Inspection Reports for
Fair Haven – Assisted Living
1424 Montclair Road, Birmingham, AL, 35210
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
142% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 3
Date: Jun 17, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, wound care, medication management, and environmental safety at Fair Haven nursing home.
Findings
The facility was found deficient in developing a complete person-centered care plan for anticoagulant medication for one resident, improper wound care practices including failure to change gloves during dressing changes, and failure to maintain the dumpster and surrounding area free of debris and pests, posing potential health risks.
Deficiencies (3)
Failure to develop and implement a complete care plan for anticoagulant medication for Resident Identifier #97.
Failure to ensure licensed staff washed hands and changed gloves appropriately during wound care for Resident Identifier #132.
Failure to maintain dumpster and area outside kitchen free of debris and pests, including uncovered trash, discarded furniture, and flies.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Employee Identifier #8 interviewed regarding anticoagulant medication care plan for Resident #97 | |
| Licensed Practical Nurse (LPN), Clinical Leader | Employee Identifier #9 interviewed regarding oversight of anticoagulant care plan for Resident #97 | |
| Licensed Practical Nurse (LPN) | Employee Identifier #4 observed and interviewed regarding wound care practices for Resident #132 | |
| Infection Control Nurse | Employee Identifier #3 interviewed regarding hand hygiene and glove use policies during wound care | |
| Registered Dietician (RD) | Employee Identifier #5 interviewed regarding dumpster and refuse area conditions | |
| Environmental Director | Employee Identifier #6 interviewed regarding trash disposal and courtyard conditions |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 17, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, infection control, and environmental safety at the Fair Haven nursing home.
Findings
The facility was found deficient in developing a complete person-centered care plan for anticoagulant medication for one resident, failure to follow proper hand hygiene and glove use during wound care for another resident, and inadequate disposal and containment of garbage and refuse leading to pest infestation risks near the kitchen area.
Deficiencies (3)
Failure to develop and implement a complete care plan for anticoagulant medication for Resident Identifier #97.
Failure to ensure licensed staff washed hands and changed gloves appropriately during wound care for Resident Identifier #132.
Failure to ensure the dumpster/area outside the kitchen was free of debris and pests, including uncovered trash and discarded furniture.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Employee Identifier #8 interviewed regarding anticoagulant medication care plan for Resident #97 | |
| Licensed Practical Nurse (LPN), Clinical Leader | Employee Identifier #9 interviewed regarding anticoagulant medication care plan for Resident #97 | |
| Licensed Practical Nurse (LPN) | Employee Identifier #4 observed and interviewed regarding wound care for Resident #132 | |
| Infection Control Nurse | Employee Identifier #3 interviewed regarding hand hygiene and glove use during wound care | |
| Registered Dietician (RD) | Employee Identifier #5 interviewed regarding garbage and refuse conditions outside kitchen | |
| Environmental Director | Employee Identifier #6 interviewed regarding trash disposal and courtyard conditions |
Inspection Report
Routine
Deficiencies: 5
Date: Jan 30, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to timely reporting of abuse, discharge summary completion, activities of daily living care, medication storage, and infection prevention and control.
Findings
The facility was found deficient in timely reporting of suspected abuse, failure to complete discharge summaries, inadequate nail care for a resident, storage of expired medication on a medication cart, and failure of a licensed nurse to perform proper hand hygiene during medication administration.
Deficiencies (5)
Failed to report an allegation of abuse involving Resident Identifier #188 within two hours of staff being made aware of the incident.
Failed to ensure a discharge summary was completed for Resident Identifier #242 upon discharge.
Failed to ensure a brown substance was not under Resident Identifier #120's fingernails, indicating inadequate nail care.
Failed to ensure that a stock bottle of expired Vitamin C 500 MG was not left on a medication cart.
Failed to ensure a licensed nurse washed hands or used hand sanitizer after taking Resident Identifier #148's blood pressure and between medication administrations.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts reviewed: 6
Residents observed: 9
Nurses observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator/Abuse Coordinator | Named in abuse reporting deficiency | |
| Registered Nurse/Director of Nursing | Named in discharge summary deficiency | |
| Licensed Practical Nurse | Named in medication storage deficiency | |
| Registered Nurse | Named in infection prevention deficiency | |
| Infection Control Preventionist/Registered Nurse | Named in infection prevention deficiency | |
| Licensed Practical Nurse | Named in nail care deficiency | |
| Certified Nursing Assistant | Named in nail care deficiency | |
| Clinical Leader | Named in nail care deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 30, 2020
Visit Reason
The inspection was conducted to investigate multiple complaints including failure to timely report suspected abuse, failure to complete discharge summaries, inadequate personal care, improper medication storage, and failure to follow infection prevention protocols.
Complaint Details
The complaint investigation revealed multiple deficiencies including failure to timely report abuse, incomplete discharge summaries, inadequate personal care, expired medication storage, and poor hand hygiene practices by nursing staff.
Findings
The facility was found deficient in timely reporting of suspected abuse, failure to complete discharge summaries, inadequate nail care for residents, storage of expired medication on medication carts, and failure of licensed nurses to perform proper hand hygiene during medication administration. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (5)
Failed to report an allegation of abuse involving Resident Identifier #188 within two hours of staff being made aware of the incident.
Failed to ensure a discharge summary was completed for Resident Identifier #242 upon discharge.
Failed to ensure a brown substance was not under Resident Identifier #120's fingernails, indicating inadequate nail care.
Failed to ensure that a stock bottle of expired Vitamin C 500 MG was not left on a medication cart.
Failed to ensure a licensed nurse washed hands or used hand sanitizer after taking Resident Identifier #148's blood pressure and between administering oral and inhalation medications.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication carts reviewed: 6
Residents observed: 9
Nurses observed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator/Abuse Coordinator | Named in failure to timely report abuse finding |
| EI #10 | Registered Nurse/Director of Nursing | Named in failure to complete discharge summary finding |
| EI #8 | Licensed Practical Nurse | Observed with resident's fingernail care deficiency |
| EI #9 | Certified Nursing Assistant | Observed with resident's fingernail care deficiency |
| EI #7 | Clinical Leader | Interviewed regarding nail care protocol |
| EI #2 | Licensed Practical Nurse | Named in expired medication storage finding |
| EI #5 | Registered Nurse | Named in hand hygiene deficiency during medication administration |
| EI #4 | Infection Control Preventionist/Registered Nurse | Interviewed regarding hand hygiene protocol |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 5
Date: Mar 7, 2019
Visit Reason
The inspection was conducted due to complaints regarding inaccurate medication coding on the MDS, improper medication handling during administration, and failure to timely report a Norovirus outbreak.
Complaint Details
The complaint investigation was substantiated with findings of inaccurate medication coding on the MDS, improper medication handling during administration, and failure to timely report a Norovirus outbreak affecting multiple residents.
Findings
The facility failed to ensure accurate medication coding on the MDS for one resident, left medications unattended during administration leading to potential medication errors, and did not timely report a Norovirus outbreak affecting three residents. Additional deficiencies included improper handling of medications that could lead to contamination and infection spread.
Deficiencies (5)
Failed to ensure anticoagulation medication was accurately coded on the 11/30/18 MDS after discontinuation on 10/4/18 for Resident #23.
Medication nurse left medications unattended on Resident #140's bedside table, allowing self-administration.
Failed to timely report a Norovirus outbreak on Unit L1 affecting Residents #4, #9, and #74 to appropriate governmental agencies.
Licensed staff placed Resident #114's medication on bedside table without a barrier and returned them to the medication cart, risking contamination.
Licensed staff dropped artificial tears box on floor, picked it up without wiping, and administered eye drops to Resident #80, risking infection spread.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Nurses observed: 4
Residents on Unit L1: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse, Clinical Leader | Employee Identifier #4 responsible for coding medications on the MDS and interviewed about inaccurate coding | |
| Licensed Practical Nurse | Employee Identifier #5 observed and interviewed regarding medication administration and infection control breaches | |
| Registered Nurse Clinical Leader on L1 Unit | Employee Identifier #3 interviewed about Norovirus outbreak and infection prevention | |
| Licensed Practical Nurse | Employee Identifier #6 observed and interviewed about medication handling errors |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Mar 7, 2019
Visit Reason
The inspection was conducted following complaints and observations related to medication coding errors on the MDS, improper medication handling during administration, and failure to timely report a Norovirus outbreak.
Complaint Details
The visit was complaint-related, triggered by concerns about inaccurate medication coding on the MDS, unsafe medication administration practices, and failure to report a communicable disease outbreak timely. The complaint was substantiated with findings of minimal harm or potential for harm.
Findings
The facility failed to ensure accurate medication coding on the MDS for one resident, left medications unattended during administration leading to self-administration by a resident, and did not timely report a Norovirus outbreak affecting multiple residents. Additional deficiencies included improper handling of medications and potential infection control risks.
Deficiencies (5)
Failed to ensure anticoagulation medication was accurately coded on the 11/30/18 MDS after discontinuation on 10/4/18 for Resident #23.
Medication nurse left medications unattended on Resident #140's bedside table, allowing self-administration of nasal spray.
Failed to timely report Norovirus outbreak on Unit L1 to appropriate governmental agencies within required timeframe.
Licensed staff placed Resident #114's medication on bedside table without a barrier and returned them to medication cart.
Licensed staff dropped artificial tears box on floor, picked it up without wiping, and administered eye drops to Resident #80.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 2
Nurses observed: 4
Residents on Unit L1: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse, Clinical Leader (EI #4) | Interviewed regarding responsibility for coding medications on the MDS and acknowledged error in coding anticoagulation medication. | |
| Licensed Practical Nurse (EI #5) | Observed leaving medications unattended and dropping artificial tears box on floor during medication pass. | |
| Registered Nurse Clinical Leader on L1 Unit (EI #3) | Interviewed about Norovirus outbreak and infection prevention procedures. | |
| Licensed Practical Nurse (EI #6) | Observed placing medications on bedside table without barrier and returning them to medication cart. |
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