Madison Heights

License status

Regular

Last survey posted

September 20, 2023

Surveys posted

2

Deficiencies cited

27

Substantiated complaints

5

Surveys

• September 20, 2023 (Follow Up): 6 deficiencies cited 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)
  • Care of Residents: Medical Direction and Supervision. ADPH found: “The facility failed to ensure the physician's order was followed for the administration of oxygen for Resident Identifier (RI)#3.” 420-5-20-.06(1)
  • Care of Residents: Personal Care and Services. ADPH found: “The facility failed to ensure the Plan of Care included goals and interventions for management of RI#3's oxygen, to include interventions for monitoring the flow rate and function of the oxygen.” 420-5-20-.06(4)(a)(b)
  • Care of Residents: Activity Program. ADPH found: “The facility failed to develop a specific activity program to meet the needs of a resident who had wandering behaviors.” 420-5-20-.06(4)(c)(d)(e)(f)
  • Care of Residents: Medications. ADPH found: “The facility failed to ensure a physician's order was in place for RI#3's self-administration of his/her oxygen.” 420-5-20-.06(5)(a)(b)(c)(d)(e)
• March 3, 2022 (Licensure/Complaint): 21 deficiencies cited, 5 complaints substantiated, 1 complaint unsubstantiated report plan of correction
  The deficient practices resulted in actual harm for at least three (3) residents (RI#1, RI#5, and RI#6) and placed the remaining nine (9) residents at risk for significant harm.
  • 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 develop, update or implement policies and procedures for medication management, health assessments, care plans, and admission, retention, and continued stay criteria.” This deficient practice resulted in harm for three (3) residents (RI#1, RI#5, and RI#6). 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 harm for at least three (3) residents (RI#1, RI#5, and RI#6). Cited as a result of a complaint investigation. 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.” Cited as a result of a complaint investigation. 420-5-20-.04(1)(2)
  • Personnel: Medical Director. ADPH found: “The RN/Care Coordinator failed to perform the required duties to ensure every residents' care needs were met.” This deficient practice resulted in actual harm for at least three (3) residents (RI#1, RI#5, and RI#6) and placed the remaining nine (9) residents living in the facility at risk for significant harm. Cited as a result of a complaint investigation. 420-5-20-.04(6)(7)(8)
  Show all 21

  • Personnel: Training. ADPH found: “The facility failed to identify and provide employees with adequate training to meet the needs of residents with dementia symptoms.” This deficient practice affected all 12 residents living in the facility and placed the residents at risk for significant harm. Cited as a result of a complaint investigation. 420-5-20-.04(9)
  • Records and Reports: Residents' Rights. ADPH found: “The facility failed to provide a safe and decent environment for all residents.” This deficient practice resulted in actual harm for three (3) residents (RI#1, RI#5, and RI#6) and placed the remaining nine (9) residents at risk for significant harm. Cited as a result of a complaint investigation. 420-5-20-.05(3)(d)
  • Records and Reports: Incident Investigation. ADPH found: “The facility failed to report at least one resident who tested positive for Covid and also failed to report a resident incident with injuries.” This deficient practice had the potential to affect all 12 residents living in the facility. 420-5-20-.05(3)(h)
  • Care of Residents: Medical Direction and Supervision. ADPH found: “The facility failed to follow physician medication orders for management of a resident's medical symptoms.” This deficient practice resulted in actual harm for RI#5 and placed the remaining 11 residents at risk for significant harm. 420-5-20-.06(1)
  • Care of Residents: Initial Assessment. ADPH found: “The facility failed to provide adequate health supervision to identify and address resident health status changes.” This deficient practice resulted in actual harm for at least two (2) residents (RI#1 and RI#5) and placed the remaining 9 residents at risk for significant harm. 420-5-20-.06(3)(a)(b)(c)(d)(e)
  • Care of Residents: Observation. ADPH found: “EI#3, RN, did not accurately assess residents to identify combative behaviors and significant changes in health status.” This deficient practice resulted in actual harm for RI#1 and placed the remaining 11 residents at risk for significant harm. 420-5-20-.06(3)(f)
  • Care of Residents: Services Beyond Capability of Specialty Care Assisted Living Facility. ADPH found: “The facility readmitted a resident who had care and safety needs which exceeded the facility's admission criteria.” This deficient practice resulted in actual harm for RI#6 as evidence by RI#6's symptoms of pain and anxiety. Cited as a result of a complaint investigation. 420-5-20-.06(3)(g)
  • Care of Residents: Personal Care and Services. ADPH found: “EI#3, RN, failed to accurately assess residents to identify combative behaviors and significant changes in health status.” This deficient practice resulted in actual harm for RI#1 and placed the remaining 11 residents at risk for significant harm. Cited as a result of a complaint investigation. 420-5-20-.06(4)(a)(b)
  • Care of Residents: Activity Program. ADPH found: “The facility failed to provide an appropriate activity program to prevent or deter wandering behaviors while also promoting mental and physical wellness.” This deficient practice affected all 12 residents living in the facility. Cited as a result of a complaint investigation. 420-5-20-.06(4)(c)(d)(e)(f)
  • Care of Residents: Medications. ADPH found: “The facility failed to ensure resident medications were only administered by a nurse or physician.” This deficient practice affected six residents and placed the remaining six (6) residents at risk for significant harm. 420-5-20-.06(5)(a)(b)(c)(d)(e)
  • Care of Residents: Medications. ADPH found: “The facility failed to ensure nurses contemporaneously recorded all medications administered to residents.” 420-5-20-.06(5)(h)
  • Care of Residents: Medications. ADPH found: “The facility failed to properly manage all resident medications under the facility's custody.” This deficiency had the potential to affect all 12 residents living in the facility. Cited as a result of a complaint investigation. 420-5-20-.06(5)(i)(j)(k)(l)(m)
  • Care of Residents: Retention. ADPH found: “The administrator retained residents who were ineligible for retention or continued stay.” This deficient practice resulted in harm to at least three (3) residents ( RI#1, RI#2, and RI#6), and placed the remaining nine (9) residents at risk for significant harm. Cited as a result of a complaint investigation. 420-5-20-.06(9)(b)
  • Physical Facilities: Recreational. ADPH found: “The facility failed to ensure the furniture in the common living room was maintained in good repair so that it could be properly cleaned.” This deficient practice affected all 12 residents living in the facility. 420-5-20-.08(5)
  • Sanitation and Housekeeping: Housekeeping and Physical Plant Maintenance. ADPH found: “The facility failed to ensure all poisons and chemicals were properly secured or supervised at all times.” This deficient practice had the potential to affect all 12 residents. 420-5-20-.10(2)
  • Physical Environment: Building Requirements - Group Specialty Care Assisted Living Facilities. ADPH found: “The facility failed to properly maintain doors mounted in smoke barriers to be smoke resistive and close upon activation of the fire alarm.” This deficient practice placed all 12 residents at significant risk for harm in the event of fire. 420-5-20-.12(6)

ADPH also lists 1 earlier survey, back to 2018.

Search ADPH’s deficiency reports for license P1602 →

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.