Inspection Reports for
Village at Cook Springs Skilled Nursing Facility
415 Cook Springs Road, Pell City, AL, 35125
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 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
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 20, 2023
Visit Reason
The inspection was conducted due to complaints regarding improper perineal care and infection control practices during incontinent care for residents at the facility.
Complaint Details
The complaint investigation found substantiated issues with perineal care technique and hand hygiene practices that posed potential harm to residents.
Findings
The facility failed to ensure proper perineal care was provided to Resident Identifier #6, with care performed incorrectly by a Certified Nursing Assistant. Additionally, a Certified Nursing Assistant (#3) did not follow proper hand hygiene protocols during perineal care for Resident Identifier #8, creating a potential risk for cross-contamination and infection.
Deficiencies (2)
Failure to provide correct and thorough perineal care to Resident Identifier #6 during incontinent care on 12/19/2023.
Failure to follow proper hand hygiene and infection control practices by Certified Nursing Assistant #3 during perineal care for Resident Identifier #8 on 12/19/2023.
Report Facts
Residents affected: 1
Residents affected: 1
Date of deficient care observation: Dec 19, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nursing Assistant | Named in deficiency for improper perineal care to Resident Identifier #6 |
| CNA #3 | Certified Nursing Assistant | Named in deficiency for improper hand hygiene during perineal care for Resident Identifier #8 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding perineal care and infection control practices |
| CNA #5 | Certified Nursing Assistant | Interviewed regarding perineal care provided to Resident Identifier #6 |
| Infection Preventionist | Infection Preventionist / Assistant Director of Nursing | Interviewed regarding infection control policies and practices |
Inspection Report
Deficiencies: 0
Date: May 5, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Village at Cook Springs Skilled Nursing Facility, representing a regulatory inspection visit.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 28, 2019
Visit Reason
The inspection was conducted as a result of complaint/report number AL00036361 involving allegations of abuse, neglect, and failure to develop appropriate care plans for residents, as well as failure to timely report abuse and ensure proper infection control.
Complaint Details
The complaint investigation involved allegations of sexual abuse by a visitor who was the spouse of a resident, failure to timely report abuse allegations involving multiple residents, failure to develop appropriate care plans for residents at risk of falls and injuries, and failure to ensure safe transfer practices and infection control. The investigation confirmed these deficiencies and immediate jeopardy was identified.
Findings
The facility failed to protect residents from abuse by a visitor, failed to timely report allegations of abuse to the State Agency, failed to develop and implement complete care plans addressing residents' needs including proper use of equipment and transfer assistance, and failed to ensure proper infection prevention practices by staff. These deficiencies placed residents in immediate jeopardy of serious injury, harm, impairment, or death.
Deficiencies (5)
Failure to protect residents from abuse by a visitor who sexually abused two residents.
Failure to timely report allegations of physical abuse involving residents to the State Agency.
Failure to develop and implement complete care plans addressing use of scoot chair and Dycem, and transfer assistance for residents, resulting in falls and injuries.
Failure to ensure adequate supervision and safe transfer practices, resulting in resident falls and head injuries.
Failure to provide and implement an infection prevention and control program, specifically failure of a CNA to wash hands between handling soiled and clean incontinence briefs.
Report Facts
Residents affected by abuse: 2
Date of first abuse incident: Feb 11, 2019
Date of second abuse incident: Apr 29, 2019
Date of report submission for abuse: Jul 19, 2019
Date of report submission for abuse: Jul 10, 2019
Date of fall incident for RI #204: Mar 21, 2019
Date of fall incident for RI #205: Mar 25, 2019
Date of survey completion: Jul 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Director of Nursing / Abuse Coordinator | Acknowledged failure to report abuse and failure to update care plans. |
| EI #5 | Certified Nursing Assistant | Transferred resident RI #205 alone using Standup Lift, resulting in fall. |
| EI #7 | Registered Nurse Supervisor | Witnessed fall of RI #204 from scoot chair and documented incident. |
| EI #11 | Certified Nursing Assistant | Failed to wash hands between handling soiled and clean briefs for RI #117. |
| EI #16 | Minimum Data Set Coordinator | Acknowledged care plan deficiencies for transfers and use of Standup Lift. |
| EI #23 | Licensed Practical Nurse / Restorative Nurse | Assessed RI #205 as totally dependent on two staff for transfers. |
| EI #33 | Occupational Therapy Assistant | Provided statements on proper use of Dycem and scoot chair. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 16, 2018
Visit Reason
The inspection was conducted based on observations, interviews, and record reviews related to complaints about resident care, medication administration, medication storage, food safety, and infection control at the Village at Cook Springs Skilled Nursing Facility.
Complaint Details
The visit was complaint-related, triggered by concerns about resident care, medication errors, medication storage security, food safety violations, and infection control practices. Specific substantiation status is not stated.
Findings
The facility was found deficient in maintaining appropriate room temperature for a resident, medication administration errors including preparing incorrect medication and leaving medication unattended, unsecured refrigerated medication storage, expired food items in the cooler, improper hand hygiene and infection control practices, and failure to ensure clean plates and proper food handling.
Deficiencies (5)
Failed to ensure air conditioner temperature in Resident #37's room was not below 71 degrees.
Licensed staff prepared Potassium liquid instead of Keppra for Resident #81 and left medication unattended at bedside.
Secured medication box in refrigerator on Hall I was not locked, potentially affecting six residents' medications.
Expired honey thickener waters found in cooler; staff failed to wash hands after dropping thermometer cover; dirty plates observed in plate warmer.
Licensed staff failed to carry stethoscope with clean gloves, did not wash hands between glove changes during wound care, and stored medication packaging in water cup used for resident medication.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 6
Expired items: 11
Residents affected: 151
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding air conditioner temperature in Resident #37's room | |
| Certified Nursing Assistant | Assigned to care for Resident #37 and interviewed about temperature control | |
| Licensed Practical Nurse (EI #3) | Observed and interviewed regarding medication administration errors for Resident #81 | |
| Registered Nurse (EI #8) | Observed and interviewed regarding unsecured medication box in refrigerator | |
| Director of Nursing (EI #2) | Interviewed regarding medication storage and hand hygiene policies | |
| Dining Service Manager (EI #9) | Interviewed regarding expired food items in cooler | |
| Dietary/Utility Staff (EI #10) | Observed and interviewed regarding hand hygiene after dropping thermometer cover | |
| Cook (EI #11) | Observed and interviewed regarding dirty plates | |
| Dietary Aide (EI #13) | Interviewed regarding plate cleanliness | |
| Registered Nurse (EI #4) | Observed and interviewed regarding hand hygiene during wound care for Resident #73 | |
| Registered Nurse (EI #5) | Observed and interviewed regarding medication preparation for Resident #138 |
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