Inspection Reports for Civic Center Health and Rehabilitation, LLC
1201 North 22nd Street, Birmingham, AL, 35234-2726
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 22, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations regarding alleged exploitation by a Licensed Practical Nurse (LPN #13) taking money from a resident and an incident where two residents were left unattended at a local health clinic during appointments.
Complaint Details
The complaint investigation included report number AL00047241 regarding exploitation by LPN #13 and report number AL00046869 regarding neglect in supervision of residents during appointments. The exploitation allegation was substantiated with LPN #13 terminated for taking money from a resident. The neglect allegation involved residents left unattended at a clinic due to staff call-offs and confusion.
Findings
The facility failed to report an allegation of exploitation involving LPN #13 taking money from Resident Identifier #27 to the State Agency, and failed to ensure adequate supervision of residents during off-site medical appointments, resulting in two residents being left unattended outside a clinic in the rain. Immediate corrective actions were taken including staff in-service and monitoring.
Deficiencies (2)
Failed to timely report suspected exploitation by LPN #13 taking money from Resident Identifier #27 to the State Agency.
Failed to ensure residents #81 and #26 were accompanied and supervised during off-site medical appointments, resulting in residents being left unattended outside a clinic.
Report Facts
Residents affected: 1
Residents affected: 2
Amount of money taken: 500
Amount of money given per occasion: 30
Complaint report date: Mar 15, 2024
Date of incident: Jan 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in exploitation finding for taking money from resident |
| Administrator | Abuse Coordinator/Administrator | Interviewed regarding failure to report exploitation and supervision issues |
| RN #15 | Registered Nurse | Interviewed regarding supervision policy and incident on 01/25/2024 |
| CNA #14 | Certified Nursing Assistant | Reported no staff present for residents during appointment on 01/25/2024 |
| CNA #9 | Certified Nursing Assistant | Responsible for staff scheduling and explained staff call-offs on 01/25/2024 |
| Transport Driver | Observed resident left unattended outside clinic on 01/25/2024 |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 22, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations regarding allegations of exploitation by a Licensed Practical Nurse (LPN) taking money from a resident, residents being left unattended at a local health clinic, and other concerns related to resident care and safety.
Complaint Details
The complaint investigation included allegations that LPN #13 was terminated for borrowing $500 from a resident, residents were left unattended at a clinic appointment, and other care and safety concerns. The exploitation allegation was substantiated with evidence that LPN #13 took money from Resident #27 on multiple occasions and the facility failed to report it timely to the State Agency.
Findings
The facility failed to timely report suspected exploitation of a resident by an LPN, left residents unattended during medical appointments, administered expired medication, had unsanitary kitchen conditions, failed to prevent cross-contamination in infection control practices, and did not ensure required dementia training for a Certified Nursing Assistant (CNA). Corrective actions were implemented for some deficiencies.
Deficiencies (6)
Failed to timely report suspected exploitation of a resident by LPN #13 taking money from Resident Identifier #27.
Failed to ensure residents #81 and #26 were not left alone after being dropped off unaccompanied at a local health clinic.
Administered expired Vitamin B12 tablets to Resident Identifier #3.
Kitchen had grease buildup, dirty floors, chipping paint above clean pots and pans, and a serving tray with unknown liquid in the walk-in cooler.
Failed to ensure proper infection prevention and control practices including hand hygiene, handling of clean and dirty linen, and glove use.
Failed to ensure Certified Nursing Assistant #12 received required dementia training from January 2023 through January 2024.
Report Facts
Residents affected: 1
Residents affected: 2
Residents observed: 3
Residents affected: 9
Employee files reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #13 | Licensed Practical Nurse | Named in exploitation allegation for taking money from resident |
| CNA #12 | Certified Nursing Assistant | Failed to receive required dementia training from January 2023 to January 2024 |
| MT #6 | Medication Technician | Administered expired medication and failed to perform hand hygiene after glove removal |
| Administrator | Administrator/Abuse Coordinator | Acknowledged failure to report exploitation allegation to State Agency |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and expired medication |
| Dietary Manager | Dietary Manager | Interviewed regarding kitchen sanitation deficiencies |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control practices and risks |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed regarding CNA #12's dementia training status |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
The inspection was conducted to review and correct deficiencies related to the accurate coding of a resident's hospice and oxygen therapy status on quarterly Minimum Data Set (MDS) assessments.
Findings
The facility failed to ensure that Resident Identifier #47's quarterly MDS assessments dated 1/22/21 and 4/23/21 accurately reflected the resident's receipt of hospice care and continuous oxygen therapy, resulting in coding errors identified during record review and staff interview.
Deficiencies (1)
Failure to document Resident Identifier #47's hospice care and continuous oxygen therapy on quarterly MDS assessments dated 1/22/21 and 4/23/21.
Report Facts
Residents affected: 1
Residents sampled for oxygen: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Employee Identifier #1 interviewed regarding MDS coding errors for Resident Identifier #47 |
Inspection Report
Deficiencies: 3
Date: Mar 1, 2019
Visit Reason
The inspection was conducted to assess compliance with regulations related to resident discharge and transfer procedures, specifically focusing on notification and bed hold policies for Resident Identifier #81 who was discharged multiple times to a hospital.
Findings
The facility failed to provide timely and proper discharge notices to Resident #81 and/or their representative, did not notify about bed hold policies during hospital transfers, and denied the resident's return to the facility despite hospital reports indicating the resident was stable and safe to return. These deficiencies affected Resident #81 and involved minimal harm or potential for actual harm.
Deficiencies (3)
Failure to provide timely notification to the resident and/or representative before transfer or discharge.
Failure to notify the resident or representative in writing about the duration of bed hold and related policies during hospital transfers.
Failure to permit the resident to return to the nursing home after hospitalization despite hospital reports indicating stability and safety.
Report Facts
Discharge dates: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Named in findings related to failure to issue discharge notices, bed hold notices, and refusal to accept resident back |
| EI #3 | Social Worker | Interviewed regarding reasons for hospital sending resident to a different facility |
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