Diversicare of Montgomery

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure the survey results for the last three years were available for residents or visitors to review. This deficient practice had the potential to affect all 108 residents who resided in the facility. Findings Include: On 04/04/2023 at 8:15 AM, the surveyor observed a sign in the front lobby indicating, Recent Survey Results And Notice of Privacy Practices. Upon review of the contents of the binder, it was noted multiple survey reports were missing. On 04/04/2023 at 8:20 AM, Employee Identifier (EI) #1, the Administrator stated she was responsible for maintaining the survey binder. On 04/04/2023 at 8:25 AM, the facility's survey history over the previous three years was reviewed to include the following surveys: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.