NORTH MOBILE NURSING AND REHABILITATION CTR
For profit - Individual
172 Beds
NORBERT BENNETT & DONALD DENZ
Data: November 2025
Trust Grade
50/100
#172 of 223 in AL
Last Inspection: October 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
North Mobile Nursing and Rehabilitation Center has a Trust Grade of C, which means it is average and sits in the middle of the pack among nursing facilities. It ranks #172 out of 223 in Alabama, placing it in the bottom half, and #16 out of 16 in Mobile County, indicating there are no better local options. The facility's trend is improving, having reduced issues from 9 in 2022 to just 1 in 2024. Staffing is rated average with a 3/5 star score and a turnover rate of 48%, which is concerning. There have been no fines recorded, which is a positive sign, but the RN coverage is below average, with less RN presence than 85% of facilities in Alabama, raising concerns about adequate medical oversight. However, there are notable weaknesses. For instance, the facility failed to discard expired medications and had issues with pest control in the kitchen, where flying insects were found landing on residents' food trays. Additionally, many residents' rooms were not maintained in a homelike condition, with issues such as scraped paint and unclean environments affecting the quality of life. While there are strengths, these weaknesses may concern families seeking a safe and comfortable place for their loved ones.
- Trust Score
- C
- In Alabama
- #172/223
- Safety Record
- Low Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Alabama facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 21 minutes of Registered Nurse (RN) attention daily — below average for Alabama. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 23%
No red flags
9 → 1 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2022: 9 issues
2024: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Alabama average (2.9)
Below average - review inspection findings carefully
Staff Turnover: 48%
Near Alabama avg (46%)
Higher turnover may affect care consistency
Chain: NORBERT BENNETT & DONALD DENZ
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 25 deficiencies on record
May 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record review, review of a facility policy titled ABUSE PREVENTION, review of Facility Reported In...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
Review of a facility policy titled ABUSE PREVENTION with a history date of 07/2018, revealed the following:
POLICY:
The facility is committed to protecting the residents from abuse by anyone including, but not necessarily limited to: . other residents .
DEFINITIONS: .
b) Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents .
d) Physical Abuse: This includes but is not limited to hitting, slapping, pinching and kicking.
1) RI #5 was admitted to the facility on [DATE].
RI #5's quarterly Minimum Data Set (MDS) assessment, with Assessment Reference Date (ARD) of 11/11/2022 indicated RI #5 had a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment with daily decision making skills during this assessment period.
RI #6 was admitted to the facility on [DATE].
RI #6's admission MDS assessment, with an ARD of 11/11/2022, indicated RI #6 had severe cognitive impairment with daily decision making skills.
On 02/08/2023, the State Agency received an Online Incident Report from the facility alleging RI #6 verbally abused RI #5 and accused RI #5 of stealing RI #6's clothes.
The facility's investigative file was reviewed and a summary of the facility's investigation documented the following:
February 8, 2023 . The allegation of verbal abuse is found to be unsubstantiated. On 2/08/2023 At approximately 7:30am both residents were in their room when the charge nurse overheard the residents arguing . (RI #6) was accusing (his/her) room mate of stealing (his/her) things, (he/she) would not stop cursing even when staff stepped in and asked them to calm down. (RI #6) continued to curse and at one point blocked the door when the charge nurse and the other resident attempted to leave the room.
On 05/31/2024 at 2:42 PM, an interview was conducted with the Administrator (ADM), who is also the facility's abuse coordinator. The ADM said her responsibility as the abuse coordinator was to investigate and determine abuse to any resident. The surveyor shared with the ADM on 02/08/2023, the facility submitted an initial report alleging verbal abuse occurred between RI #5 and RI #6; but the facility's investigation concluded that the verbal abuse was not substantiated. When asked why was the verbal abuse not substantiated, the ADM said the residents were not interviewable due to their cognitive status. When asked what type of abuse would using profanity and cursing be considered, the ADM said, verbal.
2) RI #2 was admitted to the facility on [DATE] and readmitted on [DATE].
RI #2's quarterly MDS assessment, with an ARD of 11/18/2022, documented RI #2 had long and short term memory problems and moderately impaired cognition during this assessment period.
RI #3 was admitted to the facility on [DATE] and readmitted on [DATE].
RI #3's annual MDS assessment, with an ARD of 11/02/2022, documented a BIMS score of 12 which indicated RI #3 had moderately impaired cognition.
On 02/09/2023, the State Agency received an Online Incident Report alleging RI #2 physically abused RI #3 when RI #2 hit RI #3's arm several times and grabbed RI #3's shirt.
The facility's investigative file was reviewed and a summary of the facility's investigation documented the following:
. The allegation of physical abuse is found to be unsubstantiated. On 02/09/2023 At approximately 11:20am both residents were sitting in front of the nurses desk on B wing of the facility. (RI #3) bumped into (RI #2's) wheel chair . (RI #2) became upset and started using profanities toward (RI #3), (RI #2) hit (RI #3) on (RI #3's) upper left arm grabbed (RI #3's) shirt sleeve.
On 02/09/2023 (RI #3) was interviewed . during the interview (RI #3) stated (he/she) was rolling by (RI #2) in (his/her) wheel chair and (he/she) bumped (RI #2's) chair by accident and (RI #2) hit (RI #3's) arm (RI #3) stated it didn't hurt .
Conclusion:
The facility concluded their investigation and could not substantiate the allegation of Physical Abuse .
On 05/31/2024 at 2:42 PM, when asked what type abuse hitting someone would be considered, the ADM said physical. The surveyor shared with the ADM that on 02/09/2023, the facility submitted an initial report alleging physical abuse occurred between RI #2 and RI #3; and the facility's investigation concluded the physical abuse was not substantiated. When asked why the physical abuse was not substantiated, the ADM said she thought it was a reflex. The surveyor asked the ADM to her knowledge had RI #2 had any other incidents where she had that type reflex. The ADM said not to her knowledge. When asked what type of abuse hitting someone would be, ADM said, physical abuse.
3) RI #8 was admitted to the facility on [DATE].
RI #8's quarterly MDS assessment, with an ARD of 01/15/2024, revealed RI #3 scored a 15 on the BIMS assessment indicating RI #8 had intact cognitive decision making skills during this assessment period.
RI #9 was admitted to the facility on [DATE] and readmitted on [DATE].
On review of RI #9's quarterly MDS assessment, with an ARD of 03/15/2024, revealed RI #9 scored a 10 on the BIMS assessment indicating RI #9 had moderately impaired decision making skills during this assessment period.
On 05/21/2024, the State Agency received an Online Incident Report alleging RI #8 and RI #9 were verbally abusing each other, curing each other in the dining room.
The facility's investigative file was reviewed and a summary of the facility's investigation dated 05/27/2024 documented the allegation was unsubstantiated even though RI #8 and RI #9 were witnessed arguing over candy during a bingo game and RI #9 was heard yelling at RI #8 and saying . shut up bitch, I can get some if I want it . and RI #8 was heard to reply to RI #9 saying . get the hell out of here .
On 05/30/2024 at 10:45 AM, an interview was conducted with the Activity Assistant (AA)/CNA. The AA said she heard a lot of profanity being used between RI #8 and RI #9 on 05/21/2024.
On 05/31/2024 at 2:42 PM, the surveyor shared with the ADM that on 05/21/2024, the facility submitted an initial report alleging verbal abuse occurred between RI #8 and RI #9; but the facility's investigation concluded that the verbal abuse was not substantiated. When asked why the verbal abuse was not substantiated, the ADM said when interviewing RI #9, the resident did not remember the incident. The ADM further stated she thought RI #9 cursed RI #8 because RI #8 was cursing at RI #9. When asked if the facility should have substantiated that abuse occurred with the above incidents, the ADM said she thought the incidents occurred but did not think they were abuse. When asked what type of abuse would using profanity and cursing be considered, the ADM, said, verbal abuse.
Oct 2022
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, interviews and review of facility policies titled, . SMALL VOLUME NEBULIZER THERAPY and . SELF ADMINIST...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Encourage and instruct resident to cough at completion of treatment.
A second policy titled, . SELF ADMINISTRATION PROTOCOL . with a revision date of 8/16, revealed, . RESPONSIBILITY: All Licensed Nursing Personnel/Interdisciplinary Team PROCEDURE: 1. If the resident wishes to participate, the Interdisciplinary Team will complete the Medication Self-Administration Assessment. 2. A written order for the bedside storage of medication is placed in the resident's medical record.
RI #55 was admitted to the facility on [DATE] and re-admitted on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia.
RI #55's Physician Orders for October 2022 revealed RI #55 was receiving the nebulizer treatment, . BUDESONIDE 0.25MG (Milligrams)/2ML (Milliliters) SUSP (Suspension) ONE (1) AMPULE PER NEBULIZER TWICE DAILY . FORMOTEROL 20 MCG (Micrograms)/2 ML NEB (Nebulizer) TWICE DAILY DX (diagnosis): SOB (Shortness of Breath) .
On 10/11/2022 at 5:02 PM, RI #55 was lying in bed receiving a nebulizer treatment. At 5:08 PM, RI #55 sat up in bed, turned off the nebulizer machine and placed the mask on the bed rail.
On 10/11/2022 at 5:08 PM an interview was conducted with RI #55. He/she stated They come in here and put stuff in there. I put on the mask. I don't make them come in and cut off.
On 10/11/2022 at 5:31 PM, an interview was conducted with Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN). EI #10 stated when administering a nebulizer treatment, nurses should check the resident's pulse and respirations, make sure the cup is clean, put the medication in cup, start the machine, standby to make sure the resident is okay, and re-assess the resident afterwards. EI #10 admitted she left the room while administering the nebulizer treatment for RI #55. EI #10 stated she did not think the resident had an order to self-administer nebulizer treatments and admitted she should not have left the room while the resident was being administered the treatment. EI #10 stated she did not follow the medication administration policy. EI #10 stated the concern of leaving a resident alone while administering a nebulizer treatment was anything could go wrong. She added the resident might not get all of the medication.
On 10/17/2022 at 11:15 AM, an interview was conducted with EI #2, Director of Nursing (DON). EI #2 stated residents are allowed to self-administer medication if the doctor writes an order. She stated the resident must be assessed and the care plan implemented. EI #2 was asked about the concerns of the nurse allowing RI #55 to self-administer the nebulizer treatment and she stated that was not self-administering, that was a nebulizer treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based 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 Resid...
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Based 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 . Raised Red Area . Resident room . In-house treatment .
On 10/10/2022, RI #110's Resident Incident Report documented: . staff was providing care and noted several ants on the pillow where the resident's left arm was laying . small red areas to left upper anterior arm, also noted red areas to right eye, face and neck . Immediate Actions Taken: removed the pillow and checked the resident and bed for ants .
An interview on 10/18/2022 at 1:41 PM an interview was conducted with the Medical Director. He stated the facility did not inform him of the incident dated 10/10/2022 that indicated Insect Bite or Raised Red Area, and no one told him that staff had seen ants in RI #110's room.
On 10/19/2022 at 9:36AM an interview was conducted with RI #110's Representative. The Representative stated the facility never informed him that RI #110 had been bitten by ants. He said that they told him RI #110 was moved into a different room because they were detailing his/her room. He further stated that when he asked them what that meant he said that they said painting, floor being waxed and putting everything in plastic boxes to keep ants out of the room, but they never told him there had been an ant issue.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an interview, record review, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. O0100: Special Treatments, Procedures, and Programs Facilities may code treatments, programs and procedures that the resident performed themselves independently or after set-up by facility staff . Steps for Assessment 1. Review the resident's medical record to determine whether or not the resident received or performed any of the treatments, procedures, or programs within the last 14 days. Coding Instructions for Column 1 Check all treatments, procedures, and programs received or performed by the resident prior to admission/entry or reentry to the facility and within the 14-day look-back period. Leave Column 1 blank if the resident was admitted /entered or reentered the facility more than 14 days ago. If no items apply in the last 14 days, check Z, none of the above. Coding Instructions for Column 2 Check all treatments, procedures, and programs received or performed by the resident after admission/entry or reentry to the facility and within the 14-day look-back period.
RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Acute Respiratory Failure with Hypoxia.
Physician orders, revealed, . Order date 7/13/22 start date 7/13/22 . O2 (Oxygen) AT 2L(Liters)/NC (via Nasal Cannula) TO KEEP 02 SAT (Saturation) > (greater than) 90% CHECK O2 SATS Q (every) SHIFT.
Review of a quarterly MDS with an Assessment Reference Date (ARD) of 08/11/2022, Section O . 0100C2 Treatment: oxygen therapy while resident was not identified at the time of the assessment.
An interview was conducted with Employee Identifier (EI) #5, a Registered Nurse (RN), MDS Coordinator on 10/16/2022 at 4:06 PM. EI #4 stated RI #55 has a diagnosis of Respiratory Failure and was ordered O2 at 2L on 07/13/2022. EI #5 admitted O2 was not identified on RI #55's Quarterly MDS assessment dated [DATE]. She stated it should have been identified on the assessment. EI #5 admitted the assessment was not accurate. EI #5 stated the concern of an inaccurate assessment was the staff may not know how to provide accurate care.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of Resident Identifier (RI) #98's medical record including the PASRR (Pre-admission Screening and Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 ** . For compliance with Federal and State PASRR regulations, Admitting NFs (Nursing Facilities) must: Report this admission to the OBRA (Omnibus Budget Reconciliation Act) PASRR Office at the time of admission to start the Level II Evaluation process to determine eligibility.
A review of the medical record for Resident Identifier #98 revealed he/she was admitted to the facility on [DATE]. Diagnoses included but were not limited to Aftercare following surgical amputation and Selective Mutism.
An interview on 10/16/2022 at 9:13 AM with Employee Identifier (EI) #7, the Social Worker, who reported she was responsible for making the referral to the appropriate state designated authority when the need for a valid Level 1 screening was indicated.
An interview was conducted on 10/17/2022 at 3:43 PM with EI #8, the LMSW (Licensed Master of Social Work)/Supervisor and Corporate Social Worker. EI #8 reported the Level 1 PASRR screening for RI #98 on admission to the facility on 5/21/21 indicated that they may have required a Level II screening. EI #8 added whoever had done the one on admission failed to send in the information to go with it. So, no Level 1 determination was received by the facility. EI #8 said the concern with a valid Level I determination not being obtained for a resident was not knowing if the resident met the criteria to be admitted to the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) RI #55 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of Acute Respiratory Failure with Hyp...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) 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 October 2022 Physicians' Orders documented:
. O2 (Oxygen) AT 2L (Liters)/NC (via Nasal Cannula) TO KEEP O2 SAT (Oxygen saturation) >90% CHECK O2 SATS Q (every) SHIFT .
On 10/12/2022 at 11:13 AM observed resident with oxygen cannula in nose, set at 2 (LPM, Liters Per Minute). A review of RI #55's medical record on 10/12/22, revealed there was no care plan for use of oxygen.
On 10/16/2022 at 4:06 PM, an interview was conducted with Employee Identifier (EI) #5, Registered Nurse (RN), MDS/Care Plan. EI #5 stated RI #55 was ordered for oxygen on 7/13/22. EI #10 stated a care plan for oxygen use was initiated on 10/13/22 and admitted it should have been initiated on 7/13/22. EI #5 stated the concern of not having a care plan is the staff not knowing how to provide accurate care.
3) RI #81 admitted to the facility on [DATE] with a diagnosis of Type 2 diabetes mellitus without complications.
RI #81's October 2022 Physicians' Order documented:
.INSUILIN GLARGINE-YFGN U100 VL INJECT 6 UNITS SUBQ (subcutaneous) EVERYDAY AT BEDTIME . Order date: 5/20/22 .
On 10/19/2022 at 8:58 AM, an interview was conducted with Employee Identifier (EI) #5, Registered Nurse (RN), MDS/Care Plan. EI #5 stated RI #81 was admitted to facility with a diagnosis of Diabetes and had an order for insulin. EI #5 stated RI #81 did not have a care plan and admitted a care plan should have been implemented. EI #5 stated the concern of not having a care plan for diabetes is the staff may not know exactly how to provide care.
Based 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.
1) RI #71 was admitted to the facility on [DATE] with diagnoses including Repeated Falls and Adult Failure to Thrive.
The Weekly Skin assessment dated [DATE] for RI #71's wound revealed: Wound Location Left Heel . Status Ulcer . that was not present on admission.
The INITIAL WOUND EVALUATION & MANAGEMENT SUMMARY dated 10/6/2022, revealed: . CHIEF COMPLAINT Patient presents with a wound on (his/her) left heel. PLAN OF CARE REVIEWED AND ADDRESSED Recommendations Float heels in bed; Sponge boot .
A review of RI #71's medical record identified no care plan for the newly acquired pressure ulcer. Employee Identifier (EI) #6, the Wound Care Nurse provided a Care Plan page identical to the previous Pressure Ulcer care plan with the date the Stage 2 Pressure Ulcer was identified on 10/5/2022. She reported it was a generic care plan. See interview below.
An interview was conducted on 10/15/2022 at 5:33 PM with EI #6, the Wound Care Nurse. EI #6 reported RI #71's left heel Pressure Ulcer was identified on 10/5/2022. EI #6 reported a standard care plan for wounds was put in place, nothing specific to the Left Heel wound that had been newly identified. EI #6 stated the purpose of a care plan being individualized was to show the interventions put in place were for that particular resident. EI #6 reported she was responsible for developing care plan for newly identified Pressure Ulcers/Injuries. EI #6 was asked about the Wound Care Physician's Care Plan recommendations and agreed they should have been included in RI #71's Plan of Care. EI #6 stated she was given the standardized or generic care plan to put in place for every new wound by the previous wound care nurse and the DON (EI #3) was aware. EI #6 reported the plan of care that was initiated did not include the Wound Care Physicians' recommendations. She added she did not know she had to add the recommendations to the care plan. EI #6 said staff would not know to implement those interventions because they were not added to the plan of care. EI #6 stated the concern of not having a Care Plan that was specific to a resident with a newly identified Pressure Ulcer was the interventions would not have been implemented.
An interview was conducted on 10/15/2022 at 6:02 PM with EI #3, the Director of Nursing. EI #3 said when the resident has something specific going on with them, staff should care plan for that specific issue. She added for newly identified wounds staff should add interventions to address the specific resident's wounds. She further added for CNAs (Certified Nursing Assistants) to know to implement those interventions for RI #71, those interventions should be on the plan of care, so that they would be on the pocket guide. EI #3 verbalized specific interventions would not have been implemented for the newly identified Pressure Ulcer for RI #71 if the care plan was not specific to the concern of injury/wound.
An interview was conducted on 10/17/2022 at 2:58 PM with EI #5, the Care Plan Coordinator. EI #5 acknowledged the care plan initiated on 10/05/2022 did not address RI #71's left heel wound. EI #5 stated the purpose of a person-centered plan of care was so that a person would receive individualized care to meet their needs. EI #5 added that it was important to improve or assist in the healing process. EI #5 said the Physician's recommendations should be included in the plan of care so the nurses and aides could follow the ordered recommendations.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the facility policy titled, COMPREHENSIVE PERSON CENTERED CARE PLANS, the facili...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 .
RI #14 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include Parkinson's Disease and Persistent Vegetative State.
The Quarterly MDS (Minimum Data Set Assessment) dated 10/02/2022 revealed, . Splint or brace assistance: number of days 0 .
Observations were made of RI #14 on 10/12/2022 at 2:35 PM, 10/13/2022 at 4:37 PM and 10/14/2022 at 11:14 AM and it was noted that he/she had no hand splints in place.
Review of the care plan revealed RI #14 as care planned for splints daily with an onset date of 12/4/2015.
An interview was conducted on 10/16/2022 at 10:13 AM with Employee Identifier (EI) #4, the Administrator in Training. She indicated the MDS (Minimum Data Set) assessment/Care Plan Nurse should be made aware of changes in the Medicare meetings and was responsible for reviewing and revising care plans. She admitted RI #14's care plan had not been updated as it should have. EI #4 said that it should have been updated to ensure the plan of care was accurate for the resident.
A follow-up interview was conducted on 10/17/2022 at 10:32 AM with EI #4, the Administrator in Training. EI #4 reported the significance of the care plan being accurate was to reflect the resident's needs and ensure staff met the resident's needs.
An interview was conducted on 10/17/2022 at 2:51 PM with EI #5, the Care Plan Coordinator. She said RI #14's MDS indicated the number of days splints or braces were used was zero. She reviewed RI #14's care plan and reported it indicated RI #14 would tolerate splints daily per instructions. She admitted the care plan and resident assessment did not match. She gave the reason as the care plan was not updated to match the assessment. EI #5 said the concern of the care plan not being reviewed and revised to match the assessment was the patient may not receive the care they needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility's policy titled, . SMALL VOLUME NEBULIZER THERAPY, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 . BUDESONIDE 0.25MG (Milligrams)/2ML (Milliliters) SUSP (Suspension) ONE (1) AMPULE PER NEBULIZER TWICE DAILY . FORMOTEROL 20 MCG (Micrograms)/2 ML NEB (Nebulizer) TWICE DAILY DX (diagnosis): SOB (Shortness of Breath) .
On 10/11/2022 at 5:02 PM, RI #55 was lying in bed receiving a nebulizer treatment. At 5:08 PM, RI #55 sat up in bed, turned off the nebulizer machine and placed the mask on the bed rail in no bag.
On 10/12/2022 at 11:13 AM the nebulizer was observed sitting on nightstand, tube dated 10/12/22 mask was hanging on side of the bed rail in no bag. According to the MAR (Medication Administration Record), the last time RI #55 received a nebulizer treatment was 10/12/22 at 9AM.
On 10/13/2022 at 1:35 PM mask for nebulizer was observed hanging on side of the bed rail in no bag. According to the MAR, the last time RI #55 received a nebulizer treatment was 10/13/22 at 9 AM.
On 10/13/2022 at 5:14 PM resident sleeping in bed and the nebulizer mask was observed uncovered and hanging on right of the bed rail. According to the MAR, the last time RI #55 received a nebulizer treatment was 10/13/22 at 9:00 AM.
On 10/13/2022 at 5:15 PM, an interview was conducted with Employee Identifier (EI) #10, a Licensed Practical Nurse (LPN). EI #10 was asked to observe RI #55's nebulizer in the room. EI #10 stated the mask was not in a bag and was hanging on the bed rail. EI #10 admitted the mask should have been stored in a bag with the date on it. EI #10 stated the concern of not storing the mask properly was an infection control issue.
On 10/13/2022 at 5:18 PM, an interview was conducted with EI #9, a Registered Nurse (RN), Unit Manager. EI #9 was asked to observe RI #55's nebulizer in the room. EI #9 stated RI #55's mask was not in a bag and hanging on the bed rail. EI #9 stated the mask should be stored in a plastic bag and on the holder of nebulizer machine with the room number and name on it. EI #9 stated the concern of not storing nebulizer mask properly was germs and possible infection.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, a review of [NAME] and [NAME], Fundamentals of Nursing, NINTH EDITION, and the Facility's f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Review of facility's form titled, Medication Administration-General Guidelines dated 1/15, documented, POLICY: Medications are administered as prescribed, in accordance with good nursing principles and practices . PROCEDURE: . 11. The resident's MAR/TAR (Treatment Administration Record) was initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose following medication administration .
RI #81 admitted to the facility on [DATE] with a diagnosis of Type 2 Diabetes Mellitus without complications.
RI #81's MAR for September 2022 documented, . INSULIN GLARGINE- . U (Units)100 VL(Vial) INJECT 6 UNITS SUBQ (Subcutaneous) EVERYDAY AT BEDTIME . Order date: 5/20/22 .
Review of the September 2022 MAR revealed missing documentation for administration of Insulin Glargine on the following days: 9/8/2022, 9/9/2022, 9/13/2022, 9/15/2022, 9/16/2022, 9/20/2022, 9/22/2022, 9/23/2022, 9/27/2022,9/29/2022 and 9/30/2022.
RI #81's MAR for October 2022 documented . INSUILIN GLARGINE- . U100 VL INJECT 6 UNITS SUBQ EVERYDAY AT BEDTIME . Order date: 5/20/22 .
Review of the October 2022 MAR revealed missing documentation for administration of Insulin Glargine on the following days: 10/4/2022 and 10/7/2022.
On 10/15/2022 at 6:44 PM, an interview was conducted with Employee Identifier (EI) #11, a Licensed Practical Nurse (LPN). EI #11 stated she could not remember what days she cared for RI #81 in September and October. EI #11 stated that some days when she came to work the computer system was down and once it came back up, she was unable to reboot it. EI #11 stated there was supposed to be a dumb book which contained MARs. EI #11 stated she has always given residents there medications even if the system was down. She stated on those days, she had to ask another nurse to look at MARs for residents in order to see what medications were to be given. EI #11 admitted medications given on those days were not documented on eMAR due to her not having access to the computer.
In a follow-up interview conducted with EI #11 on 10/17/2022 at 12:16 PM. EI #11 stated if the eMAR was not available, medication that has was not given should be documented on MAR books located on the hall. EI #11 admitted she did not document medications given on those days. EI #11 stated the concern of not documenting medication given was staff would not know if the resident received the medication.
On 10/17/2022 at 9:11 AM an interview was conducted with EI #3, the Director of Nursing (DON). EI #3 stated sometimes the computer system is unavailable and nurses were not able to document on the eMAR. She stated if that happened, nurses were instructed to document medication given on the paper MAR. EI #3 said, there was a book at the nurse's station with MARs. EI #3 stated the concern of not documenting medication given, was the next person coming on wouldn't know if medication had been given.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based 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 ...
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Based 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:
10/11/2022 04:57 PM Area Locator (AL) 21 patchy touched up paint,
10/11/2022 04:58 PM AL 22 wall paint was scraped,
10/11/2022 05:02 PM AL 23 wall by beds were patched and painted different color,
10/11/2022 05:25 PM AL 26 wall paint was scraped,
10/11/2022 05:27 PM AL 25 walls behind bed patched up paint behind door beds,
10/11/2022 05:30 PM AL 24 walls by bed were patched up paint with different color,
10/11/2022 05:46 PM AL 27 wall paint patched, and
10/11/2022 05:52 PM AL 28 the wall on other side of room where bed would go was patched.
On 10/15/2022 02:06 PM, the following observations were made during another tour of the facility:
AL 1 Paint touched up around wall outlet in the middle of the room with a different color paint,
AL 2 paint scraped on wall behind headboards of both beds,
AL 3 paint touch ups in several locations with scrapes on wall noted by call light outlet in the middle of the wall,
AL 4 paint touch up on wall behind D (Door) Bed,
AL 6 paint touched up on concrete wall behind W (Window) Bed,
AL 7 paint touch ups on wall beside bed with different color (Private room),
AL 9 paint touch ups on concrete wall by D Bed.
AL 8 paint scraped on concrete wall behind the headboard of D Bed,
AL 10 paint touch up on wall above D Bed, and
AL 11 paint touched up on the wall to the left of the headboard of D Bed.
Another observation was made of resident rooms on 10/17/2022 at 4:08 PM and revealed the following:
AL 12 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 13 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 14 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 15 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 16 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 17 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions,
AL 18 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions, and
AL 19 was found with painted walls with mismatched colors; The painted area was not in a uniform shape. It was irregular, as in up, down, different length of strokes in different directions.
These observations were not reflective of a homelike environment.
On 10/18/2022 at 3:38 PM an interview with EI #14, the Maintenance Director. EI #14 reported he/she was responsible for the maintenance of resident rooms and residential areas. Regarding how often resident rooms and residential areas were checked for condition, EI #14 reported it was done during weekly staff room-rounds, during their heart to heart/one on one meeting with residents. He/she added that during those weekly meetings, the staff assess the rooms and then maintenance request forms are filled out from the findings. EI #14 was asked to describe the findings of the tour he/she had done on AL #s 1 through 28. EI #14 described each Area Locator as the head area behind the head of the bed or accent wall was found with mismatched paint. EI #14 observed this in a total of 28 rooms. EI #14 stated the concern of resident rooms having painted walls with mismatched colors, the area not being painted in a uniform shape, but in an irregular up, down, and with different length of strokes in all different directions, was not a neatly finished room made for a good home environment. EI #14 added that in regards to the expectations of the facility to provide a homelike atmosphere, the facility's resident rooms needed an update.
Jun 2021
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of Resident Identifier (RI) #45's medical record and the facility's policy titled MDS (Minimum Data S...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled MDS ASSESSMENT dated November 2017, documented POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets as defined by Federal/State regulations. These assessments provide information on the resident's condition to facilitate development of an individualized plan of care is a means by which the facility can track changes in a resident's status . PROCEDURE: . 2. Non-Medicare Covered Residents Upon admission, discharge, quarterly and annual reviews, an MDS assessment will be completed as per Federal/State requirements .
RI #45 was admitted to the facility on [DATE]. According to the RI #45's June 2021 Physician Orders on 9/27/2019, the resident was admitted to hospice services.
RI #45's Quarterly MDS with an assessment reference date of 12/16/2020 did not indicate the resident was receiving hospice services.
In an interview on 6/8/2021 at 11:15 AM, Employee Identifier (EI) #1, a Licensed Practical Nurse confirmed hospice services should have been coded but it was missed and there was a need to do a correction.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, review of Resident Identifier (RI) #75's medical record and the facility's policy titled FING...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled FINGERNAILS/TOENAILS CARE dated October 2009, documented POLICY: The purpose of this procedure is to clean the nail bed, to keep nails trimmed, and to prevent infection. RESPONSIBILITY: Nursing Assistant of Licensed Nurse Key Procedural Points: 1. Nails can be partially cleaned during bath care. 2. Nursing Assistants do not trim the nails of diabetic residents. 3. Nail care includes daily cleaning and regular trimming .
RI #75 was admitted to the facility on [DATE].
RI #75's Quarterly Minimum Data Set with an assessment reference date of 3/25/2021 indicated the resident required extensive assistance with personal hygiene and bathing.
On 6/6/2021 at 10:59 AM, RI #75's fingernails were observed to be dirty.
On 6/7/2021 at 11:52 AM and 6/8/2021 at 9:12 AM, RI #75's fingernails were full of layers of brownish colored debris.
During an interview on 6/8/2021 at 9:33 AM, Employee Identifier (EI) #2, a Certified Nursing Assistant (CNA) stated RI #75 required total care. EI #2 stated the CNAs cleaned the residents' nails daily with bathing and as needed. The surveyor and EI #2 observed RI #75's fingernails at 9:36 AM. When EI #2 looked at RI #75's fingernails she stated, Yes it's dirty under (his/her) nails, it needs cleaning bad.
In an interview on 6/8/2021 at 1:11 PM, EI #3, the Director of Nursing stated the CNAs should provide a complete head to toe bed bath, and to clean and cut the resident's nails as the resident allowed. The CNAs should check the resident's nails every day and clean them as needed.
During interview on 6/8/2021 at 1:33 PM, EI #4, a Registered Nurse stated the CNAs should have noticed RI #75's dirty nails and cleaned them when the resident was gotten up every day. EI #4 stated RI #75's nails are just nasty.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and review of Resident Identifier (RI) #70's medical record, the facility failed to consistent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
RI #70 was admitted to the facility on [DATE] with a medical history to include diagnoses of: Non-pressure chronic ulcer of the left foot and Type II Diabetes Mellitus with foot ulcer.
RI #70's admission Minimum Data Set with an assessment reference date of 4/7/2021 indicated the resident was cognitively intact with a Brief Interview for Mental Status of 15. RI #70 was assessed as having a diabetic foot ulcer during this assessment period.
According to a review of RI #70's medical record, on 5/10/2021, the resident was transferred and admitted to a local hospital. RI #70 returned to North Mobile Nursing and Rehabilitation Center on 5/14/2021 with a physician's order to the treat the resident's left heel with 1/4 STRENGTH DAKINS WET TO DRY DRESSING DAILY AND AS NEEDED.
A review of the May 2021 eTAR (electronic Treatment Administration Record) for RI #70 indicated the treatment was documented as being administered on 5/15/2021, 5/16/2021, 5/22/2021, 5/23/2021 and 5/24/2021.
During wound care observation on 6/7/2021 at 9:07 AM, Employee Identifier (EI) #12, a Registered Nurse (RN) removed an undated soiled dressing from RI #70's left heel. When RI #70 was asked if his/her dressing was changed on yesterday (6/6/2021), the resident replied No, it hasn't been changed since Saturday (6/5/2021).
In an interview on 6/7/2021 at 9:26 AM, EI #12, a RN stated it was the facility's protocol to initial and date when the dressing was changed so that one would know who and when the dressing was changed.
During an interview on 6/8/2021 at 2:04 PM, EI #7, the RN Unit Manager stated the eTAR reflected whether the dressing change was done. EI #7 acknowledged the blank spaces on the May and June eTAR and stated, we can't prove if it (the dressing change) was done or not.
In an interview on 6/8/2021 at 3:09 PM, EI #3, the Director of Nursing stated when the eTAR is signed (initialed), it acknowledges the treatment was done. EI #3 acknowledged the blank spaces on the May and June eTAR. EI #3 stated the purpose of signing the eTAR and doing the dressing changes were to carry out the orders of the physician to ensure the wound was healing properly. EI #3 stated she expected the nurses to document when the dressing change was done. EI #3 further stated if it is not documented, that meant it wasn't done.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of Resident Identifier (RI) #60's medical record, the facility failed to adequately monitor the ef...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
RI #60 was readmitted to the facility on [DATE] with a medical history to include a diagnosis of Hypothyroidism.
According to RI #60's medical record, on 12/17/2019 the resident was ordered to have a TSH (Thyroid-Stimulating Hormone) IN 6 WEEKS AND EVERY 3 MONTHS DX (diagnosis): HYPOTHYROIDISM
According to RI #60's medical record, on 12/18/2019 the resident was ordered LEVOTHYROXINE (a medication used to treat Hypothyroidism) 88 MCG (microgram) TABLET ONE (1) TABLET BY MOUTH 30 MINS (minutes) BEFORE BREAKFAST DX: LOW THYROID LEVELS to begin on 1/22/2020.
A review of RI #60's medical record revealed on 5/11/2021, a TSH laboratory test was done, which indicated the resident's thyroid level was low at 0.31. The normal reference range was 0.45 to 5.33.
During an interview on 6/8/2021 at 11:00 AM, Employee Identifier (EI) #8, the Licensed Practical Nurse stated the facility could not find laboratory results other than the 5/11/2021 laboratory results.
In an interview with EI #13, the facility's Certified Registered Nurse Practitioner on 6/8/2021 at 1:00 PM, she stated she had never seen (been made aware of) RI #60's 5/11/2021 laboratory results. EI #13 stated had she been aware of those results, she would have changed the dosage of the resident's medication (Levothyroxine) before today. EI #13 further stated she was called by the facility this morning and given the results of RI #60's 5/11/2021 laboratory test. EI #13 stated she gave the facility orders for a new dosage of the medication and follow-up laboratory test.
RI #60's PHYSICIAN'S TELEPHONE ORDERS dated 6/8/2021, documented Levothyroxine .75 mcg TSH 6 weeks. Then every 3 months.
The prescribing information for Levothyroxine revised February 2017, documented . 2.4 Monitoring TSH and/or Thyrooxine (T4) Levels Assess the adequacy of therapy by periodic assessment of laboratory tests and clinical evaluation . In adult patients with primary hypothyroidism, monitor serum TSH levels after an interval of 6 to 8 weeks after any change in dose. In patients on a stable and appropriate replacement dose, evaluate clinical and biochemical response every 6 to 12 months and whenever there is a change in the patient's clinical status .
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0773
(Tag F0773)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of Resident Identifier (RI) #60's medical record and the facility's policy titled LABORATORY TESTS, t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled LABORATORY TESTS dated November 2017, documented POLICY: . Lab tests are completed as ordered by the physician or physician extended (Nurse Practitioner, Physician Assistant or Clinical Nurse Specialist) . RESPONSIBILITY: All Licensed Nursing Personnel monitored by Director of Nursing or Designee . PROCEDURE: 1. Licensed Nurse, or designee, shall obtain the labs ordered by the physician or physician extender . 9. The physician or physician extender will be promptly notified of abnormal results according to facility policy. 10. The Licensed Nurse, or designee, will review all labs scheduled routinely to ensure all scheduled labs have been drawn and results have been received .
RI #60 was readmitted to the facility on [DATE] with a medical history to include a diagnosis of Hypothyroidism.
A review of RI #60's medical record revealed on 5/11/2021, a Thyroid-Stimulating Hormone (TSH) laboratory test was done, which indicated the resident's thyroid level was low at 0.31. The normal reference range was 0.45 to 5.33.
During an interview on 6/8/2021 at 11:00 AM, Employee Identifier (EI) #8, the Licensed Practical Nurse stated she called the Certified Registered Nurse Practitioner (CRNP) earlier today to notify her of RI #60's abnormal laboratory results dated [DATE]. EI #8 stated she should have notified the CRNP after the laboratory result was received.
In an interview with EI #13, the CRNP, stated she had never seen (been made aware of) RI #60's 5/11/2021 laboratory results. EI #13 stated had she been aware of those results, she would have changed the dosage of the resident's medication (Levothyroxine) before today. EI #13 further stated she was called by the facility this morning and given the results of RI #60's 5/11/2021 laboratory test. EI #13 stated she gave the facility orders for a new dosage of the medication and follow-up laboratory test.
RI #60's PHYSICIAN'S TELEPHONE ORDERS dated 6/8/2021, documented Levothyroxine (a medication used to treat Hypothyroidism) .75 mcg (microgram) TSH 6 weeks. Then every 3 months.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected most or all residents
Based 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 disca...
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Based 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.
Findings include:
The facility's policy titled EXPIRATION DATING & DOCUMENT REQUIREMENTS dated January 2015, documented POLICY: Time frames for expiration of medications / solutions are to be followed per manufacturer's recommendation . RESPONSIBILITY All Licensed Nursing Personnel . PROCEDURE: 1. Medications will be discarded by the product expiration date OR the date on which the suggested length of time after opening the product has passed, whichever occurs first .
On 6/7/2021 at 11:23 AM, an observation of the A-wing medication storage area was conducted with Employee Identifier (EI) #5, a Licensed Practical Nurse (LPN). Banophen, an antihistamine used to treat pain and itching, had an expiration date of September 2020 and Geri Tussin, cough medicine, had an expiration date of May 2021. EI #5 acknowledged the medications were expired.
On 6/7/2021 at 11:45 AM, an observation of the B-wing medication storage area was conducted with EI #6, a LPN. Mantoux, an injectable fluid used to screen for Tuberculosis, had an opened date of 2/28/2021. EI #6 stated Mantoux expired 28 days after opened.
The Mantoux manufacturer's information indicated . A vial of TUBERSOL (Mantoux) which has been entered (opened) and in use for 30 days should be discarded .
On 6/7/2021 at 11:56 AM, an observation of the D-wing medication storage area was conducted with EI #7, a Registered Nurse. There were 13 VanishPoint IV (intravenous) Catheters with an expiration date of May 2018. EI #7 acknowledged the expiration date. EI #7 stated the Charge Nurse checked (for expired medications and supplies) and it was responsibility of the Unit Manager to go behind the Charge Nurse and check once a week.
On 6/7/2021 at 12:15 PM, an observation of the C-wing medication storage area was conducted with EI #8, a LPN. The Medikmark IV Start Kit had an expiration date of June 2017 and the Care Fusion NeutraClear needle-free connector had an expiration date of January 2021. EI #8 acknowledged the supplies were expired. She stated the Charge Nurse is responsible to check but ultimately the Unit Manager was responsible and supposed to check once a week.
During an interview on 6/8/2021 at 3:21 PM, EI #3, the Director of Nursing stated the Charge Nurse check the medication storage area first and then the Unit Manager checked them once a week.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0925
(Tag F0925)
Could have caused harm · This affected most or all residents
Based 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...
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Based 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.
Findings include:
During a tour of the kitchen on 6/6/2021 at 9:47 AM, with EI #9, the Certified Dietary Manager (CDM), there were a small number of flying insets observed near the back door.
During the lunch tray line observation on 6/7/2021 at 11:15 AM, multiple flying insects were observed in the kitchen area. The insects landed on cups, food, and pieces of cake on the residents' food trays. Two dietary staff members were observed fanning their hands to prevent flies from landing on the food. A staff member who observed the insects replaced the cake. Two of the dietary staff members were observed fanning his/her hands over the food to prevent flies from landing on food. EI #10, another CDM, fanned flying insects as she took the temperatures of the food on the tray line.
During an observation of the area outside the kitchen near the backdoor on 6/7/2021 at 4:50 PM with EI #11, the Administrator, there were several flying insects. The area was also noted with several cardboard boxed and a dustpan full of trash items. EI #11 confirmed the presence of the insects and items and how they could contribute to the pest control issues.
Apr 2019
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, medical record reviews and the facility's policy titled, A.M CARE, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled, A.M. CARE, dated October 2009, documented POLICY: . RESPONSIBILITY: All . PROCEDURE: .11. Place call light within easy reach.
1) RI #111 was admitted to the facility on [DATE].
On 4/9/2919 at 8:23 AM, 4/9/2019 at 10:03 AM, 4/9/2019 at 2:27 PM and 4/11/2019 at 10:24 AM, RI #111's call light was observed behind the bed on the floor; not within the resident's reach.
On 4/11/19 at 10:42 AM, Employee Identifier (EI) #17, a Licensed Practical Nurse, (LPN) entered RI #111's room. RI #111 asked EI #17 where the call light was and EI #17 pulled it from behind the bedside table and placed it on RI #111's bed. EI #17 was asked where the call light was and she said behind the bed. When asked where it should be, EI #17 said within RI #111's reach.
2) RI #11 was admitted to the facility on [DATE].
On 4/11/2019 at 10:42 AM, RI #11's call light was observed on the floor of his/her room. EI #10, a Certified Nursing Assistant (CNA) acknowledged that she had just left RI #11's room. When asked where RI #11's call light was, EI #10 said it was on the floor. EI #10 confirmed the resident's call light was approximately three feet from the resident, not within reach. EI #10 was asked where should RI #11's call light be and she replied, by the resident's head. EI #10 was asked what was the concern of the call light being out of reach. EI #10 replied the resident may not be able to get the staff's attention.
3) RI #117 was admitted to the facility on [DATE].
On 4/11/2019 at 10:49 AM, RI #117's call light was observed hanging over the foot of the resident's bed. EI #10, a CNA was acknowledged that she had been in RI #117's room earlier. When asked where was RI #117's call light, EI #10 said the call light was hanging over the foot of the resident's bed, out of the resident's reach. EI #10 was asked where should RI #117's call light be. EI #10 replied clipped to the resident's bed. EI #10 was asked what was the concern of the call light being out of reach. EI #10 replied the resident might not be able to contact the staff.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policies titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS and G...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled, GLUCOSE MONITORING VIA GLUCOMETER dated August 2014, revealed the following: . RESPONSIBILITY: Licensed Nurses
PROCEDURE: . 3. Notify the physician of abnormal results, per MD (Medical Doctor) order . 4. The Nurse will document notification of the MD in the Interdisciplinary Progress Notes and indicate any new order .
The facility's policy titled, NOTIFICATION OF A CHANGE IN A RESIDENT'S STATUS dated November 2017, revealed the following: . RESPONSIBILITY:
All Licensed Nursing Personnel. PROCEDURE: 1. Guideline for notification of physician . (not all inclusive): . m. Glucometer reading below 70 or above 200 unless specific parameters given by physician for reporting .
RI #216 was admitted to the facility on [DATE], with a diagnosis of Type II Diabetes Mellitus.
A review of RI #216's January 2019 e-MAR (electronic-Medication Administration Record) revealed if RI #216's Sliding Scale (SS) BS was greater than 400, the Medical Doctor was to be called. A review of the e-MAR revealed on 1/2/2019 at 11:00 AM, RI #216 had a BS reading of 444.
RI #216's Departmental Notes revealed there was no evidence that RI #216's physician had been notified of the BS of 444.
On 4/10/2019 at 12:11 p.m., the surveyor conducted an interview with Employee Identifier (EI) #14, the Licensed Practical Nurse (LPN) recording RI #216's 11:00 AM BS of 444 on 1/2/2019. When asked if RI #216's physician had been notified of the 444 BS reading, EI #14 said she did not have evidence the physician had been notified.
On 4/11/2019 at 3:51 p.m., the surveyor conducted an interview with EI #13, RI #216's physician. The surveyor asked EI #13 was he in agreement with the facility's SS coverage to call him when a resident's BS was greater than 400. EI #13 said yes.
When asked why would he expect the facility to call him when a resident's BS was greater than 400, EI #13 said because something else could be going on like an infection or a Urinary Tract Infection, and he wanted to address the situation before it became a real problem.
On 4/11/2019 at 4:44 p.m., the surveyor conducted an interview with EI #2, the Director of Nursing (DON). EI #2 said when a resident's BS was greater than 400, it should be documented in the nurse's notes and the physician should be notified. When asked to show the surveyor where this had been done, EI #2 said she did not see where RI #216's physician had been notified of the BS greater than 400 on 01/02/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, review of Resident Identifier (RI) #149's medical record and the facility's policy's titled DISCHARGE AND TR...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled, DISCHARGE AND TRANSFER POLICIES - INVOLUNTARY dated July 2018, documented POLICY: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not . RESPONSIBILITY: All staff, monitored by the Director of Nursing and Executive Director. PROCEDURE: . e. A statement that the resident has the right to appeal the action to State Long Term Care Ombudsman, .
RI #149 was admitted to the facility on [DATE].
RI #149's DISCHARGE/TRANSFER NOTICE signed by Employee Identifier (EI) #1, the Administrator and dated 2/11/2019, indicated the discharge notice was sent to the Alabama Department of Public Health and the Local Ombudsman.
In an interview on 4/11/2019 at 12:39 PM, EI #1, the Administrator confirmed RI #149's discharge notice was sent to ADPH and the Local Ombudsman. When asked why the notice was not sent to the Alabama Medicaid Office and the Office of the State Long-Term Care Ombudsman, EI #1 stated she thought the notice was supposed to go to ADPH and the Local Ombudsman.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) RI #163 was admitted to the facility on [DATE].
According to RI #163's FACESHEET, the resident was transferred to a local ho...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) RI #163 was admitted to the facility on [DATE].
According to RI #163's FACESHEET, the resident was transferred to a local hospital on 3/15/2019.
In an interview on 4/11/2019 at 5:02 PM, EI #1, the Administrator stated the facility had only discussed bed hold notice on admission and she was not aware the facility had to issue another notice prior to the resident being transferred to a hospital.
Based 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.
Findings include:
1) RI #567 was admitted to the facility on [DATE].
According to RI #567's FACESHEET, the resident was transferred/discharged to a local hospital on 1/11/2019.
In an interview on 4/11/2019 at 12:39 PM, Employee Identifier (EI) #1, the Administrator confirmed the facility did not issue RI #567 and/or the resident's representative written notice of the facility's bed-hold policy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
A review of the facility policy titled, MDS ASSESSMENT, updated 11/17, 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 #137 was re-admitted to the facility on [DATE], with diagnoses to include Heart Failure, Chronic Atrial Fibrillation, and Dementia.
RI #137's Significant Change MDS with an assessment reference date of 2/20/2019, revealed the assessment tool had been opened and initiated but incomplete.
On 4/11/2019 at 5:06 PM, an interview was conducted with Employee Identifier (EI) #12, the Licensed Practical Nurse (LPN) / MDS staff member. EI #12 was asked, if RI #137's Significant Change MDS with an assessment reference date of 2/20/2019 was completed. EI #12 replied, no. EI #12 was asked why not. EI #12 replied they had not gotten to it yet. EI #12 was asked, when should the assessment have been completed. EI #12 replied by 3/6/19. EI #12 was asked what was the concern of not completing a Significant Change MDS. EI #12 replied, the significant change might not get addressed in RI #137's care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0638
(Tag F0638)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of a facility policy titled, MDS (Minimum Data Set) ASSESSMENT, the facility failed...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
A review of RI #121's Quarterly MDS, on 4/11/2019 at 1:10 PM, revealed RI #121 had an open, incomplete MDS assessment dated [DATE].
RI #165 was admitted to the facility on [DATE], with a diagnosis of Encephalopathy.
A review of RI #165's Quarterly MDS, on 4/11/2019 at 1:10 PM, revealed RI #165 had an open, incomplete MDS assessment, dated 3/17/2019.
An interview was conducted on 4/11/1209 at 3:53 PM, with Employee Identifier (EI) #12, Licensed Practical Nurse (LPN)/MDS staff member. EI #12 was asked, how long had she worked with MDS. EI #12 replied, over 10 years. EI #12 was asked,when should MDS's be completed. EI #12 replied, generally within 14 days of the ARD (Assessment Reference Date). EI #12 was asked, what was the potential concern for MDS's being completed late. EI #12 replied, it could impact the plan of care if we (the facility) did not have a current assessment of the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews, and a facility policy titled,DRESSING CHANGE, the facility failed to ensure a l...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
The facility's policy titled,DRESSING CHANGE, with a review date of October 2009, documented POLICY: A dressing change will be done to promote wound healing, prevent infection and to provide an opportunity for wound assessment.PROCEDURE: . 13. Remove the dressing. 14. Assess the dressing for the amount, color, consistency and odor of drainage and discard in waste bag. 15. Remove exam gloves and discard in waste in waste bag .17. Apply gloves. 18. Cleanse wound .
RI #154 was admitted to the facility on [DATE] with diagnoses to include Pressure Ulcer of Right Heel, Unspecified Stage and Pressure Ulcer of Left Hip, Unspecified Stage.
RI #154's April 2019 physician's orders revealed: .CLENS (CLEANSE) LEFT HIP STAGE 2 WITH SAF CLENS PAT DRY APPLY BARRIER CREAM TO PERIWOUND PACK WITH IODOFORM GAUZE COVER WITH FOAM DRESSING .
On 4/10/2019 at 1:57 PM, Employee Identifier (EI) #16, the Licensed Practical Nurse (LPN)/Treatment Nurse was observed performing wound care for RI #154. EI #16 removed the soiled dressing from the Stage II pressure ulcer to the left hip. Without removing her gloves or washing her hands, EI #16 cleaned the wound with safe cleanse, placed Iodoform packing in the wound and applied barrier cream. EI #16 then removed her gloves and washed her hands.
On 4/10/2019 at 3:24 PM, an interview was conducted with EI #16. EI #16 was asked, what should be done after removing a dressing and before cleaning a wound. EI #16 replied, wash your hands. EI #16 was asked,did she do that every time. EI #16 replied, no. EI #16 was asked, what was the potential concern of not performing hand hygiene after removing a soiled dressing and before cleaning a wound. EI #16 replied, infection control.
An interview was conducted with EI #2, the Director of Nurses (DON) on 4/11/2019 at 4:10 PM. EI #2 was asked, what should a nurse do after removing a dressing from a pressure ulcer and before cleaning the wound. EI #2 replied, wash her hands. EI #2 was asked, what was the potential concern of not washing hands before cleaning the wound. EI #2 replied, cross contamination.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure there was medical justification for the use an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
RI #163 was readmitted to the facility on [DATE], with a diagnosis of Acute Respiratory Distress.
On 4/10/2019 at 4:28 PM, RI #163 was observed with a urinary catheter. The catheter was in a privacy bag, located on the right side of the resident's bed.
A review of RI #163's medical record did not reveal a diagnosis or physician's order for the use of the urinary catheter.
In an interview on 4/11/2019 at 4:12 PM, Employee Identifier (EI) #2, the Director of Nursing (DON), acknowledged RI #163 had a catheter. EI #2 was asked, did RI #163 have an order or diagnosis for the use of the urinary catheter prior to 4/10/2019. EI #2 replied, the resident came from the hospital on 3/25/2019 with the catheter but there was no an order and the nurse failed to obtain an order for the catheter.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Alabama facilities.
Concerns
- • 25 deficiencies on record. Higher than average. Multiple issues found across inspections.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is North Mobile Nursing And Rehabilitation Ctr's CMS Rating?
CMS assigns NORTH MOBILE NURSING AND REHABILITATION CTR an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Alabama, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is North Mobile Nursing And Rehabilitation Ctr Staffed?
CMS rates NORTH MOBILE NURSING AND REHABILITATION CTR's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Alabama average of 46%.
What Have Inspectors Found at North Mobile Nursing And Rehabilitation Ctr?
State health inspectors documented 25 deficiencies at NORTH MOBILE NURSING AND REHABILITATION CTR during 2019 to 2024. These included: 25 with potential for harm.
Who Owns and Operates North Mobile Nursing And Rehabilitation Ctr?
NORTH MOBILE NURSING AND REHABILITATION CTR is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NORBERT BENNETT & DONALD DENZ, a chain that manages multiple nursing homes. With 172 certified beds and approximately 146 residents (about 85% occupancy), it is a mid-sized facility located in EIGHT MILE, Alabama.
How Does North Mobile Nursing And Rehabilitation Ctr Compare to Other Alabama Nursing Homes?
Compared to the 100 nursing homes in Alabama, NORTH MOBILE NURSING AND REHABILITATION CTR's overall rating (2 stars) is below the state average of 2.9, staff turnover (48%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting North Mobile Nursing And Rehabilitation Ctr?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is North Mobile Nursing And Rehabilitation Ctr Safe?
Based on CMS inspection data, NORTH MOBILE NURSING AND REHABILITATION CTR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Alabama. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at North Mobile Nursing And Rehabilitation Ctr Stick Around?
NORTH MOBILE NURSING AND REHABILITATION CTR has a staff turnover rate of 48%, which is about average for Alabama nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was North Mobile Nursing And Rehabilitation Ctr Ever Fined?
NORTH MOBILE NURSING AND REHABILITATION CTR has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is North Mobile Nursing And Rehabilitation Ctr on Any Federal Watch List?
NORTH MOBILE NURSING AND REHABILITATION CTR is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.