Inspection Reports for
Cavalier Healthcare of Trussville
119 Watterson Parkway, Trussville, AL, 35173
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 8, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding the facility's failure to properly investigate and resolve a grievance about Resident Identifier (RI) #1's dressing not being changed as ordered by the physician.
Complaint Details
The complaint was substantiated as the investigation revealed the facility did not complete a grievance form nor inform the family of the resolution regarding the dressing changes for RI #1. The deficiency was cited as a result of investigation of complaint/report #AL00042836.
Findings
The facility failed to complete a grievance investigation and inform the family of the findings regarding RI #1's wound care. Additionally, the facility failed to provide evidence that wound care treatments were consistently provided to RI #1's right above-knee amputation stump and stage II sacral ulcer as ordered by the physician.
Deficiencies (2)
Failure to ensure a grievance was completed and the family informed of the findings regarding RI #1's dressing not being changed as ordered.
Failure to provide evidence of wound care to RI #1's right above-knee amputation stump and stage II sacral ulcer as ordered by the physician.
Report Facts
Days treatment not provided to sacrum: 12
Days treatment not provided to right stump: 12
Working days for grievance resolution: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Referred to as EI #1, involved in grievance investigation process and communication with family. | |
| Social Service Director | Referred to as EI #3, admitted failure to complete grievance form and inform family of resolution. | |
| Treatment Nurse | Referred to as EI #4, provided information on wound care treatments and documentation. | |
| Licensed Practical Nurse | Referred to as EI #5, provided care for RI #1 and confirmed importance of wound treatment. | |
| Director of Nursing | Referred to as EI #2, responsible for wound care oversight and confirmed importance of ordered treatments. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 13, 2021
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to ensure that a resident's call light was accessible and within reach, as required by the resident's care plan and facility policy.
Complaint Details
The complaint investigation found that the resident's call light was not accessible, and the resident was unable to call for help when needed. The deficiency was substantiated based on observations, interviews with staff including CNA #1, LPN #7, the Director of Nursing, and the Administrator, and review of the resident's care plan and facility policies.
Findings
The facility failed to accommodate the needs of one resident (RI #296) by not ensuring the call light was accessible and within reach, despite care plan interventions and facility policies requiring staff to keep the call light within reach. Observations and interviews confirmed the resident was unable to reach the call light and did not receive timely assistance.
Deficiencies (2)
Failed to ensure Resident Identifier #296's call light was accessible and within reach as required by care plan and facility policy.
Failed to implement care plan interventions related to call lights being within reach for Resident Identifier #296.
Report Facts
Residents sampled: 43
Residents affected: 1
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #1 | Certified Nursing Aide | Interviewed regarding knowledge of call light placement and care plan review |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Informed by surveyor that resident #296 needed assistance |
| Director of Nursing | Director of Nursing | Interviewed about staff responsibilities for call light placement and care plan adherence |
| Administrator | Facility Administrator | Interviewed about expectations for call light accessibility and staff compliance with policies |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 11, 2019
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to feeding tube care, respiratory care, infection prevention, and hand hygiene practices in the nursing home.
Findings
The facility failed to ensure proper care and handling of gastrostomy tubes, tracheostomy collars, and medication administration hygiene. Deficiencies included failure to check feeding tube placement, improper hand hygiene and glove use by staff, and contamination risks during resident care.
Deficiencies (3)
Failed to ensure licensed staff checked gastrostomy tube placement prior to use and did not push water into the gastrostomy tube with a syringe.
Failed to ensure a Certified Nursing Assistant did not contaminate a resident's tracheostomy collar while wearing soiled gloves during incontinent care.
Failed to provide and implement an infection prevention and control program, including proper hand hygiene and glove changes by CNAs and licensed staff during medication administration and resident care.
Report Facts
Volume of water pushed into gastrostomy tube: 200
Residents observed with gastrostomy: 1
Residents sampled for tracheostomy care: 2
Residents observed during medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Employee Identifier #3 failed to check gastrostomy tube placement and did not wash hands between medication administrations | |
| Certified Nursing Assistant | Employee Identifier #1 contaminated tracheostomy collar by wearing soiled gloves during incontinent care | |
| Certified Nursing Assistant | Employee Identifier #4 failed to perform hand hygiene and contaminated supplies during incontinent care | |
| Licensed Practical Nurse | Employee Identifier #5 failed to wash hands after medication administration before touching medication cart and handing cup to another resident | |
| Registered Nurse/Infection Control | Employee Identifier #2 provided expert interview responses regarding proper hand hygiene and contamination risks |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: May 3, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00035648) regarding alleged misappropriation of resident narcotics by a Licensed Practical Nurse (EI #4) on 4/1/18.
Complaint Details
The complaint investigation substantiated misappropriation of resident property (narcotics) by an LPN on 4/1/18 involving two residents. The LPN was found in possession of missing narcotics and was arrested. The facility verified discrepancies in narcotic counts and reported the incident to authorities.
Findings
The facility substantiated misappropriation of resident property involving narcotics belonging to two residents (RI #104 and RI #157) by an LPN. Additional deficiencies included failure to update resident assessments and care plans for a resident with a new seizure diagnosis, and multiple food safety violations related to labeling, storage, and cleanliness affecting many residents.
Deficiencies (8)
Misappropriation of resident narcotic medications by an LPN affecting two residents.
Failure to include new diagnosis of seizure disorder on Minimum Data Set assessments for one resident.
Failure to develop an individualized care plan for seizure disorder and anti-seizure medication for one resident.
Failure to ensure tea urn spigots were cleaned daily.
Potential cross-contamination due to storing clean sanitized dinnerware near trash barrel used for soiled food trays.
Frozen food (ice cream) not maintained frozen; measured at +9°F in freezer with door open.
Clean/sanitized sectional plates were not air-dried and contained food debris.
Mighty Shakes nutritional supplements were not labeled with use-by dates as required.
Report Facts
Residents reviewed for abuse: 4
Residents affected by narcotic misappropriation: 2
Missing narcotics count: 60
Missing narcotics count: 1
Residents whose MDS was reviewed: 26
Residents for whom care plans were reviewed: 26
Residents affected by food safety deficiencies: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Employee Identifier (EI) #4, involved in narcotic misappropriation | |
| Director of Nursing (DON) | Employee Identifier (EI) #5, verified narcotic discrepancies and involved in investigation | |
| Registered Nurse (RN) | Employee Identifier (EI) #6, oncoming nurse who discovered narcotic miscount | |
| MDS/Care Plan Coordinator | Employee Identifier (EI) #3, interviewed regarding failure to update assessments and care plans | |
| Dietary Manager (DM) | Employee Identifier (EI) #1, involved in food safety observations | |
| Dietary Aide | Employee Identifier (EI) #6, observed storing clean dishes near trash barrel | |
| Registered Dietitian (RD) | Employee Identifier (EI) #2, interviewed about food safety deficiencies |
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