Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
31% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
5% occupied
Based on a May 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
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
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 |
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