Deficiencies (last 3 years)
Deficiencies (over 3 years)
13.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
281% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Enforcement
Deficiencies: 9
Date: May 13, 2024
Visit Reason
The inspection was conducted due to multiple complaints and incidents involving resident care, including failure to honor advance directives, medication misappropriation, insufficient staffing, and inaccurate reporting.
Complaint Details
The complaint investigation involved allegations of failure to honor DNR orders, medication misappropriation, insufficient staffing, and failure to provide competent nursing care. The immediate jeopardy related to failure to honor resident's end-of-life wishes and insufficient staffing during a critical event was removed after corrective actions were verified.
Findings
The facility failed to ensure proper medication administration and self-administration assessment, honor residents' advance directives including DNR orders, maintain accurate controlled medication records, provide sufficient nursing staff, ensure staff competency and CPR certification, and submit accurate staffing data to CMS. Immediate jeopardy was identified related to failure to honor DNR orders and insufficient staffing during a critical event.
Deficiencies (9)
Failure to assess resident for self-administration of medication before providing a suppository for self-administration.
Failure to honor resident's advance directive for Do Not Resuscitate (DNR) resulting in inappropriate CPR and resuscitation efforts.
Failure to protect resident from misappropriation of medications and failure to maintain accurate controlled medication records.
Failure to provide basic life support including CPR in accordance with resident's advance directives and failure to ensure staff CPR certification and documentation.
Failure to provide sufficient nursing staff to meet resident needs, resulting in no nurses present during a critical event.
Failure to ensure nurses and nurse aides have appropriate competencies and training to care for residents, including CPR training and skills verification.
Failure to maintain accurate controlled medication records and documentation of medication administration.
Failure to electronically submit complete and accurate direct care staffing information to CMS.
Failure of Quality Assurance Performance Improvement (QAPI) committee to systemically address causal factors related to CPR on a resident with DNR and failure to notify the Governing Body of the adverse event.
Report Facts
Deficiency counts: 10
Missing medication doses: 34
Medication administration discrepancy: 35
Staffing hours: 14
Residents affected: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Named in failure to honor DNR and leaving unit during critical event |
| RN #9 | Registered Nurse | Named in failure to check code status before initiating CPR |
| LPN #11 | Licensed Practical Nurse | Named in CPR provision without current CPR certification |
| CNA #8 | Certified Nursing Assistant | Found resident unresponsive and summoned assistance |
| Director of Nursing | Director of Nursing | Interviewed regarding policies and incident response |
| Administrator | Administrator | Interviewed regarding facility policies and QAPI response |
| LPN #4 | Licensed Practical Nurse | Named in medication record discrepancy and terminated for misconduct |
| LPN #5 | Licensed Practical Nurse | Named in medication misappropriation and terminated for misconduct |
| CPR Instructor (INST) | CPR Instructor/Staffing Coordinator | Assisted during CPR and interviewed about staffing |
| Regional President | Regional President | Interviewed regarding notification of adverse event and system failures |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: May 13, 2024
Visit Reason
The inspection was conducted due to complaints and incidents involving failure to honor residents' advance directives, medication misappropriation, and staffing concerns.
Complaint Details
The complaint investigation was triggered by allegations that CPR was performed on a resident with a Do Not Resuscitate order (RI #159), medication misappropriation involving controlled substances for RI #400, and staffing inadequacies. The immediate jeopardy related to failure to honor DNR and staffing issues was removed after corrective actions were verified.
Findings
The facility failed to honor a resident's Do Not Resuscitate (DNR) order resulting in inappropriate CPR, failed to ensure accurate controlled medication records and prevent medication misappropriation, failed to provide sufficient nursing staff, failed to ensure staff competency in CPR, and failed to maintain accurate staffing data reporting. Immediate jeopardy was identified but later removed after corrective actions.
Deficiencies (6)
Failure to honor Resident Identifier (RI) #159's Advanced Directive for Do Not Resuscitate (DNR) resulting in inappropriate CPR and resuscitation efforts.
Failure to ensure accurate controlled medication records and prevent misappropriation of medications for Resident Identifier (RI) #400.
Failure to provide sufficient nursing staff on the South Unit resulting in inadequate coverage during a critical event.
Failure to ensure all nursing staff had current CPR certification and to provide adequate CPR training and skills verification.
Failure to submit accurate Payroll Based Journal (PBJ) staffing data to CMS for the quarter 10/01/2023 through 12/31/2023.
Failure of the Quality Assurance Performance Improvement (QAPI) committee to systemically address causal factors related to the inappropriate CPR event and failure to notify the Governing Body.
Report Facts
Missing Hydrocodone-Acetaminophen doses: 34
CPR duration: 56
Staffing hours: 14
PBJ reporting quarter: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Left unit during critical event, returned with DNR documentation, terminated for gross negligence. |
| LPN #11 | Licensed Practical Nurse | Performed CPR on RI #159 without current CPR certification. |
| RN #9 | Registered Nurse | Initiated CPR on RI #159 without verifying code status. |
| CNA #8 | Certified Nursing Assistant | Found RI #159 unresponsive and summoned nurses. |
| LPN #4 | Licensed Practical Nurse | Recreated narcotic count sheet and implicated in medication misappropriation. |
| Director of Nursing | Director of Nursing | Interviewed regarding medication discrepancies and CPR policy failures. |
| Administrator | Administrator | Notified of immediate jeopardy findings and involved in QAPI and corrective actions. |
| Regional President | Regional Vice President | Notified late about adverse event and CPR certification lapse. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation involving Resident Identifier (RI) #159 regarding failure to honor the resident's Do Not Resuscitate (DNR) Advanced Directive and related concerns about CPR administration and staffing.
Complaint Details
The complaint involved allegations that CPR was performed on RI #159 despite a valid DNR order, and that several nurses were not CPR certified. The complaint number is AL00047231.
Findings
The facility failed to honor RI #159's DNR wishes by initiating CPR despite the resident's documented DNR status. Staff did not verify code status before CPR, and one nurse performing CPR lacked current CPR certification. Additionally, staffing shortages were noted during the incident, and the facility's Quality Assurance Performance Improvement (QAPI) committee failed to adequately address the incident or notify the Governing Body.
Deficiencies (5)
Failure to verify resident's DNR code status before initiating CPR on RI #159.
Licensed Practical Nurse (LPN) #11 performed CPR without current CPR certification.
Insufficient nursing staff on the South Unit during the incident, resulting in no nurse present when RI #159 was found unresponsive.
Failure of the Quality Assurance Performance Improvement (QAPI) committee to thoroughly review the incident, implement corrective actions, or notify the Governing Body.
Failure to submit accurate Payroll Based Journal (PBJ) staffing data to CMS for the quarter 10/01/2023 through 12/31/2023.
Report Facts
Residents reviewed for CPR: 2
Staff involved in CPR: 5
Time CPR performed: 56
Staffing schedule hours: 14
Facility census: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Left the unit during the code to sit in her car; returned and informed staff of DNR status. |
| LPN #11 | Licensed Practical Nurse | Performed CPR on RI #159 without current CPR certification. |
| RN #9 | Registered Nurse | First to initiate CPR on RI #159 without verifying code status. |
| Director of Nursing | Director of Nursing | Acknowledged policy was not followed and staff failed to verify code status. |
| Administrator | Administrator | Notified of immediate jeopardy findings; involved in QAPI and disciplinary actions. |
| CPR Instructor (INST) | CPR Instructor/Staffing Coordinator | Assisted during code and called Code Blue; involved in staffing. |
| Regional President | Regional President | Notified late of the incident and CPR certification lapse; emphasized need for system changes. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation involving Resident Identifier (RI) #159 regarding failure to honor the resident's Advanced Directive for Do Not Resuscitate (DNR) and related issues including staff performing CPR despite the DNR order.
Complaint Details
Complaint investigation triggered by report number AL00047231 regarding failure to honor DNR order and related staffing and procedural deficiencies.
Findings
The facility failed to ensure that RI #159's end-of-life wishes were honored when staff initiated CPR despite a valid DNR order. Staff did not verify the resident's code status before initiating CPR, and one nurse performing CPR did not have current CPR certification. Additionally, staffing shortages and failure to properly notify the governing body and implement corrective actions were identified.
Deficiencies (5)
Failure to verify resident's code status before initiating CPR resulting in CPR performed on a resident with a valid DNR order.
Licensed Practical Nurse (LPN) #11 performed CPR without current CPR certification.
Failure to provide sufficient nursing staff on the South Unit during the incident.
Failure of the Quality Assurance Performance Improvement (QAPI) committee to thoroughly review the adverse event and implement effective corrective actions.
Failure to submit accurate Payroll Based Journal (PBJ) staffing data to CMS.
Report Facts
Deficiencies cited: 5
Staffing hours: 14
Time CPR performed: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #7 | Licensed Practical Nurse | Left unit during code, returned with DNR documentation, and was terminated for gross negligence. |
| LPN #11 | Licensed Practical Nurse | Performed CPR on RI #159 without current CPR certification. |
| RN #9 | Registered Nurse | Initiated CPR on RI #159 without verifying code status. |
| Administrator | Facility Administrator | Notified of immediate jeopardy findings and involved in QAPI and corrective actions. |
| Director of Nursing | Director of Nursing | Interviewed regarding policies and failures related to CPR and DNR. |
| CPR Instructor (INST) | CPR Instructor/Staffing Coordinator | Assisted during code and involved in staffing. |
| Executive Director/Administrator | Executive Director/Administrator | Provided information on staffing and PBJ reporting. |
| Regional President | Regional President | Reported not being notified timely of adverse event and CPR certification lapse. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 20, 2021
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to accommodate the needs of Resident #63 with an appropriate wheelchair and to ensure Resident #80 was free from abuse.
Complaint Details
The complaint involved Resident #63 not having an appropriate wheelchair to self-propel due to lack of footrests and improper fit, and Resident #80 being verbally abused by a housekeeping aide who called the resident a 'bitch'. The aide was suspended immediately and later terminated. The facility conducted abuse training following the incident.
Findings
The facility failed to provide a wheelchair appropriate for Resident #63, preventing self-propelling due to lack of footrests or proper fit. Additionally, the facility failed to protect Resident #80 from verbal abuse by a housekeeping aide, resulting in the aide's termination.
Deficiencies (2)
Failed to accommodate the needs of Resident #63 by providing a wheelchair appropriate for self-propelling, lacking footrests and proper fit.
Failed to protect Resident #80 from verbal abuse by a staff member, resulting in immediate suspension and termination of the employee.
Report Facts
Residents sampled: 20
Residents sampled: 24
Dates of observations: 3
Date of incident: Mar 30, 2021
Date of termination: Apr 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Confirmed Resident #63 had no footrests on wheelchair and inability to self-propel | |
| Director of Rehab | Responsible for fitting wheelchairs and attempted to fit footrests for Resident #63 | |
| Director of Nursing | Revealed facility lacked policy on proper wheelchair fitting | |
| Assistant Executive Director | Received complaint call regarding Resident #80 abuse incident | |
| Housekeeping Aide | Involved in verbal abuse incident with Resident #80, terminated | |
| Assistant Social Worker | Aware of abuse incident involving Resident #80 | |
| Administrator and Abuse Coordinator | Conducted abuse investigation and terminated housekeeping aide | |
| Certified Nursing Assistant | Witnessed verbal abuse incident involving Resident #80 | |
| Floor Technician | Witnessed verbal abuse incident and notified appropriate staff | |
| Social Worker | Made aware of abuse incident after the fact |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 20, 2021
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to accommodate the needs of a resident with an appropriate wheelchair and an allegation of verbal abuse involving a resident and a staff member.
Complaint Details
The complaint involved Resident #63 not having a properly fitted wheelchair to accommodate mobility needs and Resident #80 being verbally abused by a housekeeping aide who called the resident a 'bitch'. The abuse was substantiated, the employee was suspended immediately and later terminated. The facility conducted abuse training for staff following the incident.
Findings
The facility failed to provide a wheelchair with footrests appropriate for Resident #63, preventing self-propelling, and failed to protect Resident #80 from verbal abuse by a housekeeping aide. The facility lacked a policy for proper wheelchair fitting and terminated the employee involved in the abuse incident after investigation.
Deficiencies (2)
Failed to provide a wheelchair appropriate for Resident #63 to self-propel due to lack of footrests.
Failed to protect Resident #80 from verbal abuse by a housekeeping aide who called the resident a derogatory name.
Report Facts
Residents sampled: 20
Residents sampled: 24
Dates of observations and interviews: Observations and interviews conducted on 4/18/21, 4/19/21, and 4/20/21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Unit Manager | Interviewed regarding wheelchair fitting for Resident #63 | |
| Director of Rehab | Interviewed and observed attempting to fit wheelchair for Resident #63 | |
| Director of Nursing | Interviewed regarding facility policy on wheelchair fitting | |
| Assistant Executive Director (EI #4) | Received complaint call and managed abuse incident involving Resident #80 | |
| Housekeeping Aide (EI #5) | Involved in verbal abuse incident with Resident #80; terminated | |
| Assistant Social Worker (EI #6) | Aware of abuse incident and involved in investigation | |
| Social Worker (EI #7) | Aware of abuse incident | |
| Administrator and Abuse Coordinator (EI #8) | Conducted abuse investigation and terminated EI #5 | |
| Certified Nursing Assistant (CNA) (EI #9) | Witnessed verbal exchange during abuse incident | |
| Floor Technician (EI #10) | Witnessed verbal exchange and notified management during abuse incident |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 13, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to nurse staffing information posting, food storage and labeling, and infection prevention and control practices.
Findings
The facility failed to post nurse staffing information daily with correct dates, improperly stored outdated and unlabeled food items in the walk-in cooler, stored dented cans with other stock, allowed clean linens to touch employee uniforms, and stored personal food items in the medication refrigerator. These deficiencies posed potential minimal to actual harm risks to residents and staff.
Deficiencies (6)
Failed to post nurse staffing information daily with correct dates.
Outdated food was stored in the walk-in cooler.
Foods stored in the walk-in cooler were not labeled with open and/or use by dates.
Dented cans were stored with other stock instead of separately.
Clean linens were allowed to touch employee uniforms during laundry tasks.
Personal food items were stored in the medication refrigerator.
Report Facts
Residents affected: 111
Dented cans observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Administrator | Interviewed regarding nurse staffing information posting |
| Employee Identifier #3 | Activity Director | Responsible for posting nurse staffing information |
| Employee Identifier #4 | Cook | Observed storing dented cans with other stock |
| Employee Identifier #5 | Dietician | Interviewed regarding food storage and labeling policies and potential harms |
| Employee Identifier #6 | Laundry Aide | Observed allowing clean linens to touch uniform |
| Employee Identifier #2 | Registered Nurse, Infection Control | Interviewed regarding infection control practices |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 13, 2019
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements including nurse staffing information posting, food safety and storage, and infection prevention and control.
Findings
The facility failed to post nurse staffing information daily with correct dates, improperly stored outdated and unlabeled food items in the walk-in cooler, stored dented cans with other stock, allowed clean linens to touch employee uniforms, and stored personal food items in the medication refrigerator, posing potential minimal to actual harm to residents and staff.
Deficiencies (6)
Failed to post nurse staffing information daily with correct dates.
Stored outdated food in the walk-in cooler past discard date.
Stored foods in the walk-in cooler without proper labeling of open and use by dates.
Stored dented cans with other stock instead of separately.
Allowed clean linens to touch employee uniform during laundry tasks.
Stored personal food items in medication refrigerator.
Report Facts
Residents affected: 111
Dented cans observed: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Administrator | Interviewed regarding nurse staffing information posting |
| Employee Identifier #3 | Activity Director | Responsible for posting nurse staffing information |
| Employee Identifier #4 | Cook | Observed storing dented cans with other stock |
| Employee Identifier #5 | Dietician | Interviewed regarding food storage and labeling policies |
| Employee Identifier #6 | Laundry Aide | Observed allowing clean linens to touch uniform |
| Employee Identifier #2 | Registered Nurse, Infection Control | Interviewed regarding infection control practices |
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