Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
11% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
170% occupied
Based on a April 2021 inspection.
Occupancy rate over time
Inspection Report
Routine
Census: 78
Deficiencies: 1
Date: Apr 8, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on the kitchen floor's condition and its impact on foodborne illness prevention.
Findings
The facility failed to ensure the kitchen floor was smooth and easily cleanable, resulting in accumulation of dirt, trash, and potential contamination. The floor had rough, uneven areas with black and grey patches that were difficult to clean, posing risks for pests and physical contaminants affecting residents.
Deficiencies (1)
Kitchen floor was not smooth and easily cleanable, with rough black and grey patches that accumulated dirt and debris.
Report Facts
Residents served: 78
Floor measurements: 14
Floor measurements: 52.5
Floor measurements: 23
Floor measurements: 1.5
Floor measurements: 1.08
Floor measurements: 5
Floor measurements: 19
Floor measurements: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian and Director of Food Service | Provided information about kitchen conditions and cleaning schedule | |
| Maintenance Director | Interviewed about floor material and condition | |
| Utility Aide | Described cleaning practices and floor condition |
Inspection Report
Census: 78
Deficiencies: 1
Date: Apr 6, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with food safety standards, specifically focusing on the kitchen floor's condition and its impact on foodborne illness prevention.
Findings
The facility failed to ensure the kitchen floor was smooth and easily cleanable, resulting in accumulation of dirt, trash, and potential contamination. The floor had rough, uneven areas with black and grey patches that were difficult to clean, posing risks for pests and physical contaminants affecting residents.
Deficiencies (1)
The kitchen floor was not smooth or easily cleanable, with rough black and grey patches that accumulated dirt, trash, and contaminants.
Report Facts
Residents served: 78
Floor patch dimensions: 14
Floor patch dimensions: 52.5
Floor patch dimensions: 23
Floor patch dimensions: 1.5
Floor patch dimensions: 1.08
Floor patch dimensions: 5
Floor patch dimensions: 19
Floor patch dimensions: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) and Director of Food Service | Provided information about kitchen conditions and resident census | |
| Maintenance Director | Interviewed about floor material and condition | |
| Utility Aide | Described cleaning procedures and floor condition |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation (complaint/report # AL00038071) regarding the facility's failure to timely report suspected abuse allegations to the State Agency as required by regulation.
Complaint Details
This deficient practice was cited as a result of the investigation of complaint/report # AL00038071. The complaint involved failure to timely report abuse allegations involving residents RI #44, 24, and 68.
Findings
The facility failed to ensure all alleged abuse allegations were reported to the State Agency within two hours as required. Three residents (RI #44, 24, and 68) had abuse allegations that were reported late, with explanations citing facility policy rather than regulatory requirements. Additionally, the facility failed to label and date certain frozen food items in the kitchen, potentially affecting 82 residents.
Deficiencies (2)
Failure to timely report suspected abuse allegations to the State Agency within two hours as required by regulation.
Failure to label and date frozen food items (six ham pieces and five crab cakes) prior to storage in the walk-in freezer.
Report Facts
Residents affected: 3
Residents affected: 82
Servings: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Unit Manager | Interviewed regarding knowledge and reporting of abuse incident involving RI #44 (Employee Identifier #3) | |
| Director of Nursing (DON) | Interviewed regarding notification and reporting of abuse incidents involving RI #44, 24, and 68 (Employee Identifier #2) | |
| Executive Director and Abuse Coordinator | Interviewed regarding reporting requirements and facility policy on abuse allegations (Employee Identifier #1) | |
| Dining Services Manager | Interviewed regarding unlabeled frozen food items found in walk-in freezer (Employee Identifier #6) | |
| Dietitian | Interviewed regarding labeling responsibilities and unlabeled frozen food items (Employee Identifier #5) |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 6, 2020
Visit Reason
The inspection was conducted as a result of a complaint investigation (complaint/report # AL00038071) regarding the facility's failure to timely report suspected abuse allegations to the State Agency within the required two-hour timeframe.
Complaint Details
This deficient practice was cited as a result of the investigation of complaint/report # AL00038071. The complaint involved failure to timely report abuse allegations involving residents RI #44, 24, and 68.
Findings
The facility failed to ensure all alleged abuse allegations were reported to the State Agency within two hours as required by regulation. Three residents (RI #44, 24, and 68) had abuse allegations that were reported late due to the facility's policy allowing up to 24 hours for reporting if no bodily injury was present. Additionally, the facility failed to label and date certain frozen food items in the kitchen, potentially affecting 82 residents.
Deficiencies (2)
Failure to timely report suspected abuse allegations to the State Agency within two hours as required.
Failure to label and date frozen food items (six ham pieces and five crab cakes) stored in the walk-in freezer.
Report Facts
Residents affected by abuse reporting deficiency: 3
Residents affected by food labeling deficiency: 82
Date of abuse report for RI #44: Sep 2, 2019
Date of abuse report for RI #24: Feb 22, 2019
Date of abuse report for RI #68: Jun 4, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) Unit Manager | Employee Identifier (EI) #3 interviewed regarding knowledge and reporting of abuse incident involving RI #44. | |
| Director of Nursing (DON) | Employee Identifier (EI) #2 interviewed regarding notification and reporting of abuse incidents involving RI #44, 24, and 68. | |
| Executive Director and Abuse Coordinator | Employee Identifier (EI) #1 interviewed regarding reporting responsibilities and facility policy on abuse reporting. | |
| Dining Services Manager | Employee Identifier (EI) #6 interviewed regarding unlabeled frozen food items found in the walk-in freezer. | |
| Dietitian | Employee Identifier (EI) #5 interviewed regarding labeling responsibilities and use of unlabeled food items. |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 12, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident access to survey results, pharmaceutical services, medication destruction documentation, and infection prevention and control practices.
Findings
The facility failed to ensure survey results were readily accessible to residents and visitors, failed to have required signatures on medication destruction records, and a Licensed Practical Nurse did not wash hands before and after administering topical medication, posing potential minimal to actual harm to residents.
Deficiencies (3)
Failed to ensure the facility's most recent survey results were readily accessible to residents, visitors, and other individuals.
Failed to ensure required two signatures on two of eleven Non-Controlled Medication Destruction Sheets for April 2018.
Licensed Practical Nurse failed to wash hands prior to and after administering topical medication ointment to a resident.
Report Facts
Signature sheets missing required signatures: 2
Residents in resident council meeting: 12
Residents observed during medication administration: 5
Nurses observed during medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding accessibility of survey results and medication destruction sheets. | |
| Executive Director | Interviewed regarding location and accessibility of survey results binders. | |
| Physical Therapy Assistant | Interviewed about therapy gym access and survey results binder availability. | |
| Registered Nurse | Interviewed about access to survey results binder behind nurse's station. | |
| Licensed Practical Nurse | Observed and interviewed regarding failure to wash hands before and after topical medication administration. |
Inspection Report
Routine
Deficiencies: 3
Date: Dec 12, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident notification of survey results, pharmaceutical services, medication destruction documentation, and infection prevention and control practices.
Findings
The facility failed to ensure survey results were readily accessible to residents and visitors, failed to have required signatures on medication destruction records, and a Licensed Practical Nurse did not wash hands before and after administering topical medication, posing potential minimal harm to residents.
Deficiencies (3)
Failed to ensure the facility's most recent survey results were readily accessible to residents, visitors, and other individuals.
Failed to ensure required signatures were on two of 11 Non-Controlled Medication Destruction Sheets for April 2018.
Failed to ensure a Licensed Practical Nurse washed hands prior to and after administering a topical medication ointment to a resident.
Report Facts
Signature sheets missing required signatures: 2
Residents in resident council meeting: 12
Residents observed during medication administration: 5
Nurses observed during medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding accessibility of survey results and medication destruction documentation. | |
| Executive Director | Interviewed regarding location and accessibility of survey results binders. | |
| Physical Therapy Assistant | Interviewed about therapy gym access and survey results binder availability. | |
| Registered Nurse | Interviewed about access to survey results binder behind nurse's station. | |
| Licensed Practical Nurse | Observed and interviewed regarding failure to wash hands before and after administering topical medication. |
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