Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
36% better than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
This document is a statement of deficiencies and plan of correction related to a facility survey completed on 08/10/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Census: 77
Deficiencies: 1
Date: Apr 14, 2022
Visit Reason
The inspection was conducted to assess compliance with food safety standards, specifically regarding the cleanliness and sanitation of kitchen equipment.
Findings
The facility failed to ensure the drying rack in the kitchen was free from dust and rust, which posed a potential risk of foodborne illness affecting 74 of the 77 residents receiving meals.
Deficiencies (1)
Drying rack in the kitchen had visible dust and rust, failing to meet cleaning and sanitation standards.
Report Facts
Residents affected: 74
Residents present: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding the condition and cleaning responsibility of the drying rack |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 6, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, respiratory care, and sanitation at Hunter Creek Health and Rehabilitation, LLC.
Findings
The facility failed to complete a timely quarterly Minimum Data Set assessment for one resident, did not ensure oxygen tubing was dated and stored properly for two residents, and allowed a dumpster to leak potentially hazardous substances, posing infection control and safety risks.
Deficiencies (3)
Failure to ensure a Quarterly MDS assessment was completed timely for Resident Identifier #1.
Failure to ensure staff dated oxygen tubing and stored the oxygen tubing in a plastic bag when not in use for Residents #9 and #32.
Failure to ensure the dumpster was not leaking and that liquid was not pooling on the ground around it, affecting sanitation.
Report Facts
Residents reviewed for MDS assessments: 25
Residents sampled for receiving oxygen: 4
Dumpsters observed: 3
Residents residing in the facility: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Interviewed regarding timely completion of comprehensive assessments | |
| Registered Nurse/Unit Manager | Interviewed regarding oxygen tubing change procedures and infection control | |
| Dietary Manager | Interviewed regarding dumpster sanitation and maintenance responsibilities |
Inspection Report
Routine
Deficiencies: 5
Date: Jun 7, 2018
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, medication destruction, food service, waste management, and infection control at Hunter Creek Health and Rehabilitation, LLC.
Findings
The facility was found deficient in maintaining a safe and homelike environment due to missing furniture parts and damaged walls in resident rooms; failure to ensure two signatures on medication destruction records; inadequate hand hygiene and food temperature monitoring in the kitchen; improper stacking of wet plates; failure to keep dumpster doors closed; and lapses in infection control during wound care procedures.
Deficiencies (5)
Missing dresser drawer in Room Locator (RL) #1, missing caps on commode bolts in RL #2, 3, and 4, and peeling sheetrock on the wall behind bed A in RL #5.
Medication destruction sheets for November 2017 lacked the required two signatures for non-controlled medications.
Staff failed to wash hands upon entering the kitchen; food temperatures were not properly taken or recorded; and plates were stacked wet.
Dumpster door was left half open, contrary to facility policy requiring it to be closed at all times.
Licensed staff placed a container of 4x4 gauze on a resident's bed during wound care and touched a pen then hydrogel dressing with the same gloves, risking cross contamination.
Report Facts
Rooms affected: 5
Medication destruction sheets reviewed: 12
Residents affected: 67
Residents affected: 69
Plates with water observed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #4 | Maintenance Director | Interviewed regarding missing dresser drawer, missing commode bolt caps, and peeling sheetrock. |
| EI #1 | Director of Nursing | Interviewed about medication destruction signature policy and findings. |
| EI #5 | Dietary Manager | Observed and interviewed regarding hand washing, dumpster door, and wet plates. |
| EI #6 | Assistant Cook | Observed and interviewed regarding hand washing in the kitchen. |
| EI #7 | Cook | Interviewed about food temperature taking and recording practices. |
| EI #8 | Cook | Interviewed about food temperature taking and placing new chicken on old chicken. |
| EI #2 | Licensed Practical Nurse | Observed and interviewed regarding improper wound care practices. |
| EI #3 | Infection Control Nurse | Interviewed about wound care policies and risks of contamination. |
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