South Haven Health and Rehabilitation, LLC

Inspectors wroteBased on interviews, observations, resident record review, and review of a facility policy titled, Federal Rights of Resident/Guest(s) the facility failed to ensure Resident Identifier (RI) #7 was informed in his/her language, of care being provided.

Inspectors wroteBased on interviews, resident record review, review of facility policies titled Incidents and Accidents and Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation and review of a facility investigative file for Resident Identifier (RI) #2, the facility failed to ensure an injury of unknown origin was reported to the Alabama Department of Public Health (ADPH) online reporting system in a timely manner when Certified Nursing Assistant (CNA) #16, discovered discoloration and bruising on RI #2's right ankle on 11/07/2023. The Licensed Practical Nurse (LPN) #19 failed to report the bruising to anyone including the abuse coordinator. On 11/10/2023 an x-ray was performed on RI #2's right ankle and revealed a fracture. The injury of unknown origin was still not reported to ADPH until 11/12/2023. [...]

Inspectors wroteBased on interviews, resident record review, review of facility policies titled Incidents and Accidents and Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and review of the facility investigative file for Resident Identifier (RI) #2, the facility failed to thoroughly investigate an injury of unknown origin for Resident Identifier (RI) #2 when a bruise was identified on 11/07/2023. This affected RI #2 one of two residents for whom reportable incidents were reviewed.

Inspectors wroteBased on interviews, resident record review, and review of a facility policy titled Federal Rights of Resident/Guest(s) the facility failed to ensure staff assisted Resident Identifier (RI) #1 with hair washing and oral care on 04/09/2024 . This had the potential to affect RI #1, one of three residents sampled for Activity of Daily Living care.

Inspectors wroteBased on observations, interviews, resident record review, and review of a facility policy titled Federal Rights of Resident/Guest(s) the facility failed to ensure Resident Identifier (RI) #3 a resident with upper and lower extremity range of motion limitations, had hand splints or rolled washcloths placed in his/her hands as care planned. RI #3 was observed on 04/09/2024, 04/10/2024, and 04/11/2024, without anything placed in his/her hands. This had the potential to affect RI #3, one of three residents reviewed for extremity limitations. This tag is cited as a result of the investigation of complaint/report number AL00043223.

Inspectors wroteBased on observations, interviews, resident record review, and review of a facility policy titled Hand Hygiene, the facility failed to ensure staff provided care in a manner to prevent the spread of infection. On 04/09/2024 Certified Nursing Assistant (CNA) #8 was observed not washing or sanitizing her hands when going between Resident Identifier (RI) #4 and RI #5's rooms. Further, CNA #26 was observed on 04/11/2024 wearing the same gloves for care and transport of RI #6 in the hallway and while obtaining clean clothes and supplies for RI #6's shower. This had the potential to affect RI #4, RI #5, and RI #6, three of eight sampled residents.

Inspectors wroteBased on interviews, record review, review of facility policies titled, Activity Program Management and Activity Program Assessment, and review of Resident Identifier (RI) #81's Group Activity Participation Records, the facility failed to provide RI #81 an ongoing program of activities consistent with his/her preferences and in accordance with the individualized plan of care. This affected RI #81, one of three sampled residents reviewed for activities, but had the potential to affect any resident who wished to participate in the facility's weekend planned group activities.

Inspectors wroteBased on observation, interview, and review of the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to prevent the potential for cross-contamination by: 1) storing a chemical in close proximity with food products, 2) allowing splash from a food preparation sink to strike previously clean pots and pans on a storage shelf, 3) allowing residue to build-up on the conveyor toaster over a 24-hour period, 4) permitting an employee handling soiled items to pull the dish rack of cleaned items out of the dishwasher without washing hands, and 5) not ensuring air gaps existed between the sewer drain and the drains from the dishwasher, the spray sink, the food preparation sinks, and the pot and pan washing sinks. This had the potential to affect 94 residents receiving meals from the facility's kitchen, 94 of 94 residents in the facility.

Inspectors wroteBased on observation, interview, and review of the Food and Drug Administration (FDA) 2017 Food Code, the facility failed to ensure food-related trash and discarded items did not accumulate in the dumpster area and failed to ensure chunks of concrete did not accumulate in the oil refuse area. This had the potential to affect 94 of 94 residents in the facility.

Inspectors wroteBased on observation, interview and a review of the facility's policy titled, LAUNDRY - STORAGE, COLLECTION & (and) TRANSPORT, the facility failed to ensure employees handling the laundry did not stack clean clothes/linen against the wall or place folded clothing on the same table that employees stored their personal belongings. This affected three of six laundry carts. Findings Include: A review of the facility's policy titled, LAUNDRY - STORAGE. COLLECTION & TRANSPORT REVEALED: . POLICY: * All linens will be stored, handled, transported and processed in a manner that prevents the transmission of microorganisms to other patients and areas. On 6/20/19 at 8:24 a.m. during a tour of the laundry department, the surveyor observed stacks of clean towels (greater than ten) and stacks of bath cloths (greater than ten), touching the wall. The folding table was pushed against the wall. [...]

Inspectors wroteBased on observation, interview, and review of a facility policy titled Leftover Food Storage and Use, the facility failed to ensure: 1. peaches in a closed plastic container with a documented facility open date of 6/28/18 and a facility use by date of 6/30/18, and potato salad in a closed plastic container with a documented facility open date of 6/28/2018 and a facility use by date of 6/30/18 were discarded, and 2. gravy in a closed plastic container with no documented facility open date and no facility use by date were dated. This had the potential to affect all 92 residents receiving meals from the dietary department. Findings Include: A review of the facility policy titled Leftover Food Storage and Use, with an effective date of 8/15/2009, documented: Purpose: To ensure food borne illnesses are avoided . b. Leftover foods should be .dated. c. [...]

Inspectors wroteBased on observations, interviews, record review, and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, the facility failed to ensure licensed staff did not place Resident Identifier (RI) # 241's nebulizer mask in a bag wet with condensation/moisture after a treatment was administered. This deficient practice affected one of two residents observed for nebulizer treatments and one of five nurses observed during medication pass. Findings Include: A review of of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, Chapter 27, page 455, documented: .Cleaning. Cleaning is the removal of organic material .from objects and surfaces .when an object comes in contact with an infectious or potentially infectious material, it is contaminated . Reusable objects need to be cleaned thoroughly before reuse . RI # 241 was admitted to the facility on [DATE]. [...]