Inspection Reports for
Diversicare of Bessemer
820 Golf Course Road, Bessemer, AL, 35023
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
8.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
131% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Census: 138
Deficiencies: 13
Date: Dec 2, 2022
Visit Reason
The inspection was conducted as a complaint investigation related to multiple concerns including facility maintenance, resident care, dietary services, therapy services, infection control, and regulatory compliance.
Complaint Details
The deficiencies were cited as a result of complaint investigation AL00042272.
Findings
The facility was found deficient in maintaining the building in good repair, accurate resident assessments, care plan implementation, respiratory equipment storage, nurse staffing documentation, medication storage, dietary management qualifications, food quality and preferences, food safety and sanitation, waste disposal, therapy service provision, and infection control practices.
Deficiencies (13)
Facility failed to maintain building in good repair with stained ceiling tiles, loose handrails, broken windows, leaking toilets, holes in walls, and other maintenance issues.
Resident #120's Minimum Data Set was inaccurately coded to reflect an indwelling catheter which the resident did not have.
Failed to implement nutritional care plan for Resident #76 and pressure ulcer care plan for Resident #74.
Resident #65's nebulizer mask was not dated, labeled, or stored in a plastic bag as required, posing infection control risk.
Daily Nurse Staffing Forms were incomplete or missing census and staffing information on multiple days.
Controlled refrigerated Ativan was not stored in a secured non-removable box as required, risking diversion.
Dietary Manager did not meet state qualifications for the position per Alabama rules.
Scrambled eggs served were cold, unappetizing, and had poor texture and appearance.
Facility failed to provide Resident #65's long-standing food preferences for Chef Salad on Mondays and Cottage Cheese with Fruit on Wednesdays.
Dishmachine drain pipe extended into floor drain creating potential backflow; food stored less than 6 inches from floor with debris underneath; dishmachine wall, shelf, and food delivery carts were unclean.
Dumpster area littered with pallets, bed frame, mattress, and door creating vermin harborage risk.
Failed to initiate physical therapy evaluation for Resident #139 despite screening indicating need.
Wound bandage was improperly disposed of in a shower room, risking cross contamination and infection.
Report Facts
Residents: 138
Deficiencies cited: 13
Distance: 3
Distance: 2.5
Temperature: 174
Residents attending Resident Council: 14
Residents attending Resident Council: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #3 | Maintenance Director | Acknowledged building maintenance issues and plumbing repairs |
| EI #1 | Administrator | Responsible for building upkeep and follow-up on resident concerns |
| EI #6 | Licensed Practical Nurse | Interviewed regarding Resident #120's catheter status |
| EI #7 | MDS Coordinator | Confirmed Resident #120 MDS coding error and care plan deficiencies |
| EI #16 | Registered Nurse | Interviewed about pressure ulcer care plan for Resident #74 |
| EI #18 | Licensed Practical Nurse | Interviewed about nebulizer mask storage for Resident #65 |
| EI #2 | Director of Nursing | Interviewed about nebulizer mask storage and nurse staffing form issues |
| EI #19 | Registered Nurse Unit Manager | Interviewed about nebulizer mask storage and infection control |
| EI #20 | Work Force Manager | Responsible for posting nurse staffing forms |
| EI #10 | Registered Dietitian | Interviewed about dietary management and food service deficiencies |
| EI #11 | Dietary Manager | Interviewed about dietary management qualifications, food preferences, and food quality |
| EI #12 | Regional Dietary Manager | Interviewed about dietary management and menu changes |
| EI #4 | Activity Supervisor | Provided Resident Council meeting minutes |
| EI #8 | Physical Therapist | Conducted screening for Resident #139 |
| EI #9 | Director of Physical Therapy | Interviewed about therapy evaluation process and delays |
Inspection Report
Re-Inspection
Deficiencies: 11
Date: Jun 24, 2021
Visit Reason
The inspection was conducted as a re-inspection survey to evaluate compliance with previously cited deficiencies and to assess the facility's adherence to regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to support resident council meetings post-COVID-19, failure to notify responsible parties of medical changes, inaccurate resident assessments, incomplete care plans, failure to provide scheduled baths, inadequate activities programming, failure to provide appropriate nursing care for skin conditions and bowel management, lack of interventions for contractures, and deficiencies in pharmacy medication reviews and food safety practices.
Deficiencies (11)
Failure to support residents' right to organize and participate in resident/family groups by not restarting resident council meetings post COVID-19.
Failure to notify responsible party of change in medical treatment and new medical diagnosis for one resident.
Inaccurate Minimum Data Set (MDS) coding for hospice services and antipsychotic medication for two residents.
Failure to develop and implement complete care plans for three residents, including lack of target behaviors and non-pharmacological interventions for antipsychotic medication use.
Failure to provide scheduled baths/showers to residents requiring assistance, with documentation showing missed showers and baths due to staffing shortages.
Failure to provide ongoing activities program to meet residents' interests and well-being, with activities limited or not occurring post COVID-19 restrictions.
Failure to provide nursing care and services in accordance with physician orders and care plans for two residents, including untreated psoriasis and inadequate bowel management.
Failure to provide interventions for range of motion impairment and contractures for one resident, with worsening contractures and no splints or devices in place.
Failure to ensure pharmacy services thoroughly reviewed psychotropic medication regimens, including lack of gradual dose reductions, clinical rationale, and behavior monitoring for four residents.
Failure to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications, and inappropriate use of PRN psychotropic medications for four residents.
Failure to adhere to safe food handling practices including inadequate dishwashing sanitizing, improper cleaning of food prep sinks after raw meat exposure, storage of dented canned goods, and unclean dry storage room.
Report Facts
Residents reviewed: 34
Residents affected: 4
Sanitizer concentration: 0
Sanitizer recommended concentration: 200
Sanitizer recommended concentration: 400
Dent size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #20 | Registered Nurse (Charge Nurse) | Named in failure to notify family of catheter placement and failure to implement physician order for psoriasis treatment |
| EI #7 | MDS Coordinator | Named in inaccurate MDS coding and care plan deficiencies |
| EI #2 | Director of Nursing | Named in multiple findings including activities, skin care, bowel management, and medication oversight |
| EI #9 | Diet Tech (Kitchen Manager) | Named in food safety deficiencies including sanitizer concentration and dry storage cleanliness |
| EI #8 | Registered Dietitian | Named in food safety deficiencies and sanitizer concentration |
| Consultant Pharmacist | Named in medication review deficiencies and lack of gradual dose reduction follow-up | |
| Medical Director | Physician | Named in medication order irregularities and oversight |
Inspection Report
Deficiencies: 1
Date: Feb 20, 2020
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control practices, specifically related to wound care and glove use.
Findings
The facility failed to ensure that a licensed nurse removed gloves and washed hands between wound care and repositioning a resident, risking cross contamination. Interviews with staff confirmed the improper glove use and hand hygiene practices.
Deficiencies (1)
Failure to ensure a licensed nurse removed gloves and washed hands after wound care before assisting with repositioning and adjusting bed linens, risking cross contamination.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN)/Treatment Nurse | Observed failing to remove gloves and wash hands between wound care and repositioning resident | |
| Registered Nurse (RN)/Infection Preventionist | Interviewed regarding proper glove use and hand hygiene |
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