Deficiencies (last 5 years)
Deficiencies (over 5 years)
0.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
78% better than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 18, 2024
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding a significant medication error involving Resident Identifier #1, who did not receive prescribed anticonvulsant medication leading to seizure activity and hospitalization.
Complaint Details
The deficiency related to the medication error was cited as a result of the investigation of complaint/report #AL00044229. The complaint was substantiated, confirming that Resident #1's anti-seizure medication was not administered as ordered due to a clerical error.
Findings
The facility failed to ensure Resident #1 received Oxcarbazepine 300 mg four times daily as ordered due to a clerical error in medication order start date entry. This omission resulted in seizure activity and emergency hospital transfer. The facility implemented corrective actions including education and order reviews. Additionally, a separate deficiency was cited for failure of a Certified Nursing Assistant to perform proper hand hygiene and PPE use, risking cross-contamination during incontinent care for Resident #5.
Deficiencies (2)
Failure to administer Oxcarbazepine 300 mg four times daily as ordered, resulting in seizure activity and hospitalization.
Certified Nursing Assistant failed to perform hand hygiene and used contaminated gloves while handling clean linens during incontinent care.
Report Facts
Missed doses: 4
Medication administration frequency: 4
Medication administration frequency: 2
Medication administration frequency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #3 | Nurse providing care for Resident #1 | Interviewed regarding missed medication doses and seizure event. |
| Medical Director | Medical Director | Interviewed about medication order entry error and associated harm. |
| Director of Nursing | Director of Nursing | Interviewed about medication transcription error and seizure event. |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed about classification of medication error. |
| Certified Nursing Assistant #9 | Certified Nursing Assistant | Observed and interviewed regarding failure to perform hand hygiene and proper glove use. |
| Infection Control Preventionist | Infection Control Preventionist | Interviewed about hand hygiene policy and risks of contamination. |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed about hand hygiene policy and risks of contamination. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 31, 2023
Visit Reason
The document is an annual inspection report for Columbiana Health and Rehabilitation, LLC, conducted as part of regulatory oversight.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 24, 2022
Visit Reason
The inspection was conducted to evaluate compliance with facility policies regarding privacy during intramuscular medication administration.
Findings
The facility failed to ensure privacy when administering intramuscular medication to Resident #15, as the nurse did not pull the privacy curtain during the procedure, which was confirmed by interviews and policy review.
Deficiencies (1)
Failure to provide privacy when administering intramuscular medication to Resident #15.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in privacy deficiency during medication administration | |
| Interim Director of Nursing | Interviewed regarding proper privacy procedures |
Inspection Report
Deficiencies: 1
Date: Oct 17, 2019
Visit Reason
The inspection was conducted to assess compliance with medication storage and labeling regulations, specifically to ensure that expired medications were not stored on medication carts.
Findings
The facility failed to ensure that one medication card containing seven expired capsules of Ramipril/Altace for Resident Identifier #2 was removed from the medication cart and properly stored. Interviews confirmed the expired medication was mistakenly left on the medication cart, posing potential harm due to reduced effectiveness.
Deficiencies (1)
Expired medication (Ramipril/Altace) with an expiration date of 10/12/19 was stored on Medication Cart Two instead of being removed and destroyed as per facility policy.
Report Facts
Capsules remaining: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Licensed Practical Nurse | Interviewed regarding expired medication storage and facility policy |
| EI #1 | Director of Nursing | Interviewed regarding expired medication storage and replacement procedures |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 20, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Columbiana Health and Rehabilitation, LLC.
Findings
No health deficiencies were found during this inspection.
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