Diversicare of Pell City

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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, . [...]

Inspectors wroteBased 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. [...]