Deficiencies (last 3 years)
Deficiencies (over 3 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: 5
Date: Mar 11, 2021
Visit Reason
The inspection was conducted as a complaint investigation to assess compliance with regulations related to resident privacy, accurate resident assessments, care planning, nutrition, and food safety.
Complaint Details
The deficient practice related to weight loss recognition was cited as the result of the investigation of complaint/report number AL00041289.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy during medication administration, inaccurate coding of resident assessments, incomplete care plans for residents with urinary catheters and oxygen use, failure to recognize significant weight loss in a resident, and improper food safety practices including thermometer sanitization and food labeling.
Deficiencies (5)
Failed to ensure a Registered Nurse did not leave the Electronic Medication Administration Record screen visible and unattended, exposing resident personal information and medications.
Failed to accurately code resident assessments to reflect dialysis and indwelling catheter presence.
Failed to develop and implement complete care plans specific enough to guide urinary catheter care and oxygen use.
Failed to recognize and assess a ten pound weight loss over eight days for a resident.
Failed to ensure dietary staff sanitized food thermometers properly and washed hands after using cleaning cloths; failed to label food in the deep freezer with open and use by dates.
Report Facts
Residents sampled for weight loss: 4
Residents affected by inaccurate assessments: 2
Residents affected by incomplete care plans: 4
Residents affected by privacy breach: 1
Residents affected by food safety issues: 41
Weight loss: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #9 | Registered Nurse | Named in medication administration privacy violation. |
| EI #6 | Licensed Practical Nurse, MDS Coordinator | Interviewed regarding inaccurate resident assessments and care plans. |
| EI #4 | Registered Nurse, Director of Clinical Services, former MDS Coordinator | Interviewed regarding resident assessments and care plan responsibilities. |
| EI #21 | Certified Nursing Assistant | Interviewed about catheter care knowledge and instructions. |
| EI #20 | Certified Nursing Assistant | Interviewed about catheter care and use of care plans. |
| EI #2 | Registered Nurse, Director of Nursing | Interviewed about care plan requirements and catheter care. |
| EI #5 | Dietary Consultant | Interviewed about resident weight concerns and assessments. |
| EI #1 | Administrator | Interviewed about weight measurement process and oversight. |
| EI #8 | Dietary Manager | Interviewed about weight recording, food labeling, and food safety practices. |
| EI #7 | Cook | Observed and interviewed regarding improper thermometer sanitization and hand hygiene. |
Inspection Report
Routine
Census: 51
Deficiencies: 2
Date: Jan 15, 2020
Visit Reason
The inspection was conducted to evaluate compliance with food safety and infection control standards, including observation of kitchen sanitation and laundry handling practices.
Findings
The facility failed to ensure an air gap between the 3 compartment sink and sewage drain, risking backflow contamination affecting 51 residents. Additionally, laundry staff transported clean linens uncovered from the outside laundry building, posing a contamination risk to 57 residents.
Deficiencies (2)
Failed to ensure an air gap between the 3 compartment sink and sewage drain, risking backflow contamination.
Laundry staff transported clean linens uncovered from the outside laundry building to the main facility, risking contamination.
Report Facts
Residents affected: 51
Residents affected: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding the direct connection between the 3 compartment sink and sewage drain | |
| Maintenance Supervisor | Interviewed regarding the potential harm of direct connection between sink and sewage drain and laundry transport practices | |
| Administrator | Interviewed about the absence of an air gap under the 3 compartment sink | |
| Laundry Aide | Interviewed about uncovered linens transported on cart from outside laundry |
Inspection Report
Deficiencies: 2
Date: Nov 29, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements, including ensuring the facility's most recent survey results were accessible to residents and visitors, and to evaluate the infection prevention and control program.
Findings
The facility failed to post the most recent survey results in the designated foyer area, limiting resident and visitor access. Additionally, a Laundry Aide did not follow proper infection control procedures by allowing clean laundry to touch her clothing and by placing soiled items back into clean laundry containers, posing a contamination risk to residents.
Deficiencies (2)
Failed to ensure the facility's most recent survey results were accessible for residents and visitors as required.
Laundry Aide allowed clean laundry to touch her clothing and placed a white sock and wash cloth that fell on the floor back into the clean laundry container, violating infection control policies.
Report Facts
Residents affected: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Director of Social Services | Interviewed regarding missing posting of survey results |
| Employee Identifier #2 | Laundry Aide | Observed and interviewed regarding improper handling of clean laundry |
| Employee Identifier #3 | Director of Nursing/Infection Control Preventionist | Interviewed regarding infection control concerns related to laundry handling |
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