Pine Hill Rehabilitation and Wellness Center

Inspectors wroteBased on observations and interviews, the facility failed to ensure Laundry Staff (LS) #13 handled clean clothing in the laundry department in a manner to prevent cross-contamination on 03/06/2024 when LS #13 was observed folding clean resident clothing. This was observed while LS #13 folded clean laundry from one cart of clothing and repeatedly and systematically held the clean clothing against her body and her scrub top while she folded the clean resident clothing.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled COMPREHENSIVE PERSON CENTERED CARE PLANS the facility failed to ensure Resident Identifier (RI) #109 had the opportunity to attend and participate in care plan meetings at least quarterly since June 2023. This deficient practice affected RI #109, one of 49 residents for whom care plans were reviewed.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS, the facility failed to notify Resident Identifier (RI) #217's representative, who was the guardian, and RI #217's physician when RI #217 left the faciity on [DATE] by wheelchair van transportation. This deficient practice affected RI #217, one of three residents sampled for notification of change.

Inspectors wroteBased on an observation, interviews and review of the RESIDENT BILL OF RIGHTS, the facility failed to ensure the eMAR (electronic Medication Administration Record) screen was closed, and did not reveal personal information concerning Resident Identifier (RI) #149. This deficient practice affected RI #149; and was observed on 03/04/2024, during the morning medication pass.

Inspectors wroteBased on interview, review of a Facility Reported Incident (FRI) received by the Alabama Department of Public Health Online Incident Reporting System, and review of a facility policy titled, . ABUSE PREVENTION'' the facility failed to ensure an allegation of physical abuse was reported to the state agency within two hours on 08/29/2022 when Resident Identifier (RI) #94 was yelled at and slapped by RI #368. This deficient practice affected RI #94, one of 31 sampled residents, and one of five FRIs reviewed.

Inspectors wroteBased on interviews, review of the RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheets and review of a facility policy titled . MEDICATION DESTRUCTION ., the facility failed to ensure all of the RECORD OF MEDICATION DESTRUCTION - NON CONTROLLED MEDICATIONS sheets contained the two required signatures. This deficient practice affected 26 pages from non-controlled destruction records dated January 2023 through January 2024 reviewed during the survey.

Inspectors wroteBased on an observation, interviews, record review and review of a facility policy titled, PRESCRIBER MEDICATION ORDERS, the facility failed to address Consultant Pharmacist recommendations for Resident Identifier (RI) #4 in a timely manner. The Nurse Practitioner (NP) responded to the recommendation on 02/05/2024, but the facility failed to implement the NP's response. A month later during the survey on 03/06/2024, RI #4 was observed receiving a one milligram Haldol tablet. This deficient practice affected RI #4, one of five residents sampled for the medication regimen review.

Inspectors wroteBased on observations, interviews, record review, and review of a facility policy titled, MEDICATION STORAGE, the facility failed to ensure: 1) the medication refrigerator on the Memory Care Unit was kept between 36 degrees F and 46 degrees F; and 2) the medication room door was closed and locked and/or supervised on the memory care unit. These deficient practices had the potential to affect Resident Identifier (RI) #110 and all 36 residents on the Memory Care Unit.

Inspectors wroteBased on interviews, observations, and review of facility policies titled CONTROLLED MEDICATIONS ADMINISTRATION and MEDICATION ADMINISTRATION -GENERAL GUIDELINES the facility failed to ensure the Interim Director of Nursing (IDON) #2, Licensed Practical Nurse (LPN) #10, LPN #11, and LPN #12 documented Oxycodone/Acetaminophen on the electronic Medication Administration Record for Resident Identifier (RI) #473. This affected one of 31 sampled residents.

Inspectors wroteBased on record review, interviews, and the Payroll Based Journal (PBJ) Report, the facility failed to report accurate staffing data from July 1, 2023-September 2023 to the Center for Medicare and Medicaid Services (CMS). The PBJ report generated for the quarter of 07/01/2023 documented, .This Staffing Data Report identified area of concern that will be triggered metric . Excessively Low Weekend Staffing Triggered = Submitted Weekend Staffing data is excessively low . On 03/07/2024 at 5:23 PM, an interview was conducted with Executive Director (ED). The ED was asked why did the facility trigger for excessively low weekend staffing for the 4th Quarter, (July 1-September 30) 2023. She said because the therapy department was not there on the weekends, unless they had an evaluation that needed completed, the facility have the core nursing staffing, dietary and housekeeping on weekends. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure residents that resided on the memory care unit were not served food in disposable, Styrofoam, or plastic ware. This deficient practice all the residents who resided on the memory care unit, one of three units in the facility.

Inspectors wroteBased on observations and interview, the facility failed to ensure the dining area of the memory care unit was clean and sanitary. This deficient practice was observed on the memory care unit, one of three units within the facility.

Inspectors wroteBased on interviews, record review, review of a facility policy titled, Abuse Prevention, review of the facility's investigative file and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifiers (RI) #'s 11, 92, 270 and 272 were not missing narcotic medications. These incidents occurred on two occasions, [DATE] and [DATE]. This deficient practice affected RI #'s 11, 92, 270 and 272, four of four residents who were observed for narcotic medication and resided on two of four units at the facility. Findings Include: A review of a facility policy titled Abuse Prevention, with a history date of 08/17, revealed the following: . DEFINITIONS: . g) Misappropriation of Resident Property: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff did not stand while feeding Resident Identifier (RI) #59 the breakfast meal on 02/13/19. This deficient practice affected RI #59, one of five residents observed requiring assistance at meal time. Findings Include: RI #59 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses to include Adjustment Disorder with Mixed Anxiety and Depressed Mood. RI #59's Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 12/17/18, assessed RI #59 as having short and long term memory problems with severely impaired cognitive skills for daily decision making and needing extensive assistance with eating. [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled, INCONTINENT CARE the facility failed to ensure: 1. a Certified Nursing Assistant (CNA) did not place the soiled brief that was removed from Resident Identifier (RI) #108 on the floor beside the bed and 2. CNAs did not clean residents during incontinent care with gloved hands, then use the same gloves to place the clean brief on the resident and touch the top covers. This affected RI #108 and RI #40, two of three resident observed for incontinent care. Findings Include: A review of a facility policy titled, INCONTINENT CARE with a revised date of 7/12, revealed: POLICY: To provide routine, preventative skin, perineal care to residents after an incontinent episode. PROCEDURE: .7. Put on gloves . 8. Remove wet brief, incontinent pad, and any other soiled linen, soiled articles of clothing and discard .16. [...]

Inspectors wroteBased on interviews and observations, the facility failed to ensure the survey results for the last three years were located in an area that was readily accessible to residents and visitors. This deficient practice had the potential to affect all 177 residents who reside in the facility. Findings Include: On 02/12/19 at 1:26 PM, the surveyor walked to the 2400 and 2700 hall nursing station. The surveyor looked in the front lobby and could not find the last survey results posted. There was a sign posted at the nursing station desk on the 2400 hall and 2700 hall that stated the three years survey results were available upon request. On 2/12/19 at 3:00 PM, a Resident Council group meeting was held with 10 residents attending. All ten residents stated they did not know where to get the survey results without having to ask for them. [...]