Diversicare of Foley

Inspectors wroteBased on observations, interviews, and facility policy review, it was determined the facility failed to ensure food storage/preparation items were maintained in a clean and sanitary condition to ensure food safety for 113 of 114 residents who received nourishment from the kitchen. The facility also failed to provide evidence of a routine cleaning schedule for the kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, it was determined the facility failed to ensure activities of daily living (ADL) were provided to ensure good grooming for one (Resident #18) of three residents reviewed for ADL care. Specifically, the facility failed to ensure resident #18's fingernails were trimmed.

Inspectors wroteBased on observations, record review, and interviews the facility failed to ensure oxygen was administered at the prescribed flow rate, failed to ensure handheld updraft nebulizer masks were covered when not in use, and failed to ensure oxygen concentrator humidifier bottles were sufficiently filled for two (Resident #25 and Resident #92) of two residents reviewed for respiratory care.

Inspectors wroteBased on resident record review, interviews, and review of the facility guidelines for Pain Management, the facility failed to ensure nursing staff sought an order for treatment for ice therapy for one (Resident #169) of one residents reviewed for concerns of pain.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the risks and benefits of side rails were reviewed with the resident or the resident representative and failed to ensure informed consent was obtained prior to the use of side rails for one (Resident #100) of three residents reviewed for side rails.

Inspectors wroteBased on observations, interviews, review of the 2017 Food Code and the facility's policy titled Water Temperatures for Dishwashing Machines, the facility failed to ensure dishware was stored to prevent wet nesting and there was space between the 3-compartment sink, the food prep sinks and the facility's plumbing (sewer) system. These deficient practices had the potential to affect all the residents served food from the kitchen. The RESIDENT CENSUS AND CONDITIONS OF RESIDENTS (Form CMS-672) dated 9/24/2019 indicated the facility had a total of 134 residents and three residents were fed by way of a feeding tube. The facility further failed to ensure Employee Identifier (EI) #5, a Certified Nursing Assistant (CNA) did not touch Resident Identifier (RI) #30's toast with her bare hand during the breakfast meal on 9/24/2019. [...]

Inspectors wroteBased on observation, interviews, review of Resident Identifier (RI) #278's medical record, and the facility's policy titled Handwashing/Hand Hygiene, the facility failed to ensure Employee Identifier (EI) #6, a Certified Nursing Assistant (CNA) washed her hands between glove changes during RI #278's provision of incontinence care. This affected RI #278, one of two sampled residents reviewed for bladder and bowel incontinence.

Inspectors wroteBased on interviews, review of a complaint received by the Alabama State Survey Agency, the facility's Abuse Policy and medical record reviews, the facility failed to ensure Resident Identifier (RI) #71 and RI #85 were free from abuse perpetrated by RI #49 and RI #84, residents who reside on the secured Alzheimer's Care Unit (Dementia unit) of the facility. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. [...]

Inspectors wroteBased on interviews, medical record review and the facility's Abuse Policy, the facility failed to: 1) intervene and correct situations to prevent further abuse (Prevention); 2) ensure the Director of Nursing Service (DNS) reported allegations of abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, these allegations of abuse were not reported to the State survey agency (Reporting); 3) ensure the DNS and Administrator identified situations of resident/resident altercations as abuse (Identification); 4) protect Resident Identifier (RI) #71, RI #85 and other residents from abuse perpetrated by RI #49 and RI #84 (Protection); and 5) investigate these allegations of physical abuse (Investigation). On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. [...]

Inspectors wroteBased on interviews and review of the facility's Abuse Policy, the Director of Nursing Service (DNS) failed to report allegations of physical abuse to the Administrator, who serves as the Abuse Coordinator. Furthermore, these allegations of abuse were not reported to the State survey agency. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. [...]

Inspectors wroteBased on interviews and review of the facility's Abuse Policy, the facility failed to investigate allegations of abuse perpetrated by Resident Identifier (RI) #49 and RI #84, two cognitively impaired residents who reside on the facility's secure Alzheimer's Care Unit. On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. [...]

Inspectors wroteBased on interview and review of Resident Identifier (RI) #49's medical record, the facility failed to identify and address the behavioral health care needs of RI #49, a resident with repeated incidents of resident/resident abuse . On 4/28/2018, RI #49 was observed to willfully push RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. However, while not being supervised by staff, later in the day on 5/25/2018, during the second shift, RI #49 forcefully pushed another resident, RI #71 down, causing this resident to fall. [...]

Inspectors wroteBased on interviews and review of job description's, the facility administrative staff, to include Employee Identifier (EI) #1, the facility's Administrator, who is responsible for directing and overseeing the day to day operations of the facility and EI #2, the Director of Nursing Service (DNS), who manages the nursing department, failed to identify incidents of resident/resident altercations as abuse. They also failed to implement the facility's abuse policy and procedure and failed to ensure they educated the staff on the correct definition of abuse. These deficient practices affected Resident Identifier (RI) #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. These failures also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. [...]

Inspectors wroteBased on interview and review of the Regional [NAME] President's job description, the facility's governing body failed to provide monitoring and oversight to ensure the facility's abuse policy and procedure was implemented. This deficient practice affected Resident Identifier (RI) #71 and RI #85, two of six sampled residents reviewed for abuse; and placed these residents in immediate jeopardy for serious injury, harm or death. This failure also had the potential to affect the remaining 26 residents who resided on the facility's Alzheimer's Care Unit. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F837.

Inspectors wroteBased on interviews and review of the CENTER ASSESSMENT TOOL, the facility failed to address the care and services, as well as staff competencies, necessary to provide care to the residents who reside on the 35-bed secured Alzheimer's Care Unit. This deficient practice affected all 28 residents who reside on the secured Alzheimer's Care Unit and placed these residents in immediate jeopardy for serious injury, harm or death. On 8/1/2018 at 8:35 PM, the facility's Administrator, Director of Nursing Service, Director of Clinical Operations and Senior Director of Clinical Operations were notified of the findings of immediate jeopardy in the area of Administration, F838.

Inspectors wroteBased interview and review of the Diversicare of Foley - QAPI CENTER PLAN, the facility's Quality Assessment and Assurance committee failed to review the reported allegations of physical abuse and develop a corrective action plan to prevent recurrence. On 4/28/2018, Resident Identifier (RI) #49 was observed to willfully pushed RI #71 down, causing the resident to fall, cry and scrape the side of his/her back. Four days later, on 5/2/2018, staff observed RI #49 slap RI #85. During the first shift on 5/25/2018, the staff noted RI #49 continued to target RI #85. RI #49 yelled at RI #85, pushed RI #85's face into a wall and tried to slam a door on the resident. After this incident the staff placed RI #49 on one-to-one staff supervision. [...]