Highlands Rehabilitation and Wellness Center

Inspectors wroteBased on interviews, record review, and review of facility policies titled Quality Improvement Program, and Quality Assurance Performance Improvement Plan the facility's Quality Assurance Performance Improvement (QAPI) committee failed to systemically address all causal factors related to four staff providing Cardiopulmonary Resuscitation (CPR) to Resident Identifier (RI) #159, a resident with Advanced Directive for Do Not Resuscitate (DNR). The QAPI committee further failed to notify the Governing Body of the adverse event. On [DATE] RI #159's end-of-life wishes were not honored. Licensed staff failed to review RI #159's chart for code status prior to CPR. RI #159's nurse was not in the facility at the time of the code but was sitting outside in the car. [...]

Inspectors wroteBased on interviews, medical record review, FUNDAMENTALS OF NURSING NINTH EDITION, a complaint received by the Alabama Department of Public Health, the facility's policies titled RESIDENT BILL OF RIGHTS, ADVANCE DIRECTIVES, and Cardio Pulmonary Resuscitation (CPR), the facility failed to honor Resident Identifier (RI) #159's Advanced Directive for end-of-life wishes. RI #159 had an Advanced Directive which directed staff to withhold resuscitative measures in the event of cardiopulmonary cessation and an active physician's order for DNR (Do Not Resuscitate) code status. During the evening shift on [DATE], RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8 around 8:20 PM. The first licensed responder, Registered Nurse (RN) #9 did not check RI #159's code status in accordance with the facility's protocol before she initiated CPR. [...]

Inspectors wroteBased on record review, interviews, a complaint recieved by the Alabama Department of Public Health, and the facility policy titled Cardio Pulmonary Resuscitation (CPR) the facility failed to ensure CPR was not initiated for Resident Identifier (RI) #159 on [DATE]. RI #159 had an Advanced Directive directing staff to withhold lifesaving measures including CPR. On [DATE] at approximately 8:20 PM, RI #159 was found by Certified Nursing Assistant (CNA) #8 in respiratory distress, mumbling and appeared pale in color. CNA #8, notified Registered Nurse (RN) #9 who responded and found RI #159 to be unresponsive to sternal rub. RN #9 initiated CPR and instructed CNA #8 to call a Code Blue and summon additional assistance from facility staff. RN #12, RN #9, Licensed Practical Nurse (LPN) #11 and the CPR Instructor (INST) assisted during the code and did not check RI #159's code status. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide sufficient nursing staff to consistently meet the needs of the residents. This deficient practice affected Resident Identifier (RI) #159. The facility failed to ensure the South Unit was properly staffed on [DATE] around 8:20 PM when RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. Two nurses were scheduled to be working on the unit; however, one nurse left early after working nearly 15 hours that day and the other one was in the parking lot. The CNA left the unresponsive resident to summon nurses from another unit who responded by initiating Cardiopulmonary Resuscitation (CPR) without first checking RI #159's medical record for the DNR order that was in effect. [...]

Inspectors wroteBased on record review, interview, a facility document titled Code Blue Evaluation, and the facility CARDIOPULMONARY RESUSCITATION (CPR), the facility failed to ensure the facility provided training and skills verification to staff on their CPR policy. The facility did not implement training and skills verification to ensure all staff were able to respond to an emergent situation according to their policy to verify a resident's code status before initiating CPR. On [DATE] around 8:20 PM RI #159 was found unresponsive by Certified Nursing Assistant (CNA) #8. The staff who responded initiated CPR without first verifying Resident Identifier (RI) #159's code status in the medical record. Four staff members, Registered Nurse (RN) #12, RN #9, Licensed Practical Nurse (LPN) #11, and the CPR Instructor (INST) assisted during the code and did not check RI #159's code status. [...]

Inspectors wroteBased on interviews, resident record review, and review of a facility reported incident, the facility failed to ensure Resident Identifier (RI) #58, a resident with moderate cognitive impairment, was assessed for self-administration of medication before Licensed Practical Nurse (LPN) #13 gave RI #58 a rectal suppository for RI #58 to self-administer on 12/06/2023. This affected RI #58, one of 10 residents for whom medications were reviewed.

Inspectors wroteBased on record review, interview, and review of the Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from October 1, 2023 - December 31, 2023, to Centers for Medicare & Medicaid Services (CMS). This affected one quarter of data reviewed during the survey.

Inspectors wroteBased on resident record review, interviews, the facility investigative file for Resident Identifier (RI) #400, and a facility policy titled Abuse Prevention, the facility failed to ensure RI #400 was free from misappropriation of property when the facility was unable to account for 34 doses of RI #400's Hydrocodone-Acetaminophen Oral Tablet 5.0-325 milligrams (mg). The facility further failed to ensure the residents on the Transitional Care Unit (TCU) were free from misappropriation when Licensed Practical Nurse (LPN) #5 took medications from the TCU medication cart. This had the potential to affect RI #400, one of three residents sampled for abuse and all residents residing on the TCU. This deficiency was cited as a result of the investigation of facility reported incident/complaint/report number AL00048045.

Inspectors wroteBased on interviews, resident record review, a review of the facility's pharmacy policy titled, CONTROLLED MEDICATIONS ADMINISTRATION, the facility failed to ensure controlled medication records were maintained, accurate, and without discrepancy to allow for accurate reconciliation for Resident Identifier (RI) #400. In May 2024 Licensed Practical Nurse (LPN) #4 signed controlled medication (Hydrocodone-Acetaminophen) for Resident Identifier (RI) #400 without documenting the administration of the medication on RI #400's Electronic Medication Administration Record (EMAR) 35 times. This deficient practice had the potential to affect RI #400 one of three sampled residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to accommodate the needs for one (1) (Resident Identifier [RI]#63) of 20 sampled residents, by providing a wheelchair appropriate for RI #63 to self-propel throughout the facility at will.

Inspectors wroteBased on interview, record review, review of facility policy and review of the facility's Facility Reported Incident (FRI) investigation (AL00041339), the facility failed to ensure one (1) of 24 sampled residents (Resident Identifier [RI] #80) was free from abuse.

Inspectors wroteBased on observations, interviews and review of facility policies titled, Food Storage (Dry, Refrigerated, and Frozen), and Labeling and Dating Foods (Date Marking), the facility failed to ensure: 1. outdated food was not stored in the walk-in cooler; 2. foods stored in the walk-in cooler were labeled with an open and/or use by date; and 3. dented cans were stored separately from other stock. These failures had the potential to affect 111 of 111 residents who received meals from the kitchen. Findings Include: 1) The facility policy titled, Food Storage (Dry, Refrigerated, and Frozen), with a date of 2016 Edition, included, 1. c. Discard food that has passed the expiration date. On 03/10/19 at 10:11 AM, the surveyor observed food items in the walk-in cooler. There were two rolls of ground beef with a received by date of 02/20/19 and a discard date of 03/07/19 on both rolls. [...]

Inspectors wroteBased on observation, interview and review of facility policies titled Linens and MEDICATION STORAGE, the facility failed to ensure Employee Identifier (EI) # 6, Laundry Aide, did not allow clean linen to touch her uniform. The facility further failed to ensure personal food items were not stored in the medication refrigerator. This affected one employee observed performing laundry tasks on 3/13/19 and one of two medication refrigerators observed. Findings Include: 1) A review of a document titled Linens, dated 7/22/18, revealed the following: . Clean Linens must be protected from dust and soil until used .Keep linens away from personal clothing . On 3/13/19 at 10:05 AM the surveyor observed the laundry area of the facility. At 10:09 AM the surveyor observed EI # 6 folding sheets/towels and removing wet laundry from the washing machine and placing it in the dryer. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the Nurse Staffing Information was posted daily. On 3/10/2018 during the initial tour, the Nurse Staffing Information was posted for 03/08/2019. This was observed on one of four days of the survey and had the potential to effect all residents, staff and visitors in the facility.