Inspection Reports for
Dadeville Healthcare Center
385 East Lafayette Street, PO Box 97, Dadeville, AL, 36853
Back to Facility ProfileDeficiencies (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
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 7
Date: Apr 22, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, medication management, and infection control at Dadeville Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity in toileting, failure to provide timely written notification of transfers, inadequate restorative care for residents with range of motion limitations, improper use and assessment of bed side rails, use of unnecessary psychotropic medications without proper re-evaluation, unsecured medication carts, undated insulin vials and pens, and inadequate cleaning and storage of oxygen therapy equipment.
Deficiencies (7)
Failure to provide dignity in toileting for one resident by not assisting to bathroom or providing appropriate toileting interventions.
Failure to provide written notice of transfer to resident, representative, and Ombudsman for one resident.
Failure to provide appropriate care to maintain or improve range of motion for three residents and failure to implement restorative programs.
Failure to ensure correct assessed side rail was utilized for one resident, creating potential accident hazards.
Failure to ensure one resident's medication regimen was free of unnecessary psychotropic medications; PRN antipsychotic medication prescribed without stop order or physician re-evaluation after 14 days.
Failure to keep medication carts locked when unattended and failure to date insulin vials and pens when opened.
Failure to ensure oxygen therapy equipment was cleaned and stored properly; dusty filters, undated nasal cannulas, and improper storage increasing infection risk.
Report Facts
Residents reviewed for range of motion limitations: 3
Residents reviewed for oxygen therapy: 3
PRN Haldol administrations: 8
Assessment Reference Dates: Mar 28, 2021
Assessment Reference Dates: Jan 28, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #19 | Certified Nursing Assistant (CNA) | Interviewed regarding resident #8 continence and resident #67 assistance |
| EI #8 | Licensed Practical Nurse (LPN) | Interviewed regarding resident #8 continence and resident #67 transfers |
| EI #4 | Rehab Registered Nurse (RN) | Interviewed regarding restorative nursing program and residents #67, #73, and #11 |
| EI #20 | Physical Therapy Assistant (PTA) | Interviewed regarding therapy services for residents #67 and #11 |
| EI #21 | Occupational Therapist (OT) | Interviewed regarding therapy services for resident #67 |
| EI #1 | Director of Nursing (DON) | Interviewed regarding transfer notification policy and restorative nursing |
| EI #22 | Pharmacist | Interviewed regarding PRN antipsychotic medication policies |
| EI #3 | Registered Nurse (RN) | Observed medication cart unlocked and confirmed policy |
| EI #5 | Registered Nurse (RN), Quality Assurance Nurse and Infection Preventionist (IP) | Interviewed regarding oxygen concentrator cleaning and tubing dating |
| EI #12 | Licensed Practical Nurse (LPN) | Interviewed regarding resident #47 behavior and medication |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 14, 2019
Visit Reason
The inspection was conducted due to a complaint received by the State Agency from a family member alleging abuse of Resident Identifier #155 by a male staff member during a 5-day respite care stay.
Complaint Details
The complaint was substantiated as the facility failed to report the alleged abuse to the State Agency. The allegation involved Resident Identifier #155 and was reported by a family member and the resident's spouse. The Administrator did not believe the allegation and did not report it.
Findings
The facility failed to report an allegation of abuse involving Resident Identifier #155 to the State Agency as required by policy. The Administrator investigated but did not find evidence or incident reports and did not report the allegation, despite being informed of the claim that two male aides held the resident down and beat the resident with a belt.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Residents affected: 1
Complaint date: Aug 16, 2018
Inspection date: Feb 14, 2019
Inspection Report
Routine
Deficiencies: 8
Date: Jan 4, 2018
Visit Reason
The inspection was conducted to assess compliance with Medicare and Medicaid regulations, including review of beneficiary notices, physician orders, care plans, nursing documentation, and staff competencies.
Findings
The facility was found deficient in multiple areas including failure to issue Medicare beneficiary liability notices timely, lack of physician orders for oxygen on admission, failure to initiate significant change MDS assessments, incomplete care plans for dialysis and catheter care, failure to monitor oxygen saturations as ordered, inadequate monitoring of fluid intake for a dialysis resident, lack of annual CNA competency assessments, and incomplete nursing documentation of a resident's code event.
Deficiencies (8)
Failed to issue Medicare beneficiary liability notices at least two days prior to the end of Medicare Part A covered days for Resident #54.
Failed to ensure Resident #88 had physician orders for oxygen at the time of admission.
Failed to initiate a Significant Change in Status Minimum Data Set (MDS) Assessment after a decline in two areas for Resident #72.
Failed to develop and implement complete care plans addressing dialysis fluid intake for Resident #35 and catheter care for Resident #72.
Failed to ensure staff completed an order to monitor oxygen saturations every shift for five days for Resident #88.
Failed to ensure staff monitored Resident #35's fluid intake as per fluid restriction orders.
Failed to ensure annual competency/performance reviews were conducted for Certified Nursing Assistants.
Failed to document nursing staff's response and resuscitation efforts when Resident #88 collapsed and required transfer to hospital.
Report Facts
Residents reviewed for liability notices: 3
Residents reviewed for physician orders: 21
Residents reviewed for MDS assessments: 21
Residents reviewed for care plans: 21
Residents reviewed for dialysis: 3
Certified Nursing Assistants reviewed: 3
Residents affected by documentation deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #1 | Bookkeeper | Responsible for issuing Medicare beneficiary liability notices; confirmed notices were not issued timely. |
| Employee Identifier #2 | Certified Nurse Practitioner | Interviewed regarding lack of oxygen orders for Resident #88. |
| Employee Identifier #3 | Director of Nursing | Acknowledged lack of oxygen orders, incomplete documentation, and lack of annual CNA competencies prior to 2018. |
| Employee Identifier #4 | Director of Nursing Assistant | Responsible for CNA training and annual competencies; admitted lack of documentation prior to 2018. |
| Employee Identifier #9 | Registered Nurse | Cared for Resident #88 during collapse; described events and noted documentation should have been completed. |
| Employee Identifier #10 | Registered Nurse MDS Coordinator | Confirmed failure to complete significant change MDS assessment for Resident #72. |
| Employee Identifier #11 | Nurse | Interviewed about fluid monitoring for Resident #35; unable to locate fluid intake sheets. |
| Employee Identifier #12 | Dietitian | Provided dietary tray card showing fluid intake for Resident #35. |
| Employee Identifier #14 | Registered Nurse | Interviewed about care plan for catheter care for Resident #72; care plan was inadequate. |
| Employee Identifier #8 | Medical Director | Documented Resident #88's unresponsiveness and resuscitation efforts. |
| Employee Identifier #13 | MDS Staff | Interviewed regarding fluid restriction care plan for Resident #35. |
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