Deficiencies (last 3 years)
Deficiencies (over 3 years)
29.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
714% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident privacy, abuse, neglect, feeding tube care, and behavioral health services at Arabella Health and Wellness of Montgomery.
Complaint Details
The investigation was triggered by complaints and reports including complaint/report numbers 2563418, AL00051526, AL00048535/460742, and 2562064. Complaints involved privacy breaches, verbal and physical abuse, failure to report abuse timely, improper feeding tube care, and inadequate behavioral health care. Some allegations were substantiated, such as verbal abuse by CNA #21 and delayed reporting of physical abuse. Others, like verbal abuse by CNA #21, were unsubstantiated by the facility despite witness statements.
Findings
The facility was found deficient in maintaining resident privacy with electronic medication records, preventing verbal and physical abuse among residents and staff, timely reporting of abuse allegations, proper management of feeding tubes, and ensuring behavioral health care interventions were followed. Several staff members were involved in incidents of verbal abuse and failure to report physical abuse timely. Feeding tube protocols were not consistently followed, and behavioral care plans were not properly implemented.
Deficiencies (5)
Failed to ensure electronic Medication Administration Record (eMAR) screen was closed when nurse was away, risking resident privacy.
Failed to protect resident from verbal abuse by a Certified Nursing Assistant (CNA #21) who called resident an ugly name and escalated behavior.
Failed to timely report an allegation of physical abuse when a resident pushed another resident; report was delayed by three days.
Failed to ensure feeding tubes were managed properly, including failure to start tube feeding as ordered and failure to maintain head of bed elevation during feeding.
Failed to ensure behavioral health care interventions were implemented to prevent behavior escalation and verbal abuse.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 2
BIMS score: 8
BIMS score: 13
BIMS score: 15
Tube feeding rate: 55
Tube feeding rate: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #21 | Certified Nursing Assistant | Named in verbal abuse incident involving Resident #8 |
| LPN #17 | Licensed Practical Nurse | Named in medication privacy breach observation |
| LPN #16 | Licensed Practical Nurse | Witnessed verbal abuse incident involving Resident #8 and CNA #21 |
| RN/Unit Manager #15 | Registered Nurse/Unit Manager | Witnessed verbal abuse incident involving Resident #8 and CNA #21 |
| CNA #12 | Certified Nursing Assistant | Witnessed physical abuse incident and failed to report timely |
| CNA #13 | Certified Nursing Assistant | Witnessed physical abuse incident and failed to report timely |
| RN #26 | Registered Nurse | Interviewed regarding tube feeding start time for Resident #109 |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy breach and tube feeding care |
| Administrator | Administrator/Abuse Coordinator | Interviewed regarding verbal abuse incident and abuse reporting |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding physical abuse incident and reporting |
| CNA #22 | Certified Nursing Assistant | Witnessed verbal abuse incident involving CNA #21 and Resident #8 |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident privacy, abuse, care planning, activity provision, feeding tube management, staffing information posting, behavioral health care, food storage, and refuse disposal.
Complaint Details
Multiple complaints investigated including complaint/report numbers 2563418 (privacy breach), 2562064 (verbal abuse), AL00051526 (physical abuse reporting), and AL00048535/460742 (feeding tube management). Verbal abuse was unsubstantiated by the facility but substantiated by survey findings. Physical abuse was reported late by staff. Behavioral health care deficiencies involved verbal abuse by CNA #21 towards RI #8. Feeding tube deficiencies involved failure to start feeding on admission and improper positioning during feeding.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy with an open eMAR screen, verbal abuse by staff towards a cognitively impaired resident, delayed reporting of physical abuse allegations, failure to include a resident in care plan meetings, inadequate activity provision documentation, improper feeding tube management, incomplete nurse staffing postings, failure to provide appropriate behavioral health care, improper food storage practices, and failure to maintain dumpster area cleanliness.
Deficiencies (10)
Failed to ensure electronic Medication Administration Record (eMAR) screen was closed when nurse was away, risking resident privacy.
Failed to protect resident from verbal abuse by a Certified Nursing Assistant who used derogatory language.
Failed to timely report suspected physical abuse between residents to the Abuse Coordinator and State Agency.
Failed to invite and allow resident participation in care plan meeting.
Failed to offer activities based on resident's comprehensive assessment and failed to document activity provision.
Failed to start tube feeding as ordered on admission and failed to maintain proper head of bed elevation during tube feeding.
Failed to post nurse staffing information with required data including actual hours worked.
Failed to provide necessary behavioral health care and services, including failure to prevent verbal abuse escalation.
Failed to label and date opened food items in dry storage and failed to maintain freezer floor free of ice.
Failed to maintain dumpster area free of food debris and refuse, creating potential sanitation and pest issues.
Report Facts
Residents sampled for privacy breach: 22
Residents sampled for abuse: 3
Residents sampled for care plan concerns: 2
Residents sampled for activity concerns: 1
Residents sampled for tube feeding: 3
Residents affected by verbal abuse: 1
Staff posting forms missing actual hours: 3
Ice thickness on freezer floor: 5
Ice width on freezer floor: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #21 | Certified Nursing Assistant | Named in verbal abuse incident towards Resident RI #8 |
| LPN #16 | Licensed Practical Nurse | Witnessed verbal abuse incident involving CNA #21 and RI #8 |
| RN #15 | Registered Nurse/Unit Manager | Witnessed verbal abuse incident involving CNA #21 and RI #8 |
| CNA #12 | Certified Nursing Assistant | Witnessed physical abuse incident between residents RI #94 and RI #110 |
| ADON | Assistant Director of Nursing | Interviewed regarding delayed reporting of physical abuse |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy breach and feeding tube management |
| Director of Social Services | Director of Social Services | Interviewed regarding care plan meeting process |
| RN MDS #4 | Registered Nurse, MDS Coordinator | Interviewed regarding care plan meeting process |
| MDS Coordinator #5 | MDS Coordinator | Interviewed regarding care plan meeting process |
| Activities Director | Activities Director | Interviewed regarding activity provision |
| RN #26 | Registered Nurse | Interviewed regarding feeding tube start time |
| CNA #20 | Certified Nursing Assistant | Interviewed regarding head of bed positioning during tube feeding |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and dumpster area |
| Dietician | Dietician | Interviewed regarding food storage and freezer ice |
| Cook | Cook | Interviewed regarding freezer floor ice |
| Administrator | Administrator/Abuse Coordinator | Interviewed regarding verbal abuse incident and staffing posting |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident privacy breaches, verbal and physical abuse allegations, timely reporting of abuse, feeding tube care, and behavioral health care.
Complaint Details
The complaint investigations included: 1) Privacy breach when eMAR screen was left open exposing resident information; 2) Verbal abuse incident involving CNA #21 and Resident #8; 3) Physical abuse allegation between residents #94 and #110 that was not timely reported; 4) Feeding tube care concerns for residents #9 and #109; 5) Behavioral health care failures related to Resident #8. Some allegations were substantiated, others were unsubstantiated but deficiencies were cited based on findings.
Findings
The facility was found deficient in maintaining resident privacy during medication administration, preventing verbal and physical abuse among residents and staff, timely reporting of abuse incidents, proper management of feeding tubes, and ensuring behavioral health care interventions were followed. Several staff members were involved in incidents of verbal abuse and failure to report physical abuse timely. Feeding tube protocols were not consistently followed, and behavioral care plans were not properly implemented.
Deficiencies (5)
Failed to ensure electronic Medication Administration Record (eMAR) screen was closed when nurse was away, risking resident privacy.
Failed to protect resident from verbal abuse by a Certified Nursing Assistant (CNA) who used derogatory language and did not follow behavioral care plan.
Failed to timely report an allegation of physical abuse between residents to the Abuse Coordinator and State Agency.
Failed to ensure feeding tubes were started as ordered and to maintain proper head of bed elevation during tube feeding.
Failed to provide necessary behavioral health care and services, including failure to prevent behavior escalation and verbal abuse.
Report Facts
Residents sampled: 22
Residents affected: 1
Residents sampled: 3
Residents affected: 2
Tube feeding rate: 55
Tube feeding rate: 60
BIMS score: 8
BIMS score: 13
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #21 | Certified Nursing Assistant | Named in verbal abuse incident involving Resident #8 |
| LPN #17 | Licensed Practical Nurse | Named in medication privacy breach |
| LPN #16 | Licensed Practical Nurse | Witnessed verbal abuse incident and interviewed |
| RN/Unit Manager #15 | Registered Nurse/Unit Manager | Witnessed verbal abuse incident and interviewed |
| CNA #12 | Certified Nursing Assistant | Witnessed physical abuse incident and failed to report timely |
| CNA #13 | Certified Nursing Assistant | Witnessed physical abuse incident and failed to report timely |
| RN #26 | Registered Nurse | Interviewed regarding feeding tube care for Resident #109 |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy breach and feeding tube care |
| Administrator | Administrator/Abuse Coordinator | Interviewed regarding verbal abuse incident and abuse reporting |
| CNA #22 | Certified Nursing Assistant | Witnessed verbal abuse incident involving CNA #21 and Resident #8 |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding physical abuse incident reporting |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 10
Date: Jul 24, 2025
Visit Reason
The inspection was conducted as a result of multiple complaint investigations regarding resident privacy, abuse allegations, care plan participation, activity provision, feeding tube management, nurse staffing posting, behavioral health care, food storage, and refuse disposal.
Complaint Details
The inspection was triggered by multiple complaints including complaint/report number 2563418 regarding resident privacy breach, complaint/report AL00051526 regarding delayed reporting of physical abuse, complaint/report AL00048535/460742 regarding feeding tube management, and complaint/report number 2562064 regarding verbal abuse by staff.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, verbal abuse by staff, delayed reporting of physical abuse, failure to include a resident in care plan meetings, inadequate activity provision, improper feeding tube management, incomplete nurse staffing postings, failure to provide appropriate behavioral health care, improper food storage and labeling, ice accumulation in freezer posing safety hazards, and improper refuse disposal.
Deficiencies (10)
Failed to ensure electronic Medication Administration Record (eMAR) screen was closed when nurse was away, risking resident privacy.
Failed to protect resident from verbal abuse by Certified Nursing Assistant (CNA) #21 towards Resident #8.
Failed to timely report suspected physical abuse between residents RI #94 and RI #110.
Failed to invite and allow Resident #21 to participate in care plan meeting.
Failed to offer activities to Resident #59 based on comprehensive assessment and document activity participation.
Failed to start Resident #109's tube feeding as ordered and failed to maintain Resident #9's head of bed elevated during tube feeding.
Failed to post nurse staffing information with actual hours worked and accurate census on multiple days.
Failed to ensure CNA #21 responded appropriately to resident behaviors and implement behavioral interventions, resulting in verbal abuse of Resident #8.
Failed to label and date opened food items in dry storage and failed to maintain freezer floor free of ice.
Failed to maintain dumpster area free of food debris and refuse, creating potential sanitation and pest hazards.
Report Facts
Residents affected: 22
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 98
Residents affected: 1
Residents affected: 98
Census: 98
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #21 | Certified Nursing Assistant | Named in verbal abuse finding towards Resident #8 and failure to implement behavioral interventions |
| LPN #17 | Licensed Practical Nurse | Named in privacy breach finding related to eMAR screen left open |
| Director of Nursing | Director of Nursing | Interviewed regarding privacy screen policy and feeding tube management |
| CNA #12 | Certified Nursing Assistant | Witnessed physical abuse incident and failed to report timely |
| Administrator | Administrator | Interviewed regarding abuse incidents and nurse staffing posting |
| RN Unit Manager #15 | Registered Nurse Unit Manager | Witnessed verbal abuse incident involving CNA #21 and Resident #8 |
| LPN #16 | Licensed Practical Nurse | Witnessed verbal abuse incident involving CNA #21 and Resident #8 |
| Dietary Manager | Dietary Manager | Interviewed regarding food storage and refuse issues |
| Activities Director | Activities Director | Interviewed regarding activity provision for Resident #59 |
| RN #26 | Registered Nurse | Interviewed regarding feeding tube start time for Resident #109 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to complaints and investigations related to misappropriation of resident property, failure to report injuries of unknown origin, failure to investigate alleged abuse, failure to develop appropriate care plans, and failure to maintain resident medical records.
Complaint Details
This deficient practice was cited as a result of complaint/report #AL00043932 for misappropriation and abuse issues, #AL00043219 for failure to report and investigate injuries, and #AL00043666 for care plan and medical record deficiencies.
Findings
The facility failed to protect residents from misappropriation of controlled medications by a former Director of Nursing, failed to timely report and investigate injuries of unknown origin for a resident, failed to develop and implement care plans addressing a resident's removal of a wander monitoring bracelet, and failed to maintain and provide access to medical records for discharged residents.
Deficiencies (5)
Failed to protect 17 residents from misappropriation of Schedule II controlled medications by diversion.
Failed to timely report two injuries of unknown origin for one resident to the state survey agency.
Failed to thoroughly investigate two injuries of unknown origin for one resident.
Failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet.
Failed to ensure medical records were readily available and retained for two residents as closed records.
Report Facts
Residents affected by misappropriation: 17
Number of tablets delivered per order: 120
Dates of medication orders and discontinuations: Multiple dates from 2022 and 2023 for Norco orders and discontinuations documented
Resident #1 skin tear size: 1
Resident #2 BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #15 | Director of Nursing | Former DON terminated for misappropriation of resident property related to controlled medications |
| Pharmacist #32 | Pharmacist | Reported irregularity in faxed prescription and alerted facility and pharmacy supervisors |
| Pharmacist #33 | Pharmacist Consultant | Conducted monthly medication reviews and identified missing narcotics |
| Administrator | Provided statements regarding missing medication destruction logs and investigation | |
| Physician | Expressed concerns about short-term narcotic orders and changed faxing procedures | |
| RN #24 | Registered Nurse | Interviewed regarding narcotic counts and resident wander monitoring bracelet |
| Regional RN Consultant | Regional RN Consultant | Assisted in investigation of medication misappropriation and identified missing destruction logs |
| FM #46 | Family Member | Responsible party for Resident #2, commented on resident removing wander monitoring bracelet |
| LPN #14 | Licensed Practical Nurse | Observed and reapplied wander monitoring bracelet on Resident #2 |
| CNA #19 | Certified Nursing Assistant | Observed wander monitoring bracelet on Resident #2 |
| CNA #29 | Certified Nursing Assistant | Interviewed about Resident #1's injuries and behavior |
| LPN #27 | Licensed Practical Nurse | Interviewed about Resident #1's injuries and investigations |
| Regional Director of Operations | Acting Administrator | Unable to confirm reporting or investigations for Resident #1's injuries |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of misappropriation of resident property, failure to report injuries of unknown origin, failure to investigate alleged abuse, failure to develop appropriate care plans, and failure to maintain resident medical records.
Complaint Details
This deficient practice was cited as a result of complaint/report #AL00043932 for misappropriation of medications, #AL00043219 for failure to report and investigate injuries, and #AL00043666 for failure to develop care plans and maintain medical records.
Findings
The facility failed to protect residents from misappropriation of controlled medications by a former Director of Nursing, failed to timely report and investigate injuries of unknown origin for a resident, failed to develop and implement care plan interventions for a resident removing their wander monitoring bracelet, and failed to maintain and provide access to medical records for discharged residents.
Deficiencies (5)
Failed to protect 17 residents from misappropriation of Schedule II controlled medications by diversion, involving the former Director of Nursing.
Failed to timely report two injuries of unknown origin for one resident to the state survey agency.
Failed to thoroughly investigate two injuries of unknown origin for one resident.
Failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet.
Failed to ensure medical records were readily available and retained for two residents as closed records.
Report Facts
Residents affected by medication misappropriation: 17
Number of tablets delivered in some orders: 120
Dates of medication orders and discontinuations: Various dates between 2022 and 2023 for Norco orders and discontinuations
Resident #1 skin tear size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #15 | Director of Nursing | Former DON involved in misappropriation of medications and faxing altered prescriptions |
| Pharmacist #32 | Pharmacist | Reported irregularity in faxed prescription and alerted facility and pharmacy supervisors |
| Pharmacist #33 | Pharmacist Consultant | Conducted monthly medication reviews and identified missing narcotics |
| Administrator | Interviewed regarding missing medication destruction logs and investigation | |
| Physician | Expressed concerns about medication orders and changed faxing procedures | |
| RN #24 | Registered Nurse | Interviewed about narcotic counts and resident wander monitoring bracelet |
| Regional RN Consultant | Assisted in investigation of medication misappropriation | |
| CNA #29 | Certified Nursing Assistant | Interviewed about Resident #1's injuries and behavior |
| LPN #27 | Licensed Practical Nurse | Interviewed about Resident #1's injuries and investigations |
| Regional Director of Operations | Acting Administrator | Interviewed about reporting and investigations of injuries |
| FM #46 | Family Member | Responsible party for Resident #2, interviewed about wander monitoring bracelet |
| LPN #14 | Licensed Practical Nurse | Observed and interviewed about wander monitoring bracelet on Resident #2 |
| CNA #19 | Certified Nursing Assistant | Observed and interviewed about wander monitoring bracelet on Resident #2 |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to complaints and investigations related to misappropriation of resident property, failure to report injuries of unknown origin, failure to investigate alleged abuse, failure to develop appropriate care plans, and failure to maintain resident medical records.
Complaint Details
This deficient practice was cited as a result of complaint/report #AL00043932 for misappropriation of medications, #AL00043219 for failure to report and investigate injuries, and #AL00043666 for failure to maintain medical records and care plan issues.
Findings
The facility failed to protect 17 residents from misappropriation of Schedule II controlled medications by the former Director of Nursing, failed to timely report and investigate two injuries of unknown origin for one resident, failed to develop and implement care plan interventions for a resident removing their wander monitoring bracelet, and failed to maintain and provide access to medical records for two discharged residents.
Deficiencies (5)
Failed to protect 17 residents from misappropriation of Schedule II controlled medications by the former Director of Nursing.
Failed to timely report two injuries of unknown origin to the state survey agency for one resident.
Failed to thoroughly investigate two injuries of unknown origin for one resident.
Failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet.
Failed to ensure medical records were readily available and retained for two discharged residents.
Report Facts
Residents affected: 17
Number of tablets delivered: 120
Dates of medication orders: Multiple dates from 2022 to 2023 for Norco medication orders for affected residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #15 | Director of Nursing | Former DON terminated for misappropriation of resident property related to controlled medications. |
| Pharmacist #32 | Pharmacist | Reported irregularity in faxed prescription and notified facility and pharmacy supervisors. |
| Pharmacist #33 | Pharmacist Consultant | Conducted monthly medication reviews and discovered missing narcotics. |
| Administrator | Provided statements regarding missing medication destruction logs and oversight. | |
| Regional RN Consultant | Regional Registered Nurse Consultant | Assisted in investigation and reported missing destruction logs and oversight issues. |
| Physician | Expressed concerns about medication orders and changed faxing procedures for safety. | |
| RN #24 | Registered Nurse | Provided statements about narcotic counts and resident wandering. |
| CNA #29 | Certified Nursing Assistant | Interviewed about resident injuries and behaviors. |
| LPN #27 | Licensed Practical Nurse | Interviewed about resident injuries and investigations. |
| Regional Director of Operations | Acting Administrator | Unable to confirm reporting and investigations for resident injuries. |
| FM #46 | Family Member | Responsible party for Resident #2, commented on wander monitoring bracelet issues. |
| LPN #14 | Licensed Practical Nurse | Observed and managed wander monitoring bracelet for Resident #2. |
| CNA #19 | Certified Nursing Assistant | Observed wander monitoring bracelet on Resident #2. |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to complaints and investigations related to misappropriation of resident property, failure to report injuries of unknown origin, failure to investigate alleged abuse, failure to develop appropriate care plans, and failure to maintain resident medical records.
Complaint Details
The investigation was initiated due to complaints regarding misappropriation of narcotic medications, failure to report and investigate injuries of unknown origin, failure to develop appropriate care plans for elopement risk, and failure to maintain resident medical records. The complaint/report numbers referenced include #AL00043932, #AL00043219, and #AL00043666.
Findings
The facility failed to protect 17 residents from misappropriation of Schedule II controlled medications by a former Director of Nursing, failed to timely report and investigate two injuries of unknown origin for one resident, failed to develop and implement care plan interventions for a resident removing their wander monitoring bracelet, and failed to maintain and provide access to medical records for discharged residents.
Deficiencies (5)
Failed to protect 17 residents from misappropriation of Schedule II controlled medications by the diversion of narcotics by the former Director of Nursing.
Failed to timely report two injuries of unknown origin for one resident to the state survey agency.
Failed to thoroughly investigate two injuries of unknown origin for one resident.
Failed to develop and implement care plan interventions to address a resident removing their wander monitoring bracelet.
Failed to ensure medical records were readily available and retained for two discharged residents.
Report Facts
Residents affected by medication misappropriation: 17
Number of tablets delivered: 120
Dates of medication orders: 18
Dates of injuries: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON #15 | Director of Nursing | Former DON terminated for misappropriation of resident property related to narcotic medication diversion. |
| Pharmacist #32 | Pharmacist | Reported irregularity in faxed prescription and alerted facility and pharmacy supervisors. |
| Pharmacist #33 | Pharmacist Consultant | Conducted monthly medication reviews and identified missing narcotics. |
| Administrator | Provided statements regarding missing destruction logs and medication diversion. | |
| Physician | Expressed concerns about medication orders and changed faxing procedures to pharmacy. | |
| Regional RN Consultant | Regional RN Consultant | Assisted in investigation and identified missing destruction logs and medication discrepancies. |
| RN #24 | Registered Nurse | Provided statements about narcotic counts and resident wandering behavior. |
| LPN #14 | Licensed Practical Nurse | Observed checking and reapplying wander monitoring bracelet. |
| CNA #19 | Certified Nursing Assistant | Observed wander monitoring bracelet on resident. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 12
Date: Jan 11, 2023
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to make survey results available for residents, environmental and maintenance issues, care planning deficiencies, medication administration, infection control, food safety, and other regulatory compliance concerns.
Complaint Details
The complaint investigation included issues related to missing survey reports, environmental disrepair, inaccurate resident assessments, incomplete care plans, improper enteral feeding labeling, late medication administration, food safety violations, refuse management, QAPI committee membership, infection control practices, and privacy concerns.
Findings
The facility was found deficient in multiple areas including failure to provide survey reports for residents, environmental disrepair in resident rooms, inaccurate resident assessments, incomplete care plans, improper labeling of enteral nutrition, late medication administration, food safety violations, inadequate refuse management, incomplete QAPI committee membership, improper infection control practices, and insufficient privacy curtains in semi-private rooms.
Deficiencies (12)
Failed to ensure survey results for the last three years were available for residents or visitors to review.
Failed to ensure Room Locators #1-9 were not found in need of repair, including paint scraped walls, ceiling stains, exposed wiring, and damaged furniture.
Failed to ensure Resident Identifier #88's Minimum Data Set assessments accurately reflected current tobacco use.
Failed to ensure valid Level 1 PASRR screening was completed for Resident Identifiers #24 and #14 with mental disorders or intellectual disabilities.
Failed to develop and implement complete care plans for Resident Identifiers #1 and #7 addressing diabetes and nutritional intake respectively.
Failed to ensure enteral nutrition bags for Resident Identifiers #3 and #71 were properly labeled with resident name, ID, date/time started, and order details.
Failed to administer scheduled medications for Resident Identifiers #54 and #48 within the required one hour before or after scheduled time.
Failed to prevent potential cross-contamination by storing a 50-pound bag of sugar directly on the floor, running ceiling fans with heavy dust in the dishwashing area, and allowing the dishmachine drain to extend into the floor drain.
Failed to ensure dumpsters were kept closed and free of discarded equipment and food-related litter to prevent vermin attraction.
Failed to ensure the Infection Preventionist participated as a required member of the Quality Assessment and Assurance committee.
Failed to ensure a Certified Nursing Assistant changed gloves and performed hand hygiene before applying a clean brief during incontinent care for Resident Identifier #17.
Failed to ensure privacy curtains extended fully around beds in Room Locators #1, #3, and #7 to provide total visual privacy.
Report Facts
Residents affected: 98
Room Locators affected: 9
Residents sampled for MDS review: 24
Residents reviewed for PASRR: 10
Residents observed for enteral nutrition: 6
Residents observed for medication pass: 6
Semi-private rooms: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Interviewed regarding missing survey reports and environmental concerns. |
| EI #4 | Maintenance Director | Provided observations and descriptions of environmental disrepair in resident rooms. |
| EI #7 | MDS Coordinator | Interviewed regarding inaccurate MDS assessments and care planning. |
| EI #8 | Registered Nurse / Regional Infection Control | Interim Infection Preventionist; did not attend QAPI meetings. |
| EI #9 | LPN/Unit Manager | Interviewed regarding enteral nutrition labeling responsibilities. |
| EI #10 | Licensed Practical Nurse | Interviewed regarding enteral nutrition labeling and nursing responsibilities. |
| EI #12 | Social Worker | Interviewed regarding PASRR screening responsibilities. |
| EI #15 | Certified Nursing Assistant | Observed providing incontinent care without proper glove changes. |
| EI #16 | Certified Nursing Assistant | Interviewed regarding resident smoking behavior. |
| EI #2 | Director of Nursing | Interviewed regarding medication administration time frames and infection control. |
| EI #3 | Dietary Manager | Interviewed regarding food storage and refuse management issues. |
| EI #5 | Licensed Practical Nurse | Observed medication administration and interviewed regarding late medications. |
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 12
Date: Jan 11, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to maintain and provide access to survey reports, environmental and maintenance issues, care planning deficiencies, medication administration timeliness, infection control practices, and food safety concerns.
Complaint Details
The inspection was conducted as a result of complaint numbers AL00041914 and AL00042914, which included concerns about medication administration timeliness and other care and safety issues.
Findings
The facility failed to ensure survey reports were available for residents, maintain a safe and homelike environment, accurately assess residents, develop complete care plans, properly label enteral feedings, administer medications timely, maintain food safety standards, manage refuse properly, ensure QAPI committee membership compliance, and follow infection control protocols during incontinent care. Privacy curtains were also found to be inadequate in some semi-private rooms.
Deficiencies (12)
Failed to ensure survey results for the last three years were available for residents or visitors to review.
Failed to maintain Room Locators in good repair, including paint scraping, ceiling stains, exposed wiring, and damaged furniture.
Failed to accurately code Minimum Data Set assessments to reflect current tobacco use for a resident.
Failed to ensure valid Level 1 PASRR screening was completed for residents with mental disorders or intellectual disabilities.
Failed to develop and implement complete care plans addressing all resident needs, including diabetes and nutritional intake.
Failed to ensure enteral nutrition bags were properly labeled with resident information and feeding details.
Failed to administer scheduled medications within the required time frame of one hour before or after the scheduled time.
Failed to prevent potential cross-contamination in the kitchen by improper food storage, dusty ceiling fans, and improper dishmachine drain setup.
Failed to ensure dumpsters were kept closed and the refuse area was free of discarded equipment and food-related litter.
Failed to ensure the Infection Preventionist participated as a required member of the Quality Assessment and Assurance committee.
Failed to ensure Certified Nursing Assistant changed gloves and performed hand hygiene before applying a clean brief during incontinent care.
Failed to provide adequate visual privacy with ceiling suspended curtains in semi-private rooms.
Report Facts
Residents affected: 98
Room Locators affected: 9
Residents sampled for MDS review: 24
Residents reviewed for PASRR: 10
Residents observed for enteral nutrition: 6
Residents observed for medication pass: 6
Semi-private rooms: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Administrator | Interviewed regarding survey report availability and environmental concerns |
| EI #4 | Maintenance Director | Observed and described environmental deficiencies and privacy curtain issues |
| EI #7 | MDS Coordinator | Interviewed regarding MDS assessment coding and care planning |
| EI #10 | Licensed Practical Nurse | Interviewed regarding enteral feeding labeling |
| EI #5 | Licensed Practical Nurse | Observed and interviewed regarding medication administration timeliness |
| EI #2 | Director of Nursing | Interviewed regarding medication administration policies and infection control |
| EI #3 | Dietary Manager | Interviewed regarding food storage, kitchen cleanliness, and refuse management |
| EI #6 | Certified Nursing Assistant | Observed providing incontinent care and interviewed regarding glove use |
| EI #8 | Registered Nurse/Regional Infection Control | Interim Infection Preventionist, noted absent from QAPI meetings |
| EI #9 | LPN/Unit Manager | Interviewed regarding enteral feeding labeling |
| EI #12 | Social Worker | Interviewed regarding PASRR screening responsibilities |
| EI #15 | Certified Nursing Assistant | Observed providing incontinent care |
| EI #16 | Certified Nursing Assistant | Interviewed regarding resident tobacco use |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Sep 23, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding comprehensive resident assessments, care planning, wound care, dietary services, and sanitation procedures in a nursing home facility.
Findings
The facility failed to complete timely comprehensive, quarterly, and admission Minimum Data Set (MDS) assessments for multiple residents, failed to develop and implement comprehensive care plans within required timeframes for a resident, failed to provide ordered wound care for a resident, failed to honor dietary preferences for a resident, and failed to properly sanitize cookware according to required contact times.
Deficiencies (7)
Failed to complete timely comprehensive MDS assessments for multiple residents.
Failed to complete timely quarterly MDS assessments for multiple residents.
Failed to submit MDS assessments timely to the state for multiple residents.
Failed to develop and implement comprehensive care plans within 21 days of admission for Resident #257.
Failed to provide ordered wound care to Resident #109 as per physician's orders.
Failed to honor dietary preferences of Resident #257 by providing a ham sandwich despite pork being listed as a dislike.
Failed to properly sanitize cookware by submerging in sanitizing solution for less than the required one minute.
Report Facts
Residents affected: 7
Residents affected: 18
Residents affected: 6
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/Care Plan and MDS Director | Interviewed regarding MDS assessment completion delays and care plan deficiencies | |
| Administrator | Interviewed regarding facility issues with MDS assessments and care plans | |
| Licensed Practical Nurse (LPN), Unit Manager | Interviewed regarding resident care tools and dietary concerns | |
| Wound Care Nurse | Interviewed regarding wound care deficiencies for Resident #109 | |
| Dietary Manager | Interviewed regarding dietary preferences and cookware sanitization procedures | |
| Corporate RN | Confirmed lack of comprehensive care plans for Resident #257 | |
| Nurse caring for Resident #109 on specific dates | Interviewed regarding wound care provision | |
| Dietary Aid | Observed improperly sanitizing cookware |
Inspection Report
Routine
Deficiencies: 7
Date: Sep 23, 2021
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding timely completion and submission of Minimum Data Set (MDS) assessments, development and implementation of comprehensive care plans, pressure ulcer care, dietary preferences, and food safety procedures.
Findings
The facility failed to complete and submit MDS assessments timely for multiple residents, did not develop comprehensive care plans within required timeframes for one resident, failed to provide ordered wound care for a resident with pressure ulcers, did not honor dietary preferences for a resident, and improperly sanitized cookware in the kitchen.
Deficiencies (7)
Failed to ensure timely completion of Comprehensive MDS assessments for multiple residents.
Failed to ensure timely completion of Quarterly MDS assessments for multiple residents.
Failed to ensure timely submission of MDS assessments for multiple residents.
Failed to develop and implement comprehensive care plans within 21 days of admission for Resident #257.
Failed to provide ordered wound care to Resident #109's right buttocks daily as ordered by the physician.
Failed to ensure Resident #257's dietary preferences were honored; resident received a ham sandwich despite pork being listed as a dislike.
Failed to ensure cookware was sanitized properly; cookware was submerged in sanitizing solution for less than one minute instead of the required time.
Report Facts
Residents affected by untimely Comprehensive MDS assessments: 7
Residents affected by untimely Quarterly MDS assessments: 18
Residents affected by untimely MDS submission: 6
Residents affected by lack of comprehensive care plans: 1
Residents affected by wound care deficiency: 1
Residents affected by dietary preference violation: 1
Residents affected by improper cookware sanitization: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/Care Plan and MDS Director | Interviewed regarding MDS assessment completion and facility challenges. | |
| Administrator | Interviewed regarding facility issues with MDS assessments and care plan development. | |
| Licensed Practical Nurse (LPN), Unit Manager | Interviewed regarding CNA tools and care plan communication. | |
| Wound Care Nurse | Interviewed regarding wound care provision for Resident #109. | |
| Nurse caring for Resident #109 on specific dates | Interviewed regarding wound care provision on 9/6/21, 9/10/21, and 9/12/21. | |
| Corporate RN | Confirmed lack of comprehensive care plans for Resident #257. | |
| Dietary Manager | Interviewed regarding dietary preferences and cookware sanitization procedures. | |
| Dietary Aid | Observed sanitizing cookware improperly. | |
| Certified Nursing Assistant (CNA) | Observed assisting Resident #257 and involved in sack lunch preparation. |
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