Deficiencies (last 3 years)
Deficiencies (over 3 years)
12 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
233% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Census
Latest occupancy rate
6 residents
Based on a May 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding residents' access to personal funds after hours and on weekends, mail delivery on Saturdays, facility maintenance issues, medication misappropriation, PASARR screening accuracy, medication administration documentation, and infection control practices.
Complaint Details
The complaint investigation included allegations of residents being unable to access personal funds after hours and weekends, mail delivery issues on Saturdays, facility maintenance deficiencies, medication misappropriation by a nurse, inaccurate PASARR screening, falsified medication administration records, and infection control violations.
Findings
The facility failed to ensure residents had reasonable access to personal funds after business hours and weekends, mail was not delivered on Saturdays, rooms on multiple halls were in disrepair, a nurse misappropriated medication by signing out but not administering it, PASARR screening was inaccurate for one resident, medication administration records were falsified, and staff failed to follow proper hand hygiene and infection control protocols.
Deficiencies (7)
Failed to ensure residents had reasonable access to personal funds after business hours and weekends.
Failed to ensure mail was delivered to residents on Saturdays.
Failed to ensure rooms on three of five halls were not found in need of repair.
Failed to ensure Licensed Practical Nurse (LPN) #6 did not misappropriate Resident #43's Percocet and Lyrica after signing the medication as administered.
Failed to ensure PASARR screening was accurately marked with an admission diagnosis of Bipolar Disorder for Resident #103.
Failed to ensure Resident #43's Medication Administration Record (MAR) was accurate; medications were documented as given but not administered.
Failed to ensure staff performed hand hygiene while passing meal trays and assisting residents, and failed to properly disinfect glucometer after blood glucose testing.
Report Facts
Residents affected: 13
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication misappropriation and falsified medication administration documentation |
| RN #4 | Registered Nurse | Interviewed regarding medication administration and investigation |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding resident medication concerns |
| Financial Specialist Assistant | Interviewed about residents' access to personal funds | |
| Financial Specialist | Interviewed about residents' access to personal funds | |
| Maintenance Director | Interviewed regarding room disrepair observations | |
| Director of Nursing | Interviewed regarding mail delivery, medication misappropriation, and infection control | |
| Regional Nurse | Interviewed regarding medication misappropriation | |
| Social Services Director | MSW | Interviewed regarding mail delivery |
| Activity Director | Interviewed regarding mail delivery | |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding hand hygiene during meal tray passing |
| CNA #13 | Certified Nursing Assistant | Interviewed regarding hand hygiene during meal tray passing |
| CNA #18 | Certified Nursing Assistant | Interviewed regarding hand hygiene and feeding residents |
| MAC #12 | Interviewed regarding glucometer cleaning and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations regarding multiple deficiencies including failure to deliver mail on Saturdays, unsafe and unclean living environment, misappropriation of resident medication, inaccurate PASRR screening, inaccurate medication administration records, and infection control violations.
Complaint Details
The complaint investigation included allegations of mail delivery issues, unsafe living environment, medication misappropriation by Licensed Practical Nurse #6 involving Resident #43, inaccurate PASRR screening for Resident #103, falsified medication administration records, and infection control violations. The misappropriation was substantiated based on video evidence and interviews.
Findings
The facility was found deficient in multiple areas: mail was not delivered to residents on Saturdays affecting 13 residents; rooms on three halls were in disrepair affecting seven residents; a nurse misappropriated medication for one resident; PASRR screening was inaccurate for one resident; medication administration records were falsified for one resident; and staff failed to follow proper hand hygiene and infection control practices affecting multiple residents.
Deficiencies (6)
Failure to ensure mail was delivered to residents on Saturday affecting 13 residents.
Failure to ensure rooms on three of five halls were not found in need of repair affecting seven residents.
Licensed Practical Nurse #6 misappropriated Resident #43's Percocet and Lyrica by signing medication as administered but not giving it.
Failure to ensure PASRR screening was accurately marked with admission diagnosis of Bipolar Disorder for Resident #103.
Failure to ensure Resident #43's Medication Administration Record was accurate; medications documented as given were not administered.
Failure to ensure staff performed hand hygiene while passing meal trays and assisting residents, and failure to properly disinfect glucometer affecting multiple residents.
Report Facts
Residents affected: 13
Residents affected: 7
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication misappropriation and falsification of medication administration records |
| RN #4 | Registered Nurse | Interviewed regarding medication administration and resident complaints |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding resident medication concerns |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding mail delivery, medication misappropriation, and infection control findings |
| Administrator | Facility Administrator | Reviewed video evidence and documented medication misappropriation |
| Maintenance Director | Maintenance Director (MTD) | Interviewed regarding facility repairs and room conditions |
| Regional Nurse | Regional Nurse | Interviewed regarding medication misappropriation |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices |
| CNA #13 | Certified Nursing Assistant | Interviewed regarding hand hygiene practices |
| CNA #18 | Certified Nursing Assistant | Interviewed regarding hand hygiene and feeding practices |
| MAC #12 | Medication Aide Certified | Interviewed regarding glucometer cleaning and infection control |
| Social Services Director | Social Services Director (MSW) | Interviewed regarding mail delivery policy and PASRR screening |
| Activity Director | Activity Director (AD) | Interviewed regarding mail delivery practices |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to multiple resident rights and care concerns, including access to personal funds after hours, mail delivery, room maintenance, medication misappropriation, PASARR screening accuracy, medication administration documentation, and infection control practices.
Complaint Details
The complaint investigation included allegations of restricted access to personal funds after hours, delayed mail delivery, unsafe and unclean resident environment, medication misappropriation by a nurse, inaccurate PASARR screening, falsified medication administration records, and poor infection control practices.
Findings
The facility was found deficient in ensuring residents had reasonable access to personal funds after hours, timely mail delivery, safe and homelike environment maintenance, prevention of medication misappropriation by staff, accurate PASARR screening, proper medication administration documentation, and adherence to infection prevention and control protocols including hand hygiene and glucometer disinfection.
Deficiencies (7)
Failed to ensure residents had reasonable access to personal funds/petty cash after business hours and on weekends.
Failed to ensure mail was delivered to residents on Saturdays.
Failed to ensure rooms on three of five halls were not found in need of repair, including missing closet door, scraped paint, holes in walls, stained ceiling tiles, and toilet base needing caulking.
Failed to prevent misappropriation of resident medication by Licensed Practical Nurse (LPN) #6 who signed out but did not administer pain medications to Resident #43.
Failed to ensure PASARR screening was accurately marked with admission diagnosis of Bipolar Disorder for Resident #103.
Failed to ensure Resident #43's Medication Administration Record (MAR) was accurate; LPN #6 documented administration of medications not given.
Failed to ensure staff performed hand hygiene between passing meal trays and while assisting residents with meals, and failed to properly disinfect glucometer after blood glucose testing.
Report Facts
Residents affected: 13
Residents affected: 7
Residents affected: 1
Residents affected: 2
Medication doses misappropriated: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication misappropriation and falsification of medication administration records |
| RN #4 | Registered Nurse | Interviewed regarding medication administration and resident complaints |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding resident medication concerns |
| Financial Specialist Assistant | Financial Specialist Assistant | Interviewed regarding resident access to personal funds |
| Financial Specialist | Financial Specialist | Interviewed regarding resident access to personal funds |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication misappropriation and infection control |
| Regional Nurse | Regional Nurse | Interviewed regarding medication misappropriation |
| Social Services Director | Social Services Director | Interviewed regarding mail delivery and PASARR screening |
| Activity Director | Activity Director | Interviewed regarding mail delivery |
| Maintenance Director | Maintenance Director | Interviewed regarding room maintenance deficiencies |
| CNA #12 | Certified Nursing Assistant | Interviewed regarding hand hygiene during meal tray passing |
| CNA #13 | Certified Nursing Assistant | Interviewed regarding hand hygiene during meal tray passing |
| CNA #18 | Certified Nursing Assistant | Interviewed regarding hand hygiene and feeding practices |
| MAC #12 | Medication Aide Certified | Interviewed regarding glucometer disinfection practices |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 17, 2024
Visit Reason
The inspection was conducted as a result of complaint investigations including allegations of failure to deliver mail timely, facility maintenance issues, medication misappropriation, inaccurate PASRR screening, inaccurate medication administration records, and infection control deficiencies.
Complaint Details
The complaint investigation included allegations of failure to deliver mail on Saturdays, unsafe and unclean room conditions, medication misappropriation by LPN #6 involving Resident #43's pain medications, inaccurate PASRR screening for Resident #103, falsification of medication administration records, and infection control violations including inadequate hand hygiene and glucometer disinfection.
Findings
The facility was found deficient in multiple areas including failure to deliver mail on Saturdays affecting residents' rights, unsafe and unclean room conditions, misappropriation of resident medication by a nurse, inaccurate PASRR screening for mental disorders, falsification of medication administration records, and inadequate infection prevention practices such as improper hand hygiene and glucometer disinfection.
Deficiencies (6)
Failure to ensure mail was delivered to residents on Saturday, affecting 13 residents.
Failure to ensure rooms on three of five halls were not found in need of repair, affecting seven residents' rooms.
Misappropriation of resident medication by Licensed Practical Nurse (LPN) #6, who signed out medications as administered but did not give them to Resident #43.
Failure to accurately mark PASRR screening for Resident #103's Bipolar Disorder diagnosis.
Failure to ensure Resident #43's Medication Administration Record was accurate; medications documented as given were not administered.
Failure to ensure proper hand hygiene by staff when passing meal trays and assisting residents, and failure to properly disinfect glucometer after blood glucose testing.
Report Facts
Residents affected by mail delivery issue: 13
Residents affected by room repair deficiencies: 7
Residents affected by medication misappropriation: 1
Residents sampled for PASRR: 2
Residents affected by infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #6 | Licensed Practical Nurse | Named in medication misappropriation and falsification of medication administration records involving Resident #43. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding mail delivery, medication misappropriation, and infection control deficiencies. |
| Activity Director | Activity Director (AD) | Responsible for passing out mail to residents; interviewed about mail delivery on weekends. |
| Social Services Director | Social Services Director (MSW) | Interviewed about mail delivery policy and PASRR screening process. |
| Maintenance Director | Maintenance Director (MTD) | Interviewed regarding room repair deficiencies. |
| Regional Nurse | Regional Nurse | Interviewed regarding medication misappropriation and record falsification. |
| Certified Nursing Assistant #12 | Certified Nursing Assistant | Interviewed about hand hygiene practices while passing meal trays. |
| Certified Nursing Assistant #13 | Certified Nursing Assistant | Interviewed about hand hygiene practices while passing meal trays. |
| Certified Nursing Assistant #18 | Certified Nursing Assistant | Interviewed about hand hygiene and feeding two residents simultaneously. |
| Medication Aide #12 | Medication Aide | Interviewed about glucometer disinfection practices. |
Inspection Report
Routine
Census: 6
Deficiencies: 2
Date: May 23, 2019
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and medication administration practices during a routine survey.
Findings
The facility failed to ensure proper infection control during medication administration, including improper handling and storage of medications and supplies by licensed nurses, and stacking medication cups containing medications. These issues affected two of six residents and two of three nurses observed.
Deficiencies (2)
Did not lay the insulin pen, needles, Fentanyl pain patch, and alcohol swabs on Resident Identifier #90's bedside table without first laying a barrier down; stored medications and supplies in pocket and used scissors without disinfecting.
Stacked medication cups containing medication on top of each other after placing them on the medication cart prior to administration to Resident Identifier #63.
Report Facts
Residents affected: 2
Nurses observed: 3
Residents observed: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Observed improperly handling medications and supplies during medication administration to Resident Identifier #90 | |
| Licensed Practical Nurse | Observed stacking medication cups containing medication for Resident Identifier #63 | |
| Registered Nurse/Director of Nursing/Infection Control Officer | Interviewed regarding infection control practices and potential for harm |
Inspection Report
Routine
Deficiencies: 2
Date: May 23, 2019
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control practices during medication administration.
Findings
The facility failed to ensure licensed nurses followed proper infection control protocols, including laying medications and supplies on resident bedside tables without barriers, storing medications and supplies in pockets, and stacking medication cups containing medications. These failures posed a potential for infection control issues affecting two residents and two nurses observed.
Deficiencies (2)
Did not lay the insulin pen, needles, Fentanyl pain patch, and alcohol swabs on Resident Identifier #90's bedside table without first laying a barrier down; stored medications and supplies in pocket and used unclean scissors to cut a used Fentanyl patch.
Stacked medication cups containing medication on top of each other after placing them on the medication cart prior to administration to Resident Identifier #63.
Report Facts
Residents affected: 2
Nurses observed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | Observed storing medications and supplies in pocket and improper handling of Fentanyl patch | |
| Licensed Practical Nurse | Observed stacking medication cups containing medication | |
| Registered Nurse/Director of Nursing/Infection Control Officer | Interviewed regarding infection control practices and potential for harm |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 3
Date: Jun 7, 2018
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with federal regulations regarding resident assessments, meal scheduling, and food safety standards.
Findings
The facility failed to accurately code a resident's colostomy on the admission Minimum Data Set (MDS) assessment, had meal scheduling that exceeded the allowed 14-hour period between supper and breakfast without resident council approval, and had physical deficiencies in the kitchen's chemical/mop closet tile coving that could allow pest entry and moisture seepage.
Deficiencies (3)
Failed to ensure Resident #24's admission MDS assessment accurately reflected the presence of a colostomy.
Failed to ensure the period between scheduled supper and breakfast did not exceed fourteen hours and failed to obtain Resident Council approval for exceeding this time.
Tile coving in the chemical/mop closet was cracked and had holes allowing potential pest entry and moisture seepage.
Report Facts
Residents affected: 1
Residents affected: 91
Residents total: 93
Meal time span: 15
Meal time span: 14.5
Hole size: 4
Hole size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, MDS Coordinator | Interviewed regarding inaccurate MDS assessment for Resident #24 | |
| Restorative Licensed Practical Nurse | Interviewed regarding coding of Resident #24's colostomy on MDS assessment | |
| Administrator | Provided facility's Schedule of Meals and confirmed no resident approval for meal time span | |
| Dietary Manager | Provided current Schedule of Meals and verified holes in tile coving | |
| Registered Dietitian | Interviewed about meal scheduling and potential effects of meal time span; verified holes in tile coving | |
| Maintenance Director | Measured openings in tile coving in chemical/mop closet |
Inspection Report
Annual Inspection
Census: 91
Deficiencies: 3
Date: Jun 7, 2018
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with federal regulations regarding resident assessments, meal scheduling, and food safety standards.
Findings
The facility failed to accurately code a resident's colostomy status on the admission Minimum Data Set (MDS) assessment, had meal scheduling that exceeded the allowed 14-hour period between supper and breakfast without resident council approval, and had physical deficiencies in the kitchen's chemical/mop closet allowing potential pest entry and moisture seepage.
Deficiencies (3)
Resident Identifier #24's admission MDS assessment did not reflect the resident's colostomy status.
The facility's meal schedule allowed more than a 14-hour span between supper and breakfast without Resident Council approval.
Tile coving in the chemical/mop closet was cracked and had holes, allowing potential pest entry and moisture seepage.
Report Facts
Residents affected: 42
Residents affected: 91
Residents affected: 91
Meal time span: 15
Meal time span: 14.5
Hole size: 4
Hole size: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse, MDS Coordinator | Interviewed regarding Resident #24's colostomy coding on MDS assessment | |
| Restorative Licensed Practical Nurse | Interviewed regarding Resident #24's colostomy coding on MDS assessment | |
| Administrator | Provided facility's Schedule of Meals document | |
| Dietary Manager | Provided current Schedule of Meals and verified kitchen deficiencies | |
| Registered Dietitian | Interviewed regarding meal scheduling and kitchen deficiencies | |
| Maintenance Director | Measured openings in tile coving of chemical/mop closet |
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