Inspection Reports for
Irondale Post Acute

The complaint investigation focused on whether the facility ensured appropriate tube feeding care for Resident #2. The deficiency was substantiated based on record review and staff interviews confirming failure to implement feeding orders timely.

The facility failed to ensure Resident #2 received enteral feeding as ordered by the physician for five days after admission. The feeding orders were not entered into the resident's computerized physician orders (CPO) until five days after admission, resulting in missed nutritional requirements. Staff interviews confirmed the admitting nurse failed to verify and enter hospital discharge feeding orders into the facility's system.

The facility failed to provide adequate supervision to prevent Resident #4 from eloping, resulting in the resident being missing for approximately 46 hours. The facility also failed to maintain safe and accessible evacuation routes, with a padlocked gate blocking emergency egress. These failures created an immediate jeopardy situation affecting all 72 residents.

The complaint investigation substantiated that Resident #3 was not secured properly in the van on 2025-01-22, leading to a fall and serious injuries. The facility's investigation confirmed the failure of van driver #1 to secure the wheelchair and subsequent corrective actions were taken including suspension and termination of the driver, staff training, and policy revisions.

The facility failed to ensure Resident #3 was properly secured in her wheelchair during transport, resulting in a fall that caused multiple fractures, brain injury, and pain. The facility implemented corrective actions including staff training and policy updates, but the incident was cited as immediate jeopardy with serious harm to the resident.

The complaint investigation found that Resident #1, a high fall risk resident, fell on 9/6/24 but the fall was not reported until 9/12/24. The delay in reporting led to a six-day delay in identifying and treating a hip fracture. The facility substantiated the complaint and took corrective actions including staff termination and re-education.

The facility failed to ensure Resident #1 remained free from accidents, resulting in a fall on 9/6/24 that caused a hip fracture which was not identified until 9/12/24 due to failure to report the fall. The facility conducted an investigation, terminated an LPN who denied knowledge of the fall, and re-educated staff on fall policies and reporting procedures.

The facility had multiple deficiencies including failure to ensure fall prevention interventions for residents, improper oxygen therapy administration, inadequate pain management resulting in missed doses and hospitalization, failure to remove expired emergency narcotic kits, improper medication labeling, unsanitary food handling practices, inadequate hospice communication and documentation, and insufficient infection control practices including housekeeping and surface disinfection.

The facility had multiple deficiencies including failure to ensure fall interventions for residents, improper oxygen therapy administration, inadequate pain management resulting in missed doses and hospitalization, failure to remove expired emergency narcotic kits, improper medication labeling, unsanitary food handling practices, inadequate hospice communication and documentation, insufficient housekeeping cleaning and disinfection practices, and lack of a certified infection preventionist for several months.

The facility failed to ensure discharge summaries were completed thoroughly for two residents (#6 and #14) discharged during the review period. Key sections of the discharge summaries and post-discharge plans were incomplete or missing signatures, and the facility lacked consistent oversight to ensure completion.

The facility failed to ensure discharge summaries were completed thoroughly for two residents (#6 and #14), missing key information about the resident's stay and post-discharge care. The discharge assessments were not consistently completed or signed by staff or residents, and the facility lacked oversight to ensure thorough completion.

The complaint investigation focused on an incident of physical abuse where Resident #4 spat on Resident #3. The facility substantiated the abuse and took actions including notifying police, placing Resident #3 on 15-minute checks, and educating staff on appropriate responses to verbal aggression.

The facility failed to prevent an incident of physical abuse where Resident #4 spat on Resident #3. The facility also failed to provide accurate skin assessments and wound care orders for some residents, failed to conduct proper neurological assessments after a resident's fall, and failed to provide appropriate dementia care interventions for Resident #3.

The facility failed to identify and address severe weight loss in Resident #40, resulting in actual harm to a few residents. Additionally, the facility failed to maintain proper kitchen sanitation as the dish machine sanitizer was not functioning, potentially affecting 84 of 85 residents.

The facility failed to develop and implement comprehensive, person-centered care plans for multiple residents, ensure proper insulin administration according to physician orders, provide appropriate discharge planning, ensure safe function of medical equipment, and provide adequate respiratory and psychosocial care.