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)
4.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
19% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
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 identify deficiencies related to the accuracy of resident assessments, specifically ensuring that Resident Identifier #47's quarterly Minimum Data Set (MDS) correctly reflected hospice and oxygen therapy status.
Findings
The facility failed to document Resident Identifier #47's hospice and continuous oxygen therapy status accurately in the quarterly MDS assessments dated 1/22/21 and 4/23/21, despite physician orders indicating these treatments. The error was attributed to a coding mistake by the responsible nurse.
Deficiencies (1)
Failure to ensure Resident Identifier #47's quarterly Minimum Data Set assessments accurately reflected hospice and oxygen therapy status.
Report Facts
Residents affected: 1
Residents sampled for oxygen: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Employee Identifier #1 responsible for completing the quarterly MDS and acknowledged the coding error |
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 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 1, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide timely notification of discharge and bed hold policies to Resident Identifier (RI) #81 and/or the resident's representative, and the facility's refusal to allow RI #81 to return following hospitalization.
Complaint Details
The complaint investigation focused on the facility's failure to notify RI #81 and/or the representative about discharge and bed hold policies, and the refusal to allow RI #81 to return after hospitalization despite hospital reports indicating the resident was stable and safe to return. The facility admitted to not issuing required notices and denying readmission due to safety concerns.
Findings
The facility failed to issue proper discharge notices and bed hold notices to RI #81 and/or the resident's representative upon multiple hospital discharges. Additionally, the facility denied RI #81's return after hospitalization despite reports from the hospital that the resident was stable and safe to return. These deficient practices affected RI #81, one of one sampled residents reviewed.
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 a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Report Facts
Discharge dates: 4
Return dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Admitted facility did not issue discharge or bed hold notices and refused to readmit RI #81 due to safety concerns. |
| EI #3 | Social Worker | Explained hospital planned to send RI #81 to a different facility because the Administrator felt the facility could no longer meet RI #81's needs. |
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