Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations and infection prevention and control practices at Twin Oaks Rehabilitation and Healthcare Center.
Findings
The facility failed to properly secure controlled medications, specifically Ativan, in the medication refrigerator as required by policy. Additionally, staff failed to follow proper infection control procedures, including hand hygiene between residents, appropriate disposal of lift slings, and sanitization of mechanical lifts, posing a risk of infection spread among residents.
Deficiencies (2)
Failure to ensure stock Ativan, a controlled medication, was stored in a secured non-removable container within the medication refrigerator.
Failure to provide and implement an infection prevention and control program, including inadequate hand hygiene, improper disposal of lift slings, and failure to sanitize mechanical lifts after resident use.
Report Facts
Residents sampled: 28
Residents affected: 4
Medication refrigerators reviewed: 2
Vials of Ativan found unsecured: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Employee Identifier #9 who removed the unsecured Ativan from the medication refrigerator | |
| Director of Nursing (DON) | Employee Identifier #2 who observed the medication storage issue and provided infection control interview | |
| Assistant Director of Nursing (ADON)/Infection Control (IP) | Employee Identifier #3 who provided detailed infection control procedure interview | |
| Certified Nursing Assistant (CNA) | Employee Identifier #4 observed failing to sanitize hands and improperly handling resident care | |
| Certified Nursing Assistant (CNA) | Employee Identifier #6 involved in improper use of lift sling and mechanical lift | |
| Certified Nursing Assistant (CNA) | Employee Identifier #7 involved in improper use of lift sling and mechanical lift | |
| Certified Nursing Assistant (CNA) | Employee Identifier #8 who pushed unsanitized mechanical lift |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 26, 2023
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations and infection prevention and control practices at Twin Oaks Rehabilitation and Healthcare Center.
Findings
The facility failed to properly secure controlled substances, specifically Ativan, in the medication refrigerator as required. Additionally, staff failed to follow proper infection control procedures, including hand hygiene between residents and proper sanitation and disposal of lift slings and mechanical lifts, posing a risk of infection spread.
Deficiencies (2)
Failure to ensure stock Ativan, a controlled medication, was stored in a secured non-removable container in the medication refrigerator.
Failure to provide and implement an infection prevention and control program, including failure to wash or sanitize hands between residents, dispose of lift slings appropriately, and sanitize mechanical lifts after use.
Report Facts
Residents sampled: 28
Residents affected: 4
Vials of Ativan: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (EI #9) | Observed removing unsecured Ativan from medication refrigerator | |
| Director of Nursing (EI #2) | Observed medication storage issue and provided statements on infection control | |
| Assistant Director of Nursing/Infection Control (EI #3) | Provided statements regarding infection control procedures and risks | |
| Certified Nursing Assistants (EI #4, EI #6, EI #7, EI #8) | Observed failing to follow infection control procedures related to hand hygiene and lift sanitation |
Inspection Report
Deficiencies: 2
Date: Aug 5, 2021
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical service requirements, specifically focusing on the proper documentation and signatures for destruction of controlled and non-controlled medications.
Findings
The facility failed to ensure the required number of signatures were present and documented on destruction forms for controlled and non-controlled medications across multiple months in 2020 and 2021. The deficiency involved missing signatures on medication destruction forms, violating facility policies requiring two signatures for non-controlled and three for controlled medications.
Deficiencies (2)
Failure to ensure the required number of signatures for destruction of controlled medications were present and documented on destruction forms.
Failure to ensure the required number of signatures for destruction of non-controlled medications were present and documented on destruction forms.
Report Facts
Months reviewed for destruction: 12
Months reviewed for destruction: 6
Signatures required: 3
Signatures required: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication destruction signature requirements |
Inspection Report
Deficiencies: 2
Date: Aug 5, 2021
Visit Reason
The inspection was conducted to assess compliance with pharmaceutical service requirements, specifically focusing on the proper documentation and signatures for destruction of controlled and non-controlled medications.
Findings
The facility failed to ensure the required number of signatures were present and documented on destruction forms for controlled and non-controlled medications during multiple months in 2020 and 2021. The deficiency involved missing signatures on medication destruction forms, violating facility policies requiring two signatures for non-controlled and three for controlled medications.
Deficiencies (2)
Failure to ensure the required number of signatures for destruction of controlled medications were present and documented on destruction forms.
Failure to ensure the required number of signatures for destruction of non-controlled medications were present and documented on destruction forms.
Report Facts
Months reviewed for destruction: 12
Months reviewed for destruction: 6
Signatures required: 3
Signatures required: 2
Signatures documented: 2
Signatures documented: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding medication destruction signature requirements and facility policies |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Nov 2, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nursing home care, including infection prevention, safety, and staff training.
Findings
The facility was found deficient in proper disposal of sharps, inadequate cleaning and disinfecting of blood glucose monitoring equipment leading to immediate jeopardy, and failure to provide required annual dementia and abuse training to certain nurse aides.
Deficiencies (3)
Failure to ensure lancets were disposed of in sharps containers rather than trash, risking needle stick injuries.
Failure to clean and disinfect the Assure Prism multi Blood Glucose Monitoring System according to manufacturer's instructions between resident uses, placing residents in immediate jeopardy.
Failure to provide required yearly dementia and/or abuse training to three Certified Nursing Assistants.
Report Facts
Residents requiring finger stick blood sugar monitoring: 48
Residents affected by lancet disposal deficiency: 1
Residents affected by glucometer cleaning deficiency: 3
Certified Nursing Assistants without required training: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (EI #15) | Named in lancet disposal deficiency. | |
| Registered Nurse (EI #1) | Named in glucometer cleaning deficiency. | |
| Assistant Director of Nursing (EI #3) | Provided interviews regarding proper glucometer cleaning and lancet disposal. | |
| Director of Nursing (EI #2) | Acknowledged training deficiencies and infection control issues. | |
| Certified Nursing Assistants (EI #7, EI #11, EI #12) | Named in deficiency for lack of required annual dementia and/or abuse training. |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 2, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, including infection prevention and control, accident hazard prevention, and staff training requirements.
Findings
The facility was found deficient in proper disposal of lancets, inadequate cleaning and disinfecting of blood glucose monitoring equipment leading to immediate jeopardy, and failure to provide required annual dementia and abuse training to certain nurse aides.
Deficiencies (3)
Failure to ensure lancets were disposed of in sharps containers, instead placed in resident's trash can.
Failure to clean and disinfect the Assure Prism multi Blood Glucose Monitoring System according to manufacturer's instructions between resident uses, placing residents in immediate jeopardy.
Failure to ensure nurse aides received required yearly dementia and/or abuse training.
Report Facts
Residents requiring finger stick blood sugar monitoring: 48
Residents observed for finger stick blood sugar monitoring: 9
Nurses observed performing finger stick blood sugars: 7
Employee files reviewed for training: 34
Residents affected by lancet disposal deficiency: 1
Residents affected by infection control deficiency: 3
Employees affected by training deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (EI #15) | Named in lancet disposal deficiency finding. | |
| Registered Nurse (EI #1) | Named in glucometer cleaning and disinfecting deficiency finding. | |
| Assistant Director of Nursing (EI #3) | Interviewed regarding proper lancet disposal and glucometer cleaning procedures. | |
| Director of Nursing (EI #2) | Interviewed regarding staff training and infection control practices. | |
| Certified Nursing Assistants (EI #7, EI #11, EI #12) | Named in deficiency for missing required annual dementia and/or abuse training. |
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