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Diversicare Of Bessemer

820 Golf Course Road, Bessemer, AL 35020 · For profit - Corporation · 180 certified beds · (205) 425-5241 Medicare & Medicaid certified

Call the home — (205) 425-5241 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)2 actual-harm citations
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
Worth asking about
  • it has a citation for mishandling residents’ money or property (F0565)
  • it has 2 actual-harm citations
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its payroll-based staffing score sits well above its independent inspection score
  • its independent health-inspection rating is low (1/5)
  • its facility-reported quality-measure rating is low (2/5)
  • nursing-staff turnover (57%) runs well above the national median (45%)
  • its last standard health inspection was over 3 years ago — the star rating may not reflect current conditions

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 1 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 2 of 5

Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
985 9th Ave SW · (205) 481-7750 · Call to confirm hours
Pharmacy
1090 9th Ave SW · (205) 425-3039 · Call to confirm hours
Grocery
750 Academy Dr · (205) 424-5890 · Call to confirm hours
Park
601 2nd Ave N · (205) 425-0655 · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased26.0%12.0%15.4%worse
Long-stay residents who lose too much weight4.3%5.4%5.4%better
Long-stay residents with a catheter left in their bladder0.3%1.0%0.9%better
Long-stay residents with a urinary tract infection0.9%2.4%2.0%better
Long-stay residents with depressive symptoms0.0%1.4%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.6%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.3%3.3%3.3%worse
Long-stay residents whose ability to walk worsened18.4%12.1%16.1%worse
Long-stay residents on antianxiety or hypnotic medication20.9%24.5%18.9%worse
Long-stay residents given the seasonal flu vaccine100.0%94.8%95.3%typical
Long-stay residents with pressure ulcers5.9%5.4%4.7%worse
Long-stay residents with worsening bladder/bowel control21.4%12.8%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table14.0%21.2%17.1%better
Short-stay residents who newly got an antipsychotic medication0.0%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine98.8%80.3%79.4%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

42.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 41 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

42.0%U.S. median 51.5%
Got home and stayed home
11.6%U.S. median 10.7%
Went back to hospital
0.24U.S. median 0.31
Therapy hours / resident / day
0.08hours / resident / day
Physical therapy
0.10hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.24 therapist hours per resident per day in 2026Q1 — more than 31% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 10% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF42.0%CMS range 28.5–57.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.6%CMS range 7.5–17.410.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened0.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.771.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.52
RN hours/ resident / day
0.59
LPN hours/ resident / day
2.23
Aide hours/ resident / day
3.33
Total nurse hours/ resident / day
0.34
RN hoursweekends
56.8%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 180 beds and averages 140.6 residents a day — about 78% occupied, or roughly 39 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.33 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.52 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.23 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.91 hrs/resident/day on weekends vs 3.50 on weekdays — 17% thinner on weekends. RN hours go from 0.59 to 0.34 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 57% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

13
deficiencies at the latest standard inspection (2022-12-02)
11
at the previous standard inspection (2021-06-24)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

This trend is not current. The most recent of these two inspections was over 3 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2021-06-24 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and document review, the facility failed to ensure two of 34 sampled residents (Resident Identifier (RI) #74 and RI #69) received nursing care and services in accordance with physician's orders and/or care plans. RI#74 had significant scaly, scabbed, psoriasis noted on the skin of his/her scalp, back, and legs/feet. The skin assessments did not accurately record the resident's skin condition and a medicated cream prescribed by the physician was not implemented. RI #69 had a recent history of a fecal impaction. The resident complained of severe constipation during the survey. Staff failed to monitor and document his/her bowel movements to ensure he/she was not constipated. Findings include: 1. Review of the undated admission Record, in the electronic medical record (EMR) under the Profile tab revealed RI#74 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, mixed incontinence, hypertension, pain,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2021-06-24 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide interventions for one of eight residents reviewed for range of motion impairment (Resident Identifier (RI) #74). RI #74) had contractures, including to his/her hands with callused areas observed from where his/her fingernails dug into his/her palms in the sample of 34. The contractures developed and/or worsened over the past year. No interventions had been or were currently in place to address the limitations in range of motion. Findings include: Review of the undated admission Record, in the electronic medical record (EMR) under the Profile tab revealed RI #74 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, pain, and weakness. The diagnosis of contractures was not documented. Review of the hospital History and Physical in the resident's chart, dated 06/27/19, revealed RI #74 was admitted to the hospital and was dependent in activities of daily living (ADLs). The resident was admitted to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-02 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview; document review; the Rules of the Alabama State Board of Health, Alabama Department of Public Health (ADPH), Chapter 420-5-10, Nursing Facilities; and the facility's job description for Dining Services Director/Account Manager; the facility failed to ensure the full time Dietary Manager, Employee Identifier (EI) #11, met the definition of a Dietary Manager per the rules of the State of Alabama. This had the potential to affect 130 of 130 residents receiving meals from the facility kitchen. Findings Include: The Rules of the Alabama State Board of Health, ADPH, Chapter 420-5-10, Nursing Facilities, original rules effective 8/23/1996 and last amendments effective 7/30/2016 included the following: . 420-5-10-.01 Definitions. (1) Definitions - (a list of selected terms often used in connection with these rules): . (b) These Rules - Rules 420-5-10-.01 through 420-5-10-.11, Chapter 420-5-10, Nursing Facilities, Alabama Administrative Code. (l) Director of Food Services/Dietary Manager - . who is a full-time employee, and if not a qualified dietitian, is one who: (1) is…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-02 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, the Resident Council Meeting on 11/30/2022, and a test tray on 12/01/2022; the facility failed to ensure scrambled eggs were served warm, palatable, and appetizing in appearance. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: A Resident Council Meeting was conducted on 11/30/2022 at 11:00 AM with fourteen residents attending. During this meeting, the residents attending complained that hot foods were being served cold and the food did not taste good. On 12/01/2022 at 6:40 AM, the steamtable was observed to be setup with breakfast food items. The plate warmer not turned on. Employee Identifier (EI) #13, a Dietary Aide, turned on the plate warmer twenty minutes before the start of trayline. At 6:50 AM, the food thermometer was calibrated to 32 degrees Fahrenheit in an ice water slush by Dietary staff. At 6:55 AM, the Scrambled Eggs were 174 degrees Fahrenheit on the steamtable. At 7:00 AM, the Breakfast trayline started. EI #13, a Dietary Aide, was at the starter position, EI #15, a Dietary…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2022-12-02 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, the facility's policy for Food Storage: Cold Foods, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure: 1.) the dishmachine drain did not extend down into the floor drain, thereby creating the potential for backflow; 2.) food in the Walk-in Cooler was not stored on shelves that were less than six inches from the floor and with accumulated debris on the floor beneath the shelves; and 3.) the surfaces of the dishmachine wall, the shelf beneath the dishtable, and the interior of two food delivery carts were clean. This had the potential to affect 130 of 130 residents receiving meals from the kitchen. Findings Include: 1.) The 2017 Food Code of the U.S. Public Health Service and the FDA included the following: . 5-402.11 BackflowPrevention. (A) . a direct conection may not exist between the SEWAGE system and a drain originating from EQUIPMENT in which FOOD, portable EQUIPMENT, or UTENSILS are placed. On 11/30/2022 at 9:10 AM, Employee Identifier (EI) #10, the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2022-12-02 · tag F0814 — failed to dispose of garbage properly — widespread
    Dispose of garbage and refuse properly.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and the 2017 Food Code of the United States (U.S.) Public Health Service and U.S. Food and Drug Administration (FDA); the facility failed to ensure the dumpster area was not littered with unneeded or discarded equipment, which could provide harborage for vermin. This had the potential to affect 138 of 138 residents in the facility. Findings Include: The 2017 Food Code of the U.S. Public Health Service and FDA included the following: . 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; . On 11/30/2022 at 8:50 AM, the dumpster area was observed with Employee Identifier (EI) #10, the Registered Dietitian (RD). There were nine wooden pallets stacked up by the facility building across from dumpster area. A hospital-style bed frame and mattress were observed beside the garbage dumpsters. A wooden door was observed leaning against the retaining wall behind the dumpsters. EI…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2022-12-02 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews, a copy of Your Resident Rights and Protections Under State and Federal Law, and the facility's Position Description for Maintenance Supervisor, the facility failed to ensure the building was in good repair as evidenced by stained ceiling tiles, loose hand rails, a loose door knob, holes in walls under residents' sinks exposing pipes and adjoining rooms, hole in wall in hallway, broken window with a cut edge open to outside elements/torn window screen, missing sheetrock behind a resident's toilet, toilets leaking/not flushing properly, missing/scraped paint on walls, doors and base boards, detached pieces on residents' doors, black residue under air conditioning (AC) units, sinks and smoke detector, loose baseboards, holes in resident walls, and torn sheetrock under sinks. This affected 3 out of 4 floors of the facility. Findings Include: A review of an undated document titled, Your Resident Rights and Protections Under State and Federal Law, revealed, . A nursing home must care for you in a manner and environment that promotes the maintenance and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-02 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, observations, and review of Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, the facility failed to ensure Resident Identifier (RI) 120's Minimum Data Set (MDS), with an Annual Assessment Reference Date (ARD) of 09/07/2022 was accurately coded to reflect RI #120 did not have an indwelling catheter. This deficient practice affected RI #120, one of twenty-six sampled resident's whose MDS's were reviewed. Findings Include: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User ' s Manual, dated October 2019, revealed: . SECTION H: BLADDER AND BOWEL Intent: The intent of the items in this section is to gather information on the use of bowel and bladder appliances, the use of and response to urinary toileting programs, urinary and bowel continence, bowel training programs, and bowel patterns. Each resident who is incontinent or at risk of developing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-02 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual Chapter 4, the facility failed to ensure: 1) a nutritional care plan was implemented for Resident Identifier (RI) #76; and 2) an at risk and actual pressure ulcer care plan was implemented for RI #74. RI #74 developed a pressure ulcer to the sacrum 07/20/2022, which has since healed, however; the facility did not implement an at risk or the actual pressure ulcer care plan. This deficient practice affected RI #74 and 76, two of twenty-six sampled resident's whose plans of care were reviewed. Findings include: A review of the RAI Manual Chapter 4 October 2019 revealed . Chapter 4 Care Area Assessment Process and Care Planning . 4.7 . The care plan is driven not only by identified resident issues and/or conditions but also by a resident's unique characteristics, strengths and needs. Develops and implements a intradisciplinary care lan based on the assessment information gathered throughout the RAI process, with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-02 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review and review of the Unit Managers Duties and Responsibilities, the facility failed to ensure Resident Identifier (RI) #65's nebulizer mask was dated and labeled; and the nebulizer mask was stored in a bag on three of five days of the survey. This deficient practice affected RI #65, one of one resident observed with nebulizer equipment at the bedside. Findings include: Review of an undated UNIT MANAGER DUTIES AND RESPONSIBILITIES, revealed the following: . MONDAY • check rooms for correct dates and storage of 02 and nebulizer tubing. These are changed out, bagged, and dated weekly on Sunday night by night shift . RI #65 was was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses to include Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure and Dyspnea. A review of RI #65's November 2022 Order Summary Report (Physician Orders) revealed RI #65 had an order to receive Ipratropium-Albuterol Solution 0.5 -2.5 (3) MG…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-02 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interviews, record reviews and review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals, the facility to store controlled refrigerated Ativan/Lorazapam in a secured non removable box in the medication room. Findings Include: A review of a facility policy titled Storage and Expiration Dating of Medications, Biologicals with a revision date of 7/21/2022, revealed . Procedure .3.1.1 Store all drugs and biolgicals in locked compartments including Schedule II-V medications in a separately, permanently affixed compartments . On 12/01/2022 at 9:05 AM, an observation was made of the medication room with Employee Identifier (EI) #17, Licensed Practical Nurse (LPN). The refrigerator had a clear secured box on bottom shelf with nothing in the box, two vials of injectable Ativan belonging to a resident was not in any box only in plastic bag on the shelf and in the locked refrigerator. A green box was on the top shelf with a combination lock. EI #17 was asked what was in the green box; she said an oral Ativan and an injectable Ativan. EI…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-12-02 · tag F0806 — failed to honor food preferences — isolated
    Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, medical record review, the facility's Customer Concern / Grievance Communication Form, the facility's Resident Council Meeting minutes, the facility's Food Preference policy, and the facility's former Daily Alternate List; the facility failed to provide Resident Identifier (RI) #65's long-standing request for Chef Salad at supper on Monday nights and Cottage Cheese with Fruit at supper on Wednesday nights, which she had received for years. This affected RI #65, one of 130 residents receiving meals from the kitchen. Findings Include: The facility's Food Preferences policy, dated May 2014, included the following: Policy Statement It is the center policy that individual food preferences are identified for all residents . food and fluid preferences will be entered into the resident profile in menu management software system. Resident Identifier (RI) #65 was originally admitted to the facility on [DATE] and was last readmitted on [DATE]. RI #65's diagnoses included Anxiety Disorder, Type 2…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2022-12-02 · tag F0825 — isolated
    Provide or get specialized rehabilitative services as required for a resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record reviews and facility policies titled Resident Screening Guidelines and Evaluations, the facility failed to initiate an evaluation for Physical Therapy as indicated by a screening for Resident Identifier (RI) #139. This affected one of one resident sampled for Physical Therapy. Findings Include: A Policy titled, Resident Screening Guidelines with a revision date of 03/14/2018, documented, Policy . that screenings be completed . on all new admission, readmissions, or upon referral by the medical and/or nursing department of a facility .This is done to: .2. Help identify indications of functional loss or aptitude that may require the need for a rehabilitation referral to evaluate for additional skilled services .6. The screening process concludes with one of these possible recommendations: referral for evaluation . A policy titled Evaluations with a revision date of 09/05/2017, documented, Policy . all patients identified as needing an assessment of functional status and potential to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-12-02 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on an observation, interviews and review of [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a wound bandage was disposed of in a manner to prevent cross contamination. On 12/12/2022, a wound bandage was observed in one of the shower rooms at the facility. This deficient practice has the potential to affect all residents using one of two shower rooms on one of three floors at the facility. Findings include: A review of [NAME] and Perry's FUNDAMENTALS OF NURSING with a copyright date of 2017, Chapter 48 Skin Intergrity and Wound Care, page 1221, revealed the following: SAFETY GUIDELINES FOR NURSING SKILLS . Keep a plastic bag within reach to discard dressings and prevent cross contamination . On 11/30/2022 at 12:27 PM, a blood tinged dressing was observed laying on the shower grab bar in a shower room at the facility. At this time an interview was conducted with Employee Identifier (EI) #19, the RN (Registered Nurse) Unit Manager. When asked what was on the shower bar, EI #19 said…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2021-06-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, record review and facility policy review, the facility failed to ensure the kitchen staff adhered to safe practices to prevent the potential spread of food-borne illness to all residents who received their meals from the kitchen. Concerns were noted with dish-washing procedures, sanitizing solution concentrations, cleaning contact surfaces after exposure to raw meat, failure to remove significantly dented cans from the general canned food supply, and cleanliness in the dry food store room. Findings include: 1. On 06/21/21 from 10:40 AM - 11:05 AM, the three-sink pot washing sinks were in use, each filled with a separate solution (wash, rinse, sanitize). There were multiple pots on counter drying next to the third sink. Employee Identifier (EI)#9, Diet Tech (kitchen manager) used a quaternary ammonia test strip to check the level of the sanitizing solution in the third sink. The test strip did not register any parts per million (PPM) of the sanitizer. EI#9, asked EI#11,Cook, who was in the vicinity to drain the sink and refill it. EI#9 asked EI#11 why…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-24 · tag F0565 — failed to support the resident council — pattern
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and document review, the facility failed to support the residents' right to participate in a resident group by not restarting the resident council meetings post Coronavirus Disease 2019 (COVID-19). This deficient practice affected four residents in the sample of 34 (Resident Identifier (RI) #'s 85, 2, 39 and 53). Findings include: During an interview on 06/21/21 at 10:30 AM, Resident Identifier (RI) #85 stated he/she did attend Resident Council (RC) meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic restrictions. During an interview on 06/21/21 at 10:40 AM, RI #2 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but there have not been any meetings held since they were discontinued due to the pandemic. During an interview on 06/21/21 at 11:00 AM, RI #39 stated he/she did attend RC meetings prior to the COVID-19 pandemic, but the RC meetings have not been restarted post pandemic. During an interview on 06/21/21 at 2:30 PM, RI #53 stated he/she did attend RC meetings…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-24 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review, facility assessment, policy review and review of Centers for Medicare and Medicaid memo, the facility failed to ensure pharmacy services thoroughly reviewed the resident medication regimens to identify irregularities related to the use of psychotropic medications, and residents who were prescribed psychotropic medications received gradual dose reductions (GDR) or had a physician documented clinical rationale for the continued use of the psychotropic medication for four (Resident Identifier (RI) #32, RI#76, RI#75 and RI#18) of five residents reviewed for unnecessary psychotropic medication. Findings include: 1. Review of RI #32's electronic medical record (EMR) undated Face Sheet under the face sheet tab revealed RI #32 was admitted to the facility on [DATE]. Review of RI #32's EMR annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/20/20 under the MDS tab revealed RI #32's Brief Interview for Mental Status (BIMS) score was a 14 which…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2021-06-24 · tag F0758 — failed to limit and justify psychotropic drugs — pattern
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, review of the facility's assessment, review of the manufacturer's guidelines for medication use, review of Centers for Medicare and Medicaid Services memo and review of the facility's policies and procedures, the facility failed to ensure that four of five residents (Resident Identifier (RI) #18, RI#32, RI#75, and RI#76) were free from unnecessary psychotropic medications. Specifically, an antipsychotic and psychoactive medications were used by the facility without an attempted gradual dose reduction (GDR), proper medical rationale, proper indication for use, and the lack of /or behavior and side effect monitoring. Additionally, residents received PRN (as needed) anti-anxiety medication for more than 14 days without proper medical rationale and/or indication for use. Findings include: Review of Centers for Medicare and Medicaid S&Q Memo Ref 13-35-NH dated May 24, 2013 revealed: . The problematic use of medications, such as antipsychotics, is part of a larger, growing…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-24 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review and facility policy review, the facility failed to notify the responsible party for one of 34 sampled residents (Resident Identifier (RI) #74) of a change in medical treatment and new medical diagnosis. Specifically, an indwelling urinary catheter was inserted without notification of the responsible party. Findings include: Review of the facility's policy titled, Notification of Change in Patient/Resident Health Status dated June 2017 revealed the purpose, to ensure all interested parties are informed of the patient's/resident's change in health status so that a treatment plan can be developed which is in the best interest of the patient/resident. The policy revealed the facility would consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there was a change in . (B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. (i.e., Life…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-24 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, document review and review of the Long-Term Care Resident Assessment Instrument, the facility coded the MDS incorrectly for two of 34 residents, Resident Identifier (RI) #75 and 32. Specifically, RI#75 was not coded as receiving hospice services and RI#32 was coded as not being administered an antipsychotic medication. Findings include: Review of a document provided by EI#7 dated 06/23/21 revealed, The MDS Department follows the guidelines for Significant Change Assessments and Care plans set forth in the CMS [Center for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] [NAME] (sic). Review of the Long Term Care Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, The RAI process has multiple regulatory requirements. require that (1) the assessment accurately reflects the resident's status. 1. Review of RI#75's admission Record located under the Profile Tab in the electronic medical record (EMR) indicated the resident was admitted…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2021-06-24 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, document review and record review, the facility failed to develop a plan of care for three (Resident Identifier (RI) #32, RI#74 and RI#75) of 34 residents reviewed for care plans. Specifically, RI #32 was prescribed Abilify, an antipsychotic medication without developing and identifying specific target behavior/s and non-pharmacological interventions for the use of the medication. RI#74 care plan did not reflect interventions for the care of the resident with limited Range of Motion (ROM) and contractures. RI#75's care plan did not address that the resident had an indwelling urinary catheter and the intervention that nursing staff were to provide catheter care per shift and PRN (as needed). Findings include: Review of a document provided by EI#7, dated 06/23/21 indicated, The MDS Department follows the guidelines for Significant Change Assessments and Care plans set forth in the CMS [Center for Medicare and Medicaid Services] RAI [Resident Assessment Instrument] Manual (sic). 1. Review of RI…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-24 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, document review and record review, the facility failed to ensure two of 34 sampled residents requiring assistance with activities of daily living (ADLs) (Resident Identifier (RI) #93 and RI#32) and one supplemental resident who wished to remain anonymous received their scheduled baths. Findings include: 1. Review of the undated admission Record located in the electronic medical record (EMR) under the Profile section, revealed RI #93 was admitted to the facility on [DATE] with diagnoses including multifocal leukoencephalopathy (progressive viral disease of the central nervous system), cerebral infarction (stroke), hemiplegia (complete loss of strength or paralysis on one side of the body), muscle weakness, and lack of coordination. Review of the Care plan dated 04/06/18 in the EMR under the Care Plan tab revealed the focus area of Physical functioning deficit related to: Mobility impairment, Self-care impairment, Progressive Multifocal Leukoencephalopathy, Epilepsy, Muscle weakness, Lack of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-06-24 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, document review and interview, the facility failed to provide an ongoing program to support residents in their choice of activities designed to meet the interests of and support the well-being of each resident for three of 34 residents, Resident Identifier (RI) #'s 85, 39 and 53, reviewed for activities. Findings include: During an interview on 06/21/21 at 10:30 AM, RI#85 stated that there have not been any activities offered since the majority of the Coronavirus Disease 2019 (COVID-19) restrictions have been lifted. RI #85 stated he/she missed the church services that used to occur on site and being taken on outings. During an interview on 06/21/21 at 10:45 AM, RI #39 stated that he/she would like the opportunity to participate in activities since COVID-19 was not such an issue at this time. During an interview on 06/21/21 2:00 PM, RI #53 stated that he/she missed the morning social (10:00 AM-11:00 AM) that would occur in the main dining room. RI# 53 stated that residents could get together, drink coffee and have a snack. RI #53 stated that the residents…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2020-02-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and review of Potter and [NAME], Fundamentals of Nursing, Ninth Edition, page 465, Chapter 29, Infection Prevention and Control, the facility failed to ensure a licensed nurse did not assist with repositioning and adjusting Resident Identifier (RI) #11's bed linens while still wearing gloves worn during wound care for RI #11. This deficient practice affected RI #11, one of one residents observed during wound care. Findings Included: A review of Potter and [NAME] Fundamentals of Nursing, Ninth Edition, page 465, Chapter 29, Infection Prevention and Control, revealed the following under the heading, Gloves: . Change gloves and perform hand hygiene between tasks and procedures on the same patient after contact with material that contains a high concentration of microorganisms. RI #11 was readmitted to the facility on [DATE]. A current diagnosis included pressure ulcer of sacral region, stage 3. On 02/20/20 at 11:15 a.m., the following was observed by the surveyor during wound care…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2022-12-02 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form, the facility failed to ensure the DAILY NURSE STAFFING FORM reflected the census on one of five days of the survey; and reflected the number of staff working on two of five days of the survey. This deficient practice had the potential to affect all 138 residents residing in the facility. Findings Include: A review of the facility's RESIDENT CENSUS AND CONDITIONS OF RESIDENTS form dated 11/29/2022 revealed there were 138 residents residing in the facility during the survey. On 11/28/2022 at 6:10 PM, the surveyor observed the DAILY NURSE STAFFING FORM posted. The census was missing from the form. On 11/30/2022 at 8:29 AM, the surveyor observed the same DAILY NURSE STAFFING FORM from the following day (11/29/2022) posted. There was no number of staff and hours worked for the 3 PM - 11 PM and 11 PM - 7 AM shifts. On 11/30/2022 at 8:33 AM, Employee Identifier (EI) #20, the Work Force Manager removed the DAILY NURSE STAFFING FORM from the holder and stated she was getting ready…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to DIVERSICARE HEALTHCARE — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 1 of 52.6-1.6 vs chain
Health inspection 1 of 52.5-1.5 vs chain
Staffing 3 of 53.0≈ chain avg
Quality measures 2 of 53.5-1.5 vs chain
The other 43 homes this chain runs (chain average 2.6★, per CMS)
1 of 5Diversicare Of HaysvilleHaysville, KS 1 of 5Diversicare Of MeridianMeridian, MS 1 of 5Diversicare Of Oak RidgeOak Ridge, TN 1 of 5Diversicare Of OxfordOxford, AL 1 of 5Diversicare Of RipleyRipley, MS 1 of 5Diversicare Of SedgwickSedgwick, KS 1 of 5Diversicare Of SouthavenSouthaven, MS 1 of 5Lampasas Nursing and Rehabilitation CenterLampasas, TX 1 of 5Windsor HouseHuntsville, AL 2 of 5Diversicare Of AmoryAmory, MS 2 of 5Diversicare Of ArabArab, AL 2 of 5Diversicare Of BatesvilleBatesville, MS 2 of 5Diversicare Of BoazBoaz, AL 2 of 5Diversicare Of BrookhavenBrookhaven, MS 2 of 5Diversicare Of ChanuteChanute, KS 2 of 5Diversicare Of Council GroveCouncil Grove, KS 2 of 5Diversicare Of EuporaEupora, MS 2 of 5Diversicare Of FoleyFoley, AL 2 of 5Diversicare Of MontgomeryMontgomery, AL 2 of 5Diversicare Of Moss PointMoss Point, MS 2 of 5Diversicare Of Pell CityPell City, AL 2 of 5Diversicare Of TupeloTupelo, MS 2 of 5St Martin's In The PinesIrondale, AL 3 of 5Chisolm Trail Nursing and Rehabilitation CenterLockhart, TX 3 of 5Diversicare Of Copper BasinCopperhill, TN 3 of 5Diversicare Of LulingLuling, TX 3 of 5Diversicare Of OneontaOneonta, AL 3 of 5Diversicare Of QuitmanQuitman, MS 3 of 5Diversicare Of RiverchaseBirmingham, AL 3 of 5Diversicare Of ShelbyShelby, MS 3 of 5Park PlaceSelma, AL 3 of 5Yorktown Nursing and Rehabilitation CenterYorktown, TX 4 of 5Baron House Of HueytownHueytown, AL 4 of 5Diversicare Of Big SpringsHuntsville, AL 4 of 5Diversicare Of HutchinsonHutchinson, KS 4 of 5Diversicare Of LanettLanett, AL 4 of 5Diversicare Of WinfieldWinfield, AL 4 of 5Hartford Health CareHartford, AL 5 of 5Diversicare Of GreensboroGreensboro, AL 5 of 5Diversicare Of LarnedLarned, KS

Showing 40 of 43; lowest-rated first.

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
DIVERSICARE LEASING COMPANY III LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 07/01/2016
ADVOCAT FINANCE, LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2016
DAC NEWCORP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/04/2022
DIVERSICARE MANAGEMENT SERVICES LP.Organization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 07/01/2016
KELLMAN, FRANKLINIndividualCORPORATE DIRECTORsince 09/13/2024
KOHN, BRIANIndividualCORPORATE DIRECTORsince 11/19/2021
RATNER, ERANIndividualCORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 09/13/2024
BODIE, REBECCAIndividualCORPORATE OFFICERsince 03/02/2020
NEE, STEPHENIndividualCORPORATE OFFICERsince 02/20/2023
WEISHAAR, MATTHEWIndividualCORPORATE OFFICERsince 12/01/2003
EPHRAIM, MARIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 06/07/2021
DMS GP LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 04/04/2022
DIVERSICARE HEALTHCARE SERVICES LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 04/04/2022

CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$15.7M
Net patient revenuemost recent cost report
+13.7%
Operating marginrevenue minus expenses
$803K
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 86%Medicare 1%Other / private 12%

About 86% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $803K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$271per resident / day
operating cost
$8,235per month
≈ monthly operating cost
$314per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in AL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Alabama Medicaid page.

Typical monthly cost in Alabama
$8,334/mo
Nursing home (semi-private)
$8,787/mo
Nursing home (private)
$4,425/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 015209. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-12-02, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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