Deficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
308% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with federal regulations related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for residents with urinary catheters, inadequate nail care for several residents, failure to secure urinary catheter tubing properly, failure to check pacemaker function as ordered for residents, lack of nurse training on pacemaker checks, and failure of the Quality Assurance Performance Improvement (QAPI) committee to identify and address these issues.
Deficiencies (6)
Failure to develop and implement a complete care plan for a resident's suprapubic catheter.
Failure to provide timely nail care for three residents, resulting in long, jagged, and untrimmed nails.
Failure to check pacemaker function as ordered for three residents, resulting in immediate jeopardy to resident health or safety.
Failure to ensure urinary catheter tubing was secured to prevent trauma to the urethra for one resident.
Failure to train nurses on how to perform pacemaker checks and lack of competency validation.
Failure of the Quality Assurance Performance Improvement (QAPI) committee to thoroughly review and address the pacemaker check deficiencies and related adverse events.
Report Facts
Residents with pacemakers: 13
Residents reviewed for nail care: 8
Residents affected by nail care deficiency: 3
Residents affected by catheter care deficiency: 1
Residents affected by pacemaker check deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #15 | Unit Manager | Named in relation to pacemaker check deficiencies and interviews about responsibility and training. |
| LPN #14 | Unit Manager | Named in relation to pacemaker check deficiencies and interviews about responsibility and training. |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding care plan expectations, pacemaker check deficiencies, and QAPI committee failures. |
| Administrator | Administrator | Named in interviews regarding expectations for care, pacemaker checks, and QAPI committee. |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in interviews regarding pacemaker check deficiencies and QAPI committee. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements, including resident care, safety, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to provide timely nail care for residents, failure to check pacemaker function as ordered for residents with pacemakers, failure to secure urinary catheter tubing properly, and failure to follow food safety protocols such as wearing hairnets and gloves when handling resident food. The facility's Quality Assurance Performance Improvement (QAPI) committee also failed to adequately review and address these deficiencies, particularly the pacemaker monitoring issue.
Deficiencies (5)
Failure to provide timely nail care for residents requiring assistance with activities of daily living.
Failure to check pacemaker function as ordered for residents with pacemakers, resulting in immediate jeopardy to resident health or safety.
Failure to secure urinary catheter tubing with a leg strap or other device to prevent trauma to the urethra.
Failure to ensure staff wore hairnets in the kitchen and failure to prevent staff from handling ready-to-eat food with bare hands.
Failure of the facility's Quality Assurance Performance Improvement (QAPI) committee to thoroughly review and address the pacemaker monitoring deficiencies.
Report Facts
Residents reviewed for ADLs: 8
Residents with pacemakers: 7
Residents with pacemakers identified after review: 13
Residents affected by nail care deficiency: 3
Residents affected by pacemaker deficiency: 3
Residents affected by catheter tubing deficiency: 1
Residents affected by food handling deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #15 | Registered Nurse / Unit Manager | Interviewed regarding nail care and pacemaker checks |
| LPN #14 | Licensed Practical Nurse / Unit Manager | Interviewed regarding nail care and pacemaker checks |
| CNA #23 | Certified Nursing Assistant | Interviewed regarding nail care practices |
| DON | Director of Nursing | Interviewed regarding nail care, pacemaker checks, catheter care, and QAPI |
| Administrator | Interviewed regarding nail care, food handling, and QAPI | |
| CDM | Certified Dietary Manager | Observed and interviewed regarding hairnet use in kitchen |
| RN #52 | Registered Nurse | Documented hospital update on Resident #428 |
| Device RN | RN from cardiologist office | Interviewed regarding pacemaker checks and malfunction |
| Regional Nurse Consultant | Participated in QAPI reeducation and removal plan | |
| Regional Administrator | Participated in QAPI reeducation and removal plan | |
| Regional Quality Assurance Nurse | Participated in QAPI reeducation and removal plan |
Inspection Report
Routine
Deficiencies: 5
Date: Jul 26, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities of daily living, pacemaker monitoring, urinary catheter care, food safety, and quality assurance processes.
Findings
The facility failed to provide timely nail care for multiple residents, failed to check pacemaker function as ordered for several residents resulting in immediate jeopardy, failed to secure urinary catheter tubing properly, and failed to ensure food safety practices such as wearing hairnets and gloves when handling food. The Quality Assurance Performance Improvement (QAPI) committee failed to adequately review and address these issues, particularly the pacemaker monitoring deficiencies.
Deficiencies (5)
Failure to provide timely nail care for residents requiring assistance with activities of daily living.
Failure to check pacemaker function as ordered for discharged Resident #428 and other residents, resulting in immediate jeopardy to resident health or safety.
Failure to secure urinary catheter tubing with a leg strap or other device to prevent trauma to the urethra for Resident #31.
Failure to ensure staff wore hairnets in the kitchen and failure to prevent staff from handling ready-to-eat food with bare hands.
Failure of the Quality Assurance Performance Improvement (QAPI) committee to thoroughly review and implement corrective actions related to pacemaker monitoring deficiencies.
Report Facts
Residents reviewed for ADLs: 8
Residents with pacemakers: 7
Residents with pacemakers identified after review: 13
Length of Resident #152's right great toenail: 1
Number of LPNs educated on pacemaker monitoring: 14
Number of RNs educated on pacemaker monitoring: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #15 | Unit Manager | Interviewed regarding nail care frequency and pacemaker checks |
| LPN #14 | Unit Manager | Interviewed regarding nail care and pacemaker checks |
| CNA #24 | Observed preparing resident food without gloves and interviewed about nail care | |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding nail care, pacemaker monitoring, catheter care, food safety, and QAPI |
| Administrator | Administrator | Interviewed regarding expectations for nail care, food safety, and QAPI |
| Certified Dietary Manager (CDM) | Certified Dietary Manager | Observed not wearing hairnet in kitchen |
| Registered Dietician (RD) | Registered Dietician | Interviewed regarding hairnet use in kitchen |
| LPN #7 | Licensed Practical Nurse | Interviewed regarding nail care and pacemaker checks |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Interviewed regarding nail care and pacemaker checks |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 26, 2023
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements, including quality of care, catheter care, nail care, pacemaker monitoring, and quality assurance processes.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for catheter care, inadequate nail care for several residents, failure to check pacemaker function as ordered for multiple residents resulting in immediate jeopardy, failure to secure urinary catheter tubing properly, lack of nurse competency training on pacemaker checks, and failure of the Quality Assurance Performance Improvement (QAPI) committee to identify and correct these issues in a timely manner.
Deficiencies (6)
Failure to ensure one resident had a comprehensive care plan for suprapubic catheter care.
Failure to provide timely nail care for three residents, resulting in long, jagged, and untrimmed nails.
Failure to check pacemaker function as ordered for three residents, resulting in immediate jeopardy to resident health or safety.
Failure to secure urinary catheter tubing with a leg strap or stat lock for one resident.
Failure to train nurses on how to perform pacemaker checks and lack of competency validation.
Failure of the QAPI committee to thoroughly review and implement corrective actions related to pacemaker monitoring deficiencies.
Report Facts
Residents with pacemakers: 13
Residents reviewed for ADLs: 8
Residents affected by nail care deficiency: 3
Residents affected by catheter care deficiency: 1
Residents affected by pacemaker check deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #15 | Unit Manager | Named in relation to pacemaker check deficiencies and lack of training. |
| LPN #14 | Unit Manager | Named in relation to pacemaker check deficiencies and lack of training. |
| Director of Nursing | Director of Nursing | Named in relation to expectations for catheter care, nail care, pacemaker checks, and QAPI committee responsibilities. |
| Administrator | Administrator | Named in relation to expectations for catheter care, nail care, pacemaker checks, and QAPI committee responsibilities. |
| Assistant Director of Nursing | Assistant Director of Nursing | Named in relation to pacemaker check deficiencies and QAPI committee. |
| CNA #18 | Certified Nursing Assistant | Confirmed catheter tubing was not secured for Resident #31. |
Inspection Report
Routine
Deficiencies: 5
Date: Oct 24, 2019
Visit Reason
The inspection was conducted to assess compliance with food safety, sanitation, and infection control standards at Glen Haven Health and Rehabilitation, LLC.
Findings
The facility failed to ensure staff wore hair nets properly, maintain proper hand hygiene when handling clean dishes, avoid placing food on wet plates, keep dumpster doors closed, and follow proper infection control procedures during eye drop administration. These deficiencies had potential to affect many residents with minimal or potential for actual harm.
Deficiencies (5)
Staff did not wear hair nets covering all hair on the head as required.
Staff removed gloves and washed hands improperly by washing dirty and then moving to clean side of dish room.
Staff used wet plates to place dinner meals, which could harbor bacteria or detergent residue.
One of three dumpster doors was left open, posing risk for pest infestation.
Licensed staff member placed gloves, tissues, and eye drops in her pocket while administering eye drops, risking contamination.
Report Facts
Residents potentially affected: 184
Residents potentially affected: 3
Dumpster count: 3
Residents observed for eye drop administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Observed wearing hair net improperly covering hair | |
| Dietary Cook | Observed not wearing hair net properly, improper hand hygiene, and plating food on wet plates | |
| Registered Dietitian | Interviewed regarding hair net policy and dumpster doors | |
| Licensed Practical Nurse | Observed placing gloves, tissues, and eye drops in pocket during medication administration | |
| Registered Nurse, Infection Control | Interviewed regarding proper infection control procedures |
Inspection Report
Deficiencies: 5
Date: Oct 24, 2019
Visit Reason
The inspection was conducted to evaluate compliance with food safety, sanitation, infection control, and medication administration procedures at Glen Haven Health and Rehabilitation, LLC.
Findings
The facility failed to ensure staff wore hair nets properly, followed proper glove and handwashing protocols in the dish room, used dry plates for meals, kept dumpster doors closed, and adhered to infection prevention practices during eye drop administration. These deficiencies had potential to affect many residents with minimal harm.
Deficiencies (5)
Staff did not wear hair nets covering all hair on the head as required.
Staff removed gloves and washed hands improperly when moving from dirty to clean side in the dish room.
Staff used wet plates to place dinner meals, which could have remaining detergent.
One of three dumpster doors was left open, risking infestation.
Licensed staff member placed gloves, tissues, and eye drops in her pocket during administration, risking contamination.
Report Facts
Residents potentially affected: 184
Residents potentially affected: 3
Dumpster count: 3
Dumpster doors open: 1
Residents observed for eye drop administration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aids and Dietary Cook | Employees EI# 4, EI# 5, EI# 6, and EI# 7 observed not wearing hair nets properly | |
| Dietary Manager | Employee EI# 7 observed with hair net not covering all hair | |
| Registered Dietitian | Employee EI# 3 interviewed regarding hair net policy and dumpster doors | |
| Licensed Practical Nurse | Employee EI# 2 observed placing gloves, tissues, and eye drops in pocket during medication administration | |
| Registered Nurse, Infection Control | Employee EI# 1 interviewed regarding infection control practices |
Inspection Report
Routine
Census: 175
Deficiencies: 6
Date: Oct 11, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitation standards, including proper food storage, utensil sanitization, thermometer calibration, and labeling of food brought in from outside sources.
Findings
The facility failed to ensure proper air drying of utensils, consistent labeling of thawed milkshakes with use-by dates, adequate sanitization of utensils in the three-compartment sink, accurate calibration of food thermometers, proper labeling and timely discard of food brought in from outside sources, and maintenance of clean and sanitary conditions inside nursing station refrigerators. These deficiencies had the potential to affect all 175 residents.
Deficiencies (6)
Cleaned cooking utensils were not thoroughly air dried prior to stacking and storage.
Commercially prepared, thawed milkshakes were not consistently labeled with use-by dates for timely discard.
Utensils and pans were not properly sanitized when processed through the three-compartment sinks; final rinse water temperature was below required levels.
Food thermometers used on the tray line were not accurately calibrated prior to use.
Food brought into the facility from outside sources and stored in nursing refrigerators was not labeled with name and date to ensure timely discard.
Nursing staff did not maintain the interior of the refrigerators on each nursing station in a clean and sanitary condition for resident food storage.
Report Facts
Residents affected: 175
Use-by date timeframe: 14
Final rinse water temperature required: 171
Final rinse water temperature observed: 90
Expired yogurt use-by date: Sep 13, 2018
Food discard timeframe: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian | Employee Identifier #1, questioned regarding wet-nesting and thermometer calibration issues | |
| Dishwashing staff | Employee Identifier #2, observed processing pans through three-compartment sinks with improper sanitization | |
| Morning staff | Employee Identifier #3, observed checking tray line food temperatures and improper thermometer calibration | |
| Evening cook | Employee Identifier #4, observed checking sanitizing sink temperature and refilling sink | |
| Licensed Practical Nurse | Employee Identifier #5, observed unlabeled food in nursing station refrigerator | |
| Assistant Dietary Manager | Employee Identifier #6, accompanied surveyor to nursing station refrigerators and discussed food storage issues | |
| Unit Manager | Employee Identifier #7, provided information about unlabeled frozen food items and refrigerator cleaning responsibilities | |
| Nurse | Employee Identifier #9, verified nursing department refrigerator checks |
Inspection Report
Routine
Census: 175
Deficiencies: 6
Date: Oct 11, 2018
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety and sanitation standards, including proper food procurement, storage, preparation, and serving practices.
Findings
The facility failed to ensure proper air drying of cooking utensils, consistent labeling of thawed milkshakes with use-by dates, adequate sanitization of utensils and pans in the three-compartment sinks, accurate calibration of food thermometers, proper labeling and monitoring of food brought from outside sources, and maintenance of clean and sanitary conditions inside nursing station refrigerators. These deficiencies had the potential to affect all 175 residents.
Deficiencies (6)
Cleaned cooking utensils were not thoroughly air dried prior to stacking and storage.
Commercially prepared, thawed milkshakes were not consistently labeled with use-by dates for timely discard.
Utensils and pans were not properly sanitized when processed through the three-compartment sinks, with final rinse water temperatures below required levels.
Food thermometers used on the tray line were inaccurately calibrated, with improper calibration methods observed.
Food brought into the facility from outside sources and stored in nursing refrigerators was not labeled with name and date to ensure timely discard.
Nursing staff failed to maintain the interior of refrigerators on nursing stations in a clean and sanitary condition.
Report Facts
Residents affected: 175
Use-by date timeframe: 14
Final rinse water temperature observed: 90
Final rinse water temperature observed: 100
Final rinse water temperature observed: 143
Thermometer reading in ice-free water: 10
Thermometer reading adjusted without ice water: 20
Expired yogurt use-by date: Sep 13, 2018
Refrigerator cleaning frequency: 1
Refrigerator cleaning schedule: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian | Employee Identifier #1, questioned about wet-nesting and thawed milkshake labeling, alerted to thermometer calibration issues. | |
| Dishwashing staff | Employee Identifier #2, observed processing pans through three-compartment sinks with improper sanitization. | |
| Morning staff | Employee Identifier #3, observed checking tray line food temperatures and improper thermometer calibration. | |
| Cook | Employee Identifier #4, checked final rinse water temperature and refilled sanitizing sink. | |
| Licensed Practical Nurse | Employee Identifier #5, observed unlabeled food in nursing station refrigerator. | |
| Assistant Dietary Manager | Employee Identifier #6, accompanied surveyor to nursing station refrigerators and discussed food storage issues. | |
| Unit Manager | Employee Identifier #7, provided information about unlabeled frozen food items and refrigerator cleaning responsibilities. | |
| Nurse | Employee Identifier #9, verified daily refrigerator checks by nursing department. |
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