Fairhope Health & Rehab

In the surveyor’s words

From the most serious findings on record at Fairhope Health & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 25, 2022

  Based on observation, interview, and review of the facility's Food, Leftover - Storage and Use policy, the facility failed to ensure food was properly stored in the walk-in refrigerator and walk-in freezer. This had the potential to affect 54 of 55 residents in the facility who ate food prepared in the kitchen. Findings include: The facility's Food, Leftover - Storage and Use policy and procedure, dated 07/2016, indicated, .Standard: Leftover foods should be stored under sanitary conditions .Process: Leftover foods should be covered, labeled and dated . […]

• No harm, potential for more than minimal, patternF638Feb 25, 2022

  Based on record review, interview, review of the facility's Resident Assessment Instrument (RAI) policy, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, the facility failed to ensure the quarterly Minimum Data Set (MDS) assessments for Resident Identifier (RI) #s 9, 27, 8, 19, 23, 18, 14, 21, and 24 were completed within required timeframes. This affected nine of 23 residents reviewed for timely completion and/or transmission of MDS assessments. […]

• No harm, potential for more than minimal, patternF640Feb 25, 2022

  Based on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Minimum Data Set (MDS) assessments were submitted to CMS within 14 days of the completion date of the assessments for Resident Identifier (RI) #s 17, 15, 27, 11, 2, 23, 22, 16, 21, and 24, 10 of 23 residents reviewed for timely completion and/or transmission of MDS assessments. Findings include: Review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, revealed the following: .CHAPTER 5: SUBMISSION AND CORRECTION OF THE MDS ASSESSMENTS . […]

• No harm, potential for more than minimal, patternF758Feb 25, 2022

  Based on record review, interview, and review of the facility's Psychoactive Drug Monitoring and Behavior Management Program policies, the facility failed to ensure Resident Identifier (RI) #45 and RI #22, who both received [CONDITION(S)] medications, were monitored for the specific targeted behaviors for which medications were ordered. Further, the facility failed to ensure RI #45 and RI #22 were monitored for side effects of their ordered [CONDITION(S)] medications. This deficient practice affected RI #s 45 and 22, two of five sampled residents reviewed for unnecessary medications. Findings include: A review of the facility's Psychoactive Drug Monitoring policy and procedure, dated 3/2011, revealed, .Residents who receive psychoactive/psychopharmacological medications are monitored. […]

• No harm, potential for more than minimal, isolatedF609Sep 29, 2022

  Based on interviews, review of Personnel File for Employee Identifier (EI) #3,Certified Nursing Assistant (CNA) and a facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of abuse received on 08/29/2022 and 08/31/2022, This affected two of eight allegations of abuse/mistreatment reviewed. Findings include: Review of the facility policy titled Abuse, Neglect, and Exploitation with an effective date of 02/2020, documented, . VI. Online initial reporting of incidents to the state A: Report to State agency all alleged violations involving abuse, . immediately but no later than 2 hours after forming the suspicion or allegation .to the Alabama Department of Public Health . E. […]