Deficiencies (last 3 years)
Deficiencies (over 3 years)
17.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
381% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
36
27
18
9
0
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of abuse, neglect, misappropriation of property, and failure to provide adequate behavioral health services at the facility.
Complaint Details
The complaint investigation was triggered by allegations of abuse, neglect, misappropriation of medication, and failure to provide adequate behavioral health services. The investigation included review of medical records, interviews with staff and residents, and review of facility policies. Immediate Jeopardy was identified related to abuse and behavioral health services involving Resident Identifier #335 and #334. The Immediate Jeopardy was removed after the facility implemented corrective actions including staff education, behavioral assessments, and enhanced supervision.
Findings
The facility failed to notify a resident's representative of a hospital transfer, failed to protect a resident from physical abuse by another resident, failed to prevent misappropriation of medication by a nurse, failed to timely report an allegation of abuse to the state agency, and failed to develop and implement behavioral health interventions for a resident with aggressive and suicidal behaviors. Immediate Jeopardy was identified related to behavioral health services and abuse prevention, which was removed after corrective actions were verified.
Deficiencies (7)
Failed to notify Resident Identifier #335's representative of an incident and hospital transfer.
Failed to protect Resident Identifier #334 from physical abuse by Resident Identifier #335, resulting in Immediate Jeopardy.
Failed to protect Resident Identifier #40 from misappropriation of medication by Registered Nurse #6.
Failed to timely report an allegation of physical abuse to the state agency within two hours.
Failed to develop and implement behavioral health interventions for Resident Identifier #335 after hospital return, resulting in Immediate Jeopardy.
Failed to ensure sufficient staff competencies and skills to meet behavioral health needs of Resident Identifier #335, resulting in Immediate Jeopardy.
Failed to maintain and reconcile controlled medication records and secure medications properly, resulting in missing oxycodone for Residents #47 and #57.
Report Facts
Residents reviewed for transfer and discharge: 3
Residents reviewed for abuse and neglect prevention: 7
Residents sampled for abuse prevention: 7
Residents reviewed for behavioral health services: 4
Employees educated on abuse and behavioral health policies: 73
Nurses educated on behavioral assessment upon return from transfer: 20
Missing oxycodone tablets for Resident #47: 60
Missing oxycodone tablets for Resident #57: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in misappropriation of medication finding involving Resident #40. |
| RN #7 | Registered Nurse | Named in missing medication investigation for Residents #47 and #57; failed to properly document and secure medications. |
| RN #18 | Registered Nurse | Interviewed regarding Resident #335's behavior and medication administration. |
| RN #30 | Registered Nurse | Entered clinical notes documenting Resident #335's behaviors. |
| CNA #27 | Certified Nursing Assistant | Witnessed Resident #335 physically abusing Resident #334. |
| Administrator | Notified of Immediate Jeopardy findings and involved in corrective action plans. | |
| Director of Nursing | DON | Involved in interviews and corrective action plans related to behavioral health and abuse findings. |
| Regional Nurse Manager | Involved in education and corrective action plans. | |
| Social Services Designee | SSD | Provided information on Resident #335's behaviors and interventions. |
| Former Assistant Director of Nursing | FADON | Interviewed regarding Resident #335's behaviors and facility interventions. |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Jun 18, 2024
Visit Reason
The inspection was conducted due to complaint investigations involving allegations of abuse, neglect, misappropriation of property, failure to report abuse timely, failure to develop baseline care plans, failure to provide safe respiratory care, failure to provide necessary behavioral health services, failure to ensure sufficient competent staff for behavioral health needs, failure to meet nutritional needs per menu, failure to prevent cross-contamination in dishwashing, and failure to implement infection prevention and control.
Complaint Details
The complaint investigation involved multiple allegations including failure to notify resident representative of incidents, resident-to-resident physical abuse, misappropriation of medication by staff, failure to timely report abuse, failure to develop baseline care plans, failure to provide safe respiratory care, failure to provide necessary behavioral health services, failure to ensure sufficient competent staff for behavioral health needs, failure to meet nutritional needs per menu, failure to prevent cross-contamination in dishwashing, and failure to implement infection prevention and control. The immediate jeopardy related to abuse and behavioral health was removed after corrective actions were verified on 06/18/2024.
Findings
The facility was found deficient in multiple areas including failure to notify resident representatives of incidents, failure to protect residents from abuse including resident-to-resident physical abuse, failure to prevent misappropriation of medication by staff, failure to timely report abuse allegations, failure to develop baseline care plans within 48 hours, failure to provide safe respiratory care, failure to develop and implement behavioral health interventions for a resident with aggressive and suicidal behaviors, failure to ensure sufficient competent staff for behavioral health needs, failure to provide meals as per menu portions and diet specifications, failure to prevent cross-contamination and maintain proper dishwashing temperatures, and failure to ensure proper hand hygiene and storage of resident hygiene supplies.
Deficiencies (11)
Failure to notify resident representative of incident and transfer to hospital for Resident Identifier (RI) #335.
Failure to protect resident (RI #334) from physical abuse by another resident (RI #335), resulting in immediate jeopardy to resident health or safety.
Failure to protect resident (RI #40) from misappropriation of medication by Registered Nurse (RN) #6.
Failure to timely report suspected abuse within two hours to the state agency.
Failure to develop and provide baseline care plan within 48 hours of admission for Resident Identifier (RI) #72.
Failure to ensure physician orders for oxygen and proper labeling of oxygen tubing for RI #5; failure to store nebulizer mask in plastic bag for RI #52.
Failure to develop and implement behavioral health interventions for Resident Identifier (RI) #335 with aggressive and suicidal behaviors, resulting in immediate jeopardy.
Failure to ensure sufficient staff with competencies and skills to meet behavioral health needs of residents, specifically RI #335, resulting in immediate jeopardy.
Failure to provide meals as per menu portions and diet specifications, including adding hot water to puree foods to extend volume, serving less than required portions of chicken and noodles, and serving incorrect fruit for CCHO diets.
Failure to prevent cross-contamination in dishwashing area including staff not washing hands between dirty and clean dishes, drying trays with cloth instead of air drying, blocked hand sink access, chewing gum in kitchen, and failure to maintain proper dishwashing temperatures.
Failure to ensure staff washed hands and stored resident hygiene supplies properly to prevent cross-contamination; failure of treatment nurse to perform hand hygiene during wound care.
Report Facts
Residents affected by abuse: 1
Residents affected by misappropriation: 1
Employees educated on abuse prohibition and behavioral health: 73
Nurses educated on behavioral assessment: 20
Residents reviewed for abuse and neglect prevention: 7
Residents reviewed for behavioral health services: 4
Residents receiving meals from kitchen: 79
Dish machine temperature recordings per day: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in medication misappropriation finding. |
| RN #18 | Registered Nurse | Involved in behavioral health incident and interviews. |
| CNA #27 | Certified Nursing Assistant | Witnessed resident-to-resident abuse incident. |
| Dietary Manager | Interviewed regarding nutrition and dishwashing deficiencies. | |
| Kitchen Supervisor | Interviewed regarding nutrition and dishwashing deficiencies. | |
| Registered Dietitian | Interviewed regarding nutrition deficiencies. | |
| LPN #26 | Licensed Practical Nurse | Failed to perform hand hygiene during wound care. |
| Risk Manager/Infection Preventionist | Interviewed regarding infection control deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 18, 2024
Visit Reason
The inspection was conducted due to complaints and facility reported incidents involving abuse, neglect, misappropriation of property, and behavioral health concerns at The Health Center at Research Park.
Complaint Details
The complaint investigation involved allegations of abuse, neglect, misappropriation of medication, failure to notify family of hospital transfer, and failure to provide adequate behavioral health services. The immediate jeopardy related to abuse and behavioral health was removed after corrective actions were verified on 06/18/2024.
Findings
The facility failed to notify a resident's representative of a hospital transfer, failed to protect a resident from physical abuse by another resident, failed to prevent misappropriation of medication by a nurse, failed to timely report an allegation of abuse, and failed to provide necessary behavioral health services and competent staff to manage aggressive and suicidal residents. Corrective actions were implemented and verified by the survey team.
Deficiencies (7)
Failed to notify resident's representative of hospital transfer.
Failed to protect resident from physical abuse by another resident, resulting in immediate jeopardy.
Failed to protect resident from misappropriation of medication by nurse.
Failed to timely report suspected abuse within required timeframe.
Failed to ensure necessary behavioral health services and interventions for resident with aggressive and suicidal behaviors, resulting in immediate jeopardy.
Failed to ensure sufficient staff competencies and skills to meet behavioral health needs, resulting in immediate jeopardy.
Failed to maintain accurate controlled medication records and secure medications, resulting in missing oxycodone tablets.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Missing oxycodone tablets: 60
Missing oxycodone tablets: 30
Staff educated: 73
Nurses educated: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Involved in misappropriation of medication incident |
| RN #7 | Registered Nurse | Signed for missing oxycodone medications, left medications unattended, terminated |
| RN #18 | Registered Nurse | Witnessed resident aggressive behavior and provided clinical notes |
| RN #5 | Registered Nurse | Reported missing oxycodone medications |
| Administrator | Notified of immediate jeopardy findings and involved in corrective actions | |
| Director of Nursing | DON | Notified of immediate jeopardy findings and involved in corrective actions |
| Regional Nurse Manager | Notified of immediate jeopardy findings and involved in corrective actions | |
| Assistant [NAME] President of Operations | Involved in immediate jeopardy notification and corrective actions | |
| Social Services Director | Conducted resident interviews and involved in behavioral health interventions | |
| Charge Nurse | Made notifications and assessments related to abuse and behavioral health |
Inspection Report
Complaint Investigation
Deficiencies: 11
Date: Jun 18, 2024
Visit Reason
The inspection was conducted due to complaint investigations related to abuse, neglect, misappropriation of property, failure to notify representatives, and behavioral health service deficiencies.
Complaint Details
The complaint investigations involved allegations of abuse, neglect, misappropriation of medication, failure to notify representatives, and behavioral health service deficiencies. The immediate jeopardy related to failure to protect residents from abuse and failure to provide necessary behavioral health services was removed after corrective actions were verified on 06/18/2024.
Findings
The facility failed to notify a resident's representative of a hospital transfer, failed to protect a resident from physical abuse by another resident, failed to prevent misappropriation of medication by a nurse, failed to timely report abuse allegations, failed to develop baseline care plans timely, failed to provide safe respiratory care, failed to develop and implement behavioral health interventions for a resident with aggressive and suicidal behaviors, failed to ensure sufficient competent staff for behavioral health needs, failed to provide adequate nutrition per menu, failed to prevent cross-contamination in dishwashing and food handling, and failed to ensure proper infection prevention and control practices.
Deficiencies (11)
Failed to notify resident's representative of hospital transfer.
Failed to protect resident from physical abuse by another resident, resulting in immediate jeopardy.
Misappropriation of resident medication by nurse.
Failed to timely report suspected abuse within required two hours.
Failed to develop and provide baseline care plan within 48 hours of admission.
Failed to ensure resident's oxygen tubing was labeled and nebulizer mask stored properly.
Failed to provide necessary behavioral health care and interventions for resident with aggressive and suicidal behaviors, resulting in immediate jeopardy.
Failed to ensure sufficient competent staff to meet behavioral health needs, resulting in immediate jeopardy.
Failed to ensure menus met nutritional needs and were served as planned, including improper portion sizes and incorrect fruit served.
Failed to prevent cross-contamination in dishwashing and food handling, including improper hand hygiene, drying practices, blocked hand sink, chewing gum in kitchen, and inadequate dish machine sanitizing temperatures.
Failed to ensure infection prevention and control practices, including unlabeled shared bath basins and failure to perform hand hygiene during wound care.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 79
Residents affected: 79
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #6 | Registered Nurse | Named in misappropriation of medication finding |
| RN #18 | Registered Nurse | Named in behavioral health and abuse incident findings |
| CNA #27 | Certified Nursing Assistant | Witness to resident abuse incident |
| RN #30 | Registered Nurse | Documented clinical notes related to behavioral health and abuse incident |
| Dietary Manager | Named in food service and dishwashing deficiencies | |
| Kitchen Supervisor | Named in dishwashing and food handling deficiencies | |
| Maintenance Supervisor | Named in dishwashing machine maintenance and temperature deficiencies | |
| Registered Dietitian | Named in nutrition and food service deficiencies | |
| LPN #26 | Licensed Practical Nurse | Named in infection prevention and control deficiency |
| Risk Manager/Infection Preventionist | Named in infection prevention and control deficiency |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 22, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dietary services, and facility operations at The Health Center at Research Park.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without medical justification, incomplete Minimum Data Set (MDS) assessments, failure to follow dietary recipes and portion sizes for pureed and mechanically altered diets, and inadequate food safety and sanitation practices in the kitchen.
Deficiencies (6)
Failure to provide medical justification for use of a locked, reclined Geri-chair as a physical restraint for Resident #58.
Incomplete admission and quarterly Minimum Data Set (MDS) assessments for Resident #38 with multiple sections not assessed.
Failure to follow recipes for pureed diets for four residents, including improper addition of water diluting nutrients.
Failure to follow menu scoop sizes for pureed entrees for four residents.
Failure to serve food in the appropriate form for seven residents on mechanically altered diets; regular baked beans served instead of mashed baked beans.
Failure to ensure dishware was completely dried before storage, discard expired items, and clean kitchen equipment properly.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 7
Total residents receiving food: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (EI #1) | Verified Resident #58 was seated in reclined Geri-chair and acknowledged it as a restraint | |
| Director of Nursing (EI #2) | Acknowledged reclined Geri-chair was a restraint and observed Resident #58's distress | |
| MDS Coordinators (EI #3 and EI #4) | Acknowledged incomplete MDS assessments for Resident #38 | |
| Dietary Cook (EI #5) | Observed preparing pureed diets improperly and serving incorrect food forms | |
| Registered Dietician (EI #6) | Stated proper procedure for preparing pureed diets and nutrient concerns | |
| Certified Dietary Manager (EI #7) | Acknowledged use of incorrect scoop sizes and failure to provide mashed baked beans | |
| Dietary Cook (EI #8) | Unaware of menu requirement for mashed baked beans |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Apr 22, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, dietary services, and facility operations at The Health Center at Research Park.
Findings
The facility was found deficient in multiple areas including improper use of physical restraints without medical justification, incomplete resident assessments, failure to follow dietary recipes and menus for pureed and mechanically altered diets, and inadequate food safety and sanitation practices in the kitchen.
Deficiencies (6)
Failure to provide medical justification for the use of a physical restraint (locked, reclined Geri-chair) for Resident #58.
Incomplete admission and quarterly Minimum Data Set (MDS) assessments for Resident #38, with multiple sections left unassessed.
Failure to follow recipes for pureed diets for four residents, including improper addition of water which decreased nutrient content.
Failure to follow menu scoop sizes for pureed entrees for four residents.
Failure to serve food in a form designed to meet individual needs for seven residents on a mechanically altered diet (served regular baked beans instead of mashed).
Failure to ensure dishware was completely dried before storage, discard expired items, and clean kitchen equipment such as can opener and microwave.
Report Facts
Residents on pureed diet: 4
Residents on mechanically altered diet: 7
Total residents receiving food from kitchen: 80
Expiration date: Apr 13, 2021
Expiration date: Mar 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | EI #1 observed and commented on the use of the reclined Geri-chair as a restraint | |
| Director of Nursing (DON) | EI #2 acknowledged the reclined Geri-chair was a restraint and observed resident's distress | |
| MDS Coordinators | EI #3 and EI #4 acknowledged incomplete MDS assessments | |
| Dietary Cook | EI #5 observed preparing pureed diets improperly and serving incorrect scoop sizes | |
| Registered Dietician (RD) | EI #6 stated proper procedure for pureed diet preparation and nutrient concerns | |
| Certified Dietary Manager (CDM) | EI #7 acknowledged improper scoop sizes and kitchen sanitation issues | |
| Dietary Cook | EI #8 stated unawareness of menu requirements for mashed baked beans |
Inspection Report
Complaint Investigation
Capacity: 78
Deficiencies: 2
Date: Mar 28, 2019
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to deliver residents' mail on Saturdays and failure to ensure proper administration of a resident's tube feeding water flush as ordered by the physician.
Complaint Details
The complaint investigation found that the facility did not consistently deliver residents' mail on Saturdays, violating residents' rights. Additionally, Resident #73 did not receive the prescribed tube feeding water flush, risking dehydration.
Findings
The facility failed to ensure residents received their mail on Saturdays, affecting all 78 residents, and failed to administer Resident #73's tube feeding water flush at the prescribed rate of 55 ml/hr, potentially causing dehydration.
Deficiencies (2)
Failure to ensure residents' mail was delivered on Saturdays as per facility policy.
Failure to ensure Resident #73's tube feeding water flush was infused at the physician-ordered rate of 55 ml/hr, with the pump set at 0 ml/hr for approximately 12 hours.
Report Facts
Residents affected: 78
Tube feeding water flush rate: 55
Tube feeding water flush rate observed: 0
Duration of incorrect tube feeding flush: 12
Volume left in tube feeding water bag: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding mail delivery on Saturdays | |
| Registered Nurse | Observed and interviewed regarding Resident #73's tube feeding water flush | |
| Director of Nursing/Registered Nurse | Interviewed regarding Resident #73's tube feeding water flush |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 28, 2019
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to deliver residents' mail on Saturdays and to ensure services provided by the nursing facility meet professional standards of quality, specifically related to a resident's tube feeding water flush.
Complaint Details
The visit was complaint-related, investigating issues with mail delivery on Saturdays and proper administration of tube feeding water flush for Resident #73. The deficiencies were substantiated based on observations, interviews, and policy reviews.
Findings
The facility failed to ensure residents received their mail on Saturdays, potentially affecting all seventy-eight residents. Additionally, the facility failed to ensure that Resident #73's tube feeding water flush was administered at the physician-ordered rate of 55 ml/hr, with the flush pump set at 0 ml/hr for about 12 hours, risking dehydration.
Deficiencies (2)
Failure to ensure residents' mail was delivered on Saturdays as per facility policy.
Failure to ensure Resident #73's tube feeding water flush was infused at the physician-ordered rate of 55 ml/hr.
Report Facts
Residents affected: 78
Residents affected: 1
Tube feeding water flush rate: 55
Tube feeding water flush rate observed: 0
Duration: 12
Water volume left: 1000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding mail delivery on Saturdays | |
| Registered Nurse | Observed and interviewed regarding Resident #73's tube feeding water flush | |
| Director of Nursing/Registered Nurse | Interviewed regarding Resident #73's tube feeding water flush |
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