Elba Nursing and Rehabilitation Center, LLC

In the surveyor’s words

From the most serious findings on record at Elba Nursing and Rehabilitation Center, LLC, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF576May 17, 2022

  Based on interviews, discussion during the resident group meeting, and review of the facility's Admission Agreement, the facility failed to ensure mail was delivered to residents on Saturdays. This deficient practice had the potential to affect all 90 out of 90 residents residing in the facility. Findings Include: A review of the facility's ADMISSION AGREEMENT, with an effective date of 9/16/19, revealed: . RESIDENT BILL OF RIGHTS . A. Facility Residents shall have the right to: . 26. To send and receive mail promptly and unopened. On 5/16/22 at 10:00AM, a group meeting was held with 18 residents present. […]

• No harm, potential for more than minimal, isolatedF584Mar 2, 2023

  Based on observations, interviews, and review of the facility RESIDENT BILL OF RIGHTS, the facility failed to ensure Room Locator (RL) #1 was free of odors. This was affected one of 54 Room Locators. Findings Include: A review of the facility RESIDENT BILL OF RIGHTS , with a history date of 1/23 revealed, .A. Facility residents shall have the right to: . 32. A safe clean, comfortable home like environment. On 03/02/2023 at 8:40 AM during the surveyor's walk through of the facility observing various rooms, RL #1 was observed with a strong odor. The odor appeared to be that of urine. The facility Administrator, Employee Identifier (EI) #1 was observed in the hall and asked to come to RL #1. When EI #1 entered RL #1, she was asked what she noticed. EI #1 said the smell or urine. […]

• No harm, potential for more than minimal, isolatedF636May 17, 2022

  Based on observation, interview and record review, the facility failed to ensure the Admission Minimum Data Set (MDS) for Resident Identifier (RI) #233 was completed in a timely manner. This deficient practice affected one out of 18 resident MDS's reviewed. Findings Include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated 10/19, page 2-16, revealed the following: . RAI OBRA-required Assessment Summary . Assessment Type/Item Set . Admission . MDS Completion Date (Item Z0500B) No Later Than . 14th calendar day of the resident's admission (admitted + 13 calendar days) . RI #233 was admitted to the facility on [DATE]. RI #233's Admission MDS had an Assessment Reference Date (ARD) of 4/27/22. […]

• No harm, potential for more than minimal, isolatedF641May 17, 2022

  Based on record review, interview and review of a facility policy MDS ASSESSMENT, the facility failed to ensure the Minimum Data Set (MDS) for Resident Identifier (RI) #32 dated 2/25/22 was coded for anticoagulation medication. This affected one of one resident records reviewed for anticoagulation medication. Findings Include: A review of a facility policy titled MDS ASSESSMENT, with a date of 11/17 revealed POLICY: The facility shall conduct interdisciplinary assessments using the MDS item sets a .These assessments provide information on the resident's condition . RI #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of RI #32's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF656May 17, 2022

  Based on record review, interview and a review of the facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, the facility failed to ensure Resident Identifier (RI) #58 was care planned for a Urinary Tract Infection ([CONDITION(S)]) upon readmission to the facility on [DATE]. This affected one of 18 resident care plans reviewed. Findings Include: A review of a facility policy COMPREHENSIVE PERSON CENTERED CARE PLANS, with an effective 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 . will be updated . […]