Inspection Reports for
South Hampton Nursing & Rehabilitation Center

213 Wilson Mann Road, Owens Cross Roads, AL, 35763

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 2.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

25% better than Alabama average
Alabama average: 3.6 deficiencies/year

Deficiencies per year

4 3 2 1 0
2018
2019
2023

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Jul 14, 2023

Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00041754) regarding allegations of misappropriation of residents' funds by the Business Office Manager (BOM) #3 at South Hampton Nursing & Rehabilitation Center.

Complaint Details
The complaint investigation (#AL00041754) substantiated misappropriation of resident funds by BOM #3. The facility took corrective actions including termination, audits, police reports, and staff training.
Findings
The facility substantiated that BOM #3 misappropriated funds from 13 residents, totaling over $187,000 over a five-year period, with $18,591.57 refunded to residents' trust accounts. Corrective actions included termination of BOM #3, audits, police investigations, staff in-service training, and revised accounting policies with ongoing monitoring.

Deficiencies (1)
Failure to protect residents from misappropriation of their funds by Business Office Manager #3 affecting 13 residents.
Report Facts
Residents affected: 13 Amount misappropriated: 187000 Amount refunded: 18591.57

Employees mentioned
NameTitleContext
Business Office Manager #3Business Office ManagerNamed as responsible for misappropriation of funds
AdministratorAdministrator (ADM)Conducted interviews and signed investigation summary
Social Services DirectorSocial Services Director (SSD)Suspended pending investigation related to misappropriation
Vice President of OperationsVice President of Operations (VP)Provided interview details on embezzlement and refunds
Corporate AccountantCorporate AccountantInitiated in-house audit
Regional Financial SpecialistRegional Financial SpecialistPerformed regular audits of resident trust accounts

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Jul 14, 2023

Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00041754) regarding allegations of misappropriation of resident funds by a Business Office Manager at South Hampton Nursing & Rehabilitation Center.

Complaint Details
The complaint investigation (#AL00041754) was initiated due to allegations of misappropriation of resident funds by the Business Office Manager. The facility substantiated the allegations after an internal and third-party audit, resulting in corrective actions including termination of the employee, police report filing, and staff in-service training.
Findings
The facility substantiated that the Business Office Manager misappropriated funds from 13 residents, totaling $18,591.57 refunded to residents' trust accounts. Additionally, the facility failed to assess and use bed rail alternatives before installing bed rails for two residents, Resident #13 and Resident #64, with incomplete documentation of alternatives considered.

Deficiencies (2)
Failed to ensure residents' funds were not misappropriated for 13 residents; Business Office Manager misappropriated funds totaling $18,591.57.
Failed to assess and use bed rail alternatives before installing and using bed rails for two residents (#13 and #64).
Report Facts
Residents affected: 13 Amount refunded: 18591.57 Amount embezzled: 187000 Residents reviewed for bed rails: 2

Employees mentioned
NameTitleContext
Business Office Manager (BOM) #3Named as the employee who misappropriated resident funds
Administrator (ADM)Provided interviews and signed investigation summary letters
Vice President (VP) of OperationsProvided interview regarding embezzlement amount and refund
Regional Financial SpecialistPerformed audits of resident trust accounts
Social Services Director (SSD)Suspended pending investigation related to misappropriation
Licensed Practical Nurse (LPN) #9Licensed Practical NurseInterviewed about bed rail assessments
Assistant Director of Nursing (ADON)Assistant Director of NursingInterviewed about bed rail assessment procedures
Certified Nursing Assistant (CNA) #7Certified Nursing AssistantInterviewed about bed rail use per care plans
Certified Nursing Assistant (CNA) #19Certified Nursing AssistantInterviewed about care for Resident #13 and bed rail use
MDS CoordinatorMDS CoordinatorInterviewed about bed rail assessments not conducted by MDS staff
Director of Nursing (DON)Director of NursingInterviewed about bed rail assessments and documentation

Inspection Report

Complaint Investigation
Census: 64 Capacity: 65 Deficiencies: 3 Date: Sep 5, 2019

Visit Reason
The inspection was conducted due to an allegation of misappropriation of resident property (medication) by an employee, and to investigate compliance with abuse reporting and food safety standards.

Complaint Details
The complaint involved an allegation that Employee Identifier #5 took Resident Identifier #8's medication (Tramadol). The investigation found the employee was not suspended during the investigation and the allegation was not reported to the State Agency within 24 hours as required by policy.
Findings
The facility failed to suspend an employee during an abuse investigation, failed to report the allegation to the State Agency within 24 hours, and failed to ensure food-contact surfaces of insulated bowls and coffee cups were properly cleaned, potentially affecting all residents.

Deficiencies (3)
Failed to suspend Licensed Practical Nurse during investigation of alleged misappropriation of resident medication.
Failed to timely report allegation of misappropriation of resident property to State Agency within 24 hours.
Failed to ensure food-contact surfaces of insulated bowls and coffee cups were clean, risking cross-contamination.
Report Facts
Residents affected: 64 Total residents in facility: 65 Dates employee worked during investigation: 2 Date allegation made: Jul 16, 2019

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Employee Identifier #5 accused of misappropriation of medication
Registered Nurse (RN)/Director of Nursing (DON)/Abuse CoordinatorEmployee Identifier #4 interviewed regarding investigation and policy
AdministratorEmployee Identifier #3 interviewed regarding investigation and policy
Dietary ManagerEmployee Identifier #1 interviewed regarding food-contact surface cleanliness
Registered DietitianEmployee Identifier #2 interviewed regarding food-contact surface cleanliness

Inspection Report

Complaint Investigation
Deficiencies: 2 Date: Aug 9, 2018

Visit Reason
The inspection was conducted to investigate complaints related to the facility's Quality Assessment and Assurance committee attendance and infection prevention and control practices.

Complaint Details
The complaint investigation found substantiated issues with Medical Director attendance at Quality Assurance meetings and infection control practices involving hand hygiene and glove use during medication administration.
Findings
The facility failed to ensure the Medical Director attended all required quarterly Quality Assurance meetings, attending only two of four meetings from June 2017 to June 2018. Additionally, the facility failed to ensure licensed staff properly washed their hands and used paper towels to turn off faucets during medication administration, posing an infection risk.

Deficiencies (2)
Failure to ensure the Medical Director attended all quarterly Quality Assurance meetings from June 2017 to June 2018.
Failure to ensure licensed staff washed hands properly after glove removal and used paper towels to turn off water faucets, risking infection transmission.
Report Facts
QA meetings attended by Medical Director: 2 Residents affected: 2 Nurses observed: 2

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN)Employee Identifier #1 observed failing proper hand hygiene during medication administration
Licensed Practical Nurse (LPN)Employee Identifier #3 observed failing proper hand hygiene during medication administration
QAA and QAPI NurseEmployee Identifier #4 interviewed regarding Quality Assurance meeting attendance

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