Inspection Reports for
Crossville Health and Rehabilitation, LLC
8922 Alabama Highway 227 North, Crossville, AL, 35962
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 6, 2023
Visit Reason
The inspection was conducted due to a complaint alleging that Certified Nursing Assistant (CNA) #4 raised her voice at Resident #1, which was witnessed by other staff and reported by the resident.
Complaint Details
The complaint was substantiated based on interviews with CNAs #2 and #3, the resident's report, and statements from the nurse and CNA #4. CNA #4 was reported to have yelled at Resident #1 on 02/22/2023, which caused the resident to be upset.
Findings
The facility failed to ensure that CNA #4 did not raise her voice at Resident #1, who had moderate cognitive impairment and required extensive assistance. Interviews and document reviews confirmed CNA #4 yelled at the resident for removing their incontinence brief, causing distress.
Deficiencies (1)
CNA #4 raised her voice at Resident #1, violating the resident's right to be treated with respect and dignity.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in finding for raising voice at Resident #1 |
| CNA #2 | Certified Nursing Assistant | Witnessed CNA #4 yelling at Resident #1 and reported discomfort |
| CNA #3 | Certified Nursing Assistant | Witnessed CNA #4 yelling at Resident #1 and reported it was inappropriate |
| RN #5 | Registered Nurse | Provided statement about CNA #4's behavior |
Inspection Report
Deficiencies: 2
Date: Nov 4, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to accurate resident assessments, infection prevention and control, and proper coding of dialysis treatments in Quarterly Minimum Data Set (MDS) assessments.
Findings
The facility failed to ensure accurate coding of dialysis treatments in the Quarterly MDS assessments for two residents, RI #74 and RI #120, and failed to implement proper infection control practices when administering medications via gastrostomy tube, as licensed staff placed tubing on bed covers, risking infection.
Deficiencies (2)
Failure to ensure Quarterly MDS assessments accurately reflected residents receiving dialysis treatments.
Failure to implement infection prevention and control program; tubing from gastrostomy medication administration was placed on bed covers, risking infection.
Report Facts
Residents affected: 2
Residents affected: 1
Sample size: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/MDS Coordinator | Interviewed regarding dialysis coding inaccuracies (Employee Identifier #8) | |
| Licensed Practical Nurse (LPN) | Observed and interviewed regarding improper handling of gastrostomy tubing (Employee Identifier #5) | |
| Infection Control Nurse | Interviewed regarding infection control policy and risks (Employee Identifier #7) |
Inspection Report
Deficiencies: 1
Date: Nov 14, 2019
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control protocols, specifically focusing on hand hygiene practices during resident feeding.
Findings
The facility failed to ensure that a Certified Nursing Assistant properly washed and sanitized her hands while feeding multiple residents, leading to potential cross contamination. Observations and interviews confirmed lapses in hand hygiene, including failure to sanitize hands after coughing and between feeding residents.
Deficiencies (1)
Failure to ensure Certified Nursing Assistant washed and sanitized hands while feeding multiple residents, risking cross contamination.
Report Facts
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Employee Identifier #1 observed failing to sanitize hands while feeding residents | |
| Registered Nurse (RN)/Infection Control | Employee Identifier #2 interviewed regarding hand hygiene practices |
Inspection Report
Routine
Deficiencies: 9
Date: Sep 25, 2018
Visit Reason
The inspection was a routine survey conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy, incomplete assessments, failure to follow care plans resulting in resident falls, medication order documentation errors, improper wound care and infection control practices, unsafe environmental conditions, expired medications on medication carts, and inadequate food safety and sanitation practices.
Deficiencies (9)
Failure to ensure staff knocked and requested permission prior to entering a resident's room, violating resident privacy rights.
Failure to complete a smoking assessment for a resident identified as a smoker.
Failure to follow resident's care plan for weight bearing assist during transfer, resulting in a fall and injury.
Failure to ensure verbal physician orders included the time the order was given.
Failure to provide appropriate pressure ulcer care and prevent cross contamination during wound care for residents with infected pressure ulcers.
Failure to prevent accidents by not providing adequate supervision during resident transfers and unsafe environmental conditions including damaged bedside tables and wheelchairs.
Expired medications found on medication carts.
Failure to maintain food safety and sanitation including dirty containers, improper storage of scoops, and dust accumulation in food preparation areas.
Failure to implement infection prevention and control measures including improper use of personal protective equipment, failure to change gloves during wound care, and improper disposal of contaminated linens.
Report Facts
Residents sampled for privacy observation: 37
Residents sampled for smoking assessment: 6
Residents sampled for medication orders review: 39
Residents with pressure ulcers observed: 5
Residents identified with history of falls: 7
Residents with bedside tables observed: 27
Residents with wheelchairs observed: 21
Medication carts reviewed: 5
Residents receiving meals: 135
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | Named in privacy violation for not knocking or asking permission before entering resident's room | |
| Licensed Practical Nurse | Named in privacy violation for not knocking or asking permission before entering resident's room | |
| Registered Nurse Unit Manager | Interviewed regarding smoking assessment for resident | |
| RN/MDS Coordinator | Interviewed regarding smoking assessment for resident | |
| Certified Nursing Assistant | Witnessed fall incident involving resident | |
| Registered Nurse/RN/MDS | Interviewed regarding care plan and fall investigation | |
| Licensed Practical Nurse | Observed administering medications and interviewed regarding verbal order documentation | |
| Director of Nursing | Interviewed regarding verbal order documentation and infection control | |
| Licensed Practical Nurse | Observed and interviewed regarding wound care and infection control | |
| Certified Nursing Assistant | Observed and interviewed regarding wound care and infection control | |
| Staff Development LPN | Interviewed regarding environmental safety | |
| Dietary Manager | Interviewed regarding food safety and sanitation | |
| Infection Control Nurse | Interviewed regarding infection control policies and practices | |
| Assistant Director of Nurses | Interviewed regarding fall investigation and care plan compliance |
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