Diversicare Of Montgomery

Based on observations, interviews, facility policies titled Equipment and Personal Food Storage, and the 2022 United States (U.S.) Public Health Service Food and Drug Administration (FDA) Food Code; the facility failed to: 1.) prevent the potential for cross contamination due to dust build-up on the ceiling vents and a dirty blade on the manual can opener and 2.) ensure a temperature monitored refrigerator was available for staff to place food items brought in by family/friends for residents in order to prevent the potential for food-borne illness. This had the potential to affect 107 of 107 residents receiving meals from the facility's kitchen. Findings Include: 1.) The facility's policy for Equipment, dated September 2017, included the following: Policy Statement All foodservice equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained . 3. All food contact equipment will be cleaned and sanitized after every use. 4. All non-food contact equipment will be clean and free of debris. The 2022 U.S. Public Health…

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.

Based on observations, interviews, a facility policy titled Equipment, and the 2022 United States (U.S.) Public Health Service Food and Drug Administration (FDA) Food Code; the facility failed to ensure the walk-in freezer was maintained in proper operating condition for maintaining optimal temperature and preventing ice/frost build-up. This had the potential to affect 107 of 107 residents receiving meals from the facility's kitchen. Findings Include: 1.) The facility's policy for Equipment, dated September 2017, included the following: Policy Statement All foodservice equipment will be clean, sanitary, and in proper working order. Procedures 1. All equipment will be routinely cleaned and maintained . 5. The Dining Services Director will submit requests for maintenance or repair to the Administrator and/or Maintenance Director as needed. The 2022 U.S. Public Health Service FDA Food Code included the following: . 4-501 Equipment 4-501.11 Good Repair and Proper Adjustment. (A) EQUIPMENT shall be maintained in a state of repair . (B) EQUIPMENT components such as doors, seals, hinges,…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and resident record review the facility failed to ensure Resident Identifier (RI) #43 received showers as scheduled. This affected one of eight residents sampled for Activities of Daily Living. This deficient practice was cited as a result of the investigation of complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969. Findings Include: RI #43 was admitted to the facility on [DATE]. RI #43's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date of 02/24/2023 documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated RI #43 had intact cognition. The MDS assessment also documented RI #43 required physical assistance of one person with bathing. On 04/02/2023 at 4:38 PM, RI #43 voiced concerns of not getting showers on shower days, which were Wednesdays and Saturdays. RI #43 said he/she did not get a shower on Saturday 04/01/2023 or on the last Wednesday 03/29/2023. Review of RI #43's March and April 2023 ADL…

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.

Based on observations, interviews, review of facility's policies titled Hand Washing Procedures and Pots and Pans, review of Auto-Chlor System Solution-QA product label, and the 2017 Food and Drug Administration (FDA) Food Code, the facility failed to ensure: dietary staff washed hands after touching dirty dishes and before touching clean dishes and dietary staff properly sanitized three metal cook wares in the three-compartment sink by placing them in sanitizing solution for the recommended amount of time. This had the potential to affect 69 of 69 residents who received meals from the kitchen on 7/21/2021. Findings Include: A review of facility policy and procedure from Food Service Manual titled Hand Washing Procedures with an effective date of 8/1/12 revealed . POLICY . It is the policy of this facility to prevent the transmission of bacteria. Hands are to be frequently and thoroughly washed. PROCEDURE . 1. Hands must be washed: . j. after handling soiled dishes . 4. The technique for hand washing is as follows: a. Wet hands with warm water. b. Cover hands with germicidal liquid…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, resident record review, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, and review of a facility Abuse Investigative File, the facility failed to ensure Resident Identifier (RI) #22 was not verbally abused on 4/19/21 when Employee Identifier (EI) #2 Licensed Practical Nurse (LPN) and EI #3 Certified Nursing Assistant (CNA), heard EI #4 CNA curse and use profanity in the presence of and directed toward RI #22. RI #22 told the facility in a statement dated 4/19/21 that the girl the night before had fussed at him/her and made him/her cry. This affected one of three residents sampled for abuse. Findings include: RI #22 was admitted to the facility on [DATE]. A review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy with an effective date of January 2019 revealed, Purpose: To prohibit and prevent abuse, neglect, exploitation, . in accordance with Federal and State Laws. Definitions: . Verbal Abuse: . Verbal abuse includes…

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.

Based on observation and interview, the facility failed to ensure a Styrofoam cup (bowl) was not stored in the flour bin. These deficient practices had the potential to affect all 110 residents who received meals from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) signed by Employee Identifier (EI) #2, the Director of Nursing Service (DNS) and dated 11/17/2019 indicated the facility had a total of 115 residents and five residents were fed by way of tube feedings. Findings include: During the initial tour of the kitchen with EI #7, the Evening Cook, on 11/17/2019 at 1:14 PM, a white cup (bowl) was observed inside the flour bin. EI #7 was asked what she removed from the flour bin and she stated a white bowl. When asked what the harm was in leaving the bowel inside the flour bin, EI #7 said it could cause cross contamination.

Based on observation, interviews, and review of the facility's policy titled Privacy Program Requirements, Safeguards and Definitions, the facility failed to ensure Employee Identifier (EI) #6, a Licensed Practical Nurse (LPN) did not leave Resident Identifier (RI) #43's personal information visible during medication administration. This deficient practice affected RI #43, one of six residents observed for medication administration. Findings include: The facility's policy titled, Privacy Program Requirements, Safeguards and Definitions with a revision date of 6/1/2015, documented . III. Safeguards for Written Uses All documents contained PHI (Protected Health Information) should be stored appropriately to reduce the potential for incidental use or disclosure. Documents should not be easily accessible to any unauthorized staff or visitors. Active Records on Nursing Unit: . C. Active Clinical Records shall not be left unattended on the nurses' station desk or other areas where residents, visitors and unauthorized individuals could easily view the records . During medication…

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.

Based on observations and interview, the facility failed to ensure vents did not hang down from the bathroom ceiling in Resident Identifier (RI) #20's and RI #113's bathroom. This deficient practice was observed in two of the 77 rooms in the facility. Findings include: On 11/17/2019 at 2:45 PM, 11/18/2019 at 8:45 AM and 11/20/2019 at 2:31 PM, a vent was observed hanging from the bathroom ceiling in RI #113's bathroom. On 11/17/2019 at 3:50 PM, 11/18/2019 at 8:45 AM and 11/20/2019 at 2:36 PM, a vent was observed hanging from the bathroom ceiling in RI #20's bathroom. In an interview on 11/20/2019 at 3:39 PM, Employee Identifier (EI) #5, the Housekeeping Supervisor was asked what the purpose was of the vents located in the ceiling of RI #20's and RI #113's bathroom. EI #5 stated they were exhaust fans. When asked what the concern was with the hanging vents, EI #5 stated they might fall.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint received by the Alabama State Survey Agency, the facility's policy titled Transfer & Discharge, Resident Identifier (RI) #264's medical record and interviews, the facility failed to issue RI #264's a 30-day notice of discharge when the resident was discharged from the facility on 8/12/2019. This deficient practice affected RI # 264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency room on 8/12/2019 and would not accept the resident back into the facility. The facility's policy titled Transfer & Discharge dated 11/1/2016, documented POLICY STATEMENT Diversicare shall permit each Resident to remain at the Center, and not transfer or discharge the Resident from the Center except in accordance with Federal and State laws, and as described in this policy. PROCEDURE . Notice Requirements 5. Before Diversicare transfers or discharges…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint received by the Alabama State Survey Agency, the facility's Bed Hold Policy, Resident Identifier (RI) #264's medical record and interviews, the facility failed to provide RI #264 written notice which specified the duration of the bed hold, reserve bed payment, the facility's policy regarding bed hold and the conditions upon which RI #264 would be able to return to the facility, when RI #264 was transferred/discharged from the facility to a hospital's emergency room on 8/12/2019. This deficient practice affected RI #264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency room on 8/12/2019 and would not accept the resident back into the facility. The facility's policy titled Bed Hold Policy dated 11/1/2016, documented POLICY STATEMENT Diversicare will, in accordance, with Federal and State regulations, hold a Resident's bed during a…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint received by the Alabama State Survey Agency, the facility's policies titled Transfer & Discharge and Bed Hold Policy, Resident Identifier (RI) #264's medical record and interviews, the facility failed to allow RI #264 to return to the facility following a transfer/discharge to a local hospital. This deficient practice affected RI # 264, one of one sampled resident reviewed for a facility-initiated discharge. Findings include: On 9/17/2019, the State Agency received a complaint which alleged the facility discharged RI #264 to a hospital's emergency room on 8/12/2019 and would not accept the resident back into the facility. The facility's policy titled Bed Hold Policy dated 11/1/2016, documented POLICY STATEMENT Diversicare will, in accordance, with Federal and State regulations, hold a Resident's bed during a temporary hospitalization or therapeutic leave. PROCEDURE . 5. If the Center determines that the Resident cannot return to the facility after a hospital or therapeutic leave, it shall…

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.

Based on observations and interview, the facility failed to ensure the shower room near Room Locator (RL) #2 and RL #3 did not have a sharps box that was full with razors protruding from the top of the sharps box. This deficient practice was observed in one of six shower rooms in the facility. Findings include: On 11/17/2019 at 3:26 PM, the shower's door room near RL #2 and RI #3 on the 400 Hall was opened. The sharps box was observed with five blue razors protruding from the top of the sharps box. In an interview on 11/20/2019 at 3:21 PM, Employee Identifier (EI) #3, the Registered Nurse (RN) Unit Manager was asked what should happen with the sharps box once it was filled. EI #3 stated it should be changed out. When asked what the potential for harm was with the sharps box being filled with five razors protruding out and on top of the sharp box, EI #3 stated a resident could walk in and injury themselves. During a tour of the RL #2 and RI #3 with EI #3, the RN Unit Manager on 11/20/2019 at 3:50 PM, the sharps box was observed with five blue razors protruding from the top of 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.

Based on observation and interview, the facility failed to ensure the medication storage room on the South Hall did not contained expired medication ordered for Resident Identifier (RI) #265. This was observed in one of one medication storage room observed. Findings include: On 11/20/2019 at 9:19 AM, the South Medication Storage Room refrigerator contained three containers of Zosyn, a Penicillin antibiotic used to treat an infection, prescribed for Resident Identifier (RI) #265, with an expiration date of 11/15/2019. In an interview on 11/20/2019 at 9:24 AM, Employee Identifier (EI) #20, a Registered Nurse acknowledged the date on the Zosyn's containers were 11/15/2019. When asked what the issue was with having expired medications, EI #20 said when the medications are expired they don't have the full effect of the intended use.