Irondale Post Acute

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#25) of two residents reviewed for range of motion received services and assistance to prevent a reduction in range of motion out of 35 sample residents. Resident #25 was admitted to the facility on [DATE]. According to the resident's diagnoses on admission, Resident #25 did not admit to the facility with bilateral hand contractures. On 9/9/25 a joint mobility evaluation was completed which indicated Resident #25's right wrist and right fingers had minimum range of motion limitations and left wrist and fingers had moderate range of motion limitations. He had resting bilateral hand splints and was placed on occupational therapy (OT) services for contracture management. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to: -Ensure all residents' rooms in the secured unit were in good repair; -Ensure the small common area of the secured unit was free from unpainted areas on the walls, free of sheet rock damage and missing floor tiles; and, -Ensure the dining room area of the secured area was free from stains in the ceiling and free of sheet rock damage.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that two (#51 and #12) of four residents reviewed for abuse out of 35 sample residents were kept free from physical abuse. Specifically, the facility failed to protect Resident #51 and #12 from abuse towards each other.

Inspectors wroteBased on record review and interviews, the facility failed to protect one (#27) of three residents from misappropriation of property out of 35 sample residents. Specifically, the facility failed to prevent Resident #27 from having a significant amount of money stolen from his room.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents were free from chemical restraints for one (#8) of five residents out of 35 sample residents. Specifically, the facility failed to ensure Resident #8's continued use of an antipsychotic medication was appropriately monitored and reviewed by the interdisciplinary team (IDT) for continued medical necessity and gradual dose reduction (GDR).

Inspectors wroteBased on record review and interviews, the facility failed to thoroughly investigate allegations of abuse for three (#51, #12 and #27) of six residents out of 35 sample residents. Specifically, the facility failed to:-Complete a thorough investigation after an allegation of physical abuse between Resident #51 and Resident #12; and,-Thoroughly investigate an allegation of misappropriation of property involving Resident #27.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement activity programs that met the interests and supported the physical, mental, and psychological well-being of one (#12) of 19 residents reviewed for activities out of 35 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for Resident #12.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#25) of three residents out of 35 sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility failed to:-Obtain accurate wound care orders for Resident #25 in a timely manner; and, -Ensure interventions were followed for Resident #25 to prevent an abrasion to the resident's back.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#13) of two residents reviewed for hearing and vision problems out of 35 sample residents. Specifically, the facility failed to ensure Resident #13 was assisted to receive a replacement hearing aid after her hearing aid was broken.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of three medication refrigerators. Specifically, the facility failed to: -Ensure expired medications were removed from the medication cart and disposed of; and,-Ensure the medication refrigerator was securely locked on one of three units.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#2) of four residents reviewed out of seven sample residents. Specifically, the facility failed to ensure Resident #2 received his tube feeding administration as ordered by the physician.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for elopement out of three sample residents and other residents residing in the facility remained as free from accidents/hazards as possible. Specifically, the facility failed to:-Ensure Resident #4 received adequate supervision to prevent the resident from eloping from the facility; and,-Ensure there was an effective evacuation plan in place and that staff were trained on the plan and provided with the necessary equipment to evacuate residents from the facility in the case of an emergency, which had the potential to affect the safety of all 72 residents residing in the facility. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to: -Accident/hazards in which the facility failed to provide Residents #4 the supervision necessary to prevent elopement that rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely; [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences for one (#40) resident out of 36 sample residents. The facility failed to ensure Resident #40 was administered pain medication as ordered. Resident #40 was prescribed hydrocodone for pain management. The facility ran out of the scheduled prescribed medications and the resident missed seven doses of hydrocodone from 11/11/23 to 11/13/23. [...]

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; and, -Ensure surface disinfectant times were adhered to.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two (#38 and #20) of six residents out of 36 sample residents reviewed for accident hazards. Specifically, the facility failed to have fall interventions in place for Resident #38 and Resident #20.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#25) of three residents who required respiratory care received the care consistent with professional standards of practice out of 36 sample residents. Specifically, for Resident #25 the facility failed to: -Ensure the physician's order was followed for oxygen therapy; and, -Accurately complete section O in the comprehensive minimum data set (MDS) assessment under respiratory treatments.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to provide pharmaceutical services, including procedures regarding emergency medications and biologicals. Specifically, the facility failed to communicate and coordinate with the pharmacy to remove an emergency medication kit when an automated dispensing system was implemented.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on one of three medication carts. Specifically, the facility failed to ensure tiotropium bromide (Spiriva) inhalers were dated upon opening.

Inspectors wroteBased on observations and interviews, the facility failed to prepare and serve food in a sanitary manner. Specifically, the facility failed to ensure staff washed and dried hands appropriately while plating and serving resident meals.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for two (#24 and #56) of five residents reviewed for hospice services out of 36 sample residents. Specifically, the facility failed to: -Establish a communication process, including how the communication will be documented between the long term care (LTC) facility and the hospice provider for Resident #24 and Resident #56; and, -Ensure hospice agency notes were easily accessible to facility staff and have consistent documentation of hospice care visits and updates in Resident #24 and #56's record.

Inspectors wroteBased on interviews and record review, the facility failed to employ an infection control preventionist (ICP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified ICP involved with the facility's infection prevention and control program.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was in place for two (#6 and #14) of six residents reviewed for discharge out of 15 sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay and/or a final summary of the resident's status was completed for Resident #6 and #14.

Inspectors wroteBased on observation, interview, record review, and review of facility policies, the facility failed to ensure one (Resident #40) of three residents reviewed for nutrition maintained his/her body weight and did not sustain severe weight loss. Specifically, on 07/05/2022 the resident weighed 180.4 pounds and on 07/30/2022, Resident #40 weighed 159 pounds, a 21.4 pound or 11.86 percent (%) weight loss in 25 days. The failed to identify and address Resident #40's severe weight loss.

Inspectors wroteBased on observation, interview, document review, and review of facility policy/procedure, the facility failed to maintain proper kitchen sanitation for the dish machine. Specifically, the dish machine sanitizer was required to be 50-100 parts per million (ppm) to ensure dishes were sanitized. Observations on 08/29/2022 revealed there was no sanitizer in the dish machine. This had the potential to affect 84 of 85 residents.