Deficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 5
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident transfers, baseline and comprehensive care planning, and monitoring of psychotropic medication use and side effects.
Findings
The facility was found deficient in timely notification of the ombudsman for resident transfers, development of baseline and comprehensive care plans within required timeframes, and monitoring and documentation of behaviors and side effects related to psychotropic medications for residents.
Deficiencies (5)
Failed to provide timely notification to the ombudsman of resident transfer to hospital for Resident Identifier (RI) #30.
Failed to create and implement a baseline care plan within 48 hours of admission for Resident Identifier (RI) #89.
Failed to develop and implement a comprehensive care plan addressing antidepressant use for Resident Identifier (RI) #93.
Failed to develop comprehensive care plans within 7 days of admission Minimum Data Set (MDS) assessment for Resident Identifier (RI) #89.
Failed to implement gradual dose reductions and monitor/document behaviors and side effects of psychotropic medications for Resident Identifier (RI) #27.
Report Facts
Residents reviewed for baseline care plan: 9
Residents reviewed for comprehensive care plans: 24
Residents reviewed for unnecessary medications: 5
Days for baseline care plan development: 48
Days for comprehensive care plan development: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Provided statements regarding expectations for care plans and ombudsman notifications |
| EI #2 | Director of Nursing | Provided statements regarding care plan responsibilities and ombudsman notifications |
| EI #4 | Minimum Data Set (MDS) Coordinator | Responsible for initiating care plans; interviewed about baseline and comprehensive care plans |
| EI #5 | Treatment Nurse | Interviewed regarding care plan initiation responsibilities |
| EI #6 | Licensed Practical Nurse (LPN) | Admitting nurse for RI #89; interviewed about baseline care plan initiation |
| EI #8 | Licensed Practical Nurse (LPN) | Interviewed about documentation and monitoring of psychotropic medication side effects |
| EI #9 | Social Service Director | Interviewed about ombudsman notification for resident transfers |
| EI #20 | Licensed Practical Nurse (LPN) | Interviewed about side effect monitoring requirements for psychotropic medications |
| EI #21 | Registered Nurse (RN) | Interviewed about side effect monitoring and documentation practices |
| EI #22 | Certified Nursing Assistant (CNA) | Interviewed about reporting behaviors and side effects to nurses |
| EI #19 | Pharmacist | Interviewed about psychotropic medication monitoring and behavior tracking |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 17, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident transfers, baseline and comprehensive care planning, and monitoring of psychotropic medication use and side effects.
Findings
The facility failed to notify the ombudsman timely of a resident transfer to the hospital, did not develop baseline care plans within 48 hours of admission, failed to develop comprehensive care plans addressing antidepressant use and timely completion within 7 days of assessment, and did not adequately monitor or document behaviors and side effects related to psychotropic medications for a resident.
Deficiencies (5)
Failed to provide timely notification to the ombudsman of resident transfer to hospital.
Failed to create and implement a baseline care plan within 48 hours of admission.
Failed to develop and implement a comprehensive care plan addressing antidepressant medication use.
Failed to develop comprehensive care plans within 7 days of comprehensive assessment.
Failed to implement gradual dose reductions and monitor/document behaviors and side effects of psychotropic medications.
Report Facts
Residents reviewed for baseline care plan: 9
Residents reviewed for comprehensive care plans: 24
Residents reviewed for unnecessary medications: 5
Days baseline care plan should be developed: 2
Days comprehensive care plan should be developed: 7
Days for ombudsman notification: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Indicated no facility policy on notifying ombudsman and expectations on care plan completion and ombudsman notification | |
| Administrator | Stated expectations for timely and thorough care plans and awareness of ombudsman notification failure | |
| Social Service Director | Uncertain about who completed ombudsman notification | |
| Licensed Practical Nurse (LPN) | Admitting nurse for resident #89 who did not start baseline care plan | |
| Treatment Nurse | Responsible for care plan initiation and interviews about care plan timing | |
| Minimum Data Set (MDS) Coordinator | Responsible for starting baseline and comprehensive care plans | |
| Registered Nurse (RN) MDS Coordinator | Confirmed lack of care plan for antidepressant use | |
| Certified Nursing Assistant (CNA) | Reported behaviors to nurses and described lack of access to care plans | |
| Licensed Practical Nurse (LPN) | Described process for documenting behaviors and side effects | |
| Registered Nurse (RN) | Described side effect monitoring practices and documentation | |
| Pharmacist | Described psychotropic medication monitoring requirements and behavior tracking |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 21, 2019
Visit Reason
The inspection was conducted due to allegations of verbal abuse and concerns about infection prevention and control practices at the facility.
Complaint Details
The complaint involved an allegation of verbal abuse concerning Resident Identifiers #165 and #25, which was not reported within the required 2-hour timeframe. The allegation was substantiated as the facility reported it late.
Findings
The facility failed to timely report an allegation of verbal abuse to the State Agency within the required 2-hour timeframe and failed to ensure a licensed nurse washed hands after glove removal and prior to administering eye drop medication, posing infection control risks.
Deficiencies (2)
Failed to timely report an allegation of verbal abuse to the State Agency within 2 hours.
Failed to ensure a licensed nurse washed hands after removing gloves and prior to administering eye drop medication.
Report Facts
Residents affected: 5
Residents affected: 1
Nurses observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/Director of Nursing (DON) | Interviewed regarding abuse reporting timeline | |
| Licensed Practical Nurse (LPN) | Observed and interviewed regarding hand hygiene during medication administration | |
| Infection Control Preventionist | Interviewed regarding facility hand hygiene policy |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 21, 2019
Visit Reason
The inspection was conducted due to allegations of verbal abuse and concerns regarding infection prevention and control practices at the facility.
Complaint Details
The complaint involved an allegation of verbal abuse concerning Resident Identifiers #165 and #25, which was not reported within the required 2-hour timeframe. The allegation was substantiated as the facility reported it late. Infection control concerns were also observed related to hand hygiene during medication administration.
Findings
The facility failed to timely report an allegation of verbal abuse to the State Agency within the required 2-hour timeframe, affecting two residents. Additionally, the facility failed to ensure a licensed nurse performed proper hand hygiene during medication administration, potentially risking infection transmission.
Deficiencies (2)
Failed to timely report an allegation of verbal abuse to the State Agency within 2 hours.
Failed to ensure a licensed nurse washed hands after removing gloves and prior to administering eye drop medication.
Report Facts
Residents affected: 5
Residents affected: 2
Residents observed: 2
Nurses observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/Director of Nursing (DON) | Interviewed regarding the verbal abuse allegation reporting timeline | |
| Licensed Practical Nurse (LPN) | Observed and interviewed regarding hand hygiene during medication administration | |
| Infection Control Preventionist | Interviewed regarding facility hand hygiene policy |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 24, 2018
Visit Reason
The inspection was conducted to identify deficiencies related to the care planning for residents, specifically focusing on Resident Identifier #84's indwelling catheter care plan.
Findings
The facility failed to develop and implement a complete care plan for Resident Identifier #84's indwelling urinary catheter, which could lead to potential infection and compromised patient safety.
Deficiencies (1)
Failed to ensure a care plan was developed for Resident Identifier #84's indwelling catheter.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 24, 2018
Visit Reason
The inspection was conducted to identify deficiencies related to the care planning for residents, specifically focusing on the development and implementation of a care plan for Resident Identifier #84's indwelling catheter.
Findings
The facility failed to ensure a care plan was developed for Resident Identifier #84's indwelling catheter, which could lead to lack of care and potential infection. Interviews with staff confirmed the absence or resolution of the care plan, highlighting risks to patient safety.
Deficiencies (1)
Failed to develop and implement a complete care plan for Resident Identifier #84's indwelling catheter.
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