Inspection Reports for
St. Martin’s in the Pines
4941 Montevallo Rd, Birmingham, AL 35210, United States, AL, 35210
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
4.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Jul 18, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, safety, and facility operations, including activities of daily living assistance, accident prevention, pain management, and use of lifts and transfers.
Findings
The facility was found deficient in multiple areas including failure to provide scheduled bathing/showers to residents, unsafe food warming practices causing fire hazard, inadequate investigation of a resident's fracture, incomplete fall investigations, lack of appropriate lift equipment for transfers, and ineffective pain management practices.
Deficiencies (6)
Failure to ensure residents were provided baths/showers as scheduled for 2 residents.
Unsafe food warming practices with plastic and foam containers placed in ovens causing smoke and immediate jeopardy to resident health or safety.
Failure to conduct a thorough investigation of a resident's right femur fracture and delayed response to pain and injury.
Failure to properly investigate and document a resident's fall and lack of follow-up interventions.
Failure to provide appropriate sit-to-stand lift equipment for a resident requiring mechanical lift assistance.
Failure to have an effective pain management program including routine pain assessment, documentation, and use of non-pharmacological interventions.
Report Facts
Residents reviewed for ADLs: 11
Residents affected by bathing deficiency: 2
Plastic containers placed in oven: 5
Foam containers placed in oven: 1
Date of Immediate Jeopardy removal: Jun 29, 2025
Pain medication dosage: 10
Pain rating: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Services #12 | Director of Clinical Services | Interviewed regarding bathing procedures and policies |
| Certified Nurse Aide #47 | Certified Nurse Aide | Interviewed about shower schedule and refusals |
| Licensed Practical Nurse #51 | Licensed Practical Nurse | Interviewed about shower tracking and observations |
| Licensed Practical Nurse #48 | Licensed Practical Nurse | Interviewed about resident care and shower refusals |
| Certified Medication Technician #49 | Certified Medication Technician | Interviewed about resident care and coaxing |
| Certified Nurse Aide #50 | Certified Nurse Aide | Interviewed about shower days and hair care |
| Director of Nursing Services | Director of Nursing Services | Interviewed about expectations for resident care and shower documentation |
| Administrator | Administrator | Interviewed about expectations for resident care and shower schedules |
| Food Service Worker #24 | Food Service Worker | Placed plastic and foam containers in oven causing fire hazard |
| Certified Nurse Aide #33 | Certified Nurse Aide | Opened oven and ventilated smoke during fire hazard incident |
| Executive Chef | Executive Chef | Interviewed about food preparation and oven use |
| Community Executive Director | Community Executive Director | Interviewed about fracture incident and investigation |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Notified hospice and ordered x-ray for fractured resident |
| Registered Nurse #7 | Registered Nurse | Provided shift report and pain management for fractured resident |
| Medical Director #5 | Medical Director | Interviewed about fracture and osteopenia |
| Director of Clinical Operations #26 | Director of Clinical Operations | Interviewed about fall investigation and documentation |
| Registered Nurse #1 | Registered Nurse | Interviewed about resident transfer and lift use |
| Registered Nurse #79 | Registered Nurse | Interviewed about pain management and medication administration |
| Licensed Practical Nurse #22 | Licensed Practical Nurse, Unit Manager | Interviewed about pain management policies and documentation |
| Former Director of Nursing Services #53 | Director of Nursing Services | Interviewed about pain management policies and procedures |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 3, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing care standards, including proper labeling of feeding tubes and hand hygiene practices in the facility's kitchen.
Findings
The facility failed to ensure that a resident's feeding tube was properly labeled with date, time, rate, and initials, posing minimal harm to a few residents. Additionally, a Certified Nursing Assistant did not wash hands before returning to the kitchen after assisting a resident, risking infection control for nine residents on the 3rd floor.
Deficiencies (2)
Feeding tube bottle for Resident Identifier #4 was not labeled with date, time, rate, or nurse initials.
Certified Nursing Assistant in the 3rd floor kitchen did not wash hands before returning to the kitchen after assisting a resident.
Report Facts
Residents affected: 1
Residents affected: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Register Nurse (RN) | Employee Identifier #5 interviewed regarding feeding tube labeling | |
| Register Nurse (RN) | Employee Identifier #6 responsible for changing tube feeding and not labeling it | |
| Director of Nursing (DON) | Employee Identifier #2 interviewed about tube feeding labeling policy | |
| Certified Nursing Assistant (CNA) | Employee Identifier #4 observed and interviewed regarding hand hygiene | |
| Dietary Manager | Employee Identifier #3 interviewed about hand hygiene policy |
Inspection Report
Deficiencies: 3
Date: Sep 26, 2018
Visit Reason
The inspection was conducted to assess compliance with care plan revisions related to hospice discharge and to evaluate food storage and handling practices in the facility.
Findings
The facility failed to revise the hospice care plan for Resident Identifier #104 after discharge from hospice services. Additionally, the kitchen staff did not air dry dishes as required, and 17 prune juice cups with expired use-by dates were found in storage, posing potential harm to residents.
Deficiencies (3)
Failed to revise Resident Identifier #104's hospice care plan after discharge from hospice services.
Kitchen staff hand dried dishes instead of air drying, contrary to facility policy.
Seventeen four fluid ounce prune juice cups with a manufacture use-by date of 09/07/2018 were not discarded and were expired.
Report Facts
Residents sampled for care plan review: 26
Expired prune juice cups: 17
Residents potentially affected by expired prune juice: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse/Resident Assessment Coordinator | Employee Identifier #7 interviewed regarding hospice care plan revision for Resident Identifier #104 | |
| Certified Nursing Assistant | Employee Identifier #5 observed hand drying dishes and interviewed about drying procedures | |
| Dietician | Employee Identifier #6 interviewed about dish drying policy | |
| Certified Nursing Assistant | Employee Identifier #1 interviewed about expired prune juice cups | |
| Registered Dietitian | Employee Identifier #2 interviewed about policy on expired food items |
Inspection Report
Routine
Deficiencies: 7
Date: Aug 24, 2017
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care plans, food safety, infection control, and facility sanitation.
Findings
The facility failed to develop and implement complete care plans for several residents regarding incontinence, use of Bi-pap machines, catheter care, antipsychotic medication use, and anxiety management. Additionally, the facility failed to provide a physician-ordered sippy cup for a resident with dysphagia, maintain proper sanitizer concentration in the kitchen, prevent backflow in kitchen drains, ensure food was properly frozen, maintain dumpster sanitation, and follow infection control procedures during peri-care.
Deficiencies (7)
Failure to develop complete care plans for incontinence, Bi-pap use, catheter care, antipsychotic medication, and anxiety for multiple residents.
Failure to ensure care plan was followed for providing a sippy cup as ordered by the physician for a resident with dysphagia.
Failure to verify sanitizer concentration in the three-compartment pot and pan sink per manufacturer's instructions.
Drain pipes of food preparation sinks and dishwashing area extended into floor drains without air gaps, risking backflow contamination.
Food was not maintained frozen solid in the kitchenette freezer, risking resident safety.
Dumpster lids were left open with food residue, trash, and flies present around dumpsters, risking pest infestation and contamination.
Failure to remove soiled gloves and wash hands before placing a clean adult brief on a resident and opening blinds and door, risking infection spread.
Report Facts
Residents sampled: 24
Residents affected: 4
Residents sampled: 14
Residents affected: 1
Residents affected: 10
Residents affected: 116
Residents affected: 117
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #3 | Care Plan/MDS Coordinator | Interviewed regarding care plan development and deficiencies |
| EI #9 | Director of Nursing | Interviewed regarding care plan requirements and concerns |
| EI #1 | Certified Nursing Assistant | Interviewed regarding sippy cup use and care plan adherence |
| EI #2 | Registered Dietician | Interviewed regarding sippy cup use and care plan adherence |
| EI #10 | Kitchen Employee | Observed and interviewed regarding sanitizer concentration testing |
| EI #11 | Dining Services Manager | Interviewed regarding sanitizer concentration and dumpster sanitation |
| EI #12 | Maintenance Employee | Measured drain pipe extensions into floor drains |
| EI #13 | Director of Dietary Services | Interviewed regarding drain pipe issues and infection control |
| EI #6 | Registered Nurse | Interviewed regarding freezer temperature and food safety |
| EI #7 | Maintenance Employee | Interviewed regarding freezer temperature and repairs |
| EI #8 | Director of Nursing | Interviewed regarding infection control during peri-care |
| EI #9 | Certified Nursing Assistant | Observed and interviewed regarding peri-care infection control breach |
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