Alcoa Pines Health and Rehabilitation

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure dietary staff washed their hands between dirty and clean tasks, and before handling clean equipment for 1 of 1 meal observed.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure a physician's order for oxygen was in place before administering oxygen to 1 (Resident #59) of 1 sampled resident reviewed for oxygen therapy.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to provide appropriate handling and placement, to prevent possible contamination and complications, from an indwelling urinary catheter for 1 (Resident #59) of 1 sampled resident reviewed for urinary catheter.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observation and interview, the facility failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen, and that the refrigerator temperature was maintained at 41 degrees Fahrenheit or below to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 79 residents who received meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance to oxygen equipment in accordance with the facility policy for 1 (Resident #29) of 12 sampled residents who received oxygen therapy.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic medication, used on an as needed (PRN) basis for more than 14 days, had a duration for the order, to promote or maintain the highest practicable mental, physical, and psychosocial well-being for 1 (Resident #71) of 6 sampled residents who had physician's orders for psychotropic medications on a PRN basis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure meals were served in a method that maintained the appearance of cold product and at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 16 residents who receive meal trays in their rooms on the 100 Hall, 19 residents who receive meal trays on the 200 Hall, 19 residents who receive meal trays in their room on the 300 hall, 25 residents who receive meal trays in their room on 400 Hall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update the resident care plan to reflect a diagnosis of Diabetes with insulin usage for one (Resident #11) sampled resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a wander management device was in place to decrease the potential for elopement and safety hazards for 1 (Resident #35) of 5 sampled residents who had devices in place.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medication was removed from a medication cart to decrease the potential for harm and or misappropriation of property for 1 (Resident #11) of 10 sampled residents who resided on the 400 Hall.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Antibiotic Stewardship Program was consistently implemented, as evidenced by an antibiotic was prescribed without a duration or end date, to decrease the potential for harm and/or antibiotic resistance for 1 (Resident #35) of 3 sampled residents who were prescribed an antibiotic.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from accidents and hazards by leaving the storage room door unsecured allowing residents access to supplies that are not for human consumption. This failed practice had the possibility of affecting 14 residents with 4 (Residents #12, #21, #54, #333) sampled residents with Brief Interview for Mental Status (BIMS) scores of 11 or below; and 1 (Resident #21) sampled resident that ambulated or were self-propelled out of 22 residents the resided on the hall.

Inspectors wroteBased on observation and interview, the facility failed to ensure lunch was served at the same time for all Residents sitting at the same table to promote dignity and respect for 3 of 3 meals observed in the facility. The failed practices had the potential to affect 78 Residents who received meal trays from the Kitchen (total Census: 78) as documented on a list provided by the Registered Dietitian on 1/17/2023.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure that sharps containers were monitored and emptied when full to prevent possible injury to residents. This practice had the potential to affect all 78 residents who resided in facility and received showers or baths. a. 01/16/23 at 10:50 AM, a sharps container was mounted on the wall in the shower room shared by station 300 and 400. The container was overfilled with razors sticking out of the opening which prevented it from closing. b. On 1/19/23 at 10:15 AM, the Surveyor asked the Staffing Coordinator to describe the sharps container located in the large shower room which is shared by station 300 and 400. He stated, it is very full, overflowing actually. The Surveyor asked him to describe the process for replacing a sharps container when it is full. [...]

Inspectors wroteBased on interview, observation and record review the facility failed to assure that all nursing staff possessed the competencies and skill sets necessary to provide nursing and related services to meet the residents' needs safely and in a manner that promoted each resident's care or services.

Inspectors wroteBased on observation of the 8:00 a.m. medication pass on 1/18/23, record review, and interview, the facility failed to ensure a medication error rate of 5% [percent] or less. The facility had 4 medication errors in 26 opportunities, which resulted in a medication error rate of 15.38%. This failed practice had the potential to affect 38 residents who received medications from 2 (200 Hall and 400 Hall) of 4 hall medication carts, as documented on a list provided by the Administrator on 1/19/23 at 9:25AM.

Inspectors wroteBased on observation and interview, the facility failed to ensure that an ice scoop was kept clean to prevent any cross contamination between residents and that staff members wore their surgical masks in a manner that covered the mouth and nose. These failed practices had the potential to affect all 78 residents listed on the Daily Census list provided by the Administrator on 1/16/23 at 10:10 AM.

Inspectors wroteBased on interview and record review the facility failed to provide in writing the reason for the resident's transfer or discharge to the hospital in a manner that was understandable for the resident family or representative. The failed practice had the ability to effect 1 (Resident #72) of 27 sampled residents according to a list provided by the Administrator on 1/16/23 at 10:10 AM.