THE HEALTHCARE CENTER AT BUCK CREEK
For profit - Limited Liability company
198 Beds
Independent
Data: November 2025
Trust Grade
53/100
#136 of 223 in AL
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Photo by Anja Sellers
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Last Inspection: January 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
The Healthcare Center at Buck Creek has a Trust Grade of C, indicating it is average compared to other nursing homes, meaning it is neither great nor terrible. It ranks #136 out of 223 facilities in Alabama, placing it in the bottom half, but it is #2 out of 3 in Shelby County, suggesting only one local option is better. Unfortunately, the facility's trend is worsening, with issues rising from 4 in 2022 to 9 in 2024. Staffing is below average, with a rating of 2 out of 5 stars and a turnover rate of 44%, which is better than the state average of 48%. However, the facility has $16,801 in fines, which is concerning as it is higher than 83% of Alabama facilities. On a positive note, there is more RN coverage than 23% of state facilities, meaning that registered nurses are present to catch potential issues. However, there have been serious incidents, such as a staff member verbally abusing a resident and another case where a staff member misappropriated funds from a resident's account, leading to significant financial harm. These incidents highlight serious weaknesses in staff conduct and oversight, despite some strengths in RN availability. Families should weigh these factors carefully when considering this facility.
- Trust Score
- C
- In Alabama
- #136/223
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 44% turnover. Near Alabama's 48% average. Typical for the industry.
- Penalties ✓ Good
- $16,801 in fines. Lower than most Alabama facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 24 minutes of Registered Nurse (RN) attention daily — below average for Alabama. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 13 deficiencies on record. Higher than average. Multiple issues found across inspections.
53/100
Bottom 40%
Needs review
4 → 9 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★☆☆☆
2.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2022: 4 issues
2024: 9 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (44%)
4 points below Alabama average of 48%
Facility shows strength in fire safety.
The Bad
3-Star Overall Rating
Near Alabama average (2.9)
Meets federal standards, typical of most facilities
Staff Turnover: 44%
Near Alabama avg (46%)
Typical for the industry
Federal Fines: $16,801
Below median ($33,413)
Minor penalties assessed
The Ugly 13 deficiencies on record
2 actual harm
Sept 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and a review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to protect Resident Identifier (RI) #4 from being physically abused by RI #5. On 05/16/2024 Certified Nursing Assistant (CNA) #5 witnessed RI #5 slap RI #4 on the face in their room.
This deficient practice affected RI #4 and RI #5, two of 19 residents sampled for abuse.
Findings Include:
A review of the facility's policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of January 2019, revealed:
.Purpose: To prohibit and prevent abuse .
Definitions: Abuse: The willful infliction of injury . resulting physical harm, pain, or mental anguish.Willful, as use in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.
5. Identification . A resident to resident altercation will be reviewed as a potential situation of abuse.
RI #4 was admitted to the facility on [DATE], re-admitted on [DATE] and has diagnosis to include Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety.
A review of RI #4's, most recent Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/01/2024, documented a Brief Interview of Mental Status (BIMS) of 13 out of 15 which indicated RI #4's cognition was intact
RI #5 was admitted to the facility on [DATE], re-admitted on [DATE] and has diagnosis to include Vascular Dementia and Alzheimer's Disease.
A review of RI #5's, most recent Quarterly MDS with an ARD of 02/21/2024 documented a BIMS of 7 out of 15 which indicated RI #5's cognition was moderately impaired.
The Alabama Department of Public Health Online Incident Reporting System form, dated 05/16/2024 documented:
. Incident Type . Abuse - Physical .
Incident Detail .
Name(s) of resident(s) involved: (RI #4 and RI #5) .
Narrative summary of incident: Resident (RI #5) hit another resident (RI #4) .
A review of the Investigation Template dated 05/23/2024 documented: . Description of the Allegation: On May 16, 2024 (RI #5) hit .another resident Investigation Summary: .body audit was performed on (RI #4) with no signs of injury. Based off interviews with the resident's roommate and staff physical abuse is substantiated.
On 09/25/2024 at 1:54 PM an interview was conducted with CNA #5 who witnessed the incident on 05/16/2024 between RI #4 and RI #5. CNA #5 said, she was passing breakfast trays and entered RI #4's and RI #5's room. CNA #5 said she was removing RI #4's tray when RI #5 stood up from the bed and was unclothed. CNA #5 said she told RI #5 to wait, and she would take him/her to the restroom to get him/her cleaned up and dressed. CNA #5 said at that time RI #5 walked toward RI #4 and through the privacy curtain. CNA #5 said she responded by telling RI #5 she would take him/her to the restroom. CNA #5 said RI #5 responded by hitting her on the left side of her face. CNA #5 said she tried to move the privacy curtain back and RI #5 grabbed the curtain and slapped RI #4 across his/her face with his/her hand. CNA #5 said, the intensity of the hit was a five on a scale zero to ten. CNA #5 said she yelled for help and separated the residents. CNA #5 said CNA #8 was outside the door and she summoned LPN #7 for assistance. CNA #5 said, the incident was physical abuse. CNA #5 said, it was the resident's home, and it would not be a good feeling to be hit in your own home. CNA #5 further said this would make a reasonable person feel scared and upset.
On 09/26/2024 at 2:30 PM an interview was conducted with LPN #7. During the interview, LPN #7 said she was at the nurses' desk when she heard CNA #5 call for help. LPN #7 said when she responded the residents were separated. LPN #7 said CNA #5 exited the room and CNA #8 entered the room to assist while she assessed both residents. LPN #7 said neither resident was injured. LPN #7 said RI #5 calmed down and was assisted to the nurses' station with CNA #8 for one-to-one observation. LPN #7 said the incident between RI #4 and RI #5 was resident to resident physical abuse. LPN #7 further said this would make a reasonable person feel scared, upset, and mad.
On 09/25/2024 at 3:46 PM the Administrator (ADM) was asked about the alleged physical abuse on 05/16/2024 involving RI #4 and RI #5. The ADM said, RI #5 hit RI #4 and it was witnessed by a staff member. The ADM said, the incident was physical abuse. The ADM said, being slapped on the face would make a reasonable person upset in their home.
F 600 was cited as a result of the investigation of complaint/report number #AL00047879.
**************************************************************************
The facility took immediate actions to correct the non-compliance and prevent reoccurrence by:
- On 05/16/2024 the residents were separated and assessed for injuries. No injuries noted.
-On 05/16/2024 notifications were made to the residents' sponsor, the medical director, and local police department.
- A report was made to the Alabama Department of Public Health (ADPH) on 05/16/2024.
- Education for all staff, all departments was completed on 05/16/2024 on Abuse Education with a focus on resident to resident.
- RI #5 immediately placed on one-on-one after incident on 05/16/2024.
- RI #5 sent to Grandview Medical Center via EMS for Behavioral Disturbance on 05/16/2024.
- 5-day investigation completed and submitted the results of the investigation to ADPH on 05/23/2024.
- Root cause analysis completed 05/24/2024.
- 4 Point Plan Created on 05/24/2024.
- Began Weekly Audits (Weekly audit or embrace rounds to ensure any behaviors identified were discussed in clinical start up and plan of care updated to prevent resident to resident reoccurrence. Weekly for 4 weeks and monthly for 3 months until substantial compliance can be assured) started on 05/24/2024.
- A QAPI meeting was held on 05/25/2024. Completed 05/25/2024.
- Compliance has been met no further concerns identified.
**************************************************************************
After review of documentation supporting the above corrective actions, including the facility's investigation file, in-service/education records, QAPI documentation, and staff interviews, the survey team verified the facility implemented corrective actions including ongoing monitoring from 05/16/2024 through 05/25/2024; thus, F 600 was cited at past non-compliance.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, the facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, the facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of facility reported incidents (FRIs) information submitted to the Alabama Department of Public Health (ADPH) via the Online Incident Reporting System; the facility failed to submit their five-day investigative summary or results of their investigations for two of 18 FRIs concerning allegations of abuse, neglect, or misappropriation of resident property reviewed for timely reporting.
This deficient practice affected Resident Identifier (RI) #6 and RI #22 two of 19 residents reviewed for abuse concerns.
Findings Include:
A review of a policy titled Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019. documented the following: .7. Reporting/Response .The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of the alleged violation .
RI #6 was readmitted to the facility on [DATE] with diagnoses to include Dementia.
On 05/14/2024 the facility submitted an initial report of neglect to ADPH via the Online Incident Reporting System that alleged RI #6 had not received assistance with meals.
On 05/22/2024 the facility submitted the printed initial report regarding the allegation, RI #6's face sheet, RI #6's care plan, Section C of RI #6's Minimum Data Set (MDS) assessment, and RI #6's order summary list to ADPH via the Online Incident Reporting System. The facility did not submit the results of their investigation.
RI #22 was readmitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease.
On 07/20/2024 the facility submitted an initial report of an allegation of sexual abuse to ADPH via Online Incident Reporting System that alleged a family member had their hands in RI #22's brief.
On 07/29/2024 the facility submitted the printed initial report regarding the allegation, RI #22's face sheet, RI #22's care plan, Section C of RI #22's MDS assessment, and RI #22's order summary list to ADPH via the Online Incident Reporting System. The facility did not submit the results of their investigation.
An interview was conducted with the Administrator on 09/27/2024 at 4:15 PM. The Administrator said that the investigation template included a summary and documented the investigation. She explained the form was scanned and submitted with the five-day reports to the State Agency. She said it was important to send the investigation template with the five-day report because it provided a summary of what was done during the investigation. When asked why the investigation template was not included in the five-day report concerning RI # 6 and RI #22, she stated she did not know.
F 609 was cited as a result of the investigation of complaint/report numbers #AL00048672 and AL00048673.
May 2024
4 deficiencies
2 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Free from Abuse/Neglect
(Tag F0600)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, an...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public Health (ADPH) Online Reporting System, the facility failed to protect the Resident Identifier (RI) #5's right to be free from verbal, mental, and physical abuse by a staff.
On 04/25/2024 Certified Nursing Assistant (CNA) #9 observed Licensed Practical Nurse (LPN) #12 stand up and say she was going to go to RI #5's room and call his/her dead mother a bitch. On approximately 04/27/2024 or 04/28/2024 CNA #10 overheard LPN #12 on the phone during a break say she went in RI #5's room and called him/her an ugly bitch and called his/her dead mother an ugly bitch.
On 04/26/2024 the Social Worker (SW) was informed by LPN #12 that RI #5 was wandering in other resident's room. The Social Worker started the process of having RI #5 moved to the secure/memory unit without informing RI #5 prior to the move. On 04/29/2024 RI #5 was moved to the secure/locked unit in the facility. The resident expressed he/she did not want to move and stated he/she felt LPN #12 had him/her moved because she did not like him/her.
This failure affected RI #5, one of eight sampled residents reviewed for abuse prevention.
This deficiency was cited as a result of the investigation of complaint/report number AL00047738.
Findings Include:
The ADPH Online Facility Report Incident dated 04/29/2024, identified . Incident Type .Abuse-Verbal .Incident Detail . CNA alleged the nurse (LPN #12) told the resident (RI #5) that his/her dead mother was a bitch .
A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed:
Purpose: To prohibit and prevent abuse .
Definitions: .
Abuse: The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . It includes verbal abuse .physical abuse, and mental abuse .
Involuntary Seclusion: is defined as separation of a resident from other residents or from her/his room or confinement to her/his room (with or without roommates) against the resident's will .
Mental Abuse: is the use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation .
Physical Abuse: Includes, but is not limited to hitting, slapping, punching, biting and kicking .
Verbal abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend, or disability .
RI #5 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, without behavioral disturbance.
A review of Resident #5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/26/2024, revealed RI #5 had a Brief Interview for Mental Status (BIMS) score of 5 (five) of 15, which indicated the resident had severe cognitive impairment.
A review of a progress note for RI #5 dated 04/26/2024 documented . alert and oriented . Resident has been redirected x3 attempts out of other residents' rooms. Resident's on the hallway has c/o (complained) to this writer (LPN #12) about being in their room while coughing. Resident has been wandering around the unit and is forgetful about where (his/her) room is as well as in the dining room asking where the dining room is . This was the only note in the RI #5's medical record that documented wandering behaviors.
A review of a progress notes for RI #5 documented . 04/29/2024 . This resident was transferred from North Wing (he/she) is alert and oriented to person and place with some confusion noted .
RI #5 was interviewed on 05/01/2024 at 5:30 PM. RI #5 said that LPN #12 had told him/her how ugly his/her mother was and had physically poked his/her shoulder with two fingers while saying this to him/her. RI #5 said this caused him/her to feel bad and he/she did not like what LPN #12 had said to him/her. RI #5 informed the surveyor that he/she was not supposed to be on the secured unit (Secure/Memory) and was only there because LPN #12 did not like him/her. RI #5 stated that LPN #12 had informed him/her that this unit would be a better fit, and he/she told LPN #12 they did not want to move. RI #5 said that LPN #12 had informed him/her that he/she had no choice in the matter.
A second interview was conducted with RI #5 on 05/02/2024 at 12:46 PM. RI #5 said, LPN #12 had told him/her how ugly his/her mother was and had physically poked his/her shoulder with two fingers while saying this to him/her. RI #5 said this caused him/her to feel bad and he/she did not like what LPN #12 had said to him/her. RI #5 said this made him/her feel bad and she did not respond to the comment made by LPN #12. RI #5 said he/she was not doing good, because he/she did not belong on the secured unit. RI #5 stated LPN #12 had him/her moved because she (LPN #12) did not like him/her. RI #5 said he/she did not want to change rooms prior to being moved to the secure/locked unit. RI #5 further stated LPN #12 informed him/her of the move and said he/she had no choice. RI #5 said he/she missed his/her old room and his/her friends.
On 05/02/2024 at 9:45 AM, an interview was conducted with CNA #9. According to CNA #9, on 04/25/2024, she observed RI #5 approach the nurse's desk where LPN #12 was sitting and inquired about the results of an x-ray. LPN #12 informed RI #5 that it was too early for the results as the x-ray technician had just left. CNA #9 stated that RI #5 then proceeded to call LPN #12 a bitch as he/she was walking away. After the resident walked away, CNA #9 said, LPN #12 stood up and said she would go to RI #5's room and call his/her dead mother a bitch. CNA #9 said, LPN #12 returned to her seat without going to RI #5's room or saying anything to RI #5. CNA #9 said she believed LPN #12 had RI #5 moved to the secure/memory unit related to the incident on 04/25/2024.
On 05/02/2024 at 12:15 PM, an interview was conducted with CNA #10. According to CNA #10, on approximately 04/27/2024 or 04/28/2024, she overheard LPN #12 on the phone, during a break, saying she went to RI # 5's room and called him/her an ugly bitch and his/her dead mother an ugly bitch. CNA #10 said, she felt RI # 5 was moved to the secured unit because he/she made LPN #12 mad. When asked why she felt that way she explained it was based on what she heard LPN #12 say on the phone and it seemed likely to her that RI #5 had to move. CNA #10 stated she had never witnessed RI #5 wandering. CNA #10 said RI #5 questioned LPN #12 about the reason for the move and expressed she did not want to move. CNA #10 said, LPN #12 informed RI #5 he/she did not have a choice in the matter.
On 05/03/2024 at 12:05 PM, a telephone interview was conducted with CNA #11. CNA #11 stated she had never observed RI #5 wandering, but rather observed RI #5 parking her wheelchair outside rooms and engaging in conversations with other residents who were friends. CNA #11 recalled that LPN #12 informed her that RI #5 would be moving, so she told RI #5 about the move. CNA #11 said RI #5 wanted to know the reason and initially refused to move. CNA #11 informed LPN #12 that RI #5 did not want to move but was told, by LPN #12, RI #5 did not have a choice in the matter. CNA #11 said LPN #12 walked RI #5 to the other (secured/memory) unit.
On 05/02/2024 at 10:00 AM, an interview was conducted with the Social Worker (SW). The SW said that on 04/26/2024, LPN #12 informed her about RI #5's increased wandering in other residents' rooms. As a result, RI #5 was moved to the locked/secure unit. The SW said the process for RI #5's room change was she contacted RI #5's daughter, spoke with admissions, and confirmed the availability of a bed. The SW said the room change took place on 04/29/2024. The SW stated RI #5 had only one episode of wandering documented on 04/26/2024. The SW said that she did not have a conversation with RI #5 prior to the move. In addition, the SW said if the move was necessary, the resident would not be given a choice.
On 05/02/2024 at 10:56 AM, an interview was conducted via telephone with LPN #12. LPN #12 said that during her shift on 04/29/2024, she received information from the Social Worker that RI #5 was approved to be moved to the locked unit. Upon informing RI #5 about the move, he/she became upset upon realizing it was to the locked unit and blamed LPN #12. LPN #12 explained to RI #5 that the administration believed the locked unit was a better fit, but RI #5 was dissatisfied with that response. According to LPN #12, RI #5 was transferred to the locked unit on 04/29/2024 and eventually calmed down. LPN #12 denied requesting the move of RI #5 to the locked unit. LPN #12 stated that on 04/26/2024, she informed the Social Worker about RI #5 wandering in the rooms of other residents. LPN #12 said RI #5 wandered into RI #6, RI #7, and RI #8's rooms.
Upon review of RI #8's latest Quarterly MDS with ARD of 04/16/2024, RI #8's BIMS score was 11 out of 15, which indicated moderate impairment of cognition.
An interview was conducted with RI #8 on 05/02/2024 at 5:15 PM. RI #8 confirmed he/she were friends with RI #5 and would see each other outside his/her room. RI #8 stated that RI #5 had never entered the room without permission to visit him/her. RI #8 also denied complaining about RI #5 wandering into his/her room.
Upon review of RI #6's latest Significant Change MDS with ARD of 03/21/2024, it was found RI #6's BIMS score was 14 out of 15, which indicated that RI #6 was cognitively intact.
An interview was conducted with RI #6 on 05/02/2024, at 5:20 PM. When asked if RI #6 knew RI #5, the response was yes, stating that they use to visit together. RI #6 was further questioned about RI #5 wandering into his/her room without permission, to which RI #6 replied that RI #5 would either come in to visit or sit outside the door to talk. RI #6 denied reporting to a nurse that RI #5 came in the room uninvited.
Upon review of RI #7's latest Quarterly MDS with ARD of 02/29/2024, it was found RI #7's BIMS score was 11 out of 15, which indicated moderate impairment of cognition.
An interview was conducted with RI #7 on 05/02/2024 at 5:25 PM. RI #7 confirmed remembering the RI #5 and said that RI #5 was a friend who had moved to a different hall. RI #7 stated that RI #5 had never wandered into his/her room without permission. Additionally, RI #7 denied reporting to a nurse about RI #5 entering the room without an invitation.
On 05/02/2024 at 3:26PM, an interview was conducted with the Director of Nursing (DON). The DON said she became aware of an incident involving RI #5 and LPN #12 on 04/29/2024 when CNA #10 reported the incident. The DON explained that CNA #10 reported overhearing CNA #9 saying that LPN #12 had called RI #5's dead mother a bitch. The DON said after it was reported to her, she spoke with CNA #9, who shared that on 04/25/2024, she witnessed LPN #12 stand up and say she was going to RI #5's room and call his/her dead mother a bitch. The DON then interviewed RI #5, who she believed was interviewable. According to the DON, RI #5 said LPN #12 came in the room, saw a picture of his/her mother and told him/her she was ugly while poking his/her shoulder with two fingers. RI #5 also described LPN #12 as evil and sneaky, without providing further details.
On 05/02/2024 at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said on 04/29/2024 when RI #5 was moved to the secure/memory unit she was on vacation. The Administrator stated that the move occurred due to the resident wandering in and out of rooms, and increased confusion. The Administrator said that it was normal to communicate with the resident before the move, if possible. If the resident expressed a desire not to move, questions should be asked to understand the reason behind for not wanting to move. The Administrator said she was not sure why someone had not spoken with RI #5 before the move. The Administrator also said, the consequences of not communicating with a resident prior to a move, would result in confusion, a lack of understanding regarding the move, and difficulties in adjusting to a new environment. The administrator said abuse should be reported immediately when it was received, heard, or witnessed. In addition, the administrator said the incident involving RI #5 and LPN #12, should have been first reported on 04/25/2024 when CNA #9 overheard LPN #12 saying she was going to go to RI #5's room and call his/her dead mother a bitch. The administrator said abuse should be reported immediately so an investigation could be started and for the protection of the residents from abuse.
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0602
(Tag F0602)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Misappropriation, Exploitation Policy...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, review of a facility policy titled, Abuse, Neglect and Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure Resident Identifier (RI) #1 was free from misappropriation of funds from his/her personal funds.
On 04/13/2024 the facility administrator was informed by the Business Office Manager (BOM) that she had been arrested for elder abuse. According to information received from local law enforcement detective the BOM used RI# 1's personal bank account information to pay her personal credit card in the amount greater than $16,000.
The survey team applied the Reasonable Person Concept to determine the severity of psychosocial harm rose to the level of actual harm that was not immediate jeopardy.
This deficient practice affected RI #1, one of eight sampled residents reviewed for abuse.
This deficiency was cited as a result of the investigation of complaint/report number's and AL00047554.
Findings Include:
The ADPH Online Facility Report Incident dated 09/11/2023, identified . Incident Type .Misappropriation of Resident Property .The ADPH Incident Detail . Narrative summary of Incident: (RI #1's) daughter alleged the Business Office Manger stole $30,000 from (RI #1) .
The ADPH Online Facility Report Incident dated 04/13/2024, identified . Incident Type .Abuse-Exploitation .The ADPH Incident Detail . Narrative summary of Incident: The Business Office Manger informed the Administrator on 04/13/2024 that she was arrested for Elder Abuse on 04/12/2024 .
A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective January 2019, revealed:
Purpose: To prohibit and prevent abuse .
Definitions: .
Misappropriation of Resident Property: The deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the residents consent .
The facility's job description, titled Position Description for Business Office Manager documented:
.Accountability Objective: To perform and/or oversee the successful and timely completion of all business office functions . within the parameters established by state and federal regulation . Support an environment that promotes optimal efficiencies . and superior quality of business office employees .
A review of a document provided by the facility for the BOM titled WORKSITE EMPLOYEE WARNING NOTICE documented: .Breach of Company Policy . Business office Manager (BOM) will allow the resident's to sign their own checks. If a resident is unable to sign a check then the facility will contact the family to assist with making financial arrangements. Any additional violation will result in termination . 10/26/23 .(dated)
RI # 1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include Major Depressive Disorder and Cognitive Communication Deficit.
A review of Resident #1's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/29/2023, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 13 of 15, indicating the resident had moderately cognitive intact.
A review of RI #1's available Bank Statements for the month of June 2023 and August 2023 revealed mobile payments to Capital One in the amounts of $1725.99 on 06/22/2023, $640.81 on 08/02/2023, $1669.83 on 08/11/2023 and $1621.16 on 08/22/2023.
A review of the Capital One statement's, obtained from the local detective, from June 2023 and August 2023 identified the BOM as an account holder. The statements identified payments made in the amounts of $1725.99 on 06/21/2023, $640.81 on 08/01/2023, $1669.83 on 08/10/2023, and $1621.16 on 08/21/2023 was applied to the BOM's Capital One credit card account.
On 04/30/2024 at 3:00PM, an interview was conducted with RI # 1, who said that he/she did not have a Capital One credit card and had never set up payment through his/her bank account to pay a Capital One.
On 04/30/2024 at 4:33PM, an interview was conducted with The Administrator (ADM). The ADM stated that the BOM had various responsibilities, including managing the finances for residents, handling insurance billing, collecting liability payments, and overseeing the resident trust account. The ADM said that RI #1 was a private pay resident who managed his/her own bank account. The ADM said that RI #1 had requested the former BOM's assistance in paying the monthly room and board, as well as the pharmacy bill. The ADM said, the former BOM kept RI #1's checkbook in the business office and would take it to RI #1's room, and help write out the check for payment. The ADM said, the BOM's job description would allow her to assist residents if the resident requested assistance. However, the ADM said it was not typical for the BOM to sign a check on behalf of residents. The ADM stated she investigated an allegation of misappropriation involving RI #1 and the former business office manager in September of 2023. The ADM said that in April of 2024, the BOM called her and reported she had been arrested for elder abuse.
On 05/03/2024 at 3:15 PM, a second interview was conducted with the Administrator/Abuse Coordinator. During the interview, the Administrator said that she supervised the business office, which included the business office manager and receptionist. She explained that she provided daily supervision of the business office, and monthly audits were carried out by the corporate office. The Administrator said that she became aware in September 2023 during an investigation into the misappropriation of RI #1's funds that RI #1 's checkbook was kept in the business office by the BOM. The administrator stated the BOM could have contacted the family to assist with paying RI #1's monthly bills.
An interview was conducted with the Regional Business Office Consultant (RBOC) on 05/01/2024 at 12:00PM. The RBOC said that she conducted an audit which involved reviewing all private pay transactions, payment postings, and examining the accounts of all residents who had funds with the facility. The audit results showed no misappropriation of funds. The RBOC said it was not acceptable for the BOM to sign checks for residents. She said that during the investigation in September, it was discovered that the former BOM had signed at least one check payable to the facility for room and board. The RBOC stated that the former BOM was reprimanded and received training when this issue came to light during the September 2023 investigation. The RBOC stated that she provided monthly supervision to the business office to ensure proper cash balancing and to address any concerns that may have occurred. She also stated that she had no knowledge of the former BOM using RI #1's personal funds to pay her personal credit cards.
An interview was conducted with the facility's [NAME] President of Revenue Cycle (VPRC) on 05/01/2024 at 12:23 PM. The VPRC said that she conducted an audit of all private pay residents, checks that had been scanned, the resident trust fund, and RI #1's account. The VPRC confirmed that no missing funds were discovered during the audit. It was revealed in the audit that the former BOM had signed and written out checks for RI #1 for room and board payments in June, July, August, and September of 2023. The VPRC said following the investigation, the former BOM received in-service training and was issued a write up before returning to work. The VPRC stated she had no knowledge of the BOM using RI #1's personal funds to pay her personal credit card.
On 05/08/2024 at 10:30AM, a local detective was interviewed regarding the misappropriation of funds linked to RI #1. The detective revealed that the Former BOM at the facility utilized RI #1's banking details to pay her personal credit card bill from June 2023 through September 2023. The cumulative amount of these payments equaled $16,705.00. He said, a payment of $1725.99 was made on 06/22/2023, payment of $640.81 was made on 08/02/2023, $1669.83 was made on 08/11/2023, and a payment of $1621.16 was made on 08/22/2023 to settle credit card payments for the BOM. The detective stated the BOM was arrested on 04/12/2024 for elder abuse (Misappropriation of resident's Property).
On 05/17/2024 at 2:00 PM the Director of Nursing was interviewed via phone. The DON said it would be upsetting to a reasonable person, in a similar situation as RI #1 who had over 15 thousand of dollars misappropriated from her checking account by a staff member he/she entrusted with her checkbook and who aided writing checks.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0559
(Tag F0559)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policies titled Room & Roommate Change Policy, the facility failed to notify Res...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and facility policies titled Room & Roommate Change Policy, the facility failed to notify Resident Identifier (RI) #5 of a room change prior to the move.
This affected Resident Identifier (RI) #5, one of one resident who expressed dissatisfaction with their room change.
This deficiency was cited as a result of the investigation of complaint/report number AL00047738.
Findings include:
A review of an undated facility's policy titled Room and Roommate Change Policy documented:
.PROCEDURE .The Resident has the right to refuse to transfer to another room in the Center if the purpose of the transfer is .
c. Solely for the convenience of staff .
RI #5 was admitted to the facility on [DATE], with diagnoses to include Unspecified Dementia.
A review of a progress note for RI # 5 documented . 04/29/2024 . This resident was transferred from North wing (he/she) was alert and oriented to person and place with some confusion noted .
On 05/01/2024 at 5:30 PM, an interview was conducted with RI #5. During the interview, RI #5 informed the surveyor that he/she was not supposed to be on that unit (secure/memory) and was only there because Licensed Practical Nurse (LPN) #12 did not like him/her. RI #5 said that LPN #12 had informed him/her that this unit (secure/memory) would be a better fit, and he/she told LPN #12 he/she did not want to move. RI #5 said that LPN #12 informed him/her that he/she had no choice in the matter.
A second interview was conducted with RI #5 on 05/02/2024 at 12:46 PM. RI #5 said he/she did not belong on this unit (secure/memory), and LPN #12 had him/her moved because she did not like him/her. RI #5 said he/she did not want to change rooms. RI #5 further stated LPN #12 informed him/her of the move and no one else had spoken to him/her about the move. RI #5 said LPN #12 said he/she did not have a choice in the move. RI #5 said he/she missed his/her old room and his/her friends on the old unit (North wing).
On 05/02/2024 at 10:00 AM, an interview was conducted with the Social Worker (SW). The SW said that on 04/26/2024, LPN #12 informed her about RI #5's increased wandering in other residents' rooms. As a result, RI #5 was moved to the locked/secure unit. The SW said the process for RI #5's room change was she contacted RI #5's daughter, spoke with admissions, and confirmed the availability of a bed. The SW said the room change took place on 04/29/2024. The SW stated RI #5 had only one episode of wandering documented on 04/26/2024. The SW said that she did not have a conversation with RI #5 prior to the move. In addition, the SW said if the move was necessary, the resident would not be given a choice.
On 05/02/2024 at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said on 04/29/2024 when RI #5 was moved to the secure/memory unit she was on vacation. The Administrator stated that the move occurred due to the resident wandering in and out of rooms, and increased confusion. The Administrator said that it was normal to communicate with the resident before the move, if possible. If the resident expressed a desire not to move, questions should be asked to understand the reason behind not wanting to move. The Administrator said she was not sure why someone had not spoken with RI #5 before the move. The Administrator said the consequences of not communicating with a resident prior to a move, would result in confusion, a lack of understanding regarding the move, and difficulties in adjusting to a new environment.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and rev...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, interviews, and a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of information from the Alabama Department of Public health's (ADPH) Online Reporting System, the facility failed to ensure staff implemented the facility's abuse policies and procedures when: staff failed to identify an allegation of abuse, protect residents from further potential abuse, and immediately report an allegation of verbal abuse on [DATE] involving Resident Identifier (RI) #5 and Licensed Practical Nurse (LPN) #12. Certified Nursing Assistant (CNA) #9, and CNA #10 became aware of the allegation, but did not report the incident for three days following the incident.
On [DATE] Certified Nursing Assistant (CNA) #9 observed LPN #12 stand up and say she was going to go to RI #5's room and call his/her dead mother a bitch and she did not report the incident as LPN did not take any action only making a verbal threat. On either [DATE] or [DATE] CNA #10 overheard LPN #12 on the phone during a break say she went in RI #5's room and called him/her an ugly bitch and called his/her dead mother an ugly bitch. CNA #9 and CNA #10 did not identify the incident as abuse or suspected abuse, did not protect RI #5 from potential verbal abuse, and did not immediately report the incident. Due to the staff's failure LPN #12 continued to work on the hallway with RI #5 posing the likelihood of further harm.
This failure affected RI #5; one of eight sampled residents reviewed for abuse prevention.
This deficiency was cited as a result of the investigation of complaint/report number AL00047738.
Findings Include:
A review of the facility Abuse, Neglect, Misappropriation, Exploitation Policy, effective [DATE], revealed Purpose: To prohibit and prevent abuse . and to ensure reporting and investigation of alleged violations . Definitions: . Alleged Violation: A situation or occurrence that is observed or reported by team member . but has not yet been investigated . The following protocol has been established in the event of an allegation of abuse:
1. Protection
First and foremost the resident/patient will be immediately assessed and removed from any potential harm.
Examine the resident . for any sign of injury, including a physical assessment or psychosocial assessment .
4. Prevention.
Establish a safe environment: Team members are required to report incidents of suspected abuse, neglect, or misappropriation of property without fear of reprisal .
5. Identification
If actual violation or alleged violation occurs the resident will be immediately assessed and removed from any potential harm .
7. Reporting/Response Alleged violations/violations will be reported to the Administrator, designee immediately .
RI #5 was admitted to the facility on [DATE] with diagnoses that included Unspecified Dementia, without Behavioral Disturbance and Chronic Obstructive Pulmonary Disease with (Acute) Exacerbation.
A review of Resident #5's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of [DATE], revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 5 (five) of 15, which indicated the resident had severe cognitive impairment.
On [DATE] at 9:45AM, an interview was conducted with CNA #9. According to CNA #9, on [DATE], she observed RI #5 approach the nurses' desk where LPN #12 was sitting and inquired about the results of an x-ray. CNA #9 said, LPN #12 informed RI #5 that it was too early for the results as the x-ray technician had just left. CNA #9 said as RI #5 was walking away he/she called LPN #12 a bitch. CNA #9 said she witnessed LPN #12 stand up and say she would go to RI #5's room and call his/her dead mother a bitch. CNA #9 said she did not report what she heard because she believed that LPN #12 only made a threat and she did not witness anything being done.
On [DATE] at 12:15 PM, an interview was conducted with CNA #10. According to CNA #10, on approximately [DATE] or [DATE], she overheard LPN #12 on the phone, during a break, say she went to RI # 5's room and called him/her an ugly bitch and his/her dead mother an ugly bitch. CNA #10 said she did not do anything because she thought it was not true and she did not see LPN #12 do anything to RI #5. CNA #10 said that when she returned to work on [DATE] she overheard CNA #9 talking about the incident and she then reported the incident to the Director of Nursing.
On [DATE] at 3:26 PM, an interview was conducted with the Director of Nursing (DON). The DON said she became aware of an incident involving RI #5 and LPN #12 on [DATE] when CNA #10 reported the concern. After receiving the information an investigation was started. The DON said LPN #12, who had already left for day, was informed she would be on suspension. The DON said that CNA #9 should have reported the incident when she first heard the threat on [DATE].
On [DATE] at 6:19 PM, an interview was conducted with the Administrator/abuse coordinator. The Administrator said abuse should be reported immediately when it was received, heard, or witnessed. The Administrator said the abuse witnessed by CNA #9 should have been reported on [DATE] when CNA #9 overheard LPN #12 say she was going to go to RI # 5's room and call her deceased mother a bitch. The Administrator said abuse should be reported immediately so an investigation could be started and for the protection of the residents.
Jan 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected 1 resident
Based on an interview, review of facility personnel files, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Certified Nursing Ass...
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Based on an interview, review of facility personnel files, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, the facility failed to ensure Certified Nursing Assistant (CNA) #6 and CNA #7 had initial Alabama Certified Nurse Aide Registry and criminal background checks completed before being hired by the facility.
This deficient practice affected CNA #6 and CNA #7, two of six CNAs whose personnel files were reviewed.
Findings include:
Review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, with an effective date of 1/2019, revealed the following:
Purpose: To prohibit and prevent abuse, neglect, exploitation, misappropriation of resident property .
2. Screening
Each center will follow any and all state specific requirements
Potential team members shall, at a minimum, have the following screening checks conducted: .
2. Appropriate licensing board or registry check .
4. Criminal background check pursuant to company policy or state law .
A review of personnel files for CNAs revealed CNA #6 was hired on 11/29/2022 and CNA #7 was hired on 11/02/2020, but neither of them had an initial CNA registry check or criminal background check done prior to working at the facility.
A review of CNA #7's personnel file revealed CNA #7 was hired on 11/02/2020, but there was no initial CNA registry check or criminal background check done on CNA #7 before the CNA began work at the facility.
On 01/25/2024 at 4:50 PM, the surveyor conducted an interview with the Human Resource Director (HRD). When asked who was responsible for checking the CNAs against their licensing registry, the HRD said the staff that was part of the initial interview process. The HRD said looking at the personnel files for CNA #6 and CNA #7 they did not have an initial registry check but they should have. The HRD also said the facility did criminal back ground checks and they should be completed before the employee worked the first day. The HRD said criminal back ground checks were mandatory.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on interviews, review of the facility's RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs, and review of a facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA ...
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Based on interviews, review of the facility's RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs, and review of a facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, the facility failed to ensure the required signatures were on the non-controlled medication destruction sheets.
This deficient practice affected one of 12 months of non-controlled medication destruction sheets reviewed for 2023.
Findings include:
Review of an undated facility policy titled, RULES OF ALABAMA STATE BOARD OF HEALTH ALABAMA DEPARTMENT OF PUBLIC HEALTH CHAPTER 420-5-10 NURSING FACILITIES, revealed the following:
1. The nursing facility develops policies and procedures for the destruction of drugs and biologicals.
7. The pharmacist will verify that the list of drugs to be destroyed is accurate and with a Registered Nurse, will carry out destruction.
22 of 22 RECORD OF MEDICATION DISPOSAL forms reviewed for January 2023, marked for Non-Controlled Drugs disposal, contained only the Pharmacist's signature.
On 01/25/2024 at 7:11 PM, the Director of Nursing (DON) verified the RECORD OF MEDICATION DISPOSAL sheets for the Non-Controlled Drugs had only one signature on 22 of the 22 sheets. The DON was asked how many signatures were required for non-controlled medications. The DON said, there should be two signatures to validate that destruction occurred.
On 01/25/2024 at 7:22 PM, a telephone interview was conducted with the pharmacist. When asked how many signatures were needed on the non-controlled RECORD OF MEDICATION DISPOSAL sheets, the pharmacist said there were supposed to be two signatures.
MINOR
(C)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observations and an interview, the facility failed to ensure the DAILY ASSOCIATE POSTING form contained the name of the facility, the Resident Census at Start of Shift and the date for each s...
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Based on observations and an interview, the facility failed to ensure the DAILY ASSOCIATE POSTING form contained the name of the facility, the Resident Census at Start of Shift and the date for each shift.
This was observed on 01/23/2024, one of four days of the survey, and had the potential to affect all 162 residents residing in the facility.
Findings include:
On 01/23/2024 at 9:15 AM, the surveyor observed the DAILY ASSOCIATE POSTING form in the front lobby. There was no facility name or Resident Census at Start of Shift for the 7:00 AM - 3:00 PM shift.
On 01/23/2024 at 5:44 PM, the surveyor observed the DAILY ASSOCIATE POSTING form. There was no date or the Resident Census at Start of Shift for the 3:00 PM - 11:00 PM shift.
On 01/25/2024 at 7:44 PM, the surveyor conducted an interview with the Workforce Management Coordinator (WMC). When asked what information should be on the DAILY ASSOCIATE POSTING form, the WMC said, the number of staff in the building and the census. WMC said, the name of the facility should also be on the form. The WMC said, when looking at the DAILY ASSOCIATE POSTING form, dated 01/23/2024, for the 7 AM - 3 PM shift, the census and the name of the facility was not on the form. The WMC said, looking at the DAILY ASSOCIATE POSTING form for the 3 PM -11 PM and the 11 PM - 7 AM shift, the date and the census was not on the form. The WMC said, she would be responsible for ensuring the the form was filled out with the correct information. When asked why it would be important to ensure the form was filled out completely, the WMC said, to ensure it was known how many staff and residents were in the building.
Oct 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and a review of a facility policy titled, Pain Assessment and Management, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and a review of a facility policy titled, Pain Assessment and Management, the facility failed to ensure Resident Identifier (RI) #11, a resident with a diagnoses of chronic pain, received pain medication as ordered by physician on 10/12/2022 at 10:00 PM and 10/13/2022 at 6:00 AM.
This affected one of three residents sampled for pain concerns.
Findings Include:
A facility policy titled, Pain Assessment and Management, with an effective date of 05/2021, documented, . The purposes of this procedure are to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Implementing Pain Management Strategies: . 6. Implement the medication regimen as ordered, carefully documenting the results of the interventions.
RI #11 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included Cerebral Palsy, Unspecified Osteoarthritis, Other Chronic Pain and Dysphagia.
On 10/14/2022 at 10:00 AM, RI #11 stopped the surveyor in the hallway and reported that he/she missed a dose of morphine on Wednesday night, 10/12/2022. The resident reported this never happened before.
October 2022 physician orders for RI #11 documented, with a start date of 9/19/2022, Morphine Sulfate Tablet 15 MG (milligrams) Give 1 (one) tablet by mouth three times a day for pain related to OTHER CHRONIC PAIN.
A review of RI #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/2022 indicated Pain Frequency as Occasionally and Pain Frequency as six out of 10.
A review of RI #11's care plan revealed, . on pain medication therapy r/t (related/to) disease process CP (cerebral palsy), chronic pain, dysphagia, osteoarthritis . Administer medications as ordered by physician .
A review of RI #11's Medication Administration Record (MAR) for October 2022 documented a pain level of six for night shift on 10/12/2022 and a pain level of eight for day shift on 10/13/2022. The MAR also indicated a dose of Morphine Sulfate Tablet was not administered at 10:00 PM on 10/12/2022 nor at 6:00 AM on 10/13/2022 due to a code of 3 which meant the supply was reordered.
Progress Notes for RI #11 documented on 10/13/2022 at 6:56 AM by EI #3 revealed, . Pharmacy gave authorization number to pull from Omnicell back up. When charge nurse went to omnicell to pull the medication is not stocked in omnicell.
Progress Notes for RI #11 documented on 10/13/2022 at 7:49 AM by EI #3 revealed, . DON and ADON (Director of Nursing and Assistant Director of Nursing) notified. MD called and gave order for Tylenol 650 mg now and it was given to resident. Resident offered Lidocaine patch, Volterm gel, laying down with calm music in dim lit room, and warm and cold treatments. Resident refused all but the Tylenol.
Progress Notes for RI #11 documented on 10/13/2022 at 8:45 AM by EI #3 revealed, . Morphine arrived from pharmacy and now dose is given for 6am that was not given.
A review of a delivery receipt from Omnicare of Prattville indicated the facility received three orders of 30 Morphine Sulfate 15 mg tablets (total 90 tablets) on 10/13/2022 for RI #11.
In a follow-up interview on 10/14/2022 at 3:00 PM, RI #11 reported staff gave him/her Tylenol when he/she missed the morphine dose. The resident stated the Tylenol helped with the pain but not like the morphine. The resident reported he/she also took Lyrica for pain. The resident reported he/she had a hard time sleeping because he/she didn't have the morphine but was able to go to sleep. RI #11 reported staff offered a Lidocaine patch, voltern gel, calm music and warm and cold treatments. RI #11 stated he/she refused them because they do not work but he/she took the Tylenol but it did not provide the same relief as the morphine.
In an interview on 10/14/2022 at 4:25 PM EI #3, LPN, reported she was notified 10/12/2022 at 10:56 PM that RI #11 did not have morphine. The resident had reported that he/she brought two prescriptions from the pain clinic in August. The nurse had attempted to use a code from pharmacy for the omnicell in the building but morphine was not in the machine because the machine did not stock morphine. EI #3 stated she called the doctor who instructed them to give RI #11 Tylenol 650 mg and offer alternative pain relief until morphine arrived. RI #11 was offered Tylenol, Lidocaine patch, voltern gel, calm music and warm and cold treatments. The resident accepted Tylenol and refused all other alternatives because he/she preferred the morphine. EI #3 stated when she observed the resident on Thursday morning, the resident did not appear to be in pain but he/she was emotional, which was not out of character, and upset because the morphine had not been delivered. EI #3 stated the morphine should not have run out. EI #3 stated she called the pharmacy on Wednesday after she did an audit. EI #3 stated the morphine should have been ordered a day or two sooner. EI #3 stated she completed audits on medications on Mondays, Wednesdays and Fridays. EI #3 stated she should have noticed on Monday that it needed to be reordered and it would not have been missed if ordered on Monday. When asked about the potential negative outcome of someone not getting an ordered a dose of morphine, EI #3 stated the resident received morphine for pain so pain could be an issue when it was missed.
In a follow-up interview on 10/14/2022 at 6:06 PM, EI #3 reported there was seven morphine pills left on Monday, 10/10/2022 on the three times a week narcotic audit sheet. EI #3 stated the morphine should have been ordered on 10/10/2022 after the audit. EI #3 stated the resident was down to seven pills and the medication would have been received prior to the last pill being used. EI #3 stated she did not recall why she did not reorder the morphine on 10/10/2022. EI #3 stated the next audit was 10/12/2022 and the resident had one morphine pill left. EI #3 stated she reordered the morphine by phone on 10/12/2022.
A review of RI #11's medication audit sheets completed by EI #3, LPN on 10/10/2022 indicated the resident had seven morphine pills left. The medication audit sheet competed by EI #3 on 10/12/2022 indicated the resident had one morphine pill left.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of resident records, review of a facility policy titled Physician Medication Orders the...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of resident records, review of a facility policy titled Physician Medication Orders the facility failed to ensure medications were reordered from the pharmacy in a timely manner to have the medication available for administration to RI #55 on 10/13/2022 and RI #11 on 10/12/2022 and 10/13/2022.
This had the potential to affect two of 28 sampled residents.
Findings include:
A facility policy titled Physician Medication Orders with an effective date of 5/2022 documented the following: . 9. Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy per community protocol.
1.) RI #55 was readmitted to the facility on [DATE].
RI #55's physician orders documented an order dated 9/5/2022 for Oxcarbazepine 600 mg one tablet to be given twice a day.
On 10/13/2022 at 8:55 AM EI #5 Licensed Practical Nurse (LPN) was observed preparing medications to administer to RI #55. EI #5 said, Oxcarbazepine 600 mg was not in the medication cart and she had reordered some medications yesterday (10/12/2022). EI #5 administered other medications to EI #5 without the Oxcarbazepine. EI #5 notified EI #3 LPN unit manager of the Oxcarbazepine not being available.
On 10/13/2022 at 9:24 AM EI #3 went to look for RI #55's Oxcarbazepine in medication supply.
Review of RI #55's October 2022 Medication Administration Record (MAR) revealed Oxcarbazepine 600 mg tablet was due at 8:00 AM and 8:00 PM every day. RI #55's dose due on 10/13/2022 at 8:00 AM was documented as 3 by EI #5. RI #55's MAR documented 3 meant the supply had been reordered. A checkmark would have been used to document the medication had been administered.
Review of a REFILL REORDER FORM with a fax date and time stamp of 10/12/2022 at 6:08 PM revealed EI #5 faxed the form to the pharmacy to reorder medications for residents to include RI #55's Oxcarbazepine 600 mg tablets.
On 10/14/2022 at 4:15 PM EI #3 LPN unit manager for Building Two, was asked how many doses of Oxcarbazepine RI #55 missed. EI #3 said, one. When asked what the system was for reorders of routine medications, EI #3 said, they were to pull stickers from the pharmacy card as early as seven days. When asked what the system was to make sure that was done, EI #3 said, it was supposed to be on night shift, order any low medications, but every nurse who notices medications were low could pull the sticker and order. When asked who was responsible to ensure the medications were ordered in time for filling, EI #3 replied, the nurses on the cart. When asked what the reason was the medication was not available for medication administration on 10/13/2022 for the AM dose, EI #3 said it was a cutoff issue about the time it was ordered since it was not ordered until after 6:00 PM on 10/12/2022. When asked when the medication should have been ordered in time for refill delivery, EI #3 said, by 3:00 PM.
On 10/14/2022 at 4:36 PM EI #2 Director of Nursing (DON), was asked when non-controlled medications should be ordered. EI #2 said, when they were down to about a week supply. EI #2 was asked what the importance was of medications being available for administration as ordered. EI #2 responded, to ensure the treatment plan was followed and the medication was available.
2.) RI #11 was admitted to the facility on [DATE] and readmitted [DATE] with diagnosis that included Cerebral Palsy, Unspecified Osteoarthritis, Other Chronic Pain and Dysphagia.
In an interview on 10/14/2022 at 10:00 AM, RI #11 stopped surveyor in the hallway and reported that he/she missed a dose of morphine on Wednesday night, 10/12/2022. The resident reported this never happened before.
A review of October 2022 physician orders for RI #11 documented, with a start date of 9/19/2022, Morphine Sulfate Tablet 15 MG (milligrams) Give 1 (one) tablet by mouth three times a day for pain related to OTHER CHRONIC PAIN.
A review of RI #11's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/5/2022 indicated Pain Frequency as Occasionally and Pain Frequency as six out of 10.
A review of RI #11's care plan revealed, . on pain medication therapy r/t (related/to) disease process CP (Cerebral Palsy), chronic pain, dysphagia, osteoarthritis . Administer medications as ordered by physician .
A review of RI #11's Medication Administration Record (MAR) for October 2022 documented a pain level of six for night shift on 10/12/2022 and a pain level of eight for day shift on 10/13/2022. The MAR also indicated a dose of Morphine Sulfate Tablet was not administered at 10:00 PM on 10/12/2022 nor at 6:00 AM on 10/13/2022 due to a code of 3 which meant the supply was reordered.
Progress Notes for RI #11 documented on 10/13/2022 at 6:53 AM by Employee Identifier (EI) #3 Licensed Practical Nurse (LPN) unit manager, revealed, . Unit manager was informed at 1056 pm that resident's morphine was not delivered. Charge nurse informed unit manager that she called pharmacy and that it was being stat delivered. When unit manager arrived at 630 am again pharmacy was called due to medication not being delivered. Pharmacy informed charge nurse it was on the way.
Progress Notes for RI #11 documented on 10/13/2022 at 6:56 AM by EI #3 revealed, . Pharmacy gave authorization number to pull from Omnicell back up. When charge nurse went to omnicell to pull the medication is not stocked in omnicell.
Progress Notes for RI #11 documented on 10/13/2022 at 7:49 AM by EI #3 revealed, . DON and ADON notified. MD called and gave order for Tylenol 650 mg now and it was given to resident. Resident offered Lidocaine patch, Volterm gel, laying down with calm music in dim lit room, and warm and cold treatments. Resident refused all but the Tylenol. ADON called and spoke with pharmacy concerning delivery. will continue to follow up with pharmacy and plan or care as directed.
Progress Notes for RI #11 documented on 10/13/2022 at 8:45 AM by EI #3 revealed, . Morphine arrived from pharmacy and now dose is given for 6am that was not given.
In a follow-up interview on 10/14/22 at 3:00 PM, RI #11 reported staff gave him/her Tylenol when he/she missed the morphine dose. The resident stated the Tylenol helped with the pain but not like the morphine. The resident reported he/she also took Lyrica for pain. The resident reported he/she had a hard time sleeping because he/she did not have the morphine but was able to go to sleep. RI #11 reported staff offered a Lidocaine patch, voltern gel, calm music and warm and cold treatments. RI #11 stated he/she refused them because they do not work but he/she took the Tylenol, but it did not provide the same relief as the morphine. The resident reported he/she received two doses of morphine on 10/14/2022, a dose the morning of 10/13/2022 as well as two other doses on 10/13/2022.
In an interview on 10/14/2022 at 4:25 PM EI #3, LPN, reported she was notified 10/12/2022 at 10:56 PM that RI #11 did not have Morphine. The nurse had attempted to use a code from pharmacy for the omnicell in the building but Morphine was not in the machine because the machine did not stock morphine. EI #3 stated she called the doctor who instructed them to give RI #11 Tylenol 650 mg and offer alternative pain relief until morphine arrived. RI #11 was offered Tylenol, Lidocaine patch, voltern gel, calm music and warm and cold treatments. The resident accepted Tylenol and refused all other alternatives because he/she preferred the morphine. EI #3 stated when she observed the resident on Thursday morning, the resident did not appear to be in pain but he/she was emotional, which was not out of character, and upset because the morphine had not been delivered. EI #3 stated the morphine should not have run out. EI #3 stated she called the pharmacy on Wednesday after she did an audit. EI #3 stated the morphine should have been ordered a day or two sooner. EI #3 stated she completed audits on medications on Mondays, Wednesdays and Fridays. EI #3 stated she should have noticed on Monday that it needed to be reordered and it would not have been missed if ordered on Monday. When asked about the potential negative outcome of someone not getting an ordered dose of morphine, EI #3 stated the resident received morphine for pain so pain could be an issue when it was missed.
In a follow-up interview on 10/14/2022 at 6:06 PM, EI #3 reported there was seven morphine pills left on Monday, 10/10/2022 on the three times a week narcotic audit sheet. EI #3 stated the morphine should have been ordered on 10/10/2022 after the audit. EI #3 stated the resident was down to seven pills and the medication would have been received prior to the last pill being used. EI #3 stated she did not recall why she did not reorder the morphine on 10/10/2022. EI #3 stated the next audit was 10/12/2202 and the resident had one morphine pill left. EI #3 stated she reordered the morphine by phone on 10/12/2022. EI #3 stated the morphine was delivered to the facility on [DATE] ay 8:44 AM. EI #3 stated RI #11 missed one dose of morphine on 10/13/2022.
A review of a delivery receipt from Omnicare of Prattville indicated the facility received three orders of 30 Morphine Sulfate 15 mg tablets (total 90 tablets) on 10/13/2022 for RI #11.
A review of RI #11's medication audit sheets completed by EI #3, Licensed Practical Nurse (LPN) on 10/10/2022 indicated the resident had seven morphine pills left. The medication audit sheet competed by EI #3 on 10/12/2022 indicated the resident had one morphine pill left.
In an interview on 10/14/2022 at 4:54 PM, EI #2, Director of Nursing (DON) reported controlled medications can be ordered up to three days in advance.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, interviews, and review of the facility policy titled Controlled Substances, the facility failed to ensure controlled medications were stored in the Building Two refrigerator in a...
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Based on observation, interviews, and review of the facility policy titled Controlled Substances, the facility failed to ensure controlled medications were stored in the Building Two refrigerator in a permanently affixed compartment. This was observed on 10/14/2022 in one of four unit medication refrigerators observed.
Findings include:
A facility policy titled Controlled Substances with an effective date of 9/2022, documented the following: . The facility shall comply with all laws, regulations, and other requirements related to handling, storage, . of Schedule II and other controlled substances.
On 10/14/2022 at 3:00 PM, the Building Two medication refrigerator was observed containing a controlled medication emergency kit, a small box with a lock from the pharmacy, with a label description of a Lorazepam Injection two milligrams (mg) per milliliter (ml) and a Lorazepam Intensol (ORAL) two mg/ml with 30 mls quantity, not in a permanently affixed compartment in the refrigerator. Employee Identifier (EI) #3 Building Two unit manager and EI #4 Rehabilitation unit manager both explained, the refrigerator on Building Two stopped working and all the medications in the refrigerator were transferred to the Rehabilitation refrigerator. Building Two got a new refrigerator and everything was brought back. There was a clear canister attached inside the previous refrigerator. EI #3 and EI #4 further explained, it was previously in a small counter top refrigerator that had an affixed compartment. They were not sure who had moved the emergency kit with controlled medications back to the Building Two refrigerator that did not have a permanently affixed compartment for locking controlled medications.
Apr 2022
1 deficiency
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of a facility procedure guide titled Perineal Care, the facility fail...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interviews and review of a facility procedure guide titled Perineal Care, the facility failed to ensure a staff member changed gloves and performed hand hygiene to prevent the spread of infection.
On 03/16/2022, during incontinent care, Employee Identifier (EI) #3, a Certified Nursing Assistant (CNA), removed a dirty incontinent brief from Resident Identifier (RI) #15. The CNA failed to perform hand hygiene and put on clean gloves before placing a clean brief on the resident. This deficient practice affected RI #15, one of two residents observed for incontinent care.
Findings Include:
An undated facility procedure guide titled Perineal Care documented, . Hand Hygiene. Perform hand hygiene. Apply clean gloves . Prevents transmission of microorganisms.
RI #15 was readmitted to the facility on [DATE] and had a history of Urinary Tract Infections.
A review of RI #15's quarterly Minimum Data Set assessment with an Assessment Reference Date of 03/08/2022 revealed RI #15 was totally dependant on staff for toileting, required extensive assistance with personal hygiene and was always incontinent of bowel and bladder.
On 03/16/2022 at 10:11 AM, the surveyor observed EI #3 remove RI #15's soiled brief and clean RI #15's perineum. EI #3 placed a clean brief on RI #15, without performing hand hygiene and applying a clean set of gloves.
An interview was conducted with EI #3/CNA on 03/16/2022 at 10:15 AM. EI #3 was asked when should she change her gloves. EI #3 replied gloves should be changed when going from dirty to clean and she should wash her hands in between. EI #3 was asked if she changed gloves when providing incontinent care for RI #15. EI #3 replied, no. EI #3 was asked why did she not change gloves when going from dirty to clean. EI #3 replied, she was not thinking. EI #3 was asked, what was the harm in not changing gloves. EI #3 replied, cross contamination.
On 03/16/2022 at 4:57 PM, EI #1/Director of Nursing was interviewed. EI #1 confirmed staff should perform hand hygiene after performing something dirty, before performing something clean, as with placing the clean brief on the resident.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 44% turnover. Below Alabama's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 2 harm violation(s), Payment denial on record. Review inspection reports carefully.
- • 13 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • $16,801 in fines. Above average for Alabama. Some compliance problems on record.
- • Grade C (53/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 53/100. Visit in person and ask pointed questions.
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About This Facility
What is The Healthcare Center At Buck Creek's CMS Rating?
CMS assigns THE HEALTHCARE CENTER AT BUCK CREEK an overall rating of 3 out of 5 stars, which is considered average nationally. Within Alabama, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is The Healthcare Center At Buck Creek Staffed?
CMS rates THE HEALTHCARE CENTER AT BUCK CREEK's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 44%, compared to the Alabama average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at The Healthcare Center At Buck Creek?
State health inspectors documented 13 deficiencies at THE HEALTHCARE CENTER AT BUCK CREEK during 2022 to 2024. These included: 2 that caused actual resident harm, 10 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates The Healthcare Center At Buck Creek?
THE HEALTHCARE CENTER AT BUCK CREEK is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 198 certified beds and approximately 184 residents (about 93% occupancy), it is a mid-sized facility located in ALABASTER, Alabama.
How Does The Healthcare Center At Buck Creek Compare to Other Alabama Nursing Homes?
Compared to the 100 nursing homes in Alabama, THE HEALTHCARE CENTER AT BUCK CREEK's overall rating (3 stars) is above the state average of 2.9, staff turnover (44%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting The Healthcare Center At Buck Creek?
Based on this facility's data, families visiting should ask: "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is The Healthcare Center At Buck Creek Safe?
Based on CMS inspection data, THE HEALTHCARE CENTER AT BUCK CREEK has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #1 of 100 nursing homes in Alabama. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at The Healthcare Center At Buck Creek Stick Around?
THE HEALTHCARE CENTER AT BUCK CREEK has a staff turnover rate of 44%, which is about average for Alabama nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was The Healthcare Center At Buck Creek Ever Fined?
THE HEALTHCARE CENTER AT BUCK CREEK has been fined $16,801 across 2 penalty actions. This is below the Alabama average of $33,247. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is The Healthcare Center At Buck Creek on Any Federal Watch List?
THE HEALTHCARE CENTER AT BUCK CREEK is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.