Elba Nursing and Rehabilitation Center, LLC

Inspectors wroteBased on interviews, discussion during the resident group meeting, and review of the facility's admission Agreement, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 90 out of 90 residents residing in the facility. Findings Include: A review of the facility's admission AGREEMENT, with an effective date of 9/16/19, revealed: . RESIDENT BILL OF RIGHTS . A. Facility Residents shall have the right to: . 26. To send and receive mail promptly and unopened. On 5/16/22 at 10:00AM, a group meeting was held with 18 residents present. No one stated they received mail on Saturdays. In an interview on 5/16/22 at 11:29AM, Resident Identifier (RI) #40 stated no one received mail on Saturday because the main office staff were not present on Saturdays. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the admission Minimum Data Set (MDS) for Resident Identifier (RI) #233 was completed in a timely manner. This deficient practice affected one out of 18 resident MDS's reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/19, page 2-16, revealed the following: . RAI OBRA-required Assessment Summary . Assessment Type/Item Set . admission . MDS Completion Date (Item Z0500B) No Later Than . 14th calendar day of the resident's admission (admission date + 13 calendar days) . RI #233 was admitted to the facility on [DATE]. RI #233's admission MDS had an Assessment Reference Date (ARD) of 4/27/22. The status of the MDS was Open. No information was entered at Z0500. [...]

Inspectors wroteBased on record review, interview and review of a facility policy MDS ASSESSMENT, the facility failed to ensure the Minimum Data Set (MDS) for Resident Identifier (RI) #32 dated 2/25/22 was coded for anticoagulation medication. This affected one of one resident records reviewed for anticoagulation medication. Findings Include: A review of a facility policy titled MDS ASSESSMENT, with a date of 11/17 revealed POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets a .These assessments provide information on the resident's condition . RI #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis to include unspecified Atrial Fibrillation. A review of RI #32's Physician orders revealed . Order Date 2/18/22 . ELIQUIS 2.5 mg (milligram) . By MOUTH TWICE DAILY . [...]

Inspectors wroteBased on record review, interview and a review of the facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure Resident Identifier (RI) #58 was care planned for a Urinary Tract Infection (UTI) upon readmission to the facility on 3/23/22. This affected one of 18 resident care plans reviewed. Findings Include: A review of a facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, with an effective date of 3/18 revealed POLICY: Each resident will have a person centered plan of care to identify problems, needs, strengths, preferences, and goals that will identify how the interdisciplinary team will provide care. 9. Upon a change in condition, the Comprehensive Person Centered Care Plan . will be updated . RI #58 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Urinary Tract Infection. [...]

Inspectors wroteBased on interviews, record review and a review of the facility policies titled NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, and GUIDE FOR WOUND EVALUATION, the facility failed to provide evidence Resident Identifier (RI) #74's responsible party was notified when: 1) RI #74 developed an open area to the right ankle on 6/15/2021; and 2) when the area to RI #72's right ankle was observed to have worsened on 6/27/2021. These deficient practices affected RI #74, one of three residents sampled for notification.

Inspectors wroteBased on interview, record review and review of the Centers for Medicare & (and) Medicaid Services Long-Term Care Facility Resident Assessment Instruction (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #82's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 06/21/2021, did not code RI #82 as receiving an Anticoagulant medication during this assessment period. This deficient practice affected RI #82, one of 31 residents whose MDS assessments were reviewed.

Inspectors wroteBased on interview, record review and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to initiate an Instant Care Plan when Resident Identifier (RI) #74 developed an open area to his/her right ankle on 06/15/2021. This deficient practice affected RI #74, one of three residents sampled for pressure ulcers.

Inspectors wroteBased on interview, review of the facility's Record of Medication Destruction forms, and review of a facility policy titled, MEDICATION DESTRUCTION the facility failed to ensure the Medication Destruction forms contained the required signatures. This was observed on four out of fifteen months of non-controlled drug destruction forms viewed.

Inspectors wroteBased on observation, interviews and review of facility policies tithed, Tube feeding and Resident Rights, the facility failed to ensure (Resident Identifier) RI #5 was treated with dignity while a nurse provided nutritional care. This affected 1 of 32 residents who was observed for dignity. Findings Include: A review of a document titled Resident [NAME] of Rights revealed: Each resident has a right to a dignified existence. A. Facility Residents shall have the right to: .33 To personal privacy . in his or her personal care. A review of a facility policy titled, Tube Feeding with a history date of 11/17, revealed, . Procedure: 1. Provide privacy. RI #5 was readmitted to the facility on [DATE] with diagnoses including Ventricular Tachycardia, Gastrostomy Status, and Cerebral Palsy. [...]

Inspectors wroteBased on observation, interview, review of a facility policy Contact Precautions and record review, the facility failed to ensure staff put on Personal Protective Equipment (PPE) prior to entering Resident Identifier (RI) #89's room to provide care. This affected one of 4 residents on contact isolation. Findings Include: 1. A review of a undated facility policy titled, CONTACT PRECAUTIONS revealed: POLICY: Contact Precautions are a transmission based precaution that will be utilized to reduce the risk of transmission of epidemiologically important micro-organisms by direct of indirect contact. DEFINITION: Transmission Based Precautions are designed for residents documented or suspected to be infected or colonized with highly transmissible or . Three types of precautions utilized are Contact Precautions . PROCEDURE: . 3 Apply protective equipment as indicated upon entering the room. a. [...]

Inspectors wroteBased on observation, interviews and a review of a facility document tiled, Garbage and Rubbish Disposal, the facility failed to ensure dumpsters number one and number three were closed tightly on 3/17/19. This was observed of 2 of 3 dumpsters and had the potential to affect all residents residing in the facility. Findings Include: A review of a policy titled, Garbage and Rubbish Disposal with an edition date of 2016 revealed: .Procedure: 1. All garbage or rubbish is to be put into waste containers which are emptied as often as necessary to prevent overfilling. This will assist in the prevention of odors, pets, and possible contamination. 6. Outdoor trash receptacles will be kept covered . On 3/17/19 at 11:00 a.m., the surveyor observed dumpsters number one and number three lids opened. The dumpsters had three compartments to them. [...]