite on [DATE] at 5:10 PM. Findings include: On [DATE], the Department of Public Health received a complaint. The complainant alleged that on [DATE] around 4:15 p.m., a resident was found by a passerby outside of the facility on the cement asking for assis… | 2019-09-01 |
| 2873 | 2873 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 490 | J | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > The Director of Nursing (DON) , whose main purpose is to plan, organize, develop and implement the overall operation of the Nursing Service Department, failed to direct the nursing staff on implementing the facility's suicidal precautions for a resident who had expressed [MEDICAL CONDITION]. According to Resident Identifier (RI) #1's, Hospice Admission information, RI #1 had a history of [REDACTED]. The facility's policy directed staff to take preventative actions to prevent the resident from endangering self and others and to take all suicidal threats and actions seriously and immediately assign a staff member to the resident one-to-one. The policy further directed the facility to contact social services to provide crisis intervention counseling for the resident such as psychological evaluation. Review of RI #1's medical record revealed from the time the resident was placed on suicide precautions on 08/13/2016, the social worker did not interact with the resident until 08/22/2016, nine days after the order was written to place the resident on suicide precautions. The Director of Nursing failed ensure interventions were in place, and/or refer the resident for treatment and follow up. The DON stated the facility did not conduct every 15 minute checks as outlined by policy. The facility staff members caring for Resident Identifier (RI) #1 confirmed they were unaware and did not provide the every 15 minute checks, resulting in RI #1 exiting the building unsupervised on 9/13/16 and sustained a fall with injury that required medical attention beyond first aid. On 09/24/2016 at 5:52 PM, the Administrator, Director of Nursing Services, Corporate Nurse, and Human Resource Director were notified of the findings of Immediate Jeopardy level of J in the area of Administration, F 490. This deficient practice affected, RI #1, one of three sampled resident, who had sustained falls. The immediate jeopardy began on 08/13/2016, until the facility implemented… | 2019-09-01 |
| 2874 | 2874 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-09-26 | 514 | D | 1 | 0 | XBZL11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based observation, record review and interview the facility failed to maintain a complete clinical record on RI (Resident Identifier)#1 to reflect the incident on 09/13/2016. The facility further failed to document the behaviors on RI #4 that necessitated the use of disposable dinnerware. This affected two of four sampled residents. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.06 Documentation Standards . (c) Complete documentation includes reporting and documenting on appropriate records a patient's status, including signs and symptoms, responses, treatments, medications, other nursing care rendered, communication of pertinent information to other health team members, and unusual occurrences involving the patient. A signature of the writer, whether electronic or written, is required in order for the documentation to be considered complete. A review of a facility document titled Behavior Assessment and Monitoring with a revised date of (MONTH) 2007 revealed: .Policy Interpretation and Implementation . Monitoring . 1. If the resident is being treated for [REDACTED]. 2. The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: a. Number and frequency of episodes; b. Preceding or precipitating factors; c. Interventions attempted . d. Outcomes associated with interventions. 1) RI #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Additionally, RI #1 was admitted to Hospice Service on 8/13/16. The admission Minimal Data Set (MDS) with the assessment reference date of 8/19/16 revealed RI #1 scored a 14 out a possible score of 15, which indicates he/she was cognitively alert. RI #1 was dependent for transfers and did not ambulate since she had lower extremity deficits. On 9/20/2016 the Department of Public Health … | 2019-09-01 |
| 2982 | 2982 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 159 | E | 0 | 1 | 5MZK11 | Based on observations, interviews, a posted Banking Hours sign, and review of a facility policy titled Policy on Protection of Residents Funds, the facility failed to ensure residents had access to their resident trust fund 24 hrs (hours) a day/7 days a week. This had the potential to affect all 97 residents having funds managed by the facility with a census of 159. Findings include: A review of an undated policy titled, Policy on Protection of Residents Funds, revealed, . 3. The Resident shall have reasonable access, upon request, to the above record . A review of a facility sign revealed, Banking Hours: Monday-Friday 8 am-8 pm, Saturday and Sunday 9 am to 6 pm. On 3/16/2017 at 7:30 a.m., an interview was conducted with EI (Employee Identifier) #4, Human Resources staff member. EI #4 was asked when were resident trust funds available to residents. EI #4 stated funds were available during business hours until 8:00 p.m. in the evening when the secretaries leave for the day. On 3/16/2017 at 3:45 p.m., an interview was conducted with EI #5, the Business Office Manager. EI #5 was asked when were resident trust funds available to the residents. EI #5 responded, They are available 8 a.m. to 8 p.m. Monday through Friday and 9 a.m. to 6 p.m., Saturday and Sunday, including holidays. EI #5 was asked why were funds not available 24 hours a day, 7 days a week. EI #5 replied, I guess we did not know they had to be. EI #5 was asked if funds should be available 24 hours, 7 days a week. EI #5 replied, Yes ma'am. On 3/16/2017 at 4:30 p.m., an interview was conducted with EI #3, the Administrator. EI #3 was asked when were resident trust funds available to residents. EI #3 stated funds were available Monday-Friday 8 a.m. to 8 p.m. and Saturday-Sunday, 9 a.m.-6 p.m. | 2019-08-01 |
| 2983 | 2983 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 167 | C | 0 | 1 | 5MZK11 | Based on observations and interview, the facility failed to ensure 1.) The binder containing the annual survey results was in an area easily accessible to the residents for 3 of 3 survey days. This had the potential to affect all 159 residents in the facility. Findings include: Observations were made on 3/14/17 at 2:35 p.m., on 3/15/17 at 7:58 a.m., and on 3/16/17 at 7:35 a.m. The observations revealed the survey results were at the receptionist's desk, behind a glass window, and out of reach. During these observations, a sign was noted posted in the window that read, State Survey Book Located in This Office ask Receptionist to Review. Observations were made on 3/14/17 at 4:40 p.m., 3/15/17 at 7:37 a.m., and on 3/16/17 at 7:30 a.m. The observations revealed a note posted in a picture frame in a second lobby on the left front side of the building that read, State Survey Book Located In Front Office with Receptionist. An interview was conducted on 3/16/17 at 11:40 a.m. with EI (Employee Identifier) #3, the Administrator. EI #3 observed the posted signs. When asked where the survey results were located, he answered, Behind the window. When asked where they should be, he answered, Where publicly accessible. When EI #3 was asked why, he answered, So they can have it and access it in privacy and they don't have to ask for it. | 2019-08-01 |
| 2984 | 2984 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 322 | D | 0 | 1 | 5MZK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, and the Facility's Policy titled, Enteral Nutritional Therapy - Tube Feeding, the facility failed to ensure the container of formula was labeled with the time the feeding was administered on one of three survey days. This affected RI (Resident Identifier) #2, one of two residents sampled for receiving tube feeding. RI #2 was also identified as one of five residents in the facility who received continuous tube feedings. Findings include: A review of a facility policy titled, Enteral Nutritional Therapy - Tube Feeding, with the last revision date of (MONTH) 30, 2014, revealed: . PURPOSE: To provide liquid nourishment, through a tube, into the stomach. PR[NAME]EDURE . 9. f. Change feeding container every 24 hours. D[NAME]UMENTATION: . 1. Document time, date, amount of feeding . A review of the medical record revealed RI #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), with the Assessment Reference Date (ARD) of 01/23/2017, revealed RI #2 was in a comatose state. This assessment indicated RI #2 was totally dependent on staff for all activities of daily living. RI #2 was also identified as requiring a feeding tube. A review of RI #2's physician's orders [REDACTED]. .[MEDICATION NAME] 1.2 CAL Calorie LIQUID GIVE 60 ML (milliliter)/HR (hour) X (times) 23 HOURS . On 3/14/17 at 3:20 p.m., during the facility tour, an observation was made of RI #2's tube feeding system. The tube feeding container was dated 3/13/17. No time was documented on the container to indicate when the feeding was started. On 3/14/2017 at 6:02 p.m., a second observation was made of RI #2's tube feeding system. The tube feeding container was dated 3/14/17. There was no time documented on the container. On 3/16/17 at 12:20 p.m., an interview was conducted with EI (Employee Identifier) #1, an LPN (Licensed Practical Nurse), who worked on the unit RI… | 2019-08-01 |
| 2985 | 2985 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 323 | E | 0 | 1 | 5MZK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, interview, and a review of the facility policy titled, Bed Safety, the facility failed to ensure informed consents were obtained for side rails for Resident Identifier (RI) #1, RI #2, RI #5, RI #7, RI #10, RI #13, and RI #14. This affected 7 of 25 sampled residents and 7 of 81 residents in the facility with side rails. Findings include: A review of the facility's policy titled, Bed Safety, with the revision date of (MONTH) 2007, revealed: Policy Statement Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from the resident and family regarding previous sleeping habits and bed environment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as Specified above, side rails may be used at the resident's request to increase the resident's sense of security . A review of the medical record revealed, RI #1 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of RI #1's Annual Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 02/15/16, revealed RI #1 was cognitively intact and had no upper body impairments, but had bilateral lower body impairment. The assessment also revealed RI #1 required extensive assistance for bed mobility. Bed rails were documented as being used daily for the resident. A review of a form titled, Bed Rail /Assist Bar Evaluation, for RI #1, with a date of 11/3… | 2019-08-01 |
| 2986 | 2986 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 329 | D | 0 | 1 | 5MZK11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record reviews, review of facility policies titled, Antipsychotic Medication Use and Medication Monitoring Sedatives/Hypnotics, a signed statement by the Director of Nursing, and interviews, the facility failed to ensure - 1) AIMS (Abnormal Involuntary Movement Scale) assessments were done for 3 residents routinely while on antipsychotic medications. This affected RI (Resident Identifier) #s 4, 12, and 13; and 2) A reason was indicated for refusal of a Gradual Dose Reduction-Pharmacy recommendation for RI #4 and #12. These deficient practices affected three of fourteen residents whose medication regimens were reviewed. Findings include: 1. A review of a facility policy with a revision date of (MONTH) 2007, titled, Antipsychotic Medication Use, revealed, . Policy Statement Antipsychotic medication therapy shall be used only when it is necessary to treat a specific condition. The Abnormal Involuntary Movement Scale (AIMS) will be done on Admission and quarterly to monitor side effects of Antipsychotic medication. 14. Nursing staff shall monitor using the AIMS and report any of the following side effects to the Attending Physician: . (2.) Physician Follow-Up and Documentation 15. The Physician shall respond appropriately by changing or stopping problematic doses or medication, or clearly documenting (based on assessing the situation) why the benefits of the medication outweigh the risks or suspected or confirmed adverse consequences. 2. A review of a facility policy with a copyright date of 2011 titled, Medication Monitoring Sedatives/Hypnotics, revealed, . B. For a resident who remains on a sedative/hypnotic that is used routinely and beyond manufacturer's recommendation, a gradual dose reduction should be attempted quarterly unless clinically contraindicated. A review of the medical record for RI #4 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. A review of the Quarterly MDS (Minimum Data Set), assessment dat… | 2019-08-01 |
| 2987 | 2987 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 364 | F | 0 | 1 | 5MZK11 | Based on interview and observations, the facility failed to ensure the lunch meal served on 3/15/2017 was served at palatable temperatures. This had the potential to affect 153 of 153 residents that received meals from the kitchen. Findings include: During the initial of the facility on 3/14/17, residents complained of cold food being served. On 3/15/2017 at 1:35 p.m., a test tray was conducted in building Two at 1:35 p.m. The cart with the test tray was transported from the kitchen at 1:05 p.m. The surveyor along with the Dietary Manager, (Employee Identifier) EI #8, waited until the last resident tray was served. The temperature and taste of each food item on the regular, pureed, and mechanical soft foods were evaluated. The consensus of the EI #8, and the surveyor were as follows: Regular Chicken Tenders: 113 degrees F (Fahrenheit) Regular Mashed Potatoes:103 degrees F Regular Fried Okra: 100.6 degrees F Cranberry Juice: 54 degrees F Milk: 48 degrees F Pureed Meat: 107 degrees F Pureed Bread: 103 degrees F Pureed Okra: 96 degrees F Pureed Pork Chops: 100 degrees F Mechanical Soft Potatoes: 110 degrees F Chopped Chicken Tenders: 92 degrees F Mechanical Soft Okra: 94.6 degrees F On 3/15/2017 at 3:00 p.m., a Resident Group meeting was conducted with twelve residents present. When asked if there were any food concerns, seven of the twelve residents complained of cold food when they received their meals. On 3/15/2017 at 1:35 p.m., EI #8, Dietary Manager, was asked to describe the temperature of the foods on the test tray. EI #8 said the foods were cold. EI #8 was asked what was the concern of food being cold and EI #8 said it was not fair to the residents. | 2019-08-01 |
| 2988 | 2988 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 371 | F | 0 | 1 | 5MZK11 | Based on observation, interview, and review of the Food and Drug Administration Food Code dated 2013, the facility failed to ensure a bag of green onions with a discard date of 12/23/2016 was not in the walk-in cooler. This had the potential to affect all 153 of 153 residents receiving meals from the kitchen. Findings include: A review of THE 2013 FOOD CODE by the United State Public Health Service (USPHS) and the Food and Drug Administration (FDA) included the following: 3-402.12 Records, Creation and Retention. .(3) Marking the date or day the original container is opened in a FOOD ESTABLISHMENT, with a procedure to discard the FOOD on or before the last date or day by which the FOOD must be consumed on the premises, sold or discarded . 1.) During the initial tour of the facility on 3/14/3017 at 3:00 p.m., a bag of green onions with a discard date of 12/23/2016 was observed in the walk-in cooler. Employee Identifier (EI) #9, the Registered Dietician (RD), was present. EI #9 also observed the bag and said they belonged in the trash. An interview was conducted with EI #9, on 3/16/2017 at 5:40 p.m EI #9 was asked who was responsible for making sure the walk-in cooler was free of food items that had an expired date. EI #9 said the entire staff, but the dietary manager and she (EI #9) were primarily responsible. EI #9 was asked what was the facility's policy regarding storage of refrigerated food items. EI #9 said once the food comes in it is stored between 30 and 40 degrees and checked twice daily. EI #9 was further asked what was the potential harm in having expired food items in the walk-in freezer. EI #9 said it could be a source of food borne illness. | 2019-08-01 |
| 2989 | 2989 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2017-03-16 | 456 | D | 0 | 1 | 5MZK11 | Based on observations, interviews, and review of a facility policies titled, Wheelchair cleaning/repair policy and procedure and Equipment - General Use for All Residents,, the facility failed to ensure wheelchairs used by residents were not found with seat cushions and armrests that were cracked and torn or missing an armrest. This was observed on 6 of 27 wheelchairs assessed for their condition. This was found on four of four halls, affecting RI (Resident Identifier) #s 4, 11, 25, 26, 27, and 28, six of twenty-five sampled resident and found on six of twenty-seven wheelchairs assessed for their condition. Findings include: A review of an undated facility policy titled, Wheelchair cleaning/repair policy and procedure, revealed, Policy: It is the policy of (name of facility) to have resident's wheelchairs, Geri-chairs, shower chairs and bedside commode inspected and cleaned by Maintenance and Housekeeping. Facilities maintenance and housekeeping departments will ensure resident's wheelchairs; Geri-chairs and other equipment are clean and in good working order. A review of a facility policy titled, Equipment - General Use for All Residents, with a revision date of (MONTH) 2006, revealed, . Policy Statement Our facility shall provide routing equipment for the general use of the resident population. Policy Interpretation and Implementation 1. Wheelchairs, walkers, crutches, canes, etc. (etcetera), are maintained by our facility for the general use of all residents. An observation was made at 3:58 p.m. on 3/14/17 of RI #4's wheelchair. The seat cushion covering was found with cracks and torn. The armrests of the wheelchair were also cracked. An observation was made at 9:14 a.m. on 3/15/17 of RI #4's wheelchair with the seat cushion cover cracked and torn. The armrest was observed to be cracked. On 3/16/17 at 1:00 p.m., an observation was made of RI #11's wheelchair. RI #11 was sitting up in the wheelchair. There was no padding on the right arm rest and the left arm rest was torn with pieces missing. An observation wa… | 2019-08-01 |
| 3555 | 3555 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 167 | C | 0 | 1 | V3M011 | Based on observation and interview the facility failed to ensure all residents knew where the state survey results were located and had easy access to those results. This affected all 169 residents residing in the facility. Findings Include: On 02/23/16 at 9:35 a.m. during the initial tour of the facility, a small round table in the front lobby was found to have a small frame, approximately 5 X 7 inches. Inside the frame was a sign that read a copy of the survey results could be found in the front office. During the initial tour of the facility all other halls and additional lobbies were observed for any additional signage to inform the residents as to where the survey results could be found. There were no additional signs found anywhere else. On 02/25/16 at 2:15 P.M. an interview was conducted with EI (Employee Identifier) #1, Social Worker/BSW (Bachelor's Social Worker) and #2, Social Worker. EI #'s 1 and 2 were asked where the state survey results could be found and how did the residents know where they were located. They stated the results were located in the front office and there was a sign in the front lobby notifying them where the results were. When asked who was responsible for maintaining and displaying the state survey results, EI #1 & EI #2 did not know. When asked if all residents went to the front office they stated no and when asked if there was more than one entrance/exit to the facility they stated yes. EI #1 & EI #2 were asked how else could the residents be made aware of where the survey results were located and they stated there should be more postings throughout the facility and residents should be made aware during their Resident Council meetings. When asked why it was important to have the state survey results posted and accessible to the residents, EI #1 & EI #2 stated that it was very important for them to know where they were and to have access to them so they were aware of what they were walking into and to know what was going on in their home. | 2019-02-01 |
| 3556 | 3556 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 241 | D | 1 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) did not stand over Resident Identifier (RI) #5 while feeding the resident in bed during a breakfast and lunch meal on 02/24/2016. This affected the resident during 2 of 2 meal observations. Findings include: The facility policy titled, Quality of Life-Dignity with a revised date of (MONTH) 2009, documented, Policy Statement .Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality . RI #5 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of RI #5's Admission Minimum Data Set (MDS) with assessment reference date of 02/01/2016, identified the resident with a 6 out of 15 on the Brief Interview for Mental Status, indicating severe cognitive impairment. RI #5 was also identified as requiring extensive one person assistance with eating. RI #5's Activity of Daily Living (ADL) care plans, dated 02/10/2016, documented the resident to be assisted with feeding at all meals. On 02/24/2016 at 8:20 AM, during the breakfast meal, EI (Employee Identifier) #8 CNA, who was feeding RI #5, was observed standing over the resident while she was feeding the resident in bed. On 02/24/2016 at 1:00 PM, EI #7 LPN, was observed standing over RI #5 while she was feeding the lunch meal to the resident in bed. On 2/25/2016 at 2:25 PM, EI #7 was asked what the facility policy was regarding dignity during meals. EI #7 said she knew staff were supposed to sit down to feed residents. EI #7 was asked why she stood over RI #5 who was in the bed to feed the resident the lunch meal on 2/24/2016. EI #7 said she did not know why and admitted she did not get the chair to sit down. When asked what the potential for harm would be for the resident when staff stands over RI #5 to feed meals, EI #7 said, You are supposed to be at their level and not… | 2019-02-01 |
| 3557 | 3557 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 281 | D | 0 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews the facility failed to ensure licensed staff did not initial the URI (Unsampled Resident Identifier) #1's Medication Administration Record prior to administering medications on 02/24/2016. This affected one of four nurses on one of four units. Findings Include: A review of the Alabama Board of Nursing Alabama Administrative Code Chapter 610-X-6 Standards of Nursing Practice revealed: .610-X-6-.06 Documentation Standards (1) The standards for documentation of nursing care provided to patients by registered nurses and licensed practical nurses are based on principles of documentation . (2) Documentation of nursing care shall be: . (i) Charted at the time or after the care, including medications, is provided. Charting prior to care being provided, including medications, violates principles of documentation. A review of a facility policy titled, Documentation of Medication Administration with a revised date of (MONTH) 2007 revealed: . Policy Statement The facility shall maintain a medication administration record to document all medications administered. Policy Interpretation and Implementation . 2. Administration of medication must be documented immediately after (never before) it is given. URI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 02/24/2016 at 9:00 AM, EI (Employee Identifier) #4 RN (Registered Nurse) was observed during Medication Administration on URI #1. EI #4 prepared the medication and initialed all medications on the Medication Administration Record before administering. On 02/25/2016 at 2:00 PM, an interview was conducted with EI #4. EI #4 was asked what was the facility's policy and procedure on documenting medication with medication administration. EI #4 said sign the Medication Administration Record after administering medications. EI #4 was asked when did she sign the Medication Administration Record for URI #1. EI #4 said she signed the Medicatio… | 2019-02-01 |
| 3558 | 3558 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 312 | D | 1 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) provided incontinent care in a manner to provide comfort and prevent the potential for cross -contamination. This affected Resident Identifier (RI) #2, one of 2 sampled residents observed for incontinent care. Findings include: The facility policy with the subject Incontinence Care with a revised date of 10/30/2014, revealed the following: POLICY: To provide guidelines that will aid in preventing exposure to urine and fecal matter. PR[NAME]EDURE .5. Wash the resident's skin with soap and water . 7. Rinse well and pat dry.10. Remove soiled items. Replace with clean dry disposable diapers or underpad, .GUIDELINES . 3. Disposable items soiled with feces ( .disposable diapers or disposable underpads), must be handled so as to prevent contamination of the environment with feces. RI #2 was readmitted back to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/07/2015, documented the resident with an 11 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The MDS also identified RI #2 was always incontinent of both bowel and bladder and impaired in both upper and lower extremities. On 2/23/2016 at 4:40 PM, EI (Employee Identifier) #6 CNA, provided incontinent care for RI #2. EI #6 used shampoo/body wash and wash cloth to clean RI #2's perineum. EI #6 did not rinse the soap from RI #2. EI #6 then rolled up the soiled brief and pad, placed a clean brief under the soiled brief and pad, and continued to clean RI #2's buttocks. EI #6 then placed the soiled brief and pad in a bag, continued to clean bowel movement (BM) from RI #2's buttocks with RI #2 lying on the clean brief, and then fastened the brief on RI #2. On 2/23/2016 at 5:10 PM, EI #6 was asked how she would perform perineal car… | 2019-02-01 |
| 3559 | 3559 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 315 | D | 1 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews the facility failed to ensure a CNA (Certified Nursing Assistant) wiped front to back on RI (Resident Identifier) #7, a resident with a history of UTI's (Urinary Tract Infection), during incontinent care. This affected RI #7, one of two residents observed for incontinent care. The facility further failed to ensure RI #5 had a [DIAGNOSES REDACTED]. This affected one of four resident's reviewed with catheters. Findings include: 1.) A review of Potter and Perry's Fundamentals of Nursing, Unit 7, BATHING AND PERINEAL CARE, page 802 revealed: .(5) Clean buttocks and anus, washing front to back . A review of a facility document titled Infection Control Guidelines for All Nursing Procedures revealed: Purpose To provide guidelines for general infection control while caring for residents. 2. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on managing infections in residents, including: . b. Methods of preventing their spread; . A review of a facility document titled .Urinary Continence and Incontinence - Assessment and Management . with a revised date of (MONTH) 2010 revealed: .Policy Statement . 3. The physician and staff will provide appropriate services and treatment . and prevent urinary tract infections to the extent possible. RI #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 09/07/2015 revealed RI #7 was totally dependent for all ADL's (Activities of Daily Living). A review of RI #7's laboratory results revealed: .Culture, Urine . Collected: 08/01/2015 .> (greater than) 100,000 .Beta [DIAGNOSES REDACTED] Streptococcus . A review of RI #7's laboratory results dated [DATE] revealed: .URINALYSIS . Clarity Cloudy .Leukocyte Esterase 3+ .Blood 3+ . On 02/24/2016 at 10:15 AM, an observation was made of incontinent care with RI #… | 2019-02-01 |
| 3560 | 3560 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 322 | D | 0 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure a licensed staff member checked placement of the Gastrostomy tube of URI (Unsampled Resident Identifier) #1 prior to medication administration on 02/24/2016. This affected 1 of 1 residents observed for medication administration via Gastrostomy tube. The facility further failed to ensure 3 bottles of [MEDICATION NAME] HN (High Nutrition) Ready to Hang tube feeding formula used as bolus feeding for RI (Resident Identifier) #17 was labeled with an open date and time. These were observed three of three days during the survey. This affected 1 of 4 residents requiring tube feeding. Findings Include: A review of a facility policy titled, Medication Administration Procedures with a date of (MONTH) 2011 revealed: .ENTERAL TUBE ADMINISTRATION Policy: Medications are administered via feeding tube in a safe and accurate manner when the resident is unable to take medication by mouth. Medications should be provided through a feeding tube under the order of a physician. Procedures . 4.Regardless of the type of tube, check for proper placement before administering medications or water. This is done in 2 ways: auscultation and aspiration of gastric contents. A review of URI #1's (MONTH) (YEAR) physician's orders [REDACTED].CHECK PEG RESIDUAL PRIOR TO MEDS, FLUSHES, . URI #1 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of URI #1's MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of 01/19/2016 revealed in Section K that there was a feeding tube in place. On 02/24/2016 at 9:00 AM, EI (Employee Identifier) #4, RN (Registered Nurse) was observed during Medication Administration with URI #1. EI #4 prepared the medication and went to URI #1's bedside. EI #4 attached the syringe to the Peg Tube and flushed the tube with 30 ML's (Milliliter) of water. EI #4 then began administering URI #1's medication without checking residual or auscultatin… | 2019-02-01 |
| 3561 | 3561 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 327 | D | 1 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure adequate fluids were provided for Resident Identifier (RI) #2 to promote hydration. RI #2 had no water pitcher in the room [ROOM NUMBER] of 3 days of the survey and was not provided coffee per tray card for 3 meals observed during the survey. This affected 1 of 8 residents sampled for hydration. Findings include: The facility policy titled Resident Hydration and Prevention of Dehydration with a revised date of 12/2008 revealed the following: .Policy Statement This facility will endeavor to provide adequate hydration . Treatment/Management . 2. The staff will provide supportive measures such as providing fluids . RI #2 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with an assessment reference date of 12/07/2015, documented the resident with an 11 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. A review of RI #2's tray cards revealed the following: .Breakfast .Beverages Milk 1 Srv (serving) . Coffee 1Srv . .Lunch .Beverages Coffee 1 Srv . Glucerna 1 Srv . Tea 1 Srv . Milk 1 Srv . On 2/23/2016 at 10:20 AM, during the initial tour, there was not a water pitcher in RI #2's room. On 2/23/2016 at 3:10 PM, there was not a water pitcher in RI #2's room. RI #2 was asked if there was usually a water pitcher in the room. RI #2 did not respond about the water pitcher, but did want some water to drink. On 2/23/2016 at 4:40 PM, there was not a water pitcher in RI #2's room. On 2/24/2016 at 8:30 AM, there was not a water pitcher in RI #2's room. On 2/24/2016 at 8:40 AM, RI #2 only had an eight ounce carton of milk on the breakfast tray provided. There was not any other fluid served to RI #2 during breakfast. The coffee dispenser and cups were on the top of the tray cart in the hall outside RI #2's room. RI #2 consumed 100 percent of the … | 2019-02-01 |
| 3562 | 3562 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 328 | D | 1 | 1 | V3M011 | **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) #14's oxygen was delivered at 2 liters per minute as ordered. RI #14's oxygen was set at 2 and a half to 3 liters per minute on 3 of 3 days of the survey. This affected 1 of 7 sampled residents receiving oxygen therapy. Findings include: The facility's policy for Oxygen Administration, last revised date (MONTH) 19, (YEAR), documented, . Procedure: . 8 . e. Set the flow meter to the rate ordered by the physician. RI #14 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of RI #14's recent Quarterly Minimum Data Set (MDS) with an assessment reference date of 01/20/2016, identified the resident with a 13 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition was intact. The MDS also indicated the resident required oxygen. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. On 2/23/2016 at 10:10 AM, during the initial tour of the facility, RI #14's O2 concentrator was set between two and a half and three liters per minute. On 2/23/2016 at 4:30 PM, RI #14's O2 concentrator was set between two and a half and three liters per minute. RI #14 said it was usually set on two liters per minute. During the three days of the survey, RI #14's O2 concentrator was set between two and a half and three liters per minute This was observed on: 2/23/2016 at 3:05 PM 2/23/2016 at 4:30 PM 2/24/2016 at 8:15 AM 2/24/2016 at 11:55 AM 2/24/2016 at 1:10 PM 2/24/2016 at 5:30 PM 2/25/2016 at 8:35 AM On 2/25/2016 at 10:15 AM, EI (Employee Identifier) #7 unit manager, observed RI #14's O2 concentrator with the surveyor. On 2/25/2016 at 10:20 AM, EI #7 was asked what RI #14's O2 was set at. EI #7 said when she was standing it looked like three and when she was at eye level it looked like two and a half to three. When asked who was responsible to ensure that O2 was administered as ordered, EI #7 said any of the … | 2019-02-01 |
| 3563 | 3563 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 371 | F | 0 | 1 | V3M011 | Based on observations, record review and interview: 1. The facility failed to prevent potential Time/Temperature abuse as evidence by a failure to maintain a (TCS temperature control for safety) cold food (Tuna Salad Sandwich) at 41 degrees F. (Fahrenheit) or below when served from the trayline. 2. The facility failed to prevent poor personal hygiene practices (failure to effectively restrain hair). On one day of the survey, one employee was observed with hair not restrained. 3. The facility failed to assure equipment was properly cleaned and sanitized. The above practices posed the potential for food contamination and compromised food safety. This had the potential to affect 153 residents who received meal trays from dining services. Findings include: The 2013 Food Code by the United States Public Health (USP) and the Food and Drug Administration (FDA) included the following: 1. 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: . (2) At 5 C (41 F) or less. '' On 2/23/2016 the Week At a Glance, week 4 menu was reviewed. The planned entree was Tuna Salad Sandwiches. At 4:50 PM the internal temperature of the pre-prepared Tuna Salad Sandwich on the tray line was measured by a cook (EI #10 and a Food Service Worker, EI #11) to be 65 degrees F. A second value was 57.9 degrees F. The Dietary Manager, EI #9 was interviewed on 2/25/2016 at 9:32 AM. EI #9 stated the cook (EI #10) failed to cut the storage volume down, started late and did not prepare the day before. When asked about the potential risk, the Dietary Manager said it could make 'em (them, residents) sick and there was a potential for the growth of harmful bacteria. 2. The facility failed to prevent poor personal hygiene practices (failure to effectively restrain hair). One employee wa… | 2019-02-01 |
| 3564 | 3564 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 441 | D | 0 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure a CNA changed her gloves and washed her hands in a manner to prevent potential cross-contamination of RI #2 during the provision of incontinent care. The facility further failed to ensure Certified Nursing Assistants (CNA) washed their hands after removing dirty gloves and before touching clean linen during the provision of incontinent care of Resident Identifier (RI) #7. These failures affected 2 of 2 residents observed during incontinent care. Findings include: A review of Potter and Perry's Fundamentals of Nursing Eight Edition, Chapter 28, Infection Prevention and Control, page 419 revealed: .Change gloves and perform hand hygiene between tasks and procedures on the same patient, .PERFORM HAND HYGIENE IMMEDIATELY TO AVOID TRANSFER OF MICROORGANISMS TO OTHER PATIENTS OR ENVIRONMENTS. A review of a facility document titled .Infection Control Guidelines for All Nursing Procedures . with a revised date of (MONTH) 2010 revealed: . General Guidelines . 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; . c. After contact with .body fluids . d. After removing gloves; e. After handling items potentially contaminated with .body fluids . 1). RI #2 was readmitted back to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) with an assessment date of 12/07/2015, documented the resident with an 11 out of 15 on the Brief Interview for Mental Status, indicating the resident's cognition was moderately impaired. The MDS also identified RI #2 was always incontinent of both bowel and bladder. On 2/23/2016 at 4:40 PM, EI #6, CNA provided perineal care for RI #2. EI #6 cleaned bowel movement (BM) from RI #2's buttocks, placed a soiled brief and pad into a bag, and changed… | 2019-02-01 |
| 3565 | 3565 | AHAVA HEALTHCARE OF ALABASTER | 15144 | 850 9TH STREET, NORTHWEST | ALABASTER | AL | 35007 | 2016-02-25 | 514 | D | 0 | 1 | V3M011 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to assure clinical records were accurate as evidenced by a failure to transcribe a new verbal order for RI #16 (Resident Identifier) dated 4/09/2015 for a multi-therapeutic diet restriction Regular NAS/LCS (No Added Salt and Low Concentrated Sweets). This affected one of sixteen residents sampled. Findings include: A review of the Fundamentals of Nursing (Eighth Edition) by Potter/Perry page 305 documented: Health Care Providers' Orders .The nurse is responsible for transcribing written orders correctly . RI #16 was admitted to the facility 4/08/2015, with [DIAGNOSES REDACTED]. An review of a facility document New Order Transmission Form revealed a verbal order on 4/09/2015 for a Regular NAS/LCS diet. Review of the physician's orders [REDACTED]. (MONTH) (YEAR) orders for the diet was void of diet data. The (MONTH) (YEAR) physician's orders [REDACTED]. On 02/25/2016 at 10:15 AM, the Director of Nursing, Employee Identifier (EI) #3 was interviewed. The DON indicated there was a failure to correctly transcribe the new order written on 04/09/2015, and that pharmacy too failed to pick up the new order. EI #3 stated the Unit Manager was responsible for making sure orders were brought forward and were accurate. When asked about the potential harm to RI #16, EI #3 said there was potential for elevated blood glucose levels and harm to kidneys. | 2019-02-01 |
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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 );