Irondale Post Acute

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from the wrongful use of the resident's belongings or money.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

A complaint survey, prompted by #CO39683 and #CO39811 was conducted on 4/15/25 to 4/30/25. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure one (#3) of eight residents reviewed for accidents received adequate supervision out of eight sample residents.Specifically, the facility failed to ensure Resident #3 was provided safe transportation. Resident #3 was wheelchair bound and dependent on staff for mobility and positioning. She had functional limitations in range of motion for her lower extremities due to below the knee amputations.Resident #3 was assisted into the van after an appointment on 1/22/25 by van driver #1. Resident #3 was not secured properly in the van. When the van accelerated, Resident #3' s wheelchair tipped backward and she fell onto the floor with the wheelchair landing on top of her. When van driver #1 pulled over, she noticed the resident had blood in her mouth. Emergency services were called and the resident was transported to the hospital. The resident was diagnosed with fractures of the sixth and seventh cervical vertebra, first and second thoracic vertebra, epidural hemorrhage (brain bleed), multiple rib fractures and pain. Resident #3 required hospitalization in the intensive care unit (ICU). Findings include:Observations, record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/15/25 to 4/30/25, resulting in the deficiency being cited as past noncompliance with a correction date of 1/28/25. I. Situation of serious harmThe facility' s failure to ensure van driver #1 secured Resident #3' s wheelchair in the facility' s van when she was being transported to and from her appointment placed the resident at serious risk of harm, serious impairment or death. Resident #3 suffered multiple fractures, brain injury and pain. II. Facility plan of correctionThe corrective action plan the facility implemented in response to the accident on 1/22/25 involving Resident #3' s was provided by the director of nursing (DON) on 4/16/25 at 10:35 a.m. The correction plan revealed the following:A. Immediate actionResident #3 was sent to the hospital immediatel..

A survey prompted by #CO37796, #CO38054, and #CO38207 was conducted 11/20/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#1) of three residents reviewed for accidents out of five sample residents remained free from accidents.Resident #1, who was identified as a high fall risk, sustained a fall on 9/6/24 which resulted in a hip fracture that required hospitalization. The hip fracture was not identified until 9/12/24 due to the nurse failing to report the fall. Due to the facility' s failure to assess, report and identify the injury, the resident was not treated for her fractured hip for six days. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 11/20/24, resulting in the deficiency being cited as past noncompliance with a correction date of 9/12/24.I. Incident on 9/12/24The nursing home administrator (NHA) and the director of nursing (DON) started an investigation of Resident #1' s change of condition and her bruising on 9/12/24. The NHA and the DON reviewed camera footage for Friday 9/6/24. The video footage revealed Resident #1 was in the doorway to her room when she stood up from her wheelchair and sat back down. Resident #1 backed her wheelchair into her room and then her feet came out into the doorway. The video footage also revealed certified nurse aide (CNA) #3, who was an agency staff member, and facility licensed practical nurse (LPN) #2 were present. The DON interviewed CNA #3 who verified the resident did have a fall.-The fall was not reported until 9/12/24 (see below). II. Facility corrective actionA. Immediate action to correct the deficient practice for Resident #1A thorough investigation of the incident was conducted on 9/12/24. The facility reviewed the camera footage which revealed Resident #1 sustained a fall on 9/6/24, in her doorway. CNA #3 and LPN #2 were identified in the video and interviewed. LPN #2 denied knowing anything about Resident #1' s fall and was terminated. CNA #3 verified Resident #1 sustained a fall on 9/6/24. All of the nursing staff were educated by the assistant director of nur..