Diversicare of Oxford

Inspectors wroteBased on interviews, record review, review of Facility Reported Incidents (FRIs), review of the facility's investigative file and review of a facility policy titled, Elopement, the facility failed to ensure Resident Identifiers (RI) #119, RI #88, RI #127, and RI #106 received supervision in a manner to ensure their whereabouts were known to the facility and the residents were in an environment free of accident hazards, failed to ensure its Wander Guard system alerted staff when RI #119 exited the facility, and failed to ensure RI #106 was supervised in a manner to prevent elopement after becoming agitated and stating he/she wanted to leave. The facility further failed to implement and follow fall precautions interventions for RI #60 a resident identified at risk for falls. Specifically: [...]

Inspectors wroteBased on record review, interview and policy titled Restorative Guidelines the facility failed to implement a functional maintenance program (FMP) following discharge from therapy for Resident Identifier (RI) #60 one of one residents who experienced multiple falls. This failure had the potential to contribute to decline in function and increased risk for further falls and had the potential to affect all residents requiring ongoing maintenance services due to the absence of a functional maintenance program. This deficient practices were cited as a result of the investigations of facility reported incident/complaint/report number 2800273. [...]

Inspectors wroteBased on interview, record review and the Center Assessment Tool the facility failed to provide sufficient nursing staff to meet resident needs when the Registered Nurse (RN) #40 did not respond to a residents call light or notification of a fall, stating she did not have time because she was responsible for 50 residents. In addition, the facility did not have a restorative program to ensure residents maintained mobility and range of motion in place due to lack of staffing availability. These failures limited the facility's ability to provide timely care and services and had the potential to affect all residents who require nursing supervision and restorative services. This deficient practices were cited as a result of the investigations of facility reported incident/complaint/report number 2800273. Findings Include: The Center Assessment Tool update 3/9/2026 documented: [...]

Inspectors wroteBased on interviews, reviews of residents' medical records, review of a facility policy titled Abuse, Neglect, Misappropriation, Exploitation Policy, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the rights of residents to be free from abuse perpetrated by an employee of the facility and by other residents in the facility. Specifically: 1) On 08/05/2025 Resident Identifier (RI) #70 was physically abused by RI #106 and RI #126, when RI #106 and RI #126 struck RI #70 in the chest with their open hands. The facility failed to protect RI #70 from physical abuse. 2) On 11/19/2025 RI #102 was physically and verbally abused by a housekeeper, when the housekeeper hit RI #102 with her hand, on his/her back, and used profane language toward RI #102. [...]

Inspectors wroteBased on interviews, record review, and a review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI), the QAPI committee failed to identify all causal factors related to four elopements for Resident Identifiers (RI) #119, RI #88, RI #127 and RI #106 and to determine what corrective actions needed to be taken to prevent any further resident safety concerns. This deficient practice affected RI #119, RI #88, RI #127 and RI #106. These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers 447995, 447964, 2629802 and 2603429. Findings Include: Cross-Reference F689 and F725, A review of a facility policy titled, Quality Assurance and Performance Improvement, dated March 2025 revealed: [...]

Inspectors wroteBased on interviews, record review and review of facility's policies titled, Abuse, Neglect, Misappropriation, Exploitation Policy, Medication Destruction, facility investigation files, and review of information from the Alabama Department of Public Health's (ADPH) Online Reporting System, the facility failed to ensure residents' medications were secured from misappropriation and failed to identify, report, and investigate allegations in accordance with policies and regulatory requirements. The facility further failed to ensure proper medication destruction, failed to maintain accountability of discontinued medications, and failed to initiate timely reporting to the Alabama Department of Public Health. The deficient practice affected Resident Identifiers (RI) #12, #129, and #130 three of three residents reviewed for misappropriation of property. [...]

Inspectors wroteBased on interviews, record review, review of a facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, and review of Facility Reported Incidents (FRIs), the facility failed to report an incident of physical abuse to the State Agency (SA) and an allegation of misappropriation to the SA within required timeframes. These failures had the potential to delay initiation of investigations and implementation of protective measures to ensure resident safety and protection. Specifically:1.) The facility failed to report an incident of physical abuse involving Resident Identifier (RI) #128 and RI #132 within two hours of the incident occurring. On 11/10/2025 around 11:35 AM RI # 132 entered the room of RI #128 and pinched him/her on the hand when RI #132 attempted to redirect RI #128 out of the room. The facility reported this allegation to the SA on 11/10/2025 at 5:12 PM. [...]

Inspectors wroteBased on interviews, record reviews and review of a facility policy titled Obtaining Patient/Resident Vital Signs, the facility failed to ensure a Licensed Practical Nurse (LPN) #12 obtained and documented Resident Identifier (RI) #122's temperature on 03/01/2025, when RI #122 experienced a change in his/her condition. Failure to obtain and document RI #122's temperature, an indicator of infection, did not meet the standard of care for a resident experiencing change in his/her condition and placed RI #122 at risk for decline in condition, including worsening respiratory status and infection. This failure affected RI #122, one of one resident reviewed for change of condition during the survey. This deficient practice were cited as a result of the investigation of facility reported incident/complaint/report number 447989. [...]

Inspectors wroteBased on observation, interview, review of the Food and Drug Administration (FDA) 2017 Food Code and review of the facility policy titled Waste Control, the facility failed to ensure the area around the outside dumpsters was free from discarded medical equipment, lumber and other debris on 11/24/2019. This had the potential to affect all 153 residents in the facility. Findings Include: The 2017 FDA Food Code included the following: . 5-501.15 Outside Receptacles. (B) Receptacles and waste handling units for REFUSE . shall be installed so that accumulation of debris and insect and rodent attraction and harborage are minimized and effective cleaning is facilitated around . the unit. 5-501.110 Storing Refuse, Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents. [...]

Inspectors wroteBased on observation, record review, interviews and review of a facility policy titled Specific Medication Administration Procedures Oral Inhalation Administration, the facility failed to ensure Resident Identifier (RI) #50 was assessed to self-administer nebulizer treatments prior to the nurse leaving RI # 50 unattended during the administration. This affected RI #50, one of two residents observed receiving a nebulizer treatment. Findings Include: Review of a facility policy titled Specific Medication Administration Procedures Oral Inhalation Administration, dated 06/15, revealed: . NEBULIZER- . L. Remain with the resident for the treatment unless the resident has been assessed and authorized to self administer. [...]

Inspectors wroteBased on interview, resident record review, and review of Resident Identifier (RI) #73's care plan for falls, the facility failed to ensure RI #73's care plan intervention was followed for use of a gait/transfer belt during transfer on 9/21/19. This affected one of 30 sampled residents for whom care plans were reviewed. Findings Include: RI #73 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Spinal Stenosis and Muscle Weakness. Review of RI #73's admission Minimum Data Set (MDS) with an assessment reference date of 7/4/19, revealed RI #73 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated RI #73 had intact cognition for daily decision making and required extensive assistance of one person physical assistance for transfers. Review of RI #73's care plan with a Focus area for At risk for falls related to: . [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure Resident Identifier (RI) #73 did not sustain a fall in the shower room on 9/21/19, as a result of Employee Identifier (EI) #8, Certified Nursing Assistant (CNA), transferring RI #73 from a shower chair to a wheel chair without using a gait/transfer belt as specified in RI #73's care plan. This affected RI #73, one of three sampled residents reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to ensure there were not expired eye drops on the Two South medication cart on [DATE]. This was observed on one of three medication carts in the facility. Findings Include: On [DATE] at 5:16 PM, the surveyor observed the Two South medication cart. An expired bottle of Latanoprost eye drops, opened [DATE], was noted on the cart. Employee Identifier (EI) #1, Registered Nurse, was interviewed on [DATE] at 5:16 PM. EI#1 stated the Latanoprost eye drops were opened on [DATE]. EI#1 said these eye drops should have been discarded six weeks after opening, on [DATE]. EI#1 was asked what the potential complications/harm could be of having and using medications that have been opened for an extended period of time. EI#1 said it could result in bacteria in the body if the the cap or tip was contaminated or the eye drops may not be as effective.

Inspectors wroteBased on observation, interview and review of the DAILY NURSE STAFFING FORM the facility failed to post the nurse staffing data prior to the beginning of the shift on 11/24/19. Surveyors entered the facility on 11/24/19 at 9:45 AM and the data had not been posted for the day shift. This had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interviews, medical record review and review of facility policies titled,Self-Administration of Medications and Oral Inhalation Administration, the facility failed to ensure licensed staff did not allow Resident Identifier (RI) #135 to self-administer his/her nebulizer treatment on 09/18/18. This affected RI #135, one of five residents observed during medication pass observations and one of three nurses. Findings Include: A review of a facility policy titled, Self-Administration of Medications, dated 06/15, documented: Policy .residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. Procedures A. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a care plan was developed to address Resident Identifier (RI) #17's required assistance for bed mobility. This affected RI #17, one of thirty-three sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, interviews, medical record review and review of facility policies titled, Administration Procedures For All Medications and Oral Inhalation Administration, the facility failed to ensure licensed staff observed administration of Resident Identifier (RI) #135's nebulizer treatment while it was infusing to ensure RI #135 received the benefits of the treatment. This affected RI #135, one of five residents observed during medication pass observations, and one of three nurses. Finding Include: A review of a facility policy titled, Administration Procedures For All Medications, dated 06/15, documented: .To administer medications in a safe and effective manner. A review of a facility policy titled, Oral Inhalation Administration, dated 06/15, revealed: .L. Remain with the resident for the treatment . [...]

Inspectors wroteBased on observations, interviews, medical record reviews and review of facility policies titled, Administration Procedures For All Medications and Topical Medication Administration and a facility document titled, Hand Hygiene Care Audit, the facility failed to ensure a licensed staff: 1. washed her hands after obtaining RI #8's FSBS, did not place the glucometer used to obtain the resident's fingerstick blood sugar (FSBS) on top of the medication cart without a barrier before cleaning it, and removed her gloves and washed her hands after administering the resident's insulin injection before going back to the medication cart for medication, 2. The facility further failed to ensure a licensed staff washed her hands after eye drop administration for RI #61 and before administering RI #61's nasal spray, and 3. [...]