Robertsdale Rehabilitation & Healthcare Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and facility policy review, the facility failed to notify the Ombudsman of hospital transfers in writing for three of three residents (Resident (R) 16, R38, and R93) out of a total sample of 35 residents reviewed for hospitalization. This had the potential for the residents to have no added protection if the residents were being inappropriately discharged or transferred so they could inform them of their rights and options. Findings include: Review of the facility's policy titled, Transfer and Discharge of a Resident (including AMA [against medical advice], revised 02/04, revealed no information regarding the facility's responsibility of notifying the Ombudsman of transfers and discharges. 1. Review of R16's undated Face Sheet provided by the facility revealed the resident was admitted to the facility on [DATE]. Review of a Departmental Note, provided by the facility and dated 07/24/24, revealed at 8:50 PM, R16's oxygen saturation (O2) was 60 percent (%). He was noted to be…

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 facility policy review, the facility failed to protect the resident's right to be free from abuse for seven of nine residents (Resident (R) 48, R83, R267, R15, R117, R76, and R80) reviewed for abuse. This failure had the potential to affect resident safety. Findings include: Review of the facility policy titled, Administrative Policy, Subject: Abuse, Neglect and Exploitation, last revised 11/17, revealed Each resident of any facility .has the right to be free from verbal, sexual, physical, or mental abuse, neglect, exploitation, and misappropriation of his or her property. 1. a. Review of R12's undated ''admission Record,'' provided by the facility revealed R12 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, psychotic disorder with delusions due to known physiological condition, dementia without behavioral disturbance, anxiety disorder, and major depressive. Review of R12's quarterly Minimum Data Set (MDS) with an Assessment…

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, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure four of six residents (Resident (R) 15, R83, R93, and R94) reviewed for pneumococcal vaccines out of total sample of 35 residents were either offered pneumococcal vaccines or offered additional pneumococcal vaccines per CDC guidelines. Additionally, the facility failed to obtain consents and provide the risks and benefits to the residents and/or responsible party (RP) prior to administering pneumococcal vaccines. Additionally, the facility failed to ensure R93 was offered an influenza vaccine. The failure of not offering/providing pneumococcal vaccines increased the risk for residents to contract pneumonia. The failure for not offering influenza vaccine increased the risk for the resident to contract influenza. Findings include: Review of the facility's policy titled, Influenza, Pneumococcal, COVID-19 and Respiratory Syncytial Virus (RSV) Vaccines…

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, observation, interview, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 83) observed for dining out of 35 sample residents was positioned to ensure the resident could access their food without difficulty and at a comfortable position. This had the potential for the resident to have a decline in nutritional status and a negative dining experience. Findings include: Review of the facility's policy titled, Dining Services with the last revision date of 10/17, revealed Meal service is provided for all residents in a safe and sanitary environment and in a manner that preserves the dignity and respect of each resident .Every effort is made to provide a homelike environment in the dining room .During meal service: 3. b. Residents shall be positioned by nursing staff to enable the resident to consume food served in the safest, most efficient, and more comfortable manner possible. Review of R83's undated Face Sheet provided by the facility revealed 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 observations, record review, interview, and job description review, the facility failed to ensure two of four residents (Residents (R) 5 and R 37) reviewed for activities of daily living received adequate assistance with shaving. This failure had the potential to negatively impact the quality of life and self esteem for the affected residents. Findings include: 1. Review of R5's undated Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia, anxiety, urinary tract infection, abnormal posture, and history of stroke. Review of R5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 and located in the EMR under the MDS tab, indicated he had a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated the resident had intact cognition. R5 required extensive assistance by one staff member with personal hygiene. Review of R5's Care Plan, located in…

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, interviews, and record review the facility failed to ensure staff were providing appropriate and timely urinary catheter care for one of four residents (Resident (R) 5) reviewed for catheters and urinary tract infections of 35 sample residents. This failure placed the residents at risk for infection to the urinary tract and urethral trauma. Findings include: Review of R5's Face Sheet located in the electronic medical record (EMR) under the Face Sheet tab, indicated he was admitted to the facility on [DATE] with diagnoses including paraplegia, anxiety, urinary tract infection, abnormal posture, and history of stroke. Review of R5's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/31/24 and located in the EMR under the MDS tab, revealed he had a Brief Interview for Mental Status (BIMS) of 14 out of 15 which indicated the resident had intact cognition. R5 required extensive assistance by one staff member with personal hygiene. Review of R5's physicians orders,…

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 facility policy review, the facility failed to ensure ceiling vents did not drip condensation onto the tray line and scoops were stored appropriately. This deficient practice had the potential to affect 100 of 113 residents who received meals prepared in the facility's kitchen. Findings include: Review of the facility's policy titled, Supplies and Equipment, dated 11/08, revealed Equipment will be ready for use at all times day or night to serve the resident's needs. Review of the facility's policy titled, STORAGE OF CANNED AND DRY FOOD, revised 11/23, revealed Dry lbod [food] products such as flour, commeal [cornmeal], sugar, etc [etcetera], that are stored in bins are removed from their original packaging. These bins are cleaned and sanitized according to facility cleaning schedule. Scoops are stored in covered containers and not in thc [the] storage bin unless hanging on a hook and out offood [of food] product. 1. The tray line was observed on 08/07/24 from 11:14 AM through 12:53 PM. Two ceiling vents above the steam table were observed to…

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 and review of the facility's RECORD OF MEDICATION DISPOSAL forms, the facility failed to ensure the controlled drug destruction records had three required signatures. This was noted in 10/2018 and 5/2019, two of the six months of controlled drug destruction records reviewed. Findings Included: Review of the RECORD OF MEDICATION DISPOSAL forms, dated 10/16/18, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. Review of the RECORD OF MEDICATION DISPOSAL forms, dated 5/10/19, revealed there were only two signatures present for the disposal of controlled medications. The section of the form for Signature of Witness (Only required for Controlled Drugs) was blank. On 6/06/19 04:30 PM, the surveyor conducted an interview with Employee Identifier (EI) #1, Registered Nurse/Director of Nursing (DON). EI #1 was asked who was responsible for signing the controlled drug destruction sheets. EI #1 said the pharmacist, herself and the nurse…

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, medical record review and review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, the facility failed to ensure a physician's order was accurately transcribed for Resident Identifier (RI) #175's bilateral lower extremity Doppler study. This affected RI #175, one of 27 sampled residents for whom medical records were reviewed. Findings Include: Review of [NAME] and [NAME] Fundamentals of Nursing Ninth Edition, Chapter 23 Legal Implications in Nursing Practice, copyright 2017, page 311, revealed the following: . Health Care Providers' Orders . Make sure that all health care provider orders are in writing . and transcribed correctly . RI #175 was re-admitted to the facility on [DATE]. RI #175 had diagnoses to include Cerebral Infarction, Surgical Aftercare following Surgery, and Hemiplegia. Review of Consultation Notes revealed RI #175 saw his/her oncologist on 4/3/19. This report documented the following: . PLAN . Biggest complaint…

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, review of facility's policy titled, FOOD STORAGE LABELING and the 2017 Food Code, the staff failed to ensure food was consistently covered and stored with labels to identify contents, date of preparation and use-by date. This had the potential to affect all residents for whom meals were prepared and served at the time of the survey. Findings include: The facility's FOOD STORAGE LABELING policy, revised October 2017, documented 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 name of the food and the date they are received. TCS (Time/Temperature Control for Safety) food held for longer than 24 hours must be labeled and date marked to indicate the use by date . 2. Suggested labeling includes: a. Common Name b. Date of preparation or Use By Date . The 2017 Food Code, documented . 3-202.15 Package Integrity. FOOD packages…

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.