Inspection Reports for
Extendicare Health and Rehab
950 South St. Andrews Street, PO Box 1246, Dothan, AL, 36301-3684
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 4
Date: Jun 13, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, medication management, and food safety in a nursing home facility.
Findings
The facility was found deficient in several areas including failure to conduct proper assessments and obtain physician orders for bed rail use, failure to ensure gradual dose reductions and behavioral monitoring for psychotropic medications, medication administration errors including crushing medications without physician orders, and unsanitary conditions in the kitchen related to unlabeled frozen food and dirty fans.
Deficiencies (4)
Failed to ensure assessment and physician's order for full bed rails for one resident.
Failed to ensure gradual dose reductions and consistent behavioral monitoring for psychotropic medications for one resident.
Medication error rate exceeded 5% due to crushing medications without physician order for one resident.
Failed to ensure frozen food items were labeled and dated properly and failed to maintain kitchen fans in clean condition.
Report Facts
Medication error rate: 13.79
Medications observed: 29
Medication errors detected: 4
Residents affected by bed rail deficiency: 1
Residents affected by psychotropic medication deficiency: 1
Residents affected by food safety deficiency: 122
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #53 | Certified Nursing Assistant (CNA) | Provided information about resident requiring assistance with bed mobility and bed rails. |
| EI #44 | Licensed Practical Nurse (LPN) | Interviewed regarding bed rail type and resident assistance needs. |
| EI #11 | Registered Nurse (RN) | Documented physician order for full bed rails and completed assessment. |
| EI #2 | Director of Nursing (DON) | Provided information on staff responsibilities and regulatory expectations. |
| EI #1 | Administrator | Discussed expectations for bed rail assessments and consent. |
| EI #23 | Licensed Practical Nurse (LPN) | Cared for resident on psychotropic medications and described behavioral monitoring. |
| EI #24 | Certified Nursing Assistant (CNA) | Provided care for resident with psychotropic medication and described behaviors. |
| EI #13 | Psychiatric Nurse Practitioner | Reviewed psychotropic medication use and acknowledged minimal assessments. |
| EI #43 | Licensed Practical Nurse (LPN) | Observed administering medications and crushing medications without physician order. |
| EI #9 | Licensed Practical Nurse (LPN) | Reviewed physician orders and confirmed no order to crush medications. |
| EI #56 | Dietary Manager (DM) | Observed unlabeled frozen food and acknowledged need for cleaning kitchen fans. |
| EI #61 | Dietary Aide (DA) | Acknowledged training on food labeling and dating. |
| EI #62 | Dietary Aide (DA) | Acknowledged training on food labeling and dating and observed washing dishes near dirty fan. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jul 18, 2019
Visit Reason
The inspection was conducted following a complaint and incident report regarding misappropriation of resident funds and other regulatory compliance concerns.
Complaint Details
The visit was complaint-related due to an incident report submitted on 4/19/19 about misappropriation of resident funds. The facility reported the local police were notified and funds were replaced. The complaint was substantiated as misappropriation was confirmed.
Findings
The facility was found to have misappropriated funds from 23 residents totaling $948.00. Additional deficiencies included improper wound care, unsecured controlled medications, and unsanitary food service practices such as soft ice cream, wet utensils, and dirty plates.
Deficiencies (4)
Failure to honor the resident's right to manage his or her financial affairs resulting in misappropriation of resident funds totaling $948.00 affecting 23 residents.
Failure to provide appropriate pressure ulcer care; treatment nurse wiped over wound with same soiled 4x4 and failed to clean sacral wound before treatment.
Failure to ensure controlled medication Lorazepam was stored in a metal box permanently affixed in the medication refrigerator.
Failure to procure food from approved sources and maintain sanitary conditions: ice cream was soft, utensils were wet at tray line, and plates/bowls had food-like substances.
Report Facts
Residents affected by fund misappropriation: 23
Total residents with funds managed by facility: 47
Total amount misappropriated: 948
Number of soft ice creams observed: 12
Number of wet utensils dried with same towel: 25
Number of residents potentially affected by food service issues: 157
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed about discovery and response to misappropriation of resident funds. | |
| Employee Identifier (EI) #3, Licensed Practical Nurse (LPN) | Observed and interviewed regarding improper wound care on Resident #6. | |
| Employee Identifier (EI) #2, Director of Nursing | Interviewed about wound care policy and medication storage. | |
| Employee Identifier (EI) #4, Licensed Practical Nurse (LPN) | Observed and interviewed regarding medication storage and controlled substances. | |
| Employee Identifier (EI) #6, Dietary Staff | Observed and interviewed regarding wet utensils and food service sanitation. | |
| Employee Identifier (EI) #5, Dietary Staff | Interviewed about utensil drying procedures. | |
| Employee Identifier (EI) #10, Dietary Manager | Interviewed regarding soft ice cream in resident ice cream chests. | |
| Employee Identifier (EI) #7 | Interviewed regarding dirty plates and bowls observed on tray line. | |
| Employee Identifier (EI) #9, Cook | Interviewed regarding food residue on plates and bowls. |
Inspection Report
Routine
Deficiencies: 4
Date: Aug 2, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, medication destruction procedures, food safety, infection prevention, and control practices at Extendicare Health and Rehab.
Findings
The facility was found deficient in multiple areas including failure to replace oxygen tubing as scheduled for a resident, incomplete signatures on medication destruction sheets, improper food handling practices leading to potential cross contamination, and failure of licensed staff to perform proper hand hygiene during wound care.
Deficiencies (4)
Failure to ensure oxygen tubing was replaced weekly as per facility policy for Resident Identifier #40.
Medication destruction sheets for both controlled and non-controlled drugs lacked the required number of witness signatures.
Dietary employee picked up a stove knob from the floor and placed it back on the stove without changing gloves or washing hands, risking cross contamination.
Licensed staff member removed a resident's soiled sock and returned to the treatment cart without washing hands, risking infection.
Report Facts
Residents affected: 1
Medication destruction sheets missing signatures: 9
Medication destruction sheets missing signatures: 3
Residents affected: 150
Wound care observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #6 | Interviewed regarding oxygen tubing replacement policy and practice. | |
| Employee Identifier #7 | Interviewed regarding oxygen tubing replacement policy and practice. | |
| Employee Identifier #5, Director of Nursing | Interviewed regarding medication destruction signature requirements and deficiencies. | |
| Employee Identifier #2, Dietary Manager | Observed and interviewed regarding improper food handling and handwashing practices. | |
| Employee Identifier #3, Dietary Manager | Interviewed regarding food safety and handwashing policies. | |
| Employee Identifier #1, Registered Nurse | Observed and interviewed regarding hand hygiene during wound care. | |
| Employee Identifier #4, Licensed Practical Nurse, Infection Control Nurse | Interviewed regarding infection control policies and hand hygiene. |
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