Deficiencies (last 3 years)
Deficiencies (over 3 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
186% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey completed on 08/02/2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 2, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 3
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, food safety, infection prevention and control, and medication administration practices at Hillview Terrace nursing facility.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for medication administration, inadequate hair and hand hygiene practices among dietary staff, improper infection control practices by nursing staff during medication administration and incontinence care, and unsafe medication preparation procedures. These deficiencies posed minimal harm or potential for harm to residents.
Deficiencies (3)
Failure of RN to administer 30ML of water prior to medication administration via gastrostomy tube as ordered.
Dietary staff failed to cover all hair during food preparation and distribution and did not wash hands between glove changes.
Failure to implement proper infection prevention and control including improper hand hygiene and use of contaminated equipment by nursing staff during medication administration and incontinence care.
Report Facts
Residents affected: 124
Residents observed during medication administration: 8
Nurses observed during medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN), Employee Identifier #6 | Failed to flush gastrostomy tube with water as ordered and did not follow infection control procedures | |
| Licensed Practical Nurse (LPN), Employee Identifier #7 | Did not wash hands before administering nebulizer treatment and improperly handled nebulizer equipment | |
| Licensed Practical Nurse (LPN), Employee Identifier #8 | Placed medication cups inside one another during medication preparation | |
| Certified Nursing Assistants (CNAs), Employee Identifiers #9 and #10 | Failed to wash hands after glove removal and did not clean wash basin before storage during incontinence care | |
| LPN/Infection Control Coordinator, Employee Identifier #11 | Provided infection control guidance and interviewed regarding proper hand hygiene and contamination prevention | |
| Dietary Aide, Employee Identifier #2 | Failed to cover moustache and did not wash hands between glove changes | |
| Cook, Employee Identifier #1 | Did not cover all hair during food preparation | |
| Dietary Manager, Employee Identifier #3 | Interviewed regarding hand washing policies | |
| Registered Dietitian (RD), Employee Identifier #4 | Interviewed regarding cross-contamination risks |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 5, 2020
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in nursing care, food safety, infection prevention and control, and medication administration practices at Hillview Terrace nursing facility.
Findings
The facility was found deficient in multiple areas including failure to follow physician's orders for medication administration, inadequate hair and hand hygiene practices among dietary staff, improper infection control practices by nursing staff during medication administration and incontinence care, and unsafe medication preparation techniques.
Deficiencies (5)
Failure of RN to administer 30ML of water prior to medication administration via gastrostomy tube as ordered.
Dietary staff failed to cover all hair during food preparation and distribution and did not wash hands between glove changes.
Nursing staff failed to follow proper infection prevention practices including not cleaning stethoscope before use, not washing hands before medication administration, improper glove use, and improper cleaning and storage of equipment.
Medication cups containing medications were placed inside other medication cups during preparation.
Certified Nursing Assistants did not wash hands after glove removal and before touching clean items during incontinence care and did not clean wash basins before storage.
Report Facts
Residents affected: 124
Residents observed during medication administration: 8
Nurses observed during medication administration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #6 | Registered Nurse (RN) | Named in medication administration and infection control deficiencies |
| EI #7 | Licensed Practical Nurse (LPN) | Named in infection control deficiencies related to nebulizer treatment |
| EI #8 | Licensed Practical Nurse (LPN) | Named in medication preparation deficiencies |
| EI #9 | Certified Nursing Assistant (CNA) | Named in hand hygiene and incontinence care deficiencies |
| EI #10 | Certified Nursing Assistant (CNA) | Named in hand hygiene and incontinence care deficiencies |
| EI #11 | LPN/Infection Control Coordinator (ICC) | Interviewed regarding infection control practices |
| EI #1 | Cook | Named in hair restraint deficiency during food preparation |
| EI #2 | Dietary Aide | Named in hair restraint and hand hygiene deficiencies during food handling |
| EI #3 | Dietary Manager | Interviewed about hand hygiene policies |
| EI #4 | Registered Dietitian (RD) | Interviewed about cross-contamination risks |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 20, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding opened mail of Resident Identifier (RI) #15 and an incident of resident-to-resident physical abuse involving RI #31 and RI #107.
Complaint Details
The complaint investigation was triggered by report number AL 00035989 concerning opened mail of RI #15 and resident-to-resident physical abuse involving RI #31 and RI #107. The abuse was substantiated based on interviews, record reviews, and incident reports.
Findings
The facility failed to ensure the privacy of RI #15's mail, which was opened by staff prior to delivery. Additionally, the facility failed to prevent physical abuse when RI #31 punched RI #107. The facility also failed to follow the care plan for wound care to RI #27's tracheostomy site.
Deficiencies (3)
Failed to ensure staff did not open Resident Identifier (RI) #15's mail prior to delivering it.
Failed to protect Resident Identifier (RI) #107 from physical abuse by RI #31.
Failed to ensure Resident Identifier (RI) #27's care plan was followed for wound care to the tracheostomy site.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Days of documented trach care: 6
BIMS score: 15
BIMS score: 9
BIMS score: 7
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Comptroller | Interviewed regarding handling of RI #15's bank statements and mail | |
| Payroll Accounts Payable Employee | Interviewed regarding handling of RI #15's bank statements and mail | |
| Registered Nurse, Clinical Manager for Rehabilitation Hall | Interviewed about resident-to-resident abuse incident and care plan compliance for RI #27 | |
| Licensed Practical Nurse | Interviewed about care provided to RI #27 and incident on 12/06/18 | |
| Floor Administration for the rehab hall | Reported on incident report for RI #107 and #31 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 20, 2018
Visit Reason
The inspection was conducted as a result of a complaint investigation regarding opened mail of a resident, resident-to-resident physical abuse, and failure to follow a resident's care plan for wound care.
Complaint Details
The deficiency related to resident-to-resident physical abuse was cited as a result of the investigation of complaint/report number AL 00035989.
Findings
The facility failed to ensure resident mail was delivered unopened, failed to prevent physical abuse between residents, and failed to follow the care plan for wound care to a tracheostomy site. Deficiencies were found related to privacy violations, resident abuse, and incomplete wound care documentation.
Deficiencies (3)
Facility failed to ensure staff did not open Resident Identifier (RI) #15's mail prior to delivering it.
Facility failed to ensure Resident Identifier (RI) #107 was free from physical abuse involving RI #31.
Facility failed to ensure Resident Identifier (RI) #27's care plan was followed for wound care to the tracheostomy site.
Report Facts
Residents identified for abuse: 2
Residents whose care plans were reviewed: 46
Days with documented trach care: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Comptroller | Interviewed regarding responsibility for bank statements and mail handling. | |
| Payroll Accounts Payable Employee | Interviewed regarding mail handling and facility policy on mail. | |
| Registered Nurse, Clinical Manager for Rehabilitation Hall | Interviewed about resident abuse incident and care plan compliance. | |
| Licensed Practical Nurse | Interviewed about resident abuse incident and wound care treatment documentation. | |
| Floor Administration for the rehab hall | Wrote incident report for resident abuse and described physical abuse. |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Feb 5, 2018
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and evaluate the facility's environment, care plans, infection control, and other aspects of resident care.
Findings
The survey identified multiple deficiencies including failure to maintain a safe, clean, and homelike environment with widespread environmental concerns; inaccurate resident assessments and incomplete care plans; failure to follow menus and serve palatable food; inadequate infection control practices; and incomplete facility-wide assessments of maintenance needs.
Deficiencies (9)
Facility failed to maintain resident rooms and common areas in a safe, clean, comfortable, and homelike environment with chipped paint, missing knobs, stained ceiling tiles, and wobbly IV poles.
Facility failed to ensure accurate assessments of resident incontinence status for Resident #76.
Facility failed to implement complete, person-centered care plans for residents #48, #69, and #87, including failure to update care plans to reflect current resident needs and interventions.
Facility failed to ensure care plan interventions were followed, including failure to place fall mats at bedside for Resident #87.
Facility failed to follow menus as planned, including substitution of desserts and alternate meals without proper notification or nutritional review.
Facility failed to ensure food was palatable and served at appropriate temperatures; residents reported bland, tasteless food and undercooked baked potatoes.
Facility failed to conduct a comprehensive facility-wide assessment identifying environmental maintenance needs, incorrectly reporting no areas needing repair despite widespread environmental concerns.
Facility failed to implement effective infection prevention and control practices, including failure to use barriers during catheter care, improper handling of linen, failure to wash hands appropriately, and failure to place barriers when administering eye drops.
Facility failed to properly assess and document risks and obtain informed consent for use of bed rails, including failure to assess alternatives and entrapment risks for Resident #87.
Report Facts
Residents affected: 137
Resident rooms affected: 72
Total resident rooms: 79
Residents for MDS assessment review: 32
Residents for care plan review: 32
Residents sampled for food palatability: 29
Residents affected by food palatability issues: 9
Heated bases shortage: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Owner | Interviewed regarding environmental concerns and maintenance system |
| EI #2 | Administrator | Interviewed regarding environmental concerns, facility assessment, and side rail use |
| EI #3 | Maintenance Technician | Provided information on environmental maintenance issues |
| EI #4 | Dietary Manager | Interviewed regarding menu adherence, food preparation, and heated bases |
| EI #5 | Maintenance Director | Interviewed regarding maintenance system and facility upkeep |
| EI #8 | Infection Control Nurse / Assistant Director of Nursing | Interviewed regarding infection control practices and risks |
| EI #9 | Certified Nursing Assistant | Observed and interviewed regarding catheter and perineal care |
| EI #10 | Certified Nursing Assistant | Observed providing catheter and perineal care |
| EI #11 | Certified Nursing Assistant | Observed and interviewed regarding perineal care and linen handling |
| EI #12 | Certified Nursing Assistant | Observed providing perineal care |
| EI #13 | Certified Nursing Assistant | Observed and interviewed regarding incontinence care and linen handling |
| EI #14 | Certified Nursing Assistant | Observed and interviewed regarding incontinence care and infection control |
| EI #15 | Certified Nursing Assistant | Interviewed regarding fall mat use and side rail use |
| EI #16 | Registered Nurse | Completed side rail assessment for Resident #87 |
| EI #17 | Corporate Consultant | Interviewed regarding side rail consent and assessment |
| EI #18 | Licensed Practical Nurse | Observed administering inhaler and eye drops with poor infection control |
| EI #19 | Registered Nurse / MDS / Care Plan Coordinator | Interviewed regarding MDS assessments and care plan deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Feb 5, 2018
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements and the facility's ability to provide a safe, clean, and homelike environment for residents.
Findings
The survey identified multiple deficiencies including environmental maintenance issues affecting resident rooms and common areas, inaccurate resident assessments, incomplete and inconsistent care plans, failure to follow infection control practices, improper use and documentation of side rails, and failure to follow planned menus and serve palatable food at appropriate temperatures.
Deficiencies (8)
Facility failed to maintain resident rooms and common areas in a safe, clean, comfortable, and homelike environment with issues such as chipped paint, missing knobs, stained ceiling tiles, and wobbly IV poles.
Resident #76's quarterly and annual Minimum Data Set (MDS) assessments inaccurately reflected incontinence status.
Care plans for residents #48, #69, and #87 lacked person-centered interventions and were not updated to reflect current resident needs.
Resident #87 was observed without a fall mat at bedside despite care plan requirements.
Facility failed to ensure proper infection control practices including lack of barriers during catheter care, improper handling of linen, and failure to wash hands before and after medication administration.
Side rail consent forms lacked documentation of potential risks; side rail assessments did not address prior alternatives or entrapment risks; resident #87 had four side rails up without clear justification.
Facility failed to follow planned menus and provide palatable food at appropriate temperatures; residents reported bland, cold, or improperly prepared meals.
Facility assessment failed to identify environmental maintenance needs despite widespread issues observed throughout the facility.
Report Facts
Residents affected: 72
Total residents: 137
Deficiencies cited: 8
Heated bases shortage: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Owner | Participated in walking rounds and acknowledged environmental concerns |
| EI #2 | Administrator | Interviewed regarding facility assessment and environmental concerns |
| EI #3 | Maintenance Technician | Provided information on maintenance issues and observations |
| EI #4 | Dietary Manager | Interviewed regarding menu adherence and food preparation |
| EI #5 | Maintenance Director | Interviewed about maintenance system and facility upkeep |
| EI #8 | Infection Control Nurse / Assistant Director of Nursing | Interviewed regarding infection control practices |
| EI #9 | Certified Nursing Assistant | Observed providing catheter care without barrier |
| EI #10 | Certified Nursing Assistant | Observed providing catheter care without barrier |
| EI #11 | Certified Nursing Assistant | Observed providing perineal care and placing soiled linen on floor |
| EI #13 | Certified Nursing Assistant | Observed handling soiled linen improperly |
| EI #14 | Certified Nursing Assistant | Observed improper glove use and hand hygiene during perineal care |
| EI #15 | Certified Nursing Assistant | Interviewed about fall mat use and side rail use |
| EI #16 | Registered Nurse | Completed side rail assessment for resident #87 |
| EI #17 | Corporate Consultant | Interviewed regarding side rail consent and assessment |
| EI #18 | Licensed Practical Nurse | Observed administering medication without proper hand hygiene |
| EI #19 | Registered Nurse / MDS / Care Plan Coordinator | Interviewed regarding inaccurate assessments and care plans |
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