Greene County Nursing Home

Based on interviews, resident group meeting, the facility's document titled RESIDENT'S RIGHTS and CMS (Center for Medicare & (and) Medicaid Services) Memorandum (Memo) QSO-20-39-NH, the facility failed to implement visitation for residents of the facility since 11/12/21. This deficient practice had the potential to affect all 36 residents residing in the facility. Findings Include: An undated facility document titled RESIDENT'S RIGHTS documented: . Right to convenient visits and communications with others. A CMS Memorandum QSO-20-29-NH with a revised date of 11/12/21 documented: .Visitation Guidance: CMS is issuing new guidance for visitation in nursing homes during the COVID-19 PHE (Public Health Emergency), . Visitation is now allowed for all residents at all times . Indoor- Visitation Facilities must allow indoor visitation at all times for all residents as permitted under the regulations. facilities can no longer limit the frequency and length of visits for residents, the number of of visitors , or require advance scheduling of visits. A resident council group meeting was held…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and a facility policy titled Proper Drying and Storage of Tableware the facility failed to ensure pots, pans, and serving utensils were air dried after being washed in the three compartment sink on 2/23/22 during observation of the kitchen. This had the potential to affect all residents receiving meals from the kitchen. Findings Include: A policy titled Proper Drying and Storage of Tableware, dated November 2018 documented: . All dishes, trays, utensils, . will be air dried. After proper machine and/or pot & (and) pan washing, rinsing, and sanitizing, all dishes, trays . will be air dried. On 2/23/22 at 4:52 PM, an observation was made of pots placed on top of serving utensils in the drain rack, stacked together to dry, by the three compartment sink. On 2/24/22 at 3:59 PM an interview was conducted with Employee Identifier (EI) #3, Dietary Manager. EI #3 was asked how pots and serving utensils were to be dried. EI #3 stated, air dried on a rack, after being washed in the three compartment sink. EI 3 was asked if pots should be stored on top of serving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Comprehensive MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice affected Resident Identifier #'s 53, 54, 55, 56, 153, 155, 101, 102 and 103, nine of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, review of the MDS (Minimum Data Set) Coordinator - Job Description, and review of the updated CMS (Centers for Medicare & Medicaid Services) QSO (Quality, Safety & [and] Oversight Group) -21-17-NH (Nursing Home) Memo, the facility failed to ensure Quarterly MDS assessments were completed in a timely manner after CMS ended the Emergency Blanket MDS waiver on 02/10/2021. This deficient practice for Resident Identifier #'s 53, 54, 55, 153, 155, 101, 102, 103, 104 and 105, 10 of 13 residents whose MDS assessments were reviewed. Findings Include: A review of the updated CMS QSO-21-17-NH Memo, with an update of 02/10/2021, revealed the following: . SUBJECT: Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19 . Ending of Select Emergency Blanket Waivers During the COVID-19 PHE (Public Health Emergency) . Emergency Blanket Waiver of Minimum Data Set (MDS) Timeframe Requirements (42 CFR 483.20) CMS waived the MDS timeframe requirement at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident record review, interviews, and a facility policy titled Comprehensive Care Plans the facility failed to to develop a care plan for RI #105 for the use of anticoagulant (AC) medication since 3/6/21. This affected one of 13 sampled residents for whom care plans were reviewed. Findings Include: A review of a policy titled Comprehensive Care Plan with a revision date of 1/30/18 documented: .Purpose: To provide individualized care for each resident. Goal: To attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . RI #105 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Hypertension and history of Transient Ischemic Attack/Cerebral Infarction. A review of RI #105's physician orders documented a start date of 3/06/21 for Plavix 75 milligrams (mg) to be given daily for Cerebrovascular Accident. A review of RI #105's care plans did not reveal a care plan for the use of AC medication or Plavix. On 2/24/22 at 4:27 PM an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, review of the RECORD OF MEDICATION DESTRUCTION Control Drug Destructions forms, and review of a facility policy titled Disposal of Medications, the facility failed to ensure the required signatures were on the Controlled Drug Destruction forms. This affected two of five months, February and October of 2021, reviewed for destruction of controlled medications. Findings Include: Review of the facility policy titled Disposal of Medications, dated 12/2012, revealed the following: . PROCEDURES . 2. b. For the State of Alabama, these controlled substances shall be disposed of by the nursing care center in the presence of appropriately titled professionals . • x Two licensed nurses employed by the nursing care center • x Administrator and licensed nurse employed by the nursing care center • x Others as listed: Pharmacist . On 02/25/2022 at 8:19 AM, the surveyor observed the Controlled Medication Destruction forms for February 2022 (three signatures noted), October 2021 (two signatures noted), September 2021 (three signatures noted), July 2021 (three signatures noted),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, review of a facility policy titled, FOOD STORAGE LABELING and review of the 2017 Food and Drug Administration (FDA) Food Code, the facility failed to ensure: 1) Items in a standing refrigerator unit in the kitchen were labeled and dated; and 2) Two frozen turkeys were not thawing in a pan on the floor of the walk in cooler/refrigerator. This had the potential to affect all 41 residents receiving meals from the kitchen. Findings Include: 1) A review of a facility policy with a revised date of 6/2019, titled, FOOD STORAGE LABELING, revealed: POLICY: The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: 1. All food items must be labeled with the date they are received. 2. All food items that are not in their original containers must be labeled with the common food name of the food and the date they are received. 2. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date c. Example: Food prepared on 2/1 must be used or discarded by 2/7 . On 8/05/19 at 4:10 PM,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and a review of a facility policy titled, Change in Condition-Notification, the facility failed to ensure RI (Resident Identifier) #44's sponsor was notified of the resident's admission (transfer) to the hospital on 6/15/19 and readmission to the facility on 6/28/19. This deficient practice affected RI #44, one of three sampled residents who were reviewed for hospitalization. Findings include: A review of a facility policy titled, Change in Condition-Notification, with a reviewed dated of 06/2011 revealed: . The Nursing Home must promptly inform the resident and/or responsible party when there is a change in condition. Change in condition is defined as: . A decision to transfer or discharge the resident from the facility . Nursing Service Department is responsible for notification of . responsible party . Document as appropriate . RI #44 was admitted to the facility on [DATE], discharge(transferred) to the hospital on 6/15/19 and readmitted to the facility on [DATE]. RI #44's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the CMS (Center for Medicare and Medicaid Services) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure RI (Resident Identifier ) #1's admission MDS (Minimum Data Set) assessment was completed within 14 days of admission. This deficient practice affected one of 14 sampled residents whose MDS assessments were reviewed. Findings Include: A review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Chapter 2: Assessment for the RAI (Resident Assessment Instrument) documented: .01. admission Assessment The admission Assessment is a comprehensive Assesment for a new resident and, .must be completed by the end of day 14, counting the date of admission to the nursing home as day 1 . RI #1 was admitted to the facility on [DATE]. RI #1's admission MDS with an ARD (Assessment Reference Date) of 2/20/19 was listed as open. On 8/8/19 at 9:12 a.m., an interview was conducted with EI…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interview and the facility policies titled, STORAGE OF REFRIGERATED FOOD AND FOOD STORAGE LABELING , the facility failed to ensure: 1. a container of Vanilla Icing had a used by date 2. a box of cabbages and a carton of liquid eggs had an open and use-by-date, 3. a tray of sausage and bacon was labeled and 4. 2 gallons of buttermilk was discarded on 7/9/18. This deficient practice had the potential to affected 45 of 45 residents receiving meals from the kitchen. Finding Include: A review of a facility policy titled, STORAGE OF REFRIGERATED FOOD, with revision dates November 2017- March 2018 revealed: .PROCEDURE: .5. All opened foods are labeled with common name of food,date stored and use-by-date. 6 .foods .may be stored for 7 days . A review of a facility policy titled, FOOD STORAGE LABELING, with no effective date, revealed: .POLICY The facility will ensure the safety and quality of food by following good storage and labeling procedures. PROCEDURE: .2 All food items that are not in their original containers must be labled with the common name of the food,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and a facility policy titled, Mental Grievance Policy,the facility failed to ensure residents in the group meeting held on 07/7/17 at 10:00 a. m. were aware of the grievance process. This affected all 10 residents attending the group meeting. Finding Include: A review of a facility policy titled, Mental Grievance Policy, with a revision date of 01/31/18 documented: RESIDENT GRIEVANCE PROCEDURE GOAL To ensure that the voiced grievances of a resident are made without discrimination or reprisal in a timely manner . On 7/17/18 at 10:00 a.m., a resident council meeting was held. A total of 10 residents attended the meeting. The residents were asked if they knew how to file a grievance. All 10 residents at the meeting stated they did not know how to file a grievance. On 7/17/18 at 3:36 p.m. an interview was conducted with EI (Employee Indentifer) #2, Social Service Designee. EI #2 was asked how are residents made of aware of the how to file a written grievance. EI #2 said when she is at work she completes the form, when she is not at work residents tell the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and medical record review, the facility failed to adequately code RI (Resident Identifiers) #12's and # 37's Yearly MDS (Minimum Data Set) Assessments to reflect tobacco users. This affected 2 out of 5 residents who were identified as smokers in the facility. Finding Include: RI #13 was readmitted to the facility on [DATE]. A review of RI #13's Resident Smoking assessment dated [DATE] documented resident as a smoker. A review of RI #13's Yearly MDS with an ARD (Assessment Reference Date ) of 08/17/2017 revealed Section J 1300 was not coded for tobacco use. RI #37 was admitted to the facility on [DATE]. A review of RI #37's Resident Smoking assessment dated [DATE] documented resident as a smoker. RI #37's Yearly MDS with and ARD of 06/08/2016 revealed Section J1300 was not coded for tobacco use. On 7/17/18 at 6:35 p.m., the Surveyor observed RI #13 and RI #37 smoking in designated smoking area supervised by staff. On 7/19/18 an interview was conducted with EI (Employee…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review and a document review titled, CEU's (Continuing Education Units) for CNA's (Certified Nursing Assistant), the facility failed to ensure CNA's, Employee Identifiers (EI) #'s 5, 6, 7, 8 and 9 received 12 hours of mandatory annual training. This deficient practice affected 5 out 12 CNA's whose training records were reviewed. A review of a document titled, CEU's for CNA's, documented EI #s 5, 6, 7, 8, and 9 did not have the 12 hours of mandatory annual training for the calendar year. On 7/19/2018 at 2:19 p.m., an interview was conducted with EI #1, RN (Registered Nurse), Acting DON( Director of Nurses). EI #1 was asked how many CEUs are required for the CNA's per calendar year. EI #1 said 12 CEU's. EI #1 was asked did EI #'s 5, 6, 7, 8 7, 8, and 9 have their 12 CEU's for the calendar year. EI #1 said, No. EI #1 was asked what was the importance of CNA's having CEU's. EI #1 said to learn new things to do their job adequately.