Inspection Reports for
Coosa Valley Health and Rehab
513 Pineview Avenue, Glencoe, AL, 35905
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
103% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 29, 2022
Visit Reason
The inspection was conducted based on complaints regarding failure to provide timely incontinence care to Resident Identifier (RI) #43 and lack of documented medical justification for the use of an indwelling urinary catheter for RI #31.
Complaint Details
The complaint investigation focused on allegations that the facility failed to provide timely incontinence care to RI #43 and lacked proper medical justification for the use of an indwelling urinary catheter for RI #31. The findings substantiated these issues.
Findings
The facility failed to provide timely incontinence care to RI #43, who required total assistance and should have been checked every two hours. Additionally, the facility failed to ensure proper medical justification and documentation for the use of an indwelling urinary catheter for RI #31.
Deficiencies (2)
Failure to provide incontinence care to RI #43 in a timely manner, with staff not providing care for approximately five hours.
Failure to ensure documented medical justification for the use of an indwelling urinary catheter for RI #31.
Report Facts
Residents reviewed for catheter use: 7
Observation duration without incontinence care: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) | Employee Identifier #5 observed walking by RI #43's room and providing limited care. | |
| Licensed Practical Nurse (LPN) | Employee Identifier #13 interviewed and provided information about care requirements for RI #43 and catheter orders. | |
| Restorative Aide (RA) | Employee Identifier #9 interviewed regarding care needs of RI #43. | |
| Director of Nursing | Employee Identifier #2 interviewed regarding catheter order requirements. |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 13, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food safety, and facility environment.
Findings
The facility was found deficient in multiple areas including inaccurate medication coding on resident assessments, failure to update care plans to reflect code status, improper tube feeding rates, food safety violations in the kitchen, infection control lapses during medication administration, and environmental maintenance issues such as chipped paint, worn furniture, and equipment in disrepair.
Deficiencies (6)
Failed to ensure Resident #65's Minimum Data Set assessments accurately coded Gabapentin as an anticonvulsant rather than an antipsychotic medication.
Failed to revise Resident #87's care plan to reflect Do Not Resuscitate (DNR) status, resulting in inconsistent code status documentation.
Resident #9's tube feeding was infusing at incorrect rates, not matching physician orders.
Food safety violations including improperly frozen ice cream, unsealed opened food items, and cross contamination risk from a thermometer dropped into gravy.
Infection control failures including placing inhaler mouthpieces on unclean surfaces and not changing gloves between administering crushed medications and eye drops.
Facility environment issues including chipped paint, missing tiles, missing curtains, worn furniture, and equipment in disrepair affecting 63 of 66 resident rooms.
Report Facts
Residents affected: 24
Residents affected: 6
Residents affected: 86
Residents affected: 4
Rooms affected: 63
Temperature: 11
Ice cream cups not frozen solid: 17
Tube feeding rate observed: 50
Water flush rate observed: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Coordinator | Employee Identifier #3 interviewed regarding medication coding and care plan discrepancies | |
| Licensed Practical Nurse (LPN) | Employee Identifier #6 observed and interviewed regarding tube feeding rates and infection control practices | |
| Dietary Manager | Employee Identifier #2 interviewed regarding food safety violations and freezer conditions | |
| Dietary Aide | Employee Identifier #1 observed and interviewed regarding cross contamination incident with thermometer | |
| Registered Nurse/Director of Nursing | Employee Identifier #4 interviewed regarding infection control and tube feeding practices | |
| Administrator | Employee Identifier #5 interviewed regarding facility environment and maintenance concerns | |
| Licensed Practical Nurse (LPN) | Employee Identifier #7 observed and interviewed regarding inhaler mouthpiece handling |
Inspection Report
Routine
Deficiencies: 14
Date: Jul 26, 2018
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, activities, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure residents did not self-administer medications when assessed unable, failure to provide resident choice in bathing methods, lack of advance directive acknowledgement, breaches in confidentiality of medical records, failure to follow care plans and physician orders for weighted utensils, inadequate activity provision, improper medication administration via gastrostomy tube, incomplete medication destruction records, medication error rate exceeding 5%, failure to provide requested food preferences, failure to provide special eating utensils, improper disposal of gloves in dumpsters, and failure to follow infection control hand hygiene practices.
Deficiencies (14)
Resident #44 self-administered nebulizer treatment despite being assessed as unable to self-administer medications.
Resident #22 was not given a choice for method of bathing; facility lacked a working bathtub.
Facility failed to ensure residents were provided knowledge of advance directives and proof of acknowledgement for 18 sampled residents.
Resident #88's Medication Administration Record was left open to public view.
Staff failed to consistently follow Resident #85's care plan for self-care deficit by not providing a weighted spoon during meals.
Staff failed to follow Resident #85's physician order for weighted spoon use during meals.
Facility failed to provide activities of choice to Residents #55 and #73 during the survey period.
Staff failed to administer water flushes between medications and dilute crushed medications properly for Resident #39 via gastrostomy tube.
Facility failed to ensure drug destruction records contained method of destruction for February to May 2018.
Medication error rate was 19.23%, exceeding the 5% threshold, during medication administration observation for Resident #39.
Residents #83 and #67 did not receive fried eggs as requested on two consecutive days.
Resident #85 was not provided weighted spoon during breakfast and lunch meals on 07/24/18.
Vinyl gloves were found unsecured and loose outside dumpsters, posing potential risk for pest attraction.
Staff failed to wash hands before glove application, after glove removal, and before touching resident personal items, risking cross-contamination for Residents #88 and #39.
Report Facts
Medication error rate: 19.23
Medication destruction months: 4
Residents affected: 18
Residents observed for weighted utensil use: 1
Residents observed during medication administration: 4
Residents observed during meals: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Registered Nurse, MDS Coordinator | Interviewed regarding Resident #44's medication self-administration assessment and Resident #85's care plan |
| EI #6 | Licensed Practical Nurse | Observed and interviewed regarding medication administration and infection control breaches with Resident #88 |
| EI #8 | Licensed Practical Nurse | Observed and interviewed regarding medication administration via gastrostomy tube for Resident #39 and infection control breaches |
| EI #10 | Certified Dietary Manager | Interviewed regarding food service errors and weighted utensil provision |
| EI #15 | Infection Control Nurse | Interviewed regarding hand hygiene and infection control practices |
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