HUNTSVILLE, AL - Federal inspectors found serious deficiencies at The Health Center at Research Park, including unaccounted controlled medications and significant food safety violations that potentially affected all 79 residents during a June 2024 inspection.
Missing Oxycodone Tablets Prompt Investigation
Inspectors documented that 90 oxycodone tablets went missing from two residents' medication supplies in October 2023, triggering an investigation into potential medication misappropriation. The incident involved 60 oxycodone/acetaminophen tablets belonging to one resident and 30 oxycodone tablets belonging to another.
According to the inspection report, Registered Nurse #5 discovered the missing medications when she checked medication carts and called the pharmacy to verify deliveries. The pharmacy confirmed that both medication orders had been delivered and signed for by Registered Nurse #7 on October 13 and October 17, 2023.
The facility's investigation revealed that RN #7 failed to follow proper pharmacy procedures for documenting and securing controlled medications after receipt. Federal regulations require that controlled medications be immediately placed in secure narcotic drawers and properly recorded on control sheets to maintain accurate medication reconciliation records.
RN #7 was subsequently terminated after admitting she "left the medications unattended," according to the Regional Nurse Manager's interview with inspectors. Despite extensive searches of the facility, the missing medications were never located.
This violation represents a critical breakdown in medication security protocols. Controlled substances like oxycodone are highly regulated due to their potential for abuse and diversion. When these medications go unaccounted for, it creates risks for patient safety, potential drug diversion, and regulatory compliance issues.
Inadequate Food Portions Compromise Nutritional Standards
Inspectors identified significant nutritional deficiencies affecting the facility's meal service program. On multiple occasions, dietary staff failed to serve residents the portions specified in the approved menu, potentially compromising residents' nutritional intake.
During the June 12, 2024 lunch service, kitchen staff added hot water to pureed foods to "stretch" the available portions when supplies ran low. This practice dilutes the nutritional content of meals and alters the consistency of foods specifically prepared for residents with swallowing difficulties.
The following day, inspectors observed that residents received substantially smaller portions than specified on the menu. The approved menu called for 6 ounces of Chicken Fettuccini Alfredo and 4 ounces of Buttered Noodles (totaling 10 ounces), but kitchen staff mixed these items together and served them with a 4-ounce serving spoon - providing only 40% of the intended portion size.
When questioned about the inadequate portions, the Kitchen Supervisor acknowledged the problem, stating "the residents were not getting enough food, protein, nutrients." The Registered Dietitian confirmed that menus are specifically designed to provide serving sizes that meet residents' caloric needs, making proper portion control essential for maintaining nutritional standards.
Additionally, dietary staff substituted orange slices for apple slices on the diabetic menu without obtaining required approval from the Registered Dietitian. This unauthorized substitution affects carbohydrate management for residents with diabetes, who require consistent meal planning to maintain blood sugar control.
Proper nutrition is fundamental to resident health in nursing facilities. Inadequate food portions can lead to malnutrition, weight loss, delayed wound healing, increased infection risk, and overall decline in health status. Federal regulations require nursing homes to provide nutritionally adequate meals that meet established dietary guidelines and individual resident needs.
Serious Food Safety and Sanitation Violations
The inspection uncovered multiple food safety violations that created contamination risks for all residents receiving meals from the facility kitchen. These violations included improper hand hygiene practices, equipment failures, and inadequate sanitization procedures.
Kitchen staff repeatedly violated basic food safety protocols by moving between handling dirty dishes and clean dishes without washing their hands. Inspectors observed Diet Aide #13 pre-rinsing dirty dishes while wearing gloves, then immediately handling clean dishes without removing gloves or washing hands - a practice that directly transfers contamination from dirty surfaces to clean items.
The facility's dishwashing equipment failed to meet required sanitization temperatures. The dish machine's final rinse temperature reached only 171°F instead of the required 180°F minimum needed for effective sanitization. Additionally, staff falsified temperature logs by recording expected temperatures rather than actual readings, documenting identical numbers (160°F wash, 180°F rinse) for eleven consecutive days.
Staff also used cloth towels to dry multiple food service trays instead of allowing proper air-drying, creating additional cross-contamination opportunities. The inspection found that access to hand-washing sinks was blocked by equipment, forcing staff to reach over stored dishes to wash hands - causing water to splash onto clean dishes.
Furthermore, kitchen supervisory staff were observed chewing gum while working in food preparation areas, violating FDA Food Code regulations designed to prevent food contamination.
These food safety violations significantly increase the risk of foodborne illness transmission. Proper sanitization temperatures are essential for eliminating harmful bacteria and viruses that can cause serious illness, particularly in elderly residents with compromised immune systems. Cross-contamination through improper hand hygiene and inadequate equipment sanitization can lead to outbreaks of gastrointestinal illness, which can be life-threatening for frail nursing home residents.
Infection Control Failures Create Additional Health Risks
Inspectors also documented infection control violations that increased the risk of transmitting infections between residents. Treatment staff failed to follow proper hand hygiene protocols during wound care procedures, potentially spreading infectious agents.
During wound care for a resident with a Stage 4 pressure ulcer, Licensed Practical Nurse #26 cleaned the wound and applied new dressing materials without performing hand hygiene or changing gloves between removing contaminated materials and handling clean supplies. This practice violates fundamental infection control principles and creates serious risks for introducing bacteria into open wounds.
Additionally, unlabeled bath basins were found stored improperly in shared bathrooms between resident rooms over multiple days. Facility policy requires that personal hygiene items be clearly labeled and stored separately to prevent cross-contamination between residents.
Proper infection control is critical in nursing facilities where residents often have compromised immune systems and multiple chronic conditions. Healthcare-associated infections can lead to serious complications, extended hospitalizations, and increased mortality rates among vulnerable elderly populations.
Additional Issues Identified
Medication Management: Beyond the missing controlled substances, the facility failed to maintain proper documentation and security protocols for narcotic medications, violating federal pharmaceutical service requirements.
Staff Training Deficiencies: Kitchen supervisory staff demonstrated lack of knowledge about basic food safety requirements, including restrictions on chewing gum and proper equipment sanitization procedures.
Equipment Maintenance: The dishwashing machine's booster heater required replacement to achieve proper sanitization temperatures, indicating inadequate preventive maintenance programs.
Documentation Integrity: Staff falsified temperature monitoring logs instead of recording actual equipment readings, compromising the facility's ability to verify food safety compliance.
The violations identified during this inspection highlight systemic issues with staff training, policy compliance, and quality oversight that require immediate corrective action to protect resident health and safety.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Health Center At Research Park from 2024-06-18 including all violations, facility responses, and corrective action plans.
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