Inspection Reports for
Aspire Physical Recovery Center at Hoover, LLC
575 Southland Drive, Hoover, AL, 35226-3732
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
86% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jun 25, 2023
Visit Reason
The inspection was conducted based on complaints and reports alleging failures in care, medication administration, and documentation at Aspire Physical Recovery Center at Hoover, LLC.
Complaint Details
The deficiencies were cited as a result of multiple complaints and reports including #AL00041888, #AL00042116, #AL00043725, #AL00043835, #AL00042084, #AL00043844, and #AL00044419.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate assistance with activities of daily living, failure to provide appropriate treatment and care according to orders, failure to ensure medications were available and administered as ordered, failure to monitor blood glucose levels as ordered, failure to prevent significant medication errors including missed seizure medication and insulin doses, and failure to maintain complete and accurate medical records including incident reporting.
Deficiencies (6)
Failed to provide dependent residents assistance with activities of daily living (ADLs) to ensure good grooming, specifically failure to shave Resident #449 when needed.
Failed to provide care and treatment in accordance with professional standards for five residents, including failure to obtain orders for PICC line care, failure to transcribe and follow wound care orders, and failure to coordinate medication provision for a hospice resident.
Failed to ensure medications were available from the pharmacy for administration to residents, including Prednisone for Resident #452 and inhaler for Resident #142.
Failed to ensure adequate monitoring of blood glucose levels as ordered for insulin use for Residents #143 and #294, resulting in missed blood glucose checks and insulin doses.
Failed to prevent significant medication errors, including failure to administer five morning doses of seizure medication (Lacosamide) to Resident #299, resulting in a seizure and hospital transfer, and failure to administer insulin as ordered for Resident #143, resulting in severe hyperglycemia and emergency department transfer.
Failed to maintain complete and accurate medical records, including failure to document medication administration for Resident #141 and failure to complete an incident report after a fall for Resident #106.
Report Facts
Residents reviewed for ADL care: 7
Residents reviewed for care and treatment: 50
Residents reviewed for unnecessary medications: 6
Residents reviewed for medication administration: 6
Residents reviewed for medical record accuracy: 27
Missed doses of Lacosamide: 5
Blood glucose checks missed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #16 | Licensed Practical Nurse | Observed Resident #143 with severe hyperglycemia and documented blood glucose levels. |
| RN #26 | Registered Nurse | Worked during the time Resident #299 missed seizure medication doses. |
| RN #12 | Registered Nurse | Worked during the time Resident #299 missed seizure medication doses and discussed medication cart responsibilities. |
| Unit Manager #8 | Unit Manager | Provided information on medication availability and procedures for missing medications. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding expectations for medication administration and care. |
| Executive Director | Executive Director | Provided multiple interviews regarding expectations for medication administration and care. |
| Medication Aide Certified #23 | Medication Aide Certified | Reported missing medications and documentation issues. |
| Nurse Consultant | Nurse Consultant | Provided expert opinions on medication administration and care standards. |
| Pharmacy Consultant | Pharmacy Consultant | Discussed importance of seizure medication and insulin administration. |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Jun 25, 2023
Visit Reason
The inspection was conducted based on complaints and allegations regarding medication administration, resident care, discharge procedures, and medication availability at Aspire Physical Recovery Center at Hoover, LLC.
Complaint Details
The complaint investigation included allegations of medication errors, failure to assess residents properly, incomplete discharge documentation, failure to provide ordered care, medication availability issues, and incomplete medical records. Specific complaint/report numbers cited include #AL00041888, #AL00042116, #AL00043725, #AL00043835, #AL00042084, #AL00043844, and #AL00044419.
Findings
The facility failed to assess residents for self-administration of medications, ensure appropriate adaptive equipment for call lights, complete discharge summaries, provide care and treatment according to orders, ensure medication availability, prevent significant medication errors including missed seizure medication and insulin administration, and maintain complete medical records including incident reports for falls.
Deficiencies (8)
Failed to assess one resident for ability to self-administer medications and left medication in resident's room without proper assessment or physician order.
Failed to ensure one resident was assessed for appropriate adaptive equipment related to call lights.
Failed to complete discharge summaries with recapitulation of residents' stay for two residents.
Failed to provide care and treatment according to orders for five residents, including lack of orders for PICC line care, wound care, and medication coordination with hospice.
Failed to ensure medications were available from pharmacy for two residents, resulting in missed doses of prednisone and inhaler.
Failed to ensure adequate monitoring of blood glucose levels and insulin administration for two residents, resulting in severe hyperglycemia and emergency transfer.
Failed to prevent significant medication errors including failure to administer seizure medication for five days leading to seizure and hospital transfer, and failure to administer insulin as ordered resulting in severe hyperglycemia and emergency transfer.
Failed to maintain complete and accurate medical records including failure to document medication administration and failure to complete incident report for resident fall.
Report Facts
Missed doses of seizure medication: 5
Blood glucose checks missed: 10
Prednisone doses missed: 3
Medication delivery times: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #19 | Licensed Practical Nurse | Named in medication self-administration assessment deficiency and blood glucose monitoring. |
| LPN #11 | Licensed Practical Nurse | Named in discharge paperwork deficiency and medication availability. |
| RN #26 | Registered Nurse | Named in failure to administer seizure medication. |
| RN #12 | Registered Nurse | Named in failure to administer seizure medication. |
| LPN #16 | Licensed Practical Nurse | Named in insulin administration and blood glucose monitoring deficiency. |
| Unit Manager #8 | Unit Manager | Named in medication availability and call light assessment deficiencies. |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding medication administration, discharge, and care deficiencies. |
| Executive Director | Executive Director | Named in multiple interviews regarding facility policies and deficiencies. |
| Nurse Consultant | Nurse Consultant | Named in multiple interviews regarding medication administration and care standards. |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 18, 2021
Visit Reason
The inspection was conducted to evaluate compliance with food storage, labeling, temperature logging policies, and infection prevention practices, including incontinent care procedures.
Findings
The facility failed to ensure proper labeling of food items in the kitchen freezer and resident supplement freezer, failed to document PM temperatures for the resident supplement refrigerator and freezer on 3/17/21, and failed to ensure a Certified Nursing Assistant changed gloves during incontinent care. These deficiencies had the potential to affect many residents and posed minimal harm.
Deficiencies (4)
Food in the kitchen freezer was not labeled with an open and use by date.
PM temperatures were not logged on 3/17/21 for the resident's supplement refrigerator on the 400 hall.
Food item in the resident's supplement freezer was not labeled.
Certified Nursing Assistant failed to change gloves during incontinent care before placing the clean brief for Resident #9.
Report Facts
Residents potentially affected: 73
Residents potentially affected: 30
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Dietary Manager | Interviewed regarding food labeling and temperature logging deficiencies |
| EI #3 | Clinical Dietary Manager | Interviewed regarding food labeling and temperature logging deficiencies |
| EI #4 | Certified Nursing Assistant | Observed and interviewed regarding failure to change gloves during incontinent care |
| EI #1 | Director of Nursing | Interviewed regarding training and procedures for incontinent care |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 13, 2020
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical services and food safety standards in the facility.
Findings
The facility failed to ensure required signatures on medication destruction records and did not properly store food items in the kitchen, including placing food on the floor, unsealed food items in freezers, and use of dented cans. These deficiencies posed minimal harm or potential for actual harm to residents.
Deficiencies (2)
Failed to ensure two required signatures on nine Non-Controlled Medication Destruction Sheets for February 2020.
Food safety violations including placing a pan of frozen crab cake meat on the floor, unsealed food items in walk-in and reach-in freezers, and use of a dented can of baked beans.
Report Facts
Residents affected: 1
Residents affected: 106
Deficiency sheets missing signatures: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN), Director of Nursing (DON) | Interviewed regarding medication destruction signature requirements | |
| Chef | Interviewed regarding food storage and handling practices |
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