Kelley Place

License status

Regular

Last survey posted

September 20, 2023

Surveys posted

2

Deficiencies cited

25

Substantiated complaints

4

Surveys

• September 20, 2023 (Licensure/Complaint): 3 deficiencies cited, 1 complaint investigated (outcome in the report) report plan of correction
  The deficient practices resulted in the potential for harm to all residents and require a plan of correction.
  • Personnel: Training. ADPH found: “The facility failed to provide required special needs training for staff.” 420-5-20-.04(9)
  • Records and Reports: Residents' Rights. ADPH found: “The facility failed to maintain personal dignity and privacy for every resident at all times.” 420-5-20-.05(3)(d)
  • Physical Environment: Additional Requirements for Specialty Care Assisted Living Facilities. ADPH found: “The gate leading from the fenced area to the public way was not readily unlockable from either side.” 420-5-20-.12(8)
• March 3, 2022 (Licensure/Complaint): 22 deficiencies cited, 4 complaints substantiated, 2 complaints unsubstantiated report plan of correction
  • Administration: The Specialty Care Assisted Living Facility Governing Authority. ADPH found: “The governing authority failed to adequately oversee the administrator to ensure the facility operated in compliance with the SBOH rules for specialty care assisted living facilities (SCALF).” Cited as a result of a complaint investigation. 420-5-20-.03(1)(a)(b)(c)(d)
  • Administration. ADPH found: “The facility failed to implement and staff failed to follow policies and procedures for abuse of residents, medication storage, health assessments, care plans and admission, retention, and continued stay criteria.” This deficient practice resulted in actual harm for seven (7) residents, three (3) residents had been discharged prior to the survey. 420-5-20-.03(e)
  • Administration: Responsibility. ADPH found: “The administrator failed to perform his duties to ensure the care and safety needs of all residents were met.” This deficient practice resulted in actual harm for at least seven (7) residents (three residents RI#11, RI#12, and RI#13 had been discharged prior to the survey). 420-5-20-.03(2)(a)
  • Personnel. ADPH found: “The facility failed to provide the minimum number of required employees 24 hours a day seven (7) days a week.” This deficient practice resulted in actual harm for at least seven (7) residents [three residents (RI#11, RI#12, and RI#13) had been discharged prior to the survey] and placed the remaining nine (9) residents at significant risk for harm. 420-5-20-.04(1)(2)
  • Personnel: Medical Director. ADPH found: “The RN/Care Coordinator, failed to perform required duties to ensure each resident's care needs were met.” This deficient practice resulted in actual harm for at least seven (7) residents, three of the seven resident had been discharged prior to the survey. 420-5-20-.04(6)(7)(8)
  Show all 22

  • Personnel: Training. ADPH found: “The facility failed to identify and provide employees with adequate training to meet the needs of the residents with dementia symptoms.” 420-5-20-.04(9)
  • Records and Reports: Residents' Rights. ADPH found: “The facility failed to ensure the rights of every resident were honored and protected including the right to a safe and decent environment free from abuse, neglect, and isolation.” 420-5-20-.05(3)(d)
  • Records and Reports: Incident Investigation. ADPH found: “The facility failed to complete a thorough investigation for an injury of unknown origin.” This deficient practice resulted in harm for at least three (3) residents and placed the remaining 10 residents at risk for significant harm. 420-5-20-.05(3)(h)
  • Care of Residents: Initial Physical Examination. ADPH found: “The facility failed to ensure initial physician medical exams were completed with all required components.” This deficient practice had the potential to affect all 13 residents living in the facility. 420-5-20-.06(2)(a)(b)(c)
  • Care of Residents: Initial Assessment. ADPH found: “The RN failed to accurately assess, document, and manage resident behaviors.” This deficient practice had the potential to affect all 13 residents in the facility. 420-5-20-.06(3)(a)(b)(c)(d)(e)
  • Care of Residents: Observation. ADPH found: “The facility failed to ensure that residents who required a higher level of care received the assistance to obtain the necessary services.” This deficient practice resulted in actual harm for at least four (4) residents (two residents had been discharged at the time of the survey). 420-5-20-.06(3)(f)
  • Care of Residents: Services Beyond Capability of Specialty Care Assisted Living Facility. ADPH found: “The facility failed to transfer or discharge residents who required a higher level of care to an appropriate setting.” This deficient practice resulted in actual harm for at least seven (7) residents (RI#1, RI#2, RI#3, RI#5, RI#11, RI#12, and RI#13) (three residents RI#11, RI#12, and RI#13 had been discharged prior to the survey). 420-5-20-.06(3)(g)
  • Care of Residents: Resident Abuse, Neglect, and Exploitation. ADPH found: “The facility failed to implement and follow the facility's abuse policy and procedures.” This deficient practice resulted in actual harm for at least seven (7) residents [RI#1, RI#2, RI#3, RI#5, RI#11, RI#12, and RI#13 (RI#11, RI#12, and RI#13 had been discharged prior to the survey). 420-5-20-.06(3)(k)
  • Care of Residents: Personal Care and Services. ADPH found: “The RN failed to develop individualized care plans, update care plans with significant changes in the residents health status, and evaluate whether or not care plan interventions were effective.” This deficient practice affected all 13 residents living in the facility. 420-5-20-.06(4)(a)(b)
  • Care of Residents: Activity Program. ADPH found: “The facility failed to provide an appropriate activity program that promoted mental and physical wellness.” This deficient practice affected all 13 residents living in the facility. 420-5-20-.06(4)(c)(d)(e)(f)
  • Care of Residents: Medications. ADPH found: “The nurse failed to contemporaneously document medications on the resident's medication administration record.” This deficient practice affected at least two (2) residents. 420-5-20-.06(5)(h)
  • Care of Residents: Medications. ADPH found: “The facility failed to ensure medications kept in the custody of the facility were properly secured and stored at all times.” This deficient practice affected all 13 residents living in the facility. 420-5-20-.06(5)(i)(j)(k)(l)(m)
  • Care of Residents: Retention. ADPH found: “The facility retained residents whose care and safety needs exceeded the capabilities of the facility license.” This deficient practice resulted in harm to at least seven (7) residents (three of the seven residents had been discharged prior to the survey), and placed the other nine (9) residents at risk for significant harm. 420-5-20-.06(9)(b)
  • Physical Facilities: Food Service Facilities. ADPH found: “The facility failed to maintain wooden tables and chairs, located in the dining area, in good repair.” This deficient practice placed all 13 residents at risk for harm from food borne illness. 420-5-20-.08(4)
  • Physical Facilities: Recreational. ADPH found: “The facility failed to maintain the common living room furniture in good repair.” This deficient practice affected all 13 residents living in the facility. 420-5-20-.08(5)
  • Sanitation and Housekeeping: Housekeeping and Physical Plant Maintenance. ADPH found: “The facility failed to have adequate housekeeping and maintenance services to maintain a safe and sanitary environment for all residents.” This deficient practice had the potential to affect all 13 residents living in the facility. 420-5-20-.10(2)
  • Physical Environment: General Building Requirements - Group and Congregate. ADPH found: “The facility failed to maintain the building and equipment in good repair.” This deficient practice affected all 13 residents living in the facility. 420-5-20-.12(5)

ADPH also lists 8 earlier surveys, back to 2010.

Search ADPH’s deficiency reports for license P1601 →

ADPH posts each survey’s Statement of Deficiencies as a PDF (older ones are scans, which we read by OCR). From each report we show the deficiency tags, the rules they cite, ADPH’s own one-sentence finding and the complaint outcomes ADPH states; each cited rule is named in the rule’s own words (Alabama Administrative Code, chapter 420-5-4 for assisted living and 420-5-20 for specialty care assisted living). The report, and the facility’s plan of correction when ADPH posts it, are the official record. Some reports list a complaint as substantiated with no deficiency cited; we show both as ADPH wrote them. This community is licensed for 16 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Alabama Department of Public Health, Bureau of Health Provider Standards, data as of October 15, 2026, showing surveys from the last five years. Always visit in person and ask the community about anything listed here.