Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
75% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
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
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
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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