Inspection Reports for
Heritage Health Care & Rehab Inc
1101 Snows Mill Ave, Tuscaloosa, AL 35406, USA, AL, 35406
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to assess compliance with care plan development, treatment, and care according to orders, focusing on residents with swallowing difficulties and assistance with activities of daily living (ADLs).
Findings
The facility failed to update care plans with therapy recommendations for residents with dysphagia, resulting in inadequate supervision and assistance during meals. Observations and interviews revealed residents pocketed food and experienced coughing and gagging during feeding, with inconsistent adherence to feeding protocols.
Deficiencies (2)
F 0657: The facility failed to update Resident #48's care plan with speech therapy recommendations, including swallowing interventions, affecting one of 25 sampled residents.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences for Residents #48 and #62, including inadequate feeding assistance and failure to follow swallowing precautions.
Report Facts
Residents sampled for care plan review: 25
Residents reviewed for assistance with ADLs: 3
Residents affected: 2
Assessment Reference Date: Dec 3, 2021
BIMS score: 5
Percentage of daily calories from feeding tube: 51
Assessment Reference Date: Nov 13, 2020
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Director of Nursing (DON) | Stated nurses received therapy communication and were responsible for updating care plans and carrying out orders |
| EI #11 | Registered Nurse (RN) Supervisor | Stated care plans should be updated within 24 hours and was responsible for updating care plans; also involved in feeding Resident #62 |
| EI #1 | Licensed Nursing Home Administrator (LNHA) | Stated care plans should be reviewed quarterly and CNAs trained on functional maintenance plans |
| EI #6 | Certified Nursing Assistant (CNA) | Observed feeding Resident #62 and noted deviations from feeding instructions |
| EI #5 | Certified Nursing Assistant (CNA) | Described feeding procedures and signs to stop feeding Resident #62 |
| EI #3 | Speech Language Pathologist (SLP) | Provided therapy recommendations and functional maintenance plans for residents |
| EI #14 | Registered Dietitian (RD) | Discussed Resident #62's swallowing problems and feeding assistance needs |
| EI #10 | Licensed Practical Nurse (LPN) | Observed and assisted Resident #48 with feeding and clearing pocketed food |
| EI #4 | Certified Nursing Assistant (CNA) | Reported on feeding assistance and pocketing behavior of Resident #48 |
Inspection Report
Routine
Deficiencies: 4
Date: May 16, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements related to resident rights, care assistance, food safety, and infection control at Heritage Health Care & Rehab Inc.
Findings
The facility was found deficient in honoring resident code status labeling, timely assistance with meals, proper food temperature measurement and labeling, and infection prevention practices including oxygen equipment handling and medication administration.
Deficiencies (4)
F 0578: The facility failed to ensure the spine of the medical chart and the end of the bed for Resident #405 had the correct code status label, mislabeling a DNR resident as full code.
F 0677: Resident #406 waited thirty minutes to receive assistance with the dinner meal, contrary to facility policy requiring timely feeding assistance.
F 0812: Dietary staff took food temperatures by sticking thermometers through plastic wrap or foil and failed to date food items before placing them in unit refrigerators, risking contamination and spoilage.
F 0880: Infection control failures included a CNA not reapplying Resident #88's nasal cannula after it was found on the floor, undated oxygen tubing for Resident #89, uncleaned inhaler mouthpiece after administration, and an LPN not changing gloves or washing hands during medication administration for Resident #116.
Report Facts
Residents sampled: 31
Residents affected: 1
Residents affected: 1
Residents affected: 140
Total residents receiving meals: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | EI #9 interviewed regarding code status labeling for Resident #405 | |
| Licensed Practical Nurse Supervisor | EI #6 interviewed regarding meal assistance delays for Resident #406 | |
| Registered Nurse | EI #7 interviewed regarding meal assistance delays for Resident #406 | |
| Dietary Aide | EI #2 and EI #3 interviewed regarding improper food temperature measurement | |
| Dietary Manager | EI #1 interviewed regarding food temperature and labeling policies | |
| Registered Nurse Supervisor | EI #4 interviewed regarding food labeling and refrigerator checks | |
| Registered Nurse | EI #5 interviewed regarding food labeling and refrigerator checks | |
| Certified Nursing Assistant | EI #13 observed not reapplying oxygen tubing properly for Resident #88 | |
| Licensed Practical Nurse | EI #6 observed not cleaning inhaler mouthpiece and interviewed about infection control | |
| Licensed Practical Nurse | EI #11 observed not changing gloves or washing hands during medication administration for Resident #116 | |
| Registered Nurse/Infection Control | EI #12 interviewed regarding proper infection control practices | |
| Director of Nursing | EI #14 confirmed undated oxygen tubing for Resident #89 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 24, 2018
Visit Reason
The inspection was conducted following a complaint regarding the failure to provide a resident's medication upon admission and concerns about medication administration and documentation of care.
Complaint Details
The complaint involved Resident #313 not receiving the prescribed Mestinon medication upon admission, administration of another resident's medication to Resident #313, and failure to document colostomy and skin assessment. The complaint was substantiated based on interviews, medical record reviews, and policy analysis.
Findings
The facility failed to ensure Resident #313 received the prescribed Mestinon medication upon admission and administered another resident's medication to this resident. Additionally, the facility failed to document an assessment of the resident's colostomy and skin status as required.
Deficiencies (3)
F 0658: The facility failed to ensure Resident #313 received the prescribed Mestinon medication upon admission and administered another resident's medication to this resident, violating medication administration standards.
F 0755: The facility failed to provide pharmaceutical services to meet the needs of Resident #313 by not having the Mestinon medication available upon admission as required by policy.
F 0842: The facility failed to ensure licensed staff documented an assessment of Resident #313's colostomy and skin status on 05/20/18 as required by professional standards.
Report Facts
Residents admitted with admission orders in last 30 days: 14
Mestinon dosage frequency: 3
Brief Interview for Mental Status score: 15
Physician order start date: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (EI #1) | Named in medication error finding for failing to administer correct medication and administering another resident's medication. | |
| Registered Nurse Supervisor (EI #4) | Interviewed regarding admission procedures and medication availability. | |
| Licensed Practical Nurse (EI #3) | Gave another resident's medication to EI #1 to administer to Resident #313. | |
| Licensed Practical Nurse (EI #2) | Failed to document assessment of Resident #313's colostomy and skin status. | |
| Infection Control/Quality Assurance Registered Nurse (EI #5) | Signed facility document discussing medication concerns and standing orders. |
Report
January 27, 2022
Report
May 16, 2019
Report
May 24, 2018
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