Inspection Reports for
Summerford Health and Rehab LLC
4087 Highway 31 SW, Falkville, AL, 35622
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 2
Date: Apr 24, 2024
Visit Reason
The inspection was conducted as a result of a complaint/report #AL00042935 regarding an incident of physical abuse where Resident #404 assaulted Resident #403 on the secured unit.
Complaint Details
This investigation was initiated due to complaint/report #AL00042935. The complaint was substantiated as Resident #403 was physically abused by Resident #404 while residents were left unsupervised on the secured unit during the night shift.
Findings
The facility failed to protect Resident #403 from physical abuse by Resident #404 due to inadequate staff supervision on the secured unit during the night shift. Resident #403 sustained multiple injuries from being struck with a cane. Staffing was insufficient, leaving residents unsupervised, which contributed to the incident.
Deficiencies (2)
Failure to protect Resident #403 from physical abuse by Resident #404 due to inadequate staff supervision on the secured unit.
Failure to provide enough nursing staff every day to meet the needs of every resident and have a licensed nurse in charge on each shift, resulting in unsupervised residents on the secured unit.
Report Facts
Resident census on secured unit: 24
Staff scheduled on night shift: 9
Resident to staff ratio: 12
Length of laceration: 2.5
BIMS score Resident #403: 3
BIMS score Resident #404: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #32 | Certified Nurse Assistant | Responded to Resident #403's room, observed injuries, and reported the incident |
| LPN #15 | Licensed Practical Nurse | Assessed Resident #403's injuries and interviewed involved residents |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding staffing expectations and supervision on the secured unit |
| Administrator | Facility Administrator | Provided statements regarding staffing policies and incident investigation |
| LPN #34 | Licensed Practical Nurse | Supervised CNA #32 and provided information about staffing and unit coverage |
| CNA #33 | Certified Nurse Assistant | Reported no other staff present on the secured unit during the night shift |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 15, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations regarding allegations of abuse and concerns about care and documentation at Summerford Health and Rehab, LLC.
Complaint Details
The complaint investigation included report #AL00043481 related to abuse reporting and report #AL00041921 related to incomplete ADL documentation.
Findings
The facility failed to timely report suspected abuse by a Certified Nursing Assistant, affecting three residents, and failed to implement and maintain fall prevention interventions for a resident with recurrent falls. Additionally, the facility failed to ensure complete and accurate documentation of activities of daily living for one resident.
Deficiencies (3)
Failure to timely report suspected abuse by a Certified Nursing Assistant, resulting in delayed reporting of alleged physical abuse affecting three residents.
Failure to consider all causal factors related to falls and failure to implement care planned interventions such as fall mats and non-skid strips for Resident #38, who sustained multiple falls.
Failure to ensure medical records were complete and accurate for Resident #253, with missing documentation of assistance with activities of daily living across multiple shifts.
Report Facts
Residents affected: 3
Residents reviewed for abuse: 5
Residents reviewed for falls: 3
Residents reviewed for ADL documentation: 15
BIMS score: 9
BIMS score: 3
BIMS score: 6
Morse Fall Scale score: 75
Days with no documented bladder care: 22
Days with no documented ADL assistance: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in abuse reporting deficiency for delayed reporting |
| LPN #15 | Licensed Practical Nurse | Interviewed regarding abuse reporting expectations |
| LPN #13 | Licensed Practical Nurse | Interviewed regarding abuse reporting expectations |
| RN #17 | Registered Nurse and Trainer | Received abuse report from CNA #2 and instructed reporting to Administrator |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse reporting and fall prevention expectations |
| Administrator | Administrator | Interviewed regarding abuse reporting and fall prevention expectations |
| LPN #20 | Licensed Practical Nurse | Completed post-fall observation and interviewed about fall prevention |
| CNA #9 | Certified Nursing Assistant | Interviewed regarding fall mats and ADL documentation |
| CNA #10 | Certified Nursing Assistant | Interviewed regarding fall mats |
| CNA #29 | Certified Nursing Assistant | Interviewed regarding fall mats |
| RN #21 | Unit Manager Registered Nurse | Interviewed regarding fall investigations and care plan adherence |
| RN #16 | Unit Manager Registered Nurse | Interviewed regarding fall investigations |
| RN #19 | Registered Nurse | Interviewed regarding fall mats |
| RN #17 | Staff Educator Registered Nurse | Interviewed regarding fall investigations and prevention education |
| MDS Director | Minimum Data Set Director | Interviewed regarding fall prevention interventions |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding fall prevention and investigations |
| CNA #43 | Certified Nursing Assistant | Interviewed regarding ADL documentation |
| CNA #44 | Certified Nursing Assistant | Interviewed regarding ADL documentation |
Inspection Report
Routine
Deficiencies: 5
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, fall prevention, nutritional support, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to update care plans to reflect resident refusals of medication, inadequate assistance with activities of daily living such as nail care, incomplete fall prevention interventions and investigations, failure to provide ordered nutritional supplements, and improper use and disposal of personal protective equipment (PPE) related to infection control precautions.
Deficiencies (5)
Failure to update Resident #116's care plan to include interventions related to refusal of insulin administration.
Failure to provide adequate care and assistance with activities of daily living, specifically Resident #39's fingernails were long and dirty despite care plan interventions.
Failure to implement and maintain fall prevention interventions for Resident #38, including lack of fall mats and non-skid strips, and incomplete fall investigations.
Failure to provide physician ordered nutritional supplements (health shakes) to Resident #76, resulting in significant weight loss.
Failure to ensure staff appropriately used and discarded PPE for residents on transmission-based precautions, including Resident #308 with COVID-19 and Residents #38 and #47 with enhanced barrier precautions.
Report Facts
Residents whose care plans were reviewed: 30
Residents reviewed for ADL care: 11
Residents reviewed for falls: 3
Weight loss in pounds: 21
Weight loss in pounds: 18.4
Entries indicating health supplement not provided: 50
Entries indicating health supplement provided: 4
Entries indicating health supplement refused: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #25 | Licensed Practical Nurse | Stated care plan should address medication refusal |
| Registered Nurse #19 | Registered Nurse | Stated care plan should be updated to include medication refusal |
| Registered Nurse #28 | Registered Nurse | Stated care plan should reflect insulin refusals |
| Licensed Practical Nurse #26 | Licensed Practical Nurse | Stated care plan should be updated if resident refuses medications |
| Registered Nurse #21 | Registered Nurse | Stated refusal of medications should be in care plan |
| Administrator | Administrator | Expected timely revision of care plans and investigation of medication refusals |
| Registered Nurse #17 | Registered Nurse | Observed Resident #39's fingernails and expected trimming and cleaning |
| Certified Nursing Assistant #37 | Certified Nursing Assistant | Indicated Resident #39 was dependent on staff for nail care |
| Licensed Practical Nurse #39 | Licensed Practical Nurse | Normally cuts residents' nails; expected nails to be trimmed and cleaned |
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Reported Resident #38 fall and lack of fall prevention interventions |
| Registered Nurse #18 | Registered Nurse | Unit manager for Resident #308's hall; stated PPE should be discarded before exiting room |
| Certified Nursing Assistant #11 | Certified Nursing Assistant | Observed wearing PPE inconsistently and confused about PPE disposal |
| Infection Control Preventionist | Infection Control Preventionist | Stated staff should not wear contaminated masks outside resident rooms |
| Director of Nursing | Director of Nursing | Expected staff to follow PPE protocols and care plan interventions |
| Dietary Manager | Dietary Manager | Unaware why nutritional supplements were missed; expected dietary department to provide ordered supplements |
| Registered Dietitian | Registered Dietitian | Confirmed Resident #76 had significant weight loss and had not received ordered supplements |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 7, 2019
Visit Reason
The inspection was conducted based on complaints regarding failure to provide privacy during eye drop administration, unresolved resident grievance about missing personal items, failure to implement a care plan for fall prevention, and medication labeling issues.
Complaint Details
The complaint investigation included issues of privacy violation during medication administration, unresolved grievance about missing personal belongings, failure to follow fall prevention care plans, and medication labeling deficiencies. The grievance was not resolved timely, causing resident distress. Privacy was not provided during eye drop administration in a public dining area. Non-slip strips were missing in a resident's bathroom despite care plan orders. Multiple medication carts lacked expiration dates on medication labels.
Findings
The facility failed to ensure privacy during eye drop administration, did not resolve a resident grievance timely, failed to implement a care plan for non-slip strips in a resident's bathroom, and did not label medications with expiration dates on multiple medication carts. These deficiencies affected several residents and posed minimal harm or potential for actual harm.
Deficiencies (5)
Failure to provide privacy for a resident while administering eye drops in a dining area with other residents present.
Failure to resolve a resident's grievance regarding missing personal items in a timely manner per facility policy.
Failure to implement a care plan approach for non-slip strips in a resident's bathroom to prevent falls.
Failure to ensure non-skid strips were placed on a resident's bathroom floor to prevent falls.
Failure to ensure expiration dates were on the labels of medications on four of five medication carts in the facility.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts affected: 4
Medications without expiration dates: 11
Residents sampled for care plans: 35
Residents sampled for falls: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | EI #5, failed to provide privacy during eye drop administration | |
| Director of Nursing | EI #4, interviewed regarding privacy policy and medication labeling | |
| Social Worker | EI #1, involved in grievance process for missing items | |
| Housekeeping/Laundry Supervisor | EI #2, involved in grievance process for missing items | |
| Licensed Practical Nurse (LPN)/Charge Nurse | EI #3, interviewed about fall prevention care plan and non-slip strips | |
| Licensed Practical Nurse (LPN) | EI #6, interviewed about medication labeling deficiencies | |
| Pharmacist | EI #7, interviewed about medication labeling policies |
Inspection Report
Deficiencies: 0
Date: Sep 26, 2018
Visit Reason
The document is a statement of deficiencies and plan of correction for Summerford Health and Rehab, LLC, related to a regulatory survey completed on 2018-09-26.
Findings
No health deficiencies were found during the survey.
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