Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 2
Date: Jan 23, 2020
Visit Reason
The inspection was conducted to assess compliance with resident rights and food safety standards at Ashland Place Health and Rehabilitation, LLC.
Findings
The facility failed to ensure staff fed a resident (RI #77) in a dignified manner by standing while feeding, which could affect the resident's dignity. Additionally, the facility failed to remove 21 cups of expired yogurt from the cooler, posing a potential foodborne illness risk to residents.
Deficiencies (2)
Staff failed to sit while feeding Resident Identifier #77, standing instead during the entire supper meal on 1/21/20.
Facility failed to ensure 21 cups of expired yogurt were not left in the cooler, potentially affecting 21 residents.
Report Facts
Expired yogurt cups: 21
Residents affected by expired yogurt: 21
Residents observed being fed: 3
Residents affected by feeding deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | Observed standing while feeding Resident Identifier #77 | |
| Employee Identifier (EI) #4, CNA | Interviewed about feeding practices and standing while feeding Resident Identifier #77 | |
| Employee Identifier (EI) #3, Social Service Director | Interviewed about proper feeding practices and potential harm of standing while feeding | |
| Employee Identifier (EI) #5, Dietary Manager | Interviewed about expired yogurt found in cooler and food safety policies |
Inspection Report
Complaint Investigation
Capacity: 134
Deficiencies: 4
Date: Nov 29, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation (#AL00035945) concerning residents' awareness of survey results, environmental safety and cleanliness, food safety, and facility assessment.
Complaint Details
The inspection was conducted as a result of complaint/report #AL00035945.
Findings
The facility failed to ensure residents were aware of survey results and their location, maintain a safe and clean environment with multiple maintenance issues, properly discard expired food items, and ensure proper hand hygiene by staff. The facility also failed to conduct an adequate facility-wide assessment to identify maintenance needs.
Deficiencies (4)
Failed to ensure residents were aware of survey results and where they were located in the facility.
Failed to maintain residents' rooms and common areas to provide a safe, clean, comfortable, and homelike environment, including broken fixtures, rust, peeling paint, and debris buildup.
Failed to ensure honey thickened milks were discarded before expiration and failed to ensure proper hand washing to prevent cross contamination by dietary staff.
Failed to conduct and document a facility-wide assessment to determine necessary resources for competent resident care and maintenance.
Report Facts
Residents affected: 134
Residents affected: 122
Expired honey thickened milks: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Work Director | Interviewed regarding residents' awareness of survey results. | |
| Licensed Practical Nurse (EI #6) | Reported broken closet door and put in a work order. | |
| Maintenance and Housekeeping Director (EI #2) | Provided observations of environmental deficiencies and concerns. | |
| Dietary Manager (EI #3) | Interviewed about expired food items and stock rotation. | |
| Dietary Aide (EI #4) | Observed failing to wash hands properly leading to cross contamination. | |
| Administrator (EI #1) | Interviewed about housekeeping and maintenance expectations and facility assessment. |
Inspection Report
Routine
Census: 127
Deficiencies: 5
Date: Nov 16, 2017
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident privacy, dignity, diet order adherence, plan of care implementation, and incontinence care in a nursing home facility.
Findings
The facility failed to ensure privacy during residents' phone calls, staff did not knock before entering residents' rooms, diet orders were not consistently followed, plans of care were not fully implemented regarding meals, and incontinence care was inadequate leading to potential cross-contamination and risk of infection.
Deficiencies (5)
Failed to ensure privacy was provided while a resident used the phone.
Failed to ensure staff knocked on residents' doors prior to entering the room.
Failed to ensure the Physician's diet order was followed; no meat served at breakfast for a resident.
Failed to ensure the plan of care was followed regarding meals served with items missing for residents.
Failed to ensure staff provided incontinence care to prevent cross-contamination on a resident with a pressure ulcer.
Report Facts
Residents affected: 5
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents observed for incontinence care: 5
Residents in facility: 127
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #9 | Registered Nurse/Unit Manager | Interviewed about privacy during phone calls |
| EI #13 | Director of Nursing Services | Interviewed about privacy and knocking policy |
| EI #14 | Certified Nursing Assistant | Interviewed about missing meal items and meal card adherence |
| EI #6 | Cook | Interviewed about missing turkey on resident's meal |
| EI #7 | Dietary Manager | Interviewed about missing meal items and substitution policy |
| EI #10 | Registered Dietitian | Interviewed about dietary concerns and alternate food offerings |
| EI #1 | Certified Nursing Assistant | Observed and interviewed regarding incontinence care |
| EI #2 | Certified Nursing Assistant | Observed and interviewed regarding incontinence care |
| EI #4 | Assistant Director of Nursing/Infection Control Nurse | Interviewed about incontinence care and infection risks |
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