Pine Haven Rehabilitation and Wellness Center

Inspectors wroteBased on interviews, resident record review, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative file, the facility failed to protect residents from abuse. On 02/08/2023 Resident Identifier (RI) #5's was verbally abused by RI #6. On 02/09/2023 RI #3 was physically abused by RI #2. On 05/21/2024 RI #8 and RI #9 were each verbally abused by the other. The facility further failed to substantiate the occurrences as abuse. These deficient practices affected RI #'s 3, 5, 8 and 9, four of 14 sampled residents. This deficiency was cited as a result of the investigation of complaint/report numbers AL00043323, AL00043305 and AL00047916.

Inspectors wroteBased on observations, interviews and a copy of the facility's RESIDENT BILL OF RIGHTS, the facility failed to ensure 26 of 89 residents' rooms were found in a homelike condition. This affected 26 of 89 rooms observed during the survey. Findings Include: A review of the RESIDENT BILL OF RIGHTS with a most recent review date of 11/17, revealed, Each resident has a right to a dignified existence, . and in an environment that promotes maintenance or enhancement of (his or her) quality of life, . A. Facility residents have the right to: . 33. A safe clean, comfortable home like environment. On 10/11/2022 04:33 PM during the initial tour, the following observations were made by the surveyor: [...]

Inspectors wroteBased on an observation, interviews and review of facility policies titled, . SMALL VOLUME NEBULIZER THERAPY and . SELF ADMINISTRATION PROTOCOL ., the facility failed to ensure the licensed nurse remained with (Resident Identifier) RI #55, a resident not assessed to self-administer his/her nebulizer breathing treatment, when RI #55 received a nebulizer treatment on 10/11/2022. This deficient practice affected RI #55; one of one sampled resident observed receiving a nebulizer breathing treatment. Findings Include: Review of facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: .RESPONSIBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 10. Assist/instruct resident to close lips around the mouthpiece. 11. Instruct to inhale deeply and hold for several seconds before exhaling. 12. [...]

Inspectors wroteBased on interviews, record review, and review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS with a revision date of 11/17, the facility failed to provide evidence Resident Identifier (RI) #110's physician and sponsor were notified when RI #110 had ant bites to his/her left arm, left lower abdomen, and under his/her neck. This deficient practice affected RI #110, one of one resident sampled for notification. Findings Include: Facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, documented: . POLICY: The attending physician/physician extender (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist) and the resident representative will be notified of a change in a resident's condition, . PROCEDURE: . d. Any accident or incident . The Incident Log documented RI #110 on 10/10/2022 at 7:00 AM . Incident type: Insect Bite . [...]

Inspectors wroteBased on an interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) 55's Minimum Quarterly Data Set (MDS), with an Assessment Reference Date (ARD) of 08/11/22 was accurately coded to reflect RI #55 was receiving oxygen. This deficient practice affected RI #55, one of three sampled resident's whose MDS assessments were reviewed. Findings Include: A review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, revealed: Section O: Special Treatments, Procedures, and Programs Intent: The intent of the items in this section is to identify any special treatments, procedures, and programs that the resident received during the specified time periods. [...]

Inspectors wroteBased on interviews, review of Resident Identifier (RI) #98's medical record including the PASRR (Pre-admission Screening and Resident Review) Screening & Results, and documents provided by the facility (the Regulatory Requirements) used as their guidance for the pre-admission screening process, the facility failed to ensure a valid Level 1 PASRR was completed for RI# 98. This affected RI #98, one of five residents whose Pre-admission Screening and Resident Reviews were reviewed for completion. Findings Include: A facility document dated October 15, 2022, documented: (Name of Facility) does not have a Policy or Procedure regarding PASRR however we follow the federal guidelines. A review of RI #98's . PASRR Level 1 Screening & Results for Mental Illness . Intellectual Disability . Related Condition . with a screening date of 5/20/21, revealed, . ** MAY REQUIRE A LEVEL II ** . [...]

Inspectors wroteBased on observation, interviews, record review and review of a facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure a care plan was developed/implemented for the following residents: 1) Resident Identifier (RI) #71's newly identified Pressure Ulcer, 2) RI #81's diabetes and insulin use, and 3) RI #55's use of oxygen. These deficient practices affected RI #'s 71, 81, and 55, three of thirty-one residents whose care plans were reviewed. Findings Include: The facility's COMPREHENSIVE PERSON CENTERED CARE PLANS policy dated 3/18, revealed the following: 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 . PROCEDURE: . 5. For each problem, need, or strength a resident-centered goal is developed. [...]

Inspectors wroteBased on observations, interviews and review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to review and revise the care plan for Resident Identifier (RI) #14 regarding a hand splint that was not in use during the survey. This affected RI #14, one of 31 residents whose care plans were reviewed. Findings Include: Review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, with a last review 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 or Baseline Care Plan will be updated . [...]

Inspectors wroteBased on observations, interviews, record review, and review of the facility's policy titled, . SMALL VOLUME NEBULIZER THERAPY, the facility failed to ensure Resident Identifier (RI) #55's nebulizer mask was stored in a covering on three of three days of the survey. This deficient practice affected one of one resident sampled for nebulizer administration. Findings Include: Review of the facility policy titled, . SMALL VOLUME NEBULIZER THERAPY, with a revision date of 8/16, revealed the following: . RESPONSBILITY: All Licensed Nursing Personnel/Respiratory Therapist . PROCEDURE: . 15. Store in a labeled plastic bag. RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia. RI #55's Physician Orders for October 2022 revealed RI #55 had orders for . [...]

Inspectors wroteBased on interviews, record reviews, a review of [NAME] and [NAME], Fundamentals of Nursing, NINTH EDITION, and the Facility's form titled, Medication Administration-General Guidelines, the facility failed to provide evidence the licensed nurse was consistently documenting on the resident's eMAR (electronic Medication Administration Record) the administration of the resident's insulin. This affected RI #81, one of three residents sampled for Medication Administration. Findings Include: A review of [NAME] and [NAME]'s Fundamentals of Nursing, NINTH EDITION, page 370, revealed the following: . Chapter 26 Documentation and Informatics . Informatics and Information Management in Health Care . A nurse's electronic or handwritten signature on an entry in a record designates accountability for the contents of that entry. [...]

Inspectors wroteBased on observations, interviews, and review of the facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS, the facility failed to ensure expired mediation and medical supplies were discarded after the expiration date. This deficient practice was observed in four of four medication storage areas in the facility.

Inspectors wroteBased on observations and interview, the facility failed to have an effective pest control program so that flying insects were not observed in the kitchen. This deficient practice had the potential to affect all residents who received food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) completed by Employee Identifier (EI) #3, the Director of Nursing and dated 6/7/2021 indicated the facility had a total of 126 residents; 12 of which received nutrition by way of a tube feeding.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #45's medical record and the facility's policy titled MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure RI #45's Quarterly MDS dated [DATE] indicated the resident was receiving hospice services. This deficient practice affected RI #45; one of 41 sampled residents.

Inspectors wroteBased on observations, interviews, review of Resident Identifier (RI) #75's medical record and the facility's policy titled FINGERNAILS/TOENAILS CARE, the facility failed to provide nail care to RI #75, a resident assessed as requiring extensive assistance with personal hygiene and bathing, to ensure the resident's fingernails were cleaned. This deficient practice affected RI #75; one of one resident reviewed for Activities of Daily Living.

Inspectors wroteBased on observation, interviews, and review of Resident Identifier (RI) #70's medical record, the facility failed to consistently provide wound care to RI #70's non-pressure chronic left foot ulcer as ordered by the physician. This deficient practice affected RI #70; one of three sampled residents reviewed for non-pressure related wounds.

Inspectors wroteBased on interview and review of Resident Identifier (RI) #60's medical record, the facility failed to adequately monitor the effects of thyroid medication for RI #60 when they failed to ensure physician ordered laboratory tests were done. This deficient practice affected RI #60; one of five sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #60's medical record and the facility's policy titled LABORATORY TESTS, the facility failed to promptly notify the physician of RI #60's abnormal laboratory test result. This deficient practice affected RI #60; one of 41 sampled residents.

Inspectors wroteBased on observations, interviews, medical record reviews and the facility's policy titled, A.M CARE, the facility failed to ensure Resident Identifier (RI) #11's, RI #111's and RI #117's call bell was within reach. This affected three of thirty two residents sampled residents.

Inspectors wroteBased on interviews, record review and review of facility policies titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS and GLUCOSE MONITORING VIA (by way of) GLUCOMETER, the facility failed to notify Resident Identifier (RI) #216's physician when the resident's blood sugar (BS) was greater than 400mg/dl (milligrams per deciliter) on 1/2/2019. This deficient practice affected RI #216, one of four residents sampled for notification.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #149's medical record and the facility's policy's titled DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY, the facility failed to ensure RI #149's discharge notice dated 2/11/2019 included the name, address (mail and email) and telephone number of the entity to which the resident and/or the resident's representative can appeal the resident's discharge, which is the Alabama Medicaid Agency and the name address (mail and email) and telephone number of the Office of the State Long-Term Care Ombudsman. This deficient practice affected RI #149, one of five sampled residents reviewed for discharge.

Inspectors wroteBased on interview, review of Resident Identifier (RI) #163 and RI #567's medical record, the facility failed to provide written notice of the bed hold policy when RI #163 and RI #567 were transferred to a local hospital. This deficient practice affected RI #163, one of six residents reviewed for hospitalization and RI #567, one of five residents reviewed for discharge.

Inspectors wroteBased on record review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure a significant change assessment was completed for Resident Identifier (RI) #137. This affected RI #137, one of thirty-two sampled residents.

Inspectors wroteBased on record review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed to ensure a Quarterly MDS assessment was completed timely for Resident Identifiers (RI) #121 and RI #165. This affected two of thirty two residents whose MDS assessments were reviewed for timely completion. Findings Include: The facility's policy titled, MDS ASSESSMENT dated November 2017, revealed, POLICY: . PROCEDURE: . 6. The Interdisciplinary Team as designated will complete specified portions of the MDS . The RN (Registered Nurse) designated by the facility will assure that all disciplines have completed their portion of the MDS. RI #121 was admitted to the facility on [DATE], with a diagnosis of Unspecified Cerebrovascular Disease. [...]

Inspectors wroteBased on observation, record review, interviews, and a facility policy titled,DRESSING CHANGE, the facility failed to ensure a licensed staff member removed gloves or performed hand hygiene after removing a soiled dressing and before cleaning a wound during the wound care of Resident Identifier (RI) #154. This affected RI #154, one of one resident observed for wound care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure there was medical justification for the use an urinary catheter for Resident Identifier (RI) #163. This deficient practice affected RI #163, one of one resident observed with a urinary catheter.