Inspection Reports for
Diversicare of Big Springs
500 St Clair Ave SW, Huntsville, AL 35801, AL, 35801
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 11, 2023
Visit Reason
The inspection was conducted as a result of investigations of complaints/reports #AL00042602, #AL00043277, and others related to facility conditions, resident care, and food preferences.
Complaint Details
The deficiencies were cited as a result of investigations of complaints/reports #AL00042602 and #AL00043277.
Findings
The facility was found deficient in maintaining clean air conditioner vents with dust and debris in multiple resident rooms, failing to provide scheduled showers to a resident dependent on staff for bathing, and not honoring a resident's food preference to avoid noodles.
Deficiencies (3)
Air conditioner vents in eight of twelve observed rooms had accumulation of dust-like debris, food particles, and other foreign objects.
Resident Identifier #10, dependent on staff for bathing, was not provided a shower as scheduled on 05/09/2023.
Resident Identifier #10 was served spaghetti and meat sauce on 05/09/2023 despite a documented preference for no noodles.
Report Facts
Rooms with deficient air conditioner vents: 8
Residents sampled for ADL care: 9
Residents sampled for food preferences: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Interviewed regarding air conditioner vent cleanliness and responsibility. | |
| Administrator | Interviewed regarding oversight of air conditioner vent cleanliness and facility policy. | |
| Certified Nursing Assistant (CNA) | Assigned to care for Resident Identifier #10 on 05/09/2023; interviewed about shower provision. | |
| Director of Nursing (DON) | Interviewed regarding resident shower provision and food preference policies. | |
| Dietary Manager | Interviewed regarding honoring resident food preferences. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 11, 2023
Visit Reason
The inspection was conducted as a result of investigations of complaints/reports #AL00042602, #AL00043277, and another related to food preferences for Resident Identifier #10.
Complaint Details
The deficiencies were cited as a result of investigations of complaint/report #AL00042602 related to air conditioner vent cleanliness, and complaint/report #AL00043277 related to bathing care. Another complaint involved food preference violations for Resident Identifier #10.
Findings
The facility was found deficient in maintaining clean air conditioner vents in resident rooms, failing to provide scheduled showers to a resident dependent on staff for bathing, and not honoring a resident's food preference to avoid noodles. These deficiencies were supported by observations, interviews, and record reviews.
Deficiencies (3)
Facility failed to ensure air conditioner vents were free from dust-like debris, food particles, and foreign objects in eight of twelve observed rooms.
Facility failed to ensure Resident Identifier #10 was provided a shower as scheduled.
Facility failed to honor Resident Identifier #10's food preference of no noodles when served spaghetti and meat sauce.
Report Facts
Rooms with vent deficiencies: 8
Residents sampled for ADL care: 9
Residents sampled for food preferences: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Identified as responsible for maintaining air conditioner vents; interviewed regarding vent debris. | |
| Administrator | Interviewed regarding oversight of vent cleanliness and facility policy. | |
| Certified Nursing Assistant (CNA) | Assigned to Resident Identifier #10 on 05/09/2023; did not provide scheduled shower. | |
| Director of Nursing (DON) | Interviewed regarding resident shower rights and food preference importance. | |
| Dietary Manager | Interviewed regarding food preference violations for Resident Identifier #10. |
Inspection Report
Deficiencies: 2
Date: Jan 27, 2022
Visit Reason
The inspection was conducted to investigate grievances filed by residents and to assess compliance with respiratory care standards, including grievance process adherence and oxygen therapy equipment management.
Findings
The facility failed to follow its grievance process regarding missing resident clothing, specifically for Resident Identifier (RI) #149, where replacement clothes were purchased but not confirmed delivered. Additionally, the facility failed to ensure proper labeling and storage of oxygen tubing and nebulizer masks for RI #45, increasing infection risk.
Deficiencies (2)
Failed to ensure grievance process was followed for missing resident clothing; no documented follow-up with resident's sponsor.
Failed to ensure oxygen tubing and humidifier water bottle were dated and labeled, and nebulizer mask was stored uncovered, risking infection.
Report Facts
Residents affected: 3
Residents affected: 4
Date of grievance: Jul 30, 2021
Date of discharge: Jul 29, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #4 | Former Administrator | Named in grievance follow-up failure and mailing of jogging pants |
| EI #3 | Social Services Director | Named in purchasing jogging pants and grievance communication |
| EI #1 | Director of Nursing/Infection Preventionist | Interviewed regarding grievance and oxygen therapy deficiencies |
| EI #2 | Licensed Practical Nurse | Interviewed regarding oxygen tubing and nebulizer mask care |
Inspection Report
Deficiencies: 1
Date: Mar 26, 2021
Visit Reason
The inspection was conducted to evaluate compliance with training requirements for Certified Nursing Assistants (CNAs), specifically regarding the inclusion of Dementia Training in the required 12-hour annual training.
Findings
The facility failed to include Dementia Training in the required annual training for 2 of 9 CNAs reviewed. Interviews with staff confirmed that the CNAs had not received the required Dementia Training for 2020 due to issues with the training program and responsibility lapses.
Deficiencies (1)
Failure to include Dementia Training in the required 12-hour annual training for CNAs EI #1 and EI #2.
Report Facts
CNAs reviewed for Dementia Training: 9
CNAs affected: 2
Annual training hours required: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #1 | Certified Nursing Assistant | Named in deficiency for lack of Dementia Training |
| EI #2 | Certified Nursing Assistant | Named in deficiency for lack of Dementia Training |
| EI #9 | Director of Clinical Operations | Interviewed regarding Dementia Training deficiencies |
| EI #10 | Director of Nursing Services | Interviewed regarding Dementia Training deficiencies |
Inspection Report
Deficiencies: 6
Date: Jul 18, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, respiratory care, medication administration, food safety, medical record accuracy, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete timely quarterly resident assessments, improper documentation and changing of oxygen cannula tubing, a significant medication error involving discontinuation of an anticoagulant, food safety violations including potential backflow in sinks and expired milk, inconsistent code status documentation in medical records, and inadequate infection control practices by staff.
Deficiencies (6)
Failure to ensure a timely Minimal Data Set (MDS) quarterly assessment was completed for Resident Identifier #2.
Failure to ensure that oxygen cannula tubing was provided with a date when changed out by nursing for Resident Identifier #6.
Medication error where Resident Identifier #107's order for Eliquis was discontinued in error by nursing.
Food safety violations including lack of air gap in sink drain pipes creating potential for backflow, condensation dripping onto food assembly area, and expired milk in the milk cooler.
Failure to ensure consistent code status documentation for Resident Identifier #260 across medical records.
Failure to ensure proper infection prevention and control practices including failure of Certified Nursing Assistants to change gloves and wash hands appropriately during incontinence care for Residents #107 and #34.
Report Facts
Residents sampled: 24
Residents affected: 108
Drain pipe length: 0.5
Dates of milk expiration: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator, Registered Nurse | Interviewed regarding late quarterly MDS assessment for Resident #2 | |
| Registered Nurse/Unit Manager | Interviewed regarding oxygen tubing change and documentation | |
| Assistant Director of Nursing | Interviewed regarding oxygen tubing change policy and concerns | |
| Registered Nurse (RN)/Director of Nursing | Interviewed regarding medication error and infection control practices | |
| Dietary Manager | Interviewed regarding food safety violations including sink backflow, condensation, and expired milk | |
| Maintenance Assistant | Measured drain pipe length and interviewed about backflow risk | |
| Certified Nursing Assistant (CNA) | Observed and interviewed regarding improper glove use and hand hygiene during incontinence care | |
| Registered Nurse, Unit Manager | Interviewed regarding inconsistent code status documentation and chart checks |
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