Cordova Health and Rehabilitation, LLC

Inspectors wroteBased on observation, interviews, record reviews, and the facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and review of a Facility Reported Incident (FRI) received by the Alabama Department of Public Health, the facility failed to provide adequate supervision and appropriate interventions to prevent sexual abuse perpetrated by Resident Identifier (RI) #325 against RI #82, a resident with known manipulative romantic behaviors, history of entering male residents' rooms, and history of consenting to sexual relationships. Multiple of the facility's staff were aware of RI #82's behaviors of entering male residents' rooms and manipulative romantic behaviors. The facility did not develop or implement interventions to address RI #82's repeated behaviors and ensure he/she was protected. [...]

Inspectors wroteBased on interviews, record review, and review of facility policies titled, Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation, and Incidents and Accidents, the facility failed to thoroughly investigate an incident of abuse to prevent further occurrences. After staff witnessed an incident of sexual abuse on 06/03/2024 involving RI #82 and RI #325, the Director of Nursing (DON) reported the 06/03/2024 incident to the Administrator (ADM). There was no evidence the investigation included interviews with either resident involved. The investigation failed to identify that the facility's failure to provide supervision to RI #82, a resident with a known history of romantically manipulative behaviors and history entering male resident rooms without supervision. [...]

Inspectors wroteBased on observation, interview, medical record review, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to prevent the potential for cross-contamination by allowing: 1. staff who were chewing gum to assist residents with meals, 2. clean pots and pans to be stored on a rusty wire shelving rack, 3. a dirty floor in the storeroom for thickened liquids and nutritional supplements and additionally allowing a delivery of nutritional supplements to be placed on the dirty floor, 4. wooden shelving with gaps along the floor line, which could not be cleaned beneath, in the thickened liquids and nutritional supplement storeroom, and 5. the double sink used for food preparation to have a direct connection to the sewer.

Inspectors wroteBased on observation, interview, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure the Three-compartment Pot and Pan Sink was in good repair for use. Two of three drain levers did not work, resulting in the rinse sink and the sanitizing sink being unable to hold water. This had the potential to affect 108 of 108 residents receiving meals from the kitchen.

Inspectors wroteBased on observation, interview, the facility's policy for Sanitation Principles, and the United States (U.S.) Food and Drug Administration (FDA) 2022 Food Code; the facility failed to ensure one large return vent in the Dining Room and seven of thirteen exit vents on C and D halls were clean. The facility also failed to ensure one of two clocks on C Hall was working. In addition, the facility failed to ensure five of six vinyl covered chairs in the front lobby and front hallway did not have torn or cracked upholstery. This affected two of four halls and one of one dining room.

Inspectors wroteBased on record review, interviews, documents titled Online Incident Reporting System Report and a facility policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation the facility failed to report allegations related to physical and verbal abuse within 2 hours to the state agency on 04/09/2024, 07/03/2024 and 10/27/2024. This affected Resident Identifiers (RI) #27, #43 and #91. This deficient practice affected three of eleven residents sampled for abuse. Findings Include: A review of a policy titled Abuse, Neglect, Misappropriation of Resident/Guest Property, Suspicious Injuries of Unknown Source, Exploitation with an effective date of May 01, 2023, documented the following: .b) Investigation and Reporting Steps .All allegations of abuse and instances that result in serious bodily injury must be reported with 2 hours. 1. [...]

Inspectors wroteBased on record review, interview, and review of the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure Resident Identifier (RI) #2's completed Minimum Data Set (MDS) assessments was transmitted to the CMS system. This affected RI #2, one of 22 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on interviews, record review, and the Centers for Medicare & Medicaid Services (CMS)Center) Long- Term Care Resident Assessment Instrument 3.0 Manual, the facility failed to 1) ensure Resident Identified (RI) #60's Annual Minimum Data Set (MDS) assessment dated [DATE] section A1500 was coded accurately to reflect RI #60's Preadmission Screening and Resident Review (PASRR) Level II. 2) ensure RI #82's Annual MDS assessment dated [DATE] section A1500 was coded accurately to reflect RI #82's PASRR Level II. This deficient practice affected two of 22 sampled residents whose MDS was reviewed.

Inspectors wroteBased on observation, interview, medical record review, and the facility's policy for Enhanced Dining; the facility failed to ensure residents' lunch meals were not left upon transport trays when served to residents in the dining room on Tuesday, 11/12/2024 and Wednesday, 11/13/2024. This affected 40 of 40 residents receiving meals in the facility's dining room.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Employee Identifier (EI) #7, a Licensed Practical Nurse (LPN) washed her hands prior to putting gloves on. Without washing or sanitizing her hands, EI #7 put gloves on and administered an inhaler medication to Resident Identifier (RI) #45. This deficient practice affected RI #45, one of four residents observed for medication administration.

Inspectors wroteBased on observation, a test tray, interview, the 2017 Food Code, and the facility's policies for Tray Assembly and Food Preparation Guidelines, the facility failed to ensure hot food items were served hot and further failed to ensure equipment designed to maintain the cold temperature of individual cartons of skim milk was used during the lunch trayline on 9/5/2018. This affected Resident Identifier (RI) #28, RI #61, fifteen of fifteen residents attending Resident Council on 9/5/2018 at 1:00 PM, and had the potential to affect 108 residents receiving meals from the kitchen, 108 of 111 residents. Findings Include: The facility's policy for Tray Assembly, dated 2/1/2002, included: . Purpose: . provide foods that are at proper temperature . Process: . e. equipment designed to maintain temperature should be used. [...]

Inspectors wroteBased on observation, interview, the 2017 Food Code, and the facility's policies for Food Preparation Guidelines, Food Receipt and Storage, and Cleaning of Miscellaneous Equipment and Utensils, the facility failed to ensure the potential for cross-contamination did not occur due to food items and supplies being stored less than six inches off the floor and the accumulation of dust on the ceiling and walls of the walk-in cooler. The facility further failed to maintain the cold temperature of an individual carton of skim milk at 41 degrees F (Fahrenheit) or below during the resident lunch trayline on 9/5/2018. This had the potential to affect 108 residents receiving meals from the kitchen, 108 of 111 residents. Findings Include: The facility's policy for Food Preparation Guidelines, dated 8/15/2009, included the following: . Process: . g. [...]

Inspectors wroteBased on observations, interviews, medical record reviews and review of facility policies titled, Hand Hygiene, Medication Administration and Contact Precautions, the facility failed to ensure: 1) a Licensed Practical Nurse (LPN) washed her hands and changed her gloves appropriately during the medication administration and also place a barrier between the over bed table and medication supplies for Resident Identifier (R) #110; 2) a sign was posted outside RI #1's room to notify staff, residents and visitors to check with the nurse prior to entering the room and 3) a Certified Nursing Assistant (CNA) placed on appropriate Personal Protective Equipment (PPE) prior to entering the room of RI #1. 1)This affected 1 of 5 residents and 1 of 5 nurses during the observations of medication administration. 2) This affected 1 of 1 sampled resident on contact isolation. Findings Include: [...]