Inspection Reports for
Diversicare of Foley
1701 North Alston Street, Foley, AL, 36535
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
47% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jun 19, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about activities of daily living care, respiratory care, pain management, side rail use, and kitchen sanitation at Diversicare of Foley.
Complaint Details
This inspection was conducted as a result of the investigation of complaint/report number AL00042995.
Findings
The facility was found deficient in providing adequate ADL care including nail care, administering oxygen at prescribed flow rates with proper equipment maintenance, obtaining physician orders for ice therapy for pain management, ensuring informed consent for side rail use, and maintaining kitchen cleanliness and sanitation.
Deficiencies (5)
Failed to ensure activities of daily living (ADL) were provided to ensure good grooming for Resident #18, specifically fingernail trimming.
Failed to ensure oxygen was administered at the prescribed flow rate, handheld updraft nebulizer masks were covered when not in use, and oxygen concentrator humidifier bottles were sufficiently filled for Residents #25 and #92.
Failed to ensure nursing staff sought a physician order for ice therapy for Resident #169 for pain management.
Failed to ensure risks and benefits of side rails were reviewed and informed consent obtained prior to use for Resident #100.
Failed to maintain food storage/preparation items in a clean and sanitary condition and failed to provide evidence of a routine cleaning schedule for the kitchen.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Clinical Operations | Director of Clinical Operations (DCO) | Interviewed regarding ADL care and respiratory care deficiencies |
| Certified Nursing Assistant #2 | CNA | Interviewed regarding responsibility for nail care |
| Certified Nursing Assistant #7 | CNA | Interviewed regarding nail care responsibilities |
| Licensed Practical Nurse #19 | LPN | Interviewed regarding oxygen administration and respiratory care deficiencies |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding expectations for nail care, oxygen administration, and side rail consent |
| Registered Nurse #26 | RN | Interviewed regarding ice therapy order for pain management |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding ice therapy order for pain management |
| Registered Nurse #29 | RN, former Director of Nursing | Interviewed regarding ice therapy order for pain management |
| Administrator | Administrator | Interviewed regarding expectations for nail care, oxygen administration, ice therapy orders, side rail consent, and kitchen cleanliness |
| Regional Certified Dietary Manager | RCDM | Interviewed regarding kitchen cleaning schedule and sanitation deficiencies |
Inspection Report
Complaint Investigation
Census: 134
Deficiencies: 4
Date: Oct 10, 2019
Visit Reason
The inspection was conducted due to complaint-related concerns regarding food handling practices, infection prevention, and control procedures at the facility.
Complaint Details
The visit was complaint-related focusing on food handling and infection control practices. The complaint was substantiated based on observations and interviews confirming deficient practices.
Findings
The facility was found deficient in food handling practices including a CNA touching resident's food with bare hands, wet nesting of utensils, and improper plumbing connections risking cross contamination. Additionally, a CNA failed to wash hands between glove changes during incontinence care, posing infection control risks.
Deficiencies (4)
CNA used bare hands to handle resident's toast during breakfast meal.
Wet nesting of utensils observed with pans, spoons, knives, and forks stacked wet without air drying.
No air gap observed at 3-compartment sink plumbing, creating direct connection to sewer system.
CNA failed to wash hands between glove changes during incontinence care.
Report Facts
Resident census: 134
Wet utensils observed: 57
Residents fed by feeding tube: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) | EI #5 touched resident's toast with bare hands during breakfast meal | |
| Infection Control Nurse | EI #3 provided expert interview on proper food handling and hand hygiene | |
| Regional Dietitian | EI #8 interviewed regarding wet nesting and plumbing issues | |
| Dietary Supervisor | EI #7 acknowledged no air gap at 3-compartment sink | |
| Maintenance Supervisor | EI #10 stated direct plumbing connection to sewer system | |
| Certified Nursing Assistant (CNA) | EI #6 failed to wash hands between glove changes during incontinence care |
Inspection Report
Complaint Investigation
Capacity: 35
Deficiencies: 7
Date: Aug 4, 2018
Visit Reason
Investigation of multiple resident-on-resident abuse incidents on the secured Alzheimer's Care Unit following a complaint received by the Alabama State Survey Agency.
Complaint Details
Complaint received by the Alabama State Survey Agency regarding resident-on-resident altercations on the dementia unit, including multiple incidents of physical abuse by residents RI #49 and RI #84 against other residents.
Findings
The facility failed to protect residents from abuse by other residents, failed to report and investigate abuse allegations properly, failed to provide adequate behavioral health care and staff training, and failed to implement effective quality assurance and administrative oversight. These failures placed residents in immediate jeopardy for serious injury, harm, or death.
Deficiencies (7)
Failure to protect residents from all types of abuse including physical abuse by other residents on the secured Alzheimer's Care Unit.
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, including failure to report allegations of abuse to the appropriate authorities.
Failure to timely report suspected abuse, neglect, or theft and report the results of investigations to proper authorities.
Failure to respond appropriately to all alleged violations, including failure to investigate allegations of abuse.
Failure of administration to identify incidents of resident/resident altercations as abuse and failure to implement abuse policy and educate staff accordingly.
Failure to conduct and document a facility-wide assessment addressing care and services, and staff competencies necessary for the secured Alzheimer's Care Unit.
Failure to set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, including failure to review repeated incidents of resident abuse.
Report Facts
Residents affected: 28
Total capacity: 35
Staff trained: 135
Staff total: 128
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing Service | Failed to report abuse allegations, investigate incidents, and educate staff properly. | |
| Administrator | Failed to identify incidents as abuse, failed to implement abuse policy, and gave instructions to staff to avoid reporting abuse. | |
| Regional President of Operations | Failed to provide oversight and was unaware of facility issues related to abuse. | |
| Unit Manager/Memory Care Director | Responsible for behavior management but lacked systems to track behaviors and failed to review behavior charting. | |
| Licensed Practical Nurse | Witnessed abuse incidents and reported them but was told by administration to avoid labeling incidents as abuse. | |
| Certified Nursing Assistants | Instructed by administration not to report or document abuse accurately. | |
| Senior Director of Clinical Operations | Assumed interim DNS role and provided training and oversight after deficiencies were identified. |
Report
June 19, 2023
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