Diversicare Of Pell City

Based on observation, interviews, and review of a facility policy titled, Dispose of Garbage and Refuse the facility failed to ensure trash bags were placed in the refuse dumpster with a closed lid and a discarded mattress was not on the ground in the dumpster area. This was observed on 03/01/2022 and 03/02/2022, two of three days of the survey, and had the potential to affect all 64 residents in the facility. Findings Include: A facility policy titled Dispose of Garbage and Refuse dated 8/2017 documented: Policy Statement All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures 1. The Dining Services Director coordinates . to ensure that the area surrounding the exterior dumpster area is maintained in a manner free of rubbish or other debris. 2. The Dining Services Director will ensure that: . Appropriate lids are provided for all containers. On 03/01/2022 at 8:50 AM, an observation was made of two closed dumpsters and a big open dumpster containing five clear plastic bags with Personal Protective Equipment (PPE) in bags on top of the big…

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 and review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, the facility failed to ensure all resident medications were stored in the original containers on 03/03/2022, when loose pills and capsules were observed in drawers of all three resident medication carts. This affected three of three resident medication carts observed in the facility. Findings Include: Review of facility policy titled Storage and Expiration Dating of Medications, Biologicals, last revised 01/01/2022, revealed: . PROCEDURE . 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, . 10. Facility should ensure that the medications and biologicals for each resident are stored in the containers in which they were originally received. On 03/03/2022 at 7:55 AM, an observation of medication cart #2 was made with Employee Identifier (EI) #4, Licensed Practical Nurse (LPN). One loose white pill and one loose small white pill was found on the bottom of the second drawer. On 03/03/2022…

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, interviews, resident record review and review of a facility policy titled Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA), washed or sanitized her hands during lunch meal delivery and set up on 03/01/2022. EI #8 delivered and set up trays for Resident Identifier (RI) #29 and RI #13 without performing hand hygiene between residents. This had the potential to affect RI #13, one of two residents observed to have lunch meal trays passed to them by EI #8 on 03/01/2022. Findings Include: A facility policy titled Handwashing/Hand Hygiene, with an effective date of March 2020, documented: . POLICY This center considers hand hygiene the primary means to prevent the spread of infections. POLICY INTERPRETATION AND IMPLEMENTATION . 5. Use an alcohol-based hand rub or, alternatively, soap . and water for the following situations: . b. Before and after direct contact with residents; . m. Before and after eating or handling 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, review of Resident Identifier (RI) #47's Clinical Health Status Evaluation 1.0-V2 assessment, Resident Assessment Instrument Manual and interview, the facility failed to ensure baseline care plans, including a risk for falls, were developed and implemented with instructions necessary to direct RI #47's care within 48 hours after RI #47's admission to the facility on [DATE]. This affected RI #47, one of 22 residents sampled for care plans. Findings Include: The Centers for Medicaid and Medicare, Resident Assessment Manual, Version 3.0, Chapter 2, page 2-41, documented: .2.7 The Care Area Assessment (CAA) Process and Care Plan Completion . Within 48 hours of admission to the facility, the facility must develop and implement a Baseline Care Plan for the resident that includes instructions needed to provide effective and person-centered care . A facility document titled, Clinical Health Status Evaluation 1.0-V2, Effective Date 04/29/2019, documented: .1. Evaluation Type 1. admission…

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 observations, record reviews, interviews and a facility policy titled, Medication Storage Storage of Medication, the facility failed to ensure vials of nebulization solutions were properly stored and not left on Resident Identifier (RI) # 68's bedside table. This affected 1 of 21 sampled residents. Findings Include: The facility policy titled, Medication Storage Storage of Medication, with a date of 09/18, revealed: POLICY: Medications and biological are stored properly . The medication supply shall be accessible only to licensed nursing personnel . PROCEDURES 1. Medications are to remain in these containers and stored in a controlled environment. . 3. In order to limit access to prescription medications, only licensed nurses . should remain locked when not in use . RI #68 was admitted to the facility on [DATE] with diagnoses to include Major Depressive Disorder, Cough, Hypertension, Paroxysmal Atrial Fibrillation, Dementia, Muscle Weakness and Need for assistance with Personal Care. Review of RI #68'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 observation, record review, interviews and review of the Potter and [NAME], Fundamentals of Nursing manual, the facility failed to ensure RI #16's nasal spray and inhaler were cleaned after medication administration and prior to storing them in the medication cart. A review of POTTER AND [NAME], FUNDAMENTALS OF NURSING, NINTH EDITION, CHAPTER 32, Medication Administration, BOX 32-16 PROCEDURAL GUIDELINES, Administering Nasal Medications, documented: 16. Administer nasal spray: .18. Wipe tip of bottle with clean, dry tissue and replace the cap, .remove and dispose of gloves and perform hand hygiene. RI #16 was readmitted to the facility on [DATE], with diagnoses including, Unspecified Chronic Obstructive Pulmonary Disease and Unspecified Allergic Rhinitis. A review of RI #16's Physician Orders included the order for, DuoNeb Solution . 1 inhalation inhale orally . On 05/20/19 at 8:16 a.m., Employee Identifier (EI) #6 was observed during medication pass observation for RI #16. EI #6 was observed capping RI…

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, Refrigerated Storage, the facility failed to ensure an opened bag of diced potatoes were labeled with a used by date. This was observed during the initial tour of the kitchen with Employee Identifier (EI) #3, Dietary Manager on 06/12/18 at 8:01 a.m. This had the potential to affect 64 residents receiving meals from the kitchen. The facility had a census of 66. Findings Include: A facility policy titled: Refrigerated Storage with an Effective Date: June 1, 2013, documented: POLICY . PROCEDURE . 7. All foods will be properly wrapped and/or stored . dated and labeled, . During the initial tour of the kitchen with EI #3 on 06/12/2018 at 8:01 a.m., the surveyor observed an opened bag of diced potatoes, not labeled with a used by date. On 06/12/2018 at 6:21 p.m., an interview was conducted with EI #3. EI #3 was asked should there be a used by date on the opened bag of diced potatoes. EI #3 said yes ma'am. The surveyor asked EI #3 what would happen when there was no used by date. EI #3 said if it was old and it was used, it…

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 interview, record review and a document titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument .Version 3.0, the facility failed to ensure RI (Resident Identifier) #1's Discharge MDS (Minimum Data Set) Tracking Entry was transmitted in a timely manner. This affected one of eighteen sampled residents whose MDS assessments were received. Findings Include: A review of a document titled, Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument .Version 3.0 with a date of [DATE] revealed: .CH 2 .Assessments for the Resident Assessment Instrument (RAI) . Assessment Management Requirements . for Entry Tracking Records: . 08. Death in Facility Tracking Record . Must be completed when the resident dies in the facility . Must be completed within 7 days after the resident's death, . Must be submitted within 14 days after the resident's death, . RI #1 was admitted to the facility on [DATE] with a diagnosis of Squamous Cell…

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 record review, interview and review of a policy titled, Disposal of Medications, the facility failed to ensure two signatures were present on all of the non-controlled medication destruction sheets for the month of April, 2018. This affected one of 12 months of non-controlled medication destruction sheets reviewed. Findings Include: A review of a facility policy titled, Disposal of Medications with a date of 12/12 revealed: .A non-controlled medication disposition log shall be used for documentation .The log shall contain the following information: .Signatures of the required witnesses . On 06/14/18 at 10:56 AM, the surveyor reviewed the non-controlled medication destruction record and found 11 of 29 pages for April 2018 had one signature present. 06/14/18 at 0:45 PM the surveyor conducted an interview with EI (Employee Identifier) #5, DON/Director of Nurses. The surveyor asked EI #5 how many signatures should be on the non-controlled medication destruction sheet. EI #5 said two. The surveyor asked EI #5 what month did not have two signatures as required. EI #5 said April…

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.