Sylacauga Health and Rehab Services

Inspectors wroteBased on observations, interviews and review of facility's policies titled, Food Receipts and Storage, Food, Leftover -Storage and Use, Service ware/Silverware, Handling and, Hand Washing (Infection Control), the facility failed to ensure: 1. supplements in the resident's refrigerator were not expired; 2. utensils and plates at the tray line was not wet nesting; 3. dietary staff washed hands when entering the kitchen and; 4. roast beef in the reach in refrigerator was labeled with an open and use by date. This had the potential to affect 138 of 138 residents who received meals from the kitchen. Findings Include: 1) A review of a policy titled, Leftover-Storage and Use with an effective date of 7/2016, revealed: PURPOSE: To assure that food borne illnesses are avoided. PROCESS: . [...]

Inspectors wroteBased on record review, interview and review of a facility policy titled Notification of a Change in Medical Condition of Residents, the facility failed to ensure Resident Identifier (RI) #71's family representative was notified promptly of resident's fall on 4/16/19 at 5:00 AM. This affected one of three residents reviewed for falls. Findings Include: A review of a facility policy titled Notification of a Change in Medical Condition of Residents, with a date of 2/1/07 revealed: .STANDARD Notification of the physician, resident's representative, should occur promptly .when there is a change in the resident's condition. This would include but is not limited to: .An accident involving the resident which results in injury and has the potential for requiring physician intervention. RI #71 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Alzheimer's Disease. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure Hospice was coded on the Quarterly Minimal Data Set (MDS) dated [DATE], for Resident Identifier (RI) #46. This affected one of three residents sampled for Hospice. Findings Include: RI #46 was admitted to the facility on [DATE]. A review of RI #46's Quarterly MDS with an Assessment Reference Date of 1/22/19 did not have Hospice marked in Section O. A review of RI #46's Physician Orders dated April 2019 revealed RI #46 was admitted to Hospice services on 08/09/18. On 4/18/19 at 8:39 AM an interview was conducted with Employee Identifier (EI) #5, [NAME], LPN, MDS Coordinator and EI #6, [NAME], RN. EI #5 was asked, what were her responsibilities there. EI #5 replied, MDS assessments and care plans. The surveyor asked for the most recent MDS which was a Quarterly MDS dated [DATE], which did not have Hospice coded. [...]

Inspectors wroteBased on observation, interview, record review and review of facility policies titled, Dressings, Clean (Wound Care) and Hand Washing (Infection Control), the facility failed to ensure: 1. licensed staff changed gloves during wound care for Resident Identifier (RI) #94 and RI #111 after cleaning the wound and before placing the treatment and 2. licensed staff changed gloves during incontinent care after cleaning the resident and before placing the clean brief for RI #94 . This affected two of two residents observed for wound care and one of one resident for incontinent care. Findings Include: 1. A review of a facility policy titled, Dressings, Clean (Wound Care) with an effective date of 3/2018 revealed: .PROCESS: 4. Wash hands and put on clean gloves 5. Remove existing dressing 6. Pull your glove off .7. Wash hands and put on clean gloves 8. Cleanse the wound as ordered . 10. [...]

Inspectors wroteBased on observation, interview and a review of a facility policy titled Garbage and Refuse, the facility failed to ensure the door on number one dumpster was completely closed. This had the potential to affect all residents residing at the facility. A review of a facility policy titled, Garbage and Refuse with an effective date of 9/2014 revealed: PURPOSE to prevent the spread of bacteria that may cause food borne illnesses. STANDARD: Garbage and refuse containers should be free from cracks or leaks and covered when not in use . PROCESS: . 4. dumpster's kept outside the facility should have tightly fitting lids . On 4/15/2019 at 6:27 p.m., the surveyor and (Employee Identifier) EI #9 Dietary Aide, observed three dumpster outside of the facility. Dumpster number one door was opened at the back side of the dumpster, not completely closed. [...]

Inspectors wroteBased on observation, interview, record review, and review of [NAME] and Perry's Fundamentals of Nursing, the facility failed to ensure: 1.) CNAs (Certified Nursing Assistant) provided incontinent care in a manner to prevent infection for RI (Resident Identifier) #72 and #10. The facility further failed to ensure licensed staff: 2.) Did not pull RI #109's privacy curtain wearing gloves, wear those same gloves while administering RI #109's medication and flushes per gastrostomy tube and then straighten RI #109's covers and rinse and dry the syringe used during administration wearing those same gloves. 3.) Washed hands prior to preparing medication for RI #141, did not place gloves on RI #141's overbed table before applying them, did not operate control of RI #141's bed after washing hands and then applied gloves to administer RI #141's inhaler. [...]

Inspectors wroteBased on interview, medical record review, and review of a facility document titled Incident Report a facility policy titled Medication, Oral/Sublingual Administration and FUNDAMENTALS OF NURSING, NINTH EDITION, the facility failed to ensure a licensed nurse administered the correct medication to Resident Identifier (RI) # 96 on 5/6/18. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL00035689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration, with an effective date of 5/2014, documented: Purpose: To administer oral medications in an organized and safe manner . [...]

Inspectors wroteBased on interview, medical record review, a facility document titled Incident Report and review of a facility policy titled Medication, Oral/Sublingual Administration, the facility failed to ensure Resident Identifier (RI) # 96 received the correct medication on 5/6/18. This resulted in RI # 96 being sent to the emergency room for an evaluation. This affected 1 of 3 residents sampled for medication concerns. Findings Include: Complaint #AL00035689 alleged an unknown resident had received the wrong medication and was sent to the hospital. Additional information received during the survey identified RI #96 as the resident who received the wrong medication. A review of a policy titled Medication, Oral/Sublingual Administration with an effective date of 5/2014 documented: Purpose: To administer oral medications in an organized and safe manner . [...]

Inspectors wroteBased on observation, interview and review of a facility policy titled Nurse Staffing Information, the facility failed to ensure the Nurse Staffing Information was posted daily. On 5/20/18 the Nurse Staffing was posted for 5/18/18. This was observed on one of three days of the survey and had the potential to effect all residents, staff and visitors in the facility. Findings Include: A review of policy titled Nurse Staffing Information with an effective date of 2/2018 documented: .PURPOSE: To provide public access to nurse staffing information .The facility shall make nurse staffing information available to the public .readily accessible to residents and visitors . On 5/20/18 at 4:52 a.m., the surveyor observed the nurse staffing information posted and dated for 5/18/18. On 5/21/18 at 4:22 p.m., an interview was conducted with Employee Identifier (EI) #14, Staffing Coordinator. [...]