Inspection Reports for
Cordova Health and Rehabilitation, LLC
70 Highland Street West, Cordova, AL, 35550
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
40 residents
Based on a November 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 12
Date: Nov 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple allegations including failure to provide dignified dining experience, sanitation issues, abuse and neglect, and failure to report and investigate abuse incidents properly.
Complaint Details
The complaint investigation included allegations of failure to provide dignified dining, sanitation issues, sexual abuse by resident #325 against resident #82, failure to timely report abuse allegations involving residents #27, #43, and #91, and failure to properly investigate sexual abuse incidents. Immediate jeopardy was cited for failure to prevent and investigate sexual abuse, which was removed after corrective actions were verified on 11/20/2024.
Findings
The facility failed to ensure residents were served meals in a dignified manner, maintain clean and safe environment, prevent and investigate sexual abuse, timely report abuse allegations, and maintain accurate resident assessments. Immediate jeopardy was cited for failure to prevent and investigate sexual abuse, which was removed after corrective actions. Other deficiencies included staff chewing gum while feeding residents, rusty shelving for clean pots and pans, dirty floors in storerooms, and broken kitchen equipment.
Deficiencies (12)
Residents' lunch meals were left on transport trays during dining room service, failing to provide a dignified dining experience.
Large return vent and several exit vents were dirty and corroded; one clock was not working; vinyl chairs had torn or cracked upholstery.
Failure to provide adequate supervision and interventions to prevent sexual abuse perpetrated by one resident against another, resulting in immediate jeopardy.
Failure to timely report allegations of verbal and physical abuse within required 2-hour timeframe.
Failure to thoroughly investigate an incident of sexual abuse to prevent further occurrences.
Resident's Minimum Data Set (MDS) assessment was not transmitted to CMS within required timeframe.
Resident MDS assessments were inaccurately coded regarding PASRR Level II status.
Staff were observed chewing gum while assisting residents with meals, risking cross-contamination.
Clean pots and pans were stored on rusty wire shelving, risking contamination.
Storeroom floor for thickened liquids and nutritional supplements was dirty and had supplements stored on the floor; wooden shelving had gaps and could not be cleaned beneath.
Double sink used for food preparation lacked proper backflow prevention, risking contamination.
Three-compartment pot and pan sink was out of order for months, with two drain levers not working, preventing sinks from holding water.
Report Facts
Residents affected by meal tray deficiency: 40
Residents affected by vent and clock deficiencies: 40
Residents affected by vinyl chair deficiencies: 6
Residents sampled for abuse: 11
Residents affected by failure to report abuse: 3
Residents affected by MDS transmission deficiency: 1
Residents affected by PASRR coding deficiency: 2
Residents affected by chewing gum during meal assistance: 40
Residents affected by broken pot and pan sink: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Witnessed sexual abuse incident on 06/03/2024 |
| CNA #13 | Certified Nursing Assistant | Witnessed sexual abuse incident on 06/03/2024 |
| NA #18 | Nursing Assistant | Monitored resident #82 prior to sexual abuse incident |
| ADM | Administrator | Interviewed regarding abuse investigation and reporting |
| ADON | Assistant Director of Nursing | Interviewed regarding abuse reporting and investigation |
| Dietary Manager | Interviewed regarding kitchen sanitation and meal service deficiencies | |
| Registered Dietitian | Interviewed regarding kitchen sanitation and meal service deficiencies | |
| Director of Maintenance | Interviewed regarding facility maintenance and kitchen equipment | |
| Restorative Nurse | Observed chewing gum while assisting meals | |
| EI #7 | Certified Nursing Assistant | Observed chewing gum while assisting residents with meals |
| EI #8 | Certified Nursing Assistant | Observed chewing gum while assisting residents with meals |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 13
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to complaints and investigations related to resident rights, safety, abuse allegations, and sanitation concerns at Cordova Health and Rehabilitation, LLC.
Complaint Details
The complaint investigation included allegations of sexual abuse by Resident #325 against Resident #82, failure to timely report abuse allegations involving Residents #27, #43, and #91, and failure to properly investigate the sexual abuse incident. Immediate Jeopardy was cited for failure to prevent and investigate sexual abuse. The Immediate Jeopardy was removed after corrective actions were verified on 11/20/2024.
Findings
The facility was found deficient in multiple areas including failure to ensure dignified dining experience by leaving meals on trays, sanitation issues with vents and furniture, failure to prevent and properly investigate sexual abuse of a resident, failure to timely report abuse allegations, inaccurate MDS assessments, and food safety violations including staff chewing gum while assisting meals and equipment in disrepair.
Deficiencies (13)
Failure to ensure residents' lunch meals were not left upon transport trays when served in the dining room.
Failure to maintain clean ventilation vents, working clocks, and undamaged vinyl chairs in resident areas.
Failure to provide adequate supervision and interventions to prevent sexual abuse perpetrated by one resident against another.
Failure to timely report allegations of abuse within required 2-hour timeframe.
Failure to thoroughly investigate an incident of sexual abuse to prevent further occurrences.
Failure to transmit Resident #2's completed MDS assessment to CMS within required timeframe.
Failure to accurately code PASRR Level II status on MDS assessments for residents #60 and #82.
Staff chewing gum while assisting residents with meals, risking cross-contamination.
Storage of clean pots and pans on rusty wire shelving, risking contamination.
Dirty floor in storeroom for thickened liquids and nutritional supplements with supplements stored on floor.
Wooden shelving with gaps along floor line in storeroom, preventing proper cleaning and risking pest infestation.
Double sink used for food preparation lacked backflow prevention, risking contamination from sewer.
Three-compartment pot and pan sink was out of order for months, with two of three drain levers not working, preventing proper washing and sanitizing of kitchenware.
Report Facts
Residents affected by meal tray deficiency: 40
Residents affected by ventilation and furniture deficiencies: 40
Residents affected by sexual abuse incident: 1
Residents affected by late abuse reporting: 3
Residents affected by MDS transmission deficiency: 1
Residents affected by inaccurate PASRR coding: 2
Residents affected by chewing gum during meal assistance: 40
Residents affected by food safety deficiencies: 108
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #12 | Licensed Practical Nurse | Witnessed sexual abuse incident involving Residents #82 and #325 |
| CNA #13 | Certified Nursing Assistant | Witnessed sexual abuse incident involving Residents #82 and #325 |
| NA #18 | Nursing Assistant | Monitored Resident #82 prior to sexual abuse incident |
| ADM | Administrator | Provided Immediate Jeopardy notification and investigation oversight |
| ADON | Assistant Director of Nursing | Reported abuse allegations and participated in investigation |
| Dietary Manager | Interviewed regarding food safety and kitchen deficiencies | |
| Registered Dietitian | Interviewed regarding food safety and dining service deficiencies | |
| Director of Maintenance | Interviewed regarding facility maintenance and equipment deficiencies | |
| EI #7 | Certified Nursing Assistant | Observed chewing gum while assisting residents with meals |
| EI #8 | Certified Nursing Assistant | Observed chewing gum while assisting residents with meals |
| Restorative Nurse | Observed chewing gum while assisting residents with meals |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 3, 2019
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control protocols, specifically observing medication administration practices.
Findings
The facility failed to ensure that a Licensed Practical Nurse washed her hands prior to putting on gloves and administering inhaler medication to a resident, posing a potential infection control risk.
Deficiencies (1)
Failure to ensure Employee Identifier #7, a Licensed Practical Nurse, washed her hands prior to putting gloves on and administering inhaler medication to Resident Identifier #45.
Report Facts
Residents observed for medication administration: 4
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Employee Identifier #7 who failed to wash hands before putting on gloves and administering medication |
Inspection Report
Annual Inspection
Census: 108
Capacity: 111
Deficiencies: 3
Date: Sep 6, 2018
Visit Reason
The inspection was conducted as an annual survey to assess compliance with food safety, infection control, and other regulatory standards at Cordova Health and Rehabilitation, LLC.
Findings
The facility failed to ensure hot food items were served at proper temperatures and cold items, such as skim milk, were maintained at safe temperatures during meal service. Additionally, food storage practices risked cross-contamination due to items stored less than six inches from the floor and accumulation of dust in the walk-in cooler. Infection control lapses were observed including improper hand hygiene and PPE use during medication administration and contact isolation.
Deficiencies (3)
Failed to ensure hot food items were served hot and equipment to maintain cold temperature of skim milk was not used during lunch trayline.
Food items and supplies stored less than six inches off the floor and accumulation of dust on ceiling and walls of walk-in cooler; failed to maintain cold temperature of skim milk at 41°F or below.
Failed to provide and implement an infection prevention and control program including improper hand hygiene and glove use during medication administration and failure to use PPE appropriately for contact isolation.
Report Facts
Residents affected: 108
Total residents: 111
Temperature of skim milk: 53
Temperature of hot foods: 185
Temperature of hot foods: 139
Temperature of hot foods: 189
Distance from floor: 4.625
Distance from floor: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Dietary Manager | Interviewed regarding food temperature control and storage practices |
| EI #2 | Registered Dietitian | Interviewed regarding food temperature control and storage practices |
| EI #3 | AM Cook | Observed serving hot foods and assembling lunch trayline |
| EI #4 | Dietary Aide | Interviewed regarding skim milk placement outside insulated cooler |
| EI #6 | Licensed Practical Nurse | Observed and interviewed regarding improper hand hygiene and glove use during medication administration |
| EI #7 | Registered Nurse/Director of Nursing/Infection Control Coordinator | Interviewed regarding infection control policies and staff training |
| EI #8 | Certified Nursing Assistant | Observed and interviewed regarding failure to use PPE when entering contact isolation room |
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