Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
75% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
78% occupied
Based on a April 2023 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 9, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 5, 2023
Visit Reason
The inspection was conducted as a result of investigations of multiple complaints regarding the facility's failure to provide scheduled showers to Resident Identifier #43 and other concerns related to food safety and equipment maintenance.
Complaint Details
The investigation was triggered by complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969 concerning failure to provide scheduled showers to Resident Identifier #43 and other facility deficiencies.
Findings
The facility failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled. Additionally, the facility had issues with food safety including cross contamination risks from dirty kitchen equipment and vents, lack of temperature monitoring in refrigerators used for resident food, and maintenance problems with the walk-in freezer door causing ice buildup and potential safety hazards.
Deficiencies (4)
Failed to ensure Resident Identifier #43 received showers as scheduled on multiple dates.
Failed to prevent potential cross contamination due to dust build-up on ceiling vents and dirty blade on manual can opener.
Failed to ensure a temperature monitored refrigerator was available for staff to place food items brought in by family/friends for residents.
Failed to maintain walk-in freezer in proper operating condition; door would not close securely causing ice/frost build-up and safety hazards.
Report Facts
Residents affected: 1
Residents affected: 107
Dates of missed showers: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA | Employee Identifier #4 CNA did not give baths/showers to Resident #43 due to misunderstanding. | |
| Director of Nursing | Employee Identifier #2 DON confirmed shower schedule and lack of showers for Resident #43. | |
| Dietary Aide | Employee Identifier #12 Dietary Aide acknowledged can opener was not cleaned properly. | |
| District Manager | Employee Identifier #11 District Manager noted cross contamination risk from dirty can opener and vents. | |
| Maintenance Assistant | Employee Identifier #7 Maintenance Assistant discussed maintenance requests and cleaning schedules. | |
| Dietary Manager/Account Manager | Employee Identifier #6 Dietary Manager discussed dust build-up, can opener cleaning, and refrigerator temperature monitoring. | |
| Licensed Practical Nurse | Employee Identifier #8 LPN reported lack of nourishment refrigerator and handling of resident snacks. | |
| Activity Assistant | Employee Identifier #9 Activity Assistant reported no nourishment refrigerator on North Hall. | |
| Unit Manager | Employee Identifier #3 Unit Manager discussed procedures for handling food brought by family/friends. | |
| Administrator | Employee Identifier #1 Administrator confirmed lack of thermometer and temperature logs in staff break room refrigerator. | |
| Dietary Aide | Employee Identifier #13 Dietary Aide unable to close walk-in freezer door properly. |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 4
Date: Apr 5, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations regarding multiple issues including failure to make survey results available, failure to provide scheduled showers to a resident, food safety concerns, and equipment maintenance problems.
Complaint Details
The deficient practice regarding Resident Identifier #43's missed showers was cited as a result of the investigation of complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969.
Findings
The facility failed to ensure survey results were available for residents, did not provide scheduled showers to a resident, had food safety risks due to unclean equipment and lack of temperature monitoring for resident food storage, and had maintenance issues with the walk-in freezer door causing ice buildup and potential safety hazards.
Deficiencies (4)
Failed to ensure survey results for the last three years were available for residents or visitors to review.
Failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled for Activities of Daily Living.
Failed to prevent potential cross contamination due to dust build-up on ceiling vents and a dirty blade on the manual can opener; failed to ensure a temperature monitored refrigerator was available for staff to store food items brought in by family/friends.
Failed to maintain the walk-in freezer in proper operating condition, with door not closing securely and ice/frost build-up present.
Report Facts
Residents affected: 108
Residents affected: 107
Residents affected: 1
Residents sampled for ADL: 8
Surveys missing: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Responsible for maintaining the survey binder | |
| Employee Identifier (EI) #4 CNA | Interviewed regarding bathing/showering practices for Resident #43 | |
| Employee Identifier (EI) #2 Director of Nursing (DON) | Interviewed regarding shower schedule and ADL documentation for Resident #43 | |
| Employee Identifier (EI) #12 Dietary Aide | Interviewed about cleaning of manual can opener | |
| Employee Identifier (EI) #11 District Manager | Contract food company representative, commented on can opener and ceiling vents | |
| Employee Identifier (EI) #7 Maintenance Assistant | Interviewed about maintenance requests and cleaning schedules | |
| Employee Identifier (EI) #6 Dietary Manager/Account Manager | Interviewed about dust build-up, can opener cleaning, and refrigerator temperature monitoring | |
| Employee Identifier (EI) #8 Licensed Practical Nurse (LPN) | Interviewed about nourishment refrigerator absence | |
| Employee Identifier (EI) #9 Activity Assistant | Interviewed about nourishment refrigerator absence and food storage | |
| Employee Identifier (EI) #3 Unit Manager South Hall | Interviewed about food storage procedures and refrigerator issues | |
| Employee Identifier (EI) #13 Dietary Aide | Interviewed about walk-in freezer door issue |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 22, 2021
Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse of Resident Identifier (RI) #22 by Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), on 4/19/2021 at 2:00 AM.
Complaint Details
The complaint was substantiated. The verbal abuse allegation against EI #4 was confirmed by statements from multiple employees and the resident. EI #4 was terminated due to the substantiated verbal abuse.
Findings
The facility substantiated the allegation of verbal abuse against EI #4, who was heard cursing at RI #22. The CNA was terminated due to this behavior. Additionally, the facility failed to ensure proper hand hygiene and sanitization procedures in the dietary department, including improper hand washing by dietary staff and insufficient sanitizing time for pots and pans.
Deficiencies (3)
Verbal abuse of resident RI #22 by CNA EI #4 using profanity and unacceptable language.
Dietary staff failed to wash hands after touching dirty dishes and before touching clean dishes.
Dietary staff improperly sanitized metal cook wares by not immersing them in sanitizing solution for the required time.
Report Facts
Residents affected: 1
Residents affected: 69
Sanitizing time required: 7
Sanitizing time observed: 2
Sanitizing time reported: 60
Sanitizing time observed: 3
Sanitizing time observed: 5
Sanitizing time observed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #4 | Certified Nursing Assistant (CNA) | Named in verbal abuse finding and terminated for the incident |
| EI #2 | Licensed Practical Nurse (LPN) | Witnessed verbal abuse and intervened during incident |
| EI #3 | Certified Nursing Assistant (CNA) | Witnessed verbal abuse incident |
| EI #1 | Director of Nursing (DON) | Conducted interviews and substantiated verbal abuse allegation |
| EI #7 | Dietary Aid | Observed improperly sanitizing pots and pans |
| EI #8 | Dietary Aid | Observed failing to wash hands properly between handling dirty and clean dishes |
| EI #5 | Dietary Manager, Account Manager | Interviewed regarding dietary hand hygiene and sanitization policies |
| EI #6 | Dietitian | Interviewed regarding sanitizing procedures and times |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 8
Date: Dec 5, 2019
Visit Reason
The inspection was conducted based on complaints received by the Alabama State Survey Agency regarding multiple deficiencies including failure to provide proper discharge notices, bed hold notices, and refusal to allow a resident to return after hospitalization.
Complaint Details
The complaint investigation focused on allegations that the facility discharged resident #264 without proper notice, failed to provide bed hold notices, and refused to accept the resident back after hospitalization. The investigation confirmed these deficiencies and cited the facility accordingly.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy during medication administration, unsafe environmental conditions such as hanging vents and full sharps boxes, failure to provide timely discharge and bed hold notices to a resident, refusal to allow a resident to return after hospitalization, storage of expired medications, and improper food storage practices.
Deficiencies (8)
Failed to ensure resident's personal information was not visible during medication administration.
Failed to ensure vents did not hang down from bathroom ceilings in two resident bathrooms.
Failed to issue a 30-day notice of discharge to resident #264 upon discharge.
Failed to provide written notice of bed hold policy and duration to resident #264 upon transfer to hospital.
Failed to allow resident #264 to return to the facility after hospitalization.
Sharps box in shower room was full with razors protruding, posing injury risk.
Medication storage room contained expired medication prescribed for resident #265.
Styrofoam cup was stored inside the flour bin in the kitchen, risking cross contamination.
Report Facts
Residents affected: 6
Rooms with hanging vents: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Razors protruding: 5
Expired medication containers: 3
Resident census: 115
Residents fed by tube feeding: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | EI #6 named in privacy violation during medication administration | |
| Director of Nursing Service | EI #2 interviewed regarding privacy and discharge decisions | |
| Housekeeping Supervisor | EI #5 interviewed about hanging vents | |
| Social Service Director | EI #15 interviewed regarding discharge process | |
| Social Services Assistant | EI #14 interviewed regarding discharge process | |
| LPN Unit Manager | EI #4 responsible for resident #264 discharge | |
| MDS Coordinators | EI #20 and EI #21 interviewed about discharge planning | |
| Business Office Manager | EI #16 interviewed about bed hold notice issuance | |
| Registered Nurse (RN) Unit Manager | EI #3 interviewed about sharps box hazard | |
| Registered Nurse | EI #20 interviewed about expired medication | |
| Evening Cook | EI #7 interviewed about food storage violation |
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