Inspection Reports for
East Glen
53 Medical Park Drive East, Birmingham, AL, 35235
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 10, 2023
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding the facility's failure to initiate CPR in accordance with facility policy and American Heart Association guidelines for a resident who was found unresponsive and pulseless after sliding out of a wheelchair during transport.
Complaint Details
The complaint investigation was triggered by report number AL00044244 concerning the failure to provide CPR to a resident who slid out of a wheelchair during transport and was found unresponsive and pulseless upon return to the facility. The resident was not provided CPR by the licensed practical nurse and was instead transported to the emergency room without EMS activation.
Findings
The facility failed to initiate CPR for Resident Identifier #1 when found unresponsive and without a pulse, instead instructing the transport driver to take the resident to the emergency room without activating EMS or performing CPR. This deficient practice placed the resident in immediate jeopardy and was not in accordance with facility policy or accepted CPR standards.
Deficiencies (1)
Failure to initiate CPR in accordance with facility policy and American Heart Association guidelines for a resident found unresponsive and pulseless.
Report Facts
Residents affected: 3
Residents under care of EI #4: 26
Full code residents potentially affected: 18
Duration of ACLS performed: 20
Time to transport to ER: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | EI #4, failed to initiate CPR and activated EMS, instead instructed transport driver to take resident to ER | |
| Director of Nursing | EI #2, provided interview confirming facility policy and that CPR was not initiated as required | |
| Administrator | EI #1, confirmed staff training and facility policy regarding CPR initiation | |
| Certified Nursing Assistant (CNA) | EI #8, assisted in assessment and reported observations during incident |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, treatment and care according to physician orders, call system availability, and overall resident safety and care.
Findings
The facility failed to accurately code residents' Minimum Data Set (MDS) assessments for dialysis, oxygen therapy, and hospice services. Licensed staff did not follow physician orders for wound care treatment, specifically failing to change leg dressings as ordered. Additionally, the facility failed to ensure a working call light system was within reach of a resident, posing a risk to resident safety.
Deficiencies (3)
Failure to ensure accurate coding of quarterly MDS assessments for dialysis and oxygen therapy for Resident #24 and hospice services for Resident #7.
Licensed Practical Nurse failed to follow physician orders for wound care treatment by not changing leg dressings on Resident #24 as ordered.
Failure to ensure Resident #41's call light was positioned within reach while in a wheelchair.
Report Facts
Residents sampled for MDS assessments: 18
Residents affected by MDS coding deficiencies: 2
Residents affected by wound care deficiency: 1
Residents affected by call light deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/MDS Coordinator | Employee Identifier #3, stated MDS coding deficiencies for Residents #24 and #7 | |
| RN/Director of Nursing (DON) | Employee Identifier #2, provided information on hospice procedures and call light concerns | |
| Licensed Practical Nurse (LPN)/Wound Care Nurse | Employee Identifier #10, failed to change leg dressings as ordered for Resident #24 | |
| Certified Registered Nurse Practitioner (CRNP) | Employee Identifier #8, provided clinical information on wound care risks for Resident #24 | |
| Certified Nursing Assistant (CNA) | Employee Identifier #6, involved in call light incident for Resident #41 | |
| Registered Nurse (RN) | Employee Identifier #7, responded to Resident #41's call for help |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, treatment and care according to physician orders, call light accessibility, and overall resident safety and care quality.
Findings
The facility failed to accurately code residents' Minimum Data Set (MDS) assessments for dialysis, oxygen therapy, and hospice services. Licensed staff did not follow physician orders for wound care treatment, specifically failing to change leg dressings as ordered. Additionally, the facility failed to ensure a working call light was within reach of a resident, posing a risk to resident safety.
Deficiencies (3)
Failure to ensure accurate coding of MDS assessments for dialysis and oxygen therapy for Resident #24 and hospice services for Resident #7.
Licensed Practical Nurse failed to follow physician orders for wound care treatment by not changing leg dressings on Resident #24 as ordered.
Failure to ensure Resident #41's call light was positioned within reach while in a wheelchair.
Report Facts
Residents sampled for MDS assessments: 18
Residents affected by MDS coding deficiencies: 2
Residents affected by wound care deficiency: 1
Residents affected by call light deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/MDS Coordinator | Employee Identifier #3, stated MDS coding deficiencies for Residents #24 and #7 | |
| RN/Director of Nursing (DON) | Employee Identifier #2, provided information on hospice procedures and call light concerns | |
| Licensed Practical Nurse (LPN)/Wound Care Nurse | Employee Identifier #10, failed to change leg dressings as ordered for Resident #24 | |
| Certified Registered Nurse Practitioner (CRNP) | Employee Identifier #8, provided clinical information on wound care risks for Resident #24 | |
| Certified Nursing Assistant (CNA) | Employee Identifier #6, involved in call light incident with Resident #41 | |
| Registered Nurse (RN) | Employee Identifier #7, responded to Resident #41's calls for help |
Inspection Report
Routine
Census: 101
Capacity: 103
Deficiencies: 11
Date: Nov 8, 2019
Visit Reason
The inspection was conducted to assess compliance with food safety, sanitation, waste disposal, wound care procedures, and documentation standards at the facility.
Findings
The facility had multiple deficiencies including improper food equipment sanitation, unclean food preparation areas, improper frozen food storage, accumulation of waste and refuse near dumpsters, lack of approved standardized procedures for wound assessment and care, and incomplete wound documentation for a resident.
Deficiencies (11)
Dishwashing machine drainpipe extended three inches into the floor drain creating potential for backflow.
Standing table mixer was not clean and had dried chocolate-colored residue.
Floors in dry storeroom, behind trayline's reach-in cooler, and between backs of cooking equipment were dirty with debris and grease buildup.
Interior of trayline's reach-in cooler was leaking and unclean with pooled liquid and stained rags.
Ice cream in freezer was mushy and not frozen solid.
Dark residue buildup on water spray heads and interior housing of coffee machine.
Convection oven had heavy buildup of dark residue inside.
Griddle drip pan was one-third full of grease.
Waste including cigarette butts, pepper packets, gloves, pie box, plastic lid, and mop water was improperly disposed near dumpster and grease refuse container.
Facility failed to develop standardized procedures for wound assessment and care approved by Alabama Board of Nursing.
Treatment nurse failed to document weekly wound assessment for a resident, documenting late without indicating prior assessment date.
Report Facts
Residents affected: 101
Total residents: 103
Cigarette butts counted: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD)/Director of Food and Nutrition | Interviewed about food safety and sanitation deficiencies | |
| Director of Maintenance/Housekeeping | Measured dishwasher drainpipe and interviewed about waste disposal | |
| Dietary Aide | Interviewed about cleaning of mixer | |
| AM Relief Cook | Interviewed about oven cleaning | |
| Dining Service Manager | Interviewed about monitoring oven cleaning | |
| Housekeeping Floor Tech | Observed dumping mop water improperly | |
| Administrator | Interviewed about wound care standardized procedures | |
| Director of Nursing (DON) | Interviewed about wound care standardized procedures | |
| Director of Clinical Operations | Interviewed about wound care standardized procedures | |
| Treatment Nurse (Employee Identifier #11) | Interviewed about wound documentation deficiencies |
Inspection Report
Deficiencies: 0
Date: Nov 1, 2018
Visit Reason
The document is a statement of deficiencies and plan of correction for the nursing home East Glen, documenting the results of a survey completed on 2018-11-01.
Findings
No health deficiencies were found during the survey.
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