Deficiencies (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
Annual Inspection
Deficiencies: 6
Date: Feb 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication monitoring, food storage, infection control, and other facility operations as part of the annual survey.
Findings
The facility failed to complete comprehensive annual and quarterly Minimum Data Set (MDS) assessments timely for multiple residents, failed to transmit MDS assessments to CMS within required timeframes, did not adequately monitor residents on psychotropic medications for targeted behaviors and side effects, improperly stored food in the kitchen, and failed to ensure proper infection control during medication administration.
Deficiencies (6)
Failure to complete comprehensive annual MDS assessments timely for Resident Identifiers #5 and #7.
Failure to complete quarterly MDS assessments timely for Resident Identifiers #9, 27, 8, 19, 23, 18, 14, 21, and 24.
Failure to transmit MDS assessments to CMS within 14 days of completion for Resident Identifiers #17, 15, 27, 11, 2, 23, 22, 16, 21, and 24.
Failure to monitor residents #45 and #22 for specific targeted behaviors and side effects related to psychotropic medications.
Failure to properly store food in the walk-in refrigerator and freezer, including unlabeled and undated open food packages and food stored on the floor.
Failure to wear gloves during insulin administration to Resident Identifier #196.
Report Facts
Residents reviewed for timely MDS completion: 23
Residents affected by annual MDS assessment deficiency: 2
Residents affected by quarterly MDS assessment deficiency: 9
Residents affected by MDS transmission deficiency: 10
Residents affected by psychotropic medication monitoring deficiency: 2
Residents affected by food storage deficiency: 54
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Provided information on MDS assessments and transmission delays | |
| Administrator | Interviewed regarding expectations for timely MDS assessments and transmissions, and infection control practices | |
| Licensed Practical Nurse (EI #24) | Interviewed regarding lack of monitoring for psychotropic medication side effects and behaviors | |
| Dietary Manager (EI #13) | Interviewed regarding food storage practices and policy | |
| Licensed Practical Nurse (EI #4) | Observed not wearing gloves during insulin administration and interviewed about the incident | |
| Psychiatric Nurse Practitioner | Interviewed regarding expectations for monitoring residents on psychotropic medications |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Feb 25, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, medication monitoring, food safety, and infection control at Fairhope Health & Rehab.
Findings
The facility failed to complete comprehensive annual and quarterly Minimum Data Set (MDS) assessments within required timeframes for multiple residents, failed to timely transmit MDS data to CMS, did not adequately monitor residents on psychotropic medications for targeted behaviors and side effects, improperly stored food in the kitchen, and failed to ensure proper infection control during medication administration.
Deficiencies (6)
Failure to complete comprehensive annual MDS assessments timely for Resident Identifiers #5 and #7.
Failure to complete quarterly MDS assessments timely for Resident Identifiers #9, 27, 8, 19, 23, 18, 14, 21, and 24.
Failure to transmit MDS assessments to CMS within 14 days of completion for Resident Identifiers #17, 15, 27, 11, 2, 23, 22, 16, 21, and 24.
Failure to monitor residents #45 and #22 for specific targeted behaviors and side effects related to psychotropic medications.
Failure to properly store food in the walk-in refrigerator and freezer, including unlabeled and undated open food packages and food stored on the floor.
Failure to wear gloves during insulin administration to Resident Identifier #196.
Report Facts
Residents reviewed for timely MDS completion: 23
Residents affected by annual MDS assessment deficiency: 2
Residents affected by quarterly MDS assessment deficiency: 9
Residents affected by MDS transmission deficiency: 10
Residents affected by psychotropic medication monitoring deficiency: 2
Residents affected by food storage deficiency: 54
Residents affected by infection control deficiency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Provided information on MDS assessments and transmission delays | |
| Administrator | Interviewed regarding expectations for timely MDS assessments and transmissions, and infection control practices | |
| Licensed Practical Nurse (EI #24) | Interviewed regarding lack of monitoring for psychotropic medication side effects and behaviors | |
| Dietary Manager (EI #13) | Interviewed regarding food storage practices | |
| Licensed Practical Nurse (EI #4) | Observed not wearing gloves during insulin administration | |
| Psychiatric Nurse Practitioner | Interviewed regarding expectations for monitoring residents on psychotropic medications |
Inspection Report
Deficiencies: 1
Date: May 23, 2019
Visit Reason
The inspection was conducted to evaluate compliance with pharmaceutical service requirements, specifically reviewing the facility's medication destruction records and policies.
Findings
The facility failed to ensure that Non-Controlled Medication Destruction records for June 27, 2018 and March 29, 2019 contained the required two signatures, as only one signature was present on each record.
Deficiencies (1)
Non-Controlled Medication Destruction records for June 27, 2018 and March 29, 2019 contained only one signature instead of the required two.
Inspection Report
Deficiencies: 1
Date: May 23, 2019
Visit Reason
The inspection was conducted to review compliance with pharmaceutical service requirements, specifically to ensure proper documentation and signatures on Non-Controlled Medication Destruction records.
Findings
The facility failed to ensure that the Non-Controlled Medication Destruction records dated June 27, 2018 and March 29, 2019 contained the required two signatures. Only one signature was present on these records, contrary to facility policy requiring two witnesses.
Deficiencies (1)
Non-Controlled Medication Destruction records for June 27, 2018 and March 29, 2019 contained only one signature instead of the required two.
Report Facts
Months of Non-controlled Medication Destruction records reviewed: 7
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 25, 2018
Visit Reason
The inspection was conducted due to a complaint regarding failure to provide appropriate care and assistance with activities of daily living, specifically related to incontinence care and pressure ulcer prevention for Resident Identifier #4.
Complaint Details
The complaint investigation focused on Resident #4's care on 5/16/18, including failure to check and change for incontinence and failure to reposition, which placed the resident at risk for pressure ulcers. Interviews with staff confirmed noncompliance with facility policy requiring checks every two hours. The resident was observed left in a soiled brief for over four hours.
Findings
The facility failed to check and change Resident #4 for incontinence for over four hours despite the resident being totally dependent on staff for ADLs and at risk for pressure ulcers. Staff did not reposition or check the resident's brief for wetness or soiling during the observation period, violating facility policy and care plans.
Deficiencies (2)
Failure to check and change Resident #4 for incontinence for over four hours, contrary to care plan and facility policy.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #4 at risk due to immobility and incontinence.
Report Facts
Observation duration: 4.27
Date of observation: May 16, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #17 | Certified Nursing Assistant | Named in interview regarding failure to check and change Resident #4 for incontinence |
| EI #16 | Registered Nurse | Named in interview confirming facility policy and staff assignment for Resident #4 on 5/16/18 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 16, 2018
Visit Reason
The inspection was conducted based on a complaint regarding failure to provide adequate care and assistance with activities of daily living, specifically related to incontinence care and pressure ulcer prevention for Resident Identifier #4.
Complaint Details
The complaint investigation found that Resident #4 was not checked or changed for incontinence for over four hours, increasing risk for pressure ulcers and urinary tract infections. Interviews with staff confirmed the failure to follow facility policy requiring checks every two hours. The resident was described as a heavy wetter and totally dependent on staff for care.
Findings
The facility failed to check and change Resident #4 for incontinence over a period of four hours and 16 minutes, despite the resident being totally dependent on staff for ADLs and at risk for pressure ulcers. Staff did not reposition or check the resident's brief for wetness or soiling during this time, which posed a risk for skin breakdown and urinary tract infections.
Deficiencies (2)
Failure to check and change Resident #4 for incontinence for over four hours despite being totally dependent and at risk for skin breakdown.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for Resident #4 at risk for pressure ulcers.
Report Facts
Duration of incontinence neglect: 256
Assessment Reference Date: Apr 9, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #17 | Certified Nursing Assistant | Named in findings related to failure to check and change Resident #4 for incontinence. |
| EI #16 | Registered Nurse | Interviewed regarding Resident #4 care and facility policy on checking residents. |
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