Deficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
4
3
2
1
0
Inspection Report
Routine
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to evaluate compliance with care plan development, treatment and care according to orders, and assistance with activities of daily living, specifically focusing on residents with swallowing difficulties and restorative nursing programs.
Findings
The facility failed to update care plans with speech therapy recommendations for Resident #48 and failed to provide appropriate feeding assistance and care for Residents #48 and #62, resulting in minimal harm or potential for actual harm. Observations and interviews revealed inconsistent adherence to feeding protocols and care plan updates.
Deficiencies (2)
Failed to update Resident #48's care plan with speech therapy recommendations as required by the restorative nursing program.
Failed to provide appropriate treatment and care according to orders and resident preferences for Residents #48 and #62, including improper feeding assistance and failure to follow speech therapy feeding recommendations.
Report Facts
Residents sampled: 25
Residents reviewed for assistance with ADLs: 3
Residents affected: 2
Assessment Reference Date: Dec 3, 2021
BIMS score: 5
Daily calories from feeding tube: 51
Assessment Reference Date: Nov 13, 2020
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #2 | Director of Nursing (DON) | Stated nurses received therapy recommendations and were responsible for updating care plans |
| EI #11 | Registered Nurse (RN) Supervisor | Stated care plans should be updated within 24 hours after new interventions and was involved in feeding Resident #62 |
| EI #1 | Licensed Nursing Home Administrator (LNHA) | Stated care plans should be reviewed quarterly and CNAs trained on FMP implementation |
| EI #6 | Certified Nursing Assistant (CNA) | Observed feeding Resident #62 and reported continuous coughing |
| EI #5 | Certified Nursing Assistant (CNA) | Described feeding procedures and signs to stop feeding Resident #62 |
| EI #3 | Speech Language Pathologist (SLP) | Provided speech therapy recommendations and FMP for Resident #62 |
| EI #14 | Registered Dietitian (RD) | Stated Resident #62 required total assistance with meals |
| EI #15 | Licensed Practical Nurse (LPN) | Documented observations of Resident #48 holding food in mouth |
| EI #10 | Licensed Practical Nurse (LPN) | Observed and assisted Resident #48 with pocketed food and cueing |
| EI #4 | Certified Nursing Assistant (CNA) | Reported on Resident #48's feeding assistance and pocketing behavior |
Inspection Report
Routine
Census: 156
Deficiencies: 4
Date: May 16, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, infection control, food safety, and documentation at Heritage Health Care & Rehab Inc.
Findings
The facility was found deficient in multiple areas including incorrect code status labeling for a resident, delayed assistance with feeding, improper food temperature measurement and food dating practices, and lapses in infection prevention and control practices involving oxygen equipment, inhaler cleaning, and hand hygiene during medication administration.
Deficiencies (4)
Failed to ensure correct code status label on medical chart and bed for Resident #405.
Resident #406 waited thirty minutes to receive assistance with dinner meal.
Dietary staff took food temperatures by sticking thermometer through plastic wrap or foil and staff dated resident's food improperly.
Failed to reapply Resident #88's nasal cannula after it was found on the floor, oxygen tubing for Resident #89 was not dated, inhaler not cleaned before storage, and improper glove use and hand hygiene during medication administration for Resident #116.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 140
Residents affected: 3
Total residents receiving meals: 156
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | EI #9 interviewed regarding code status labeling for Resident #405 | |
| Licensed Practical Nurse Supervisor | EI #6 interviewed regarding feeding assistance delays for Resident #406 | |
| Registered Nurse | EI #7 interviewed regarding feeding assistance delays for Resident #406 | |
| Dietary Aide | EI #2 and EI #3 interviewed regarding improper food temperature measurement | |
| Dietary Manager | EI #1 interviewed regarding food temperature and food dating practices | |
| RN Supervisor | EI #4 interviewed regarding food dating and refrigerator checks | |
| RN | EI #5 interviewed regarding food dating and refrigerator checks | |
| Certified Nursing Assistant | EI #13 observed and interviewed regarding oxygen tubing found on floor for Resident #88 | |
| Licensed Practical Nurse | EI #6 observed administering inhaler and interviewed regarding cleaning and storage | |
| Director of Nursing | EI #14 confirmed oxygen tubing not dated for Resident #89 | |
| Licensed Practical Nurse | EI #11 observed and interviewed regarding glove use and hand hygiene during medication administration for Resident #116 | |
| Registered Nurse/Infection Control | EI #12 interviewed regarding infection control practices |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 24, 2018
Visit Reason
The inspection was conducted following a complaint regarding the failure to provide Resident Identifier (RI) #313 with the prescribed Mestinon medication upon admission and concerns about medication administration practices.
Complaint Details
The complaint involved the failure to provide the resident's prescribed medication on admission and improper medication administration practices. The complaint was substantiated with findings that the resident did not receive the prescribed Mestinon medication on admission and was given another resident's medication. The resident and family reported these issues to staff, but appropriate actions were not taken.
Findings
The facility failed to ensure RI #313 received the prescribed Mestinon medication on admission and administered another resident's medication to RI #313, violating medication administration policies. Additionally, the facility failed to document an assessment of RI #313's colostomy and skin status on 05/20/18, resulting in skin irritation due to leakage.
Deficiencies (3)
Failed to ensure RI #313 received the prescribed Mestinon medication upon admission.
Administered another resident's medication (Coumadin) to RI #313 without following policy.
Failed to document an assessment of RI #313's colostomy and skin status on 05/20/18.
Report Facts
Residents admitted with admission orders in last 30 days: 14
Mestinon dosage: 60
Medication administration times: 3
Coumadin dosage: 2.5
Brief Interview for Mental Status score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | EI #1 admitted to not administering the prescribed Mestinon medication and administering another resident's medication to RI #313. | |
| Registered Nurse Supervisor (RN) | EI #4 described responsibilities related to admissions and medication order reviews. | |
| Licensed Practical Nurse (LPN) | EI #3 admitted to giving another resident's medication to RI #313 at the request of EI #1. | |
| Licensed Practical Nurse (LPN) | EI #2 failed to document assessment of RI #313's colostomy and skin status on 05/20/18. | |
| Registered Nurse (RN) | EI #5 signed a document discussing the medication concerns and standing order for one-time doses. |
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