Inspection Reports for
Diversicare of Montgomery

AL, 36106

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 12.7 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

253% worse than Alabama average
Alabama average: 3.6 deficiencies/year

Deficiencies per year

16 12 8 4 0
2019
2021
2023

Occupancy

Latest occupancy rate 78% occupied

Based on a April 2023 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy rate over time

70% 77% 84% 91% 98% 105% Dec 2019 Apr 2023

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Aug 9, 2023

Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Aug 9, 2023

Visit Reason
Annual inspection survey conducted to assess compliance with health and safety regulations at Diversicare of Montgomery.

Findings
No health deficiencies were found during the inspection.

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Apr 5, 2023

Visit Reason
The inspection was conducted as a result of investigations of multiple complaints regarding the facility's failure to provide scheduled showers to Resident Identifier #43 and other concerns related to food safety and equipment maintenance.

Complaint Details
The investigation was triggered by complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969 concerning failure to provide scheduled showers to Resident Identifier #43 and other facility deficiencies.
Findings
The facility failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled. Additionally, the facility had issues with food safety including cross contamination risks from dirty kitchen equipment and vents, lack of temperature monitoring in refrigerators used for resident food, and maintenance problems with the walk-in freezer door causing ice buildup and potential safety hazards.

Deficiencies (4)
Failed to ensure Resident Identifier #43 received showers as scheduled on multiple dates.
Failed to prevent potential cross contamination due to dust build-up on ceiling vents and dirty blade on manual can opener.
Failed to ensure a temperature monitored refrigerator was available for staff to place food items brought in by family/friends for residents.
Failed to maintain walk-in freezer in proper operating condition; door would not close securely causing ice/frost build-up and safety hazards.
Report Facts
Residents affected: 1 Residents affected: 107 Dates of missed showers: 2

Employees mentioned
NameTitleContext
CNAEmployee Identifier #4 CNA did not give baths/showers to Resident #43 due to misunderstanding.
Director of NursingEmployee Identifier #2 DON confirmed shower schedule and lack of showers for Resident #43.
Dietary AideEmployee Identifier #12 Dietary Aide acknowledged can opener was not cleaned properly.
District ManagerEmployee Identifier #11 District Manager noted cross contamination risk from dirty can opener and vents.
Maintenance AssistantEmployee Identifier #7 Maintenance Assistant discussed maintenance requests and cleaning schedules.
Dietary Manager/Account ManagerEmployee Identifier #6 Dietary Manager discussed dust build-up, can opener cleaning, and refrigerator temperature monitoring.
Licensed Practical NurseEmployee Identifier #8 LPN reported lack of nourishment refrigerator and handling of resident snacks.
Activity AssistantEmployee Identifier #9 Activity Assistant reported no nourishment refrigerator on North Hall.
Unit ManagerEmployee Identifier #3 Unit Manager discussed procedures for handling food brought by family/friends.
AdministratorEmployee Identifier #1 Administrator confirmed lack of thermometer and temperature logs in staff break room refrigerator.
Dietary AideEmployee Identifier #13 Dietary Aide unable to close walk-in freezer door properly.

Inspection Report

Complaint Investigation
Census: 108 Deficiencies: 4 Date: Apr 5, 2023

Visit Reason
The inspection was conducted as a result of complaint investigations regarding multiple issues including failure to make survey results available, failure to provide scheduled showers to a resident, food safety concerns, and equipment maintenance problems.

Complaint Details
The deficient practice regarding Resident Identifier #43's missed showers was cited as a result of the investigation of complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969.
Findings
The facility failed to ensure survey results were available for residents, did not provide scheduled showers to a resident, had food safety risks due to unclean equipment and lack of temperature monitoring for resident food storage, and had maintenance issues with the walk-in freezer door causing ice buildup and potential safety hazards.

Deficiencies (4)
Failed to ensure survey results for the last three years were available for residents or visitors to review.
Failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled for Activities of Daily Living.
Failed to prevent potential cross contamination due to dust build-up on ceiling vents and a dirty blade on the manual can opener; failed to ensure a temperature monitored refrigerator was available for staff to store food items brought in by family/friends.
Failed to maintain the walk-in freezer in proper operating condition, with door not closing securely and ice/frost build-up present.
Report Facts
Residents affected: 108 Residents affected: 107 Residents affected: 1 Residents sampled for ADL: 8 Surveys missing: 6

Employees mentioned
NameTitleContext
AdministratorResponsible for maintaining the survey binder
Employee Identifier (EI) #4 CNAInterviewed regarding bathing/showering practices for Resident #43
Employee Identifier (EI) #2 Director of Nursing (DON)Interviewed regarding shower schedule and ADL documentation for Resident #43
Employee Identifier (EI) #12 Dietary AideInterviewed about cleaning of manual can opener
Employee Identifier (EI) #11 District ManagerContract food company representative, commented on can opener and ceiling vents
Employee Identifier (EI) #7 Maintenance AssistantInterviewed about maintenance requests and cleaning schedules
Employee Identifier (EI) #6 Dietary Manager/Account ManagerInterviewed about dust build-up, can opener cleaning, and refrigerator temperature monitoring
Employee Identifier (EI) #8 Licensed Practical Nurse (LPN)Interviewed about nourishment refrigerator absence
Employee Identifier (EI) #9 Activity AssistantInterviewed about nourishment refrigerator absence and food storage
Employee Identifier (EI) #3 Unit Manager South HallInterviewed about food storage procedures and refrigerator issues
Employee Identifier (EI) #13 Dietary AideInterviewed about walk-in freezer door issue

Inspection Report

Complaint Investigation
Deficiencies: 4 Date: Apr 5, 2023

Visit Reason
The inspection was conducted as a result of complaint investigations regarding failure to provide scheduled showers to Resident Identifier #43 and other facility concerns.

Complaint Details
The deficient practice regarding failure to provide showers to Resident Identifier #43 was cited as a result of the investigation of complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969.
Findings
The facility failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled. Additionally, the facility had issues with food safety including cross contamination risks from dirty kitchen equipment and vents, lack of temperature monitoring in refrigerators used for resident food, and maintenance problems with the walk-in freezer door causing ice buildup and potential safety hazards.

Deficiencies (4)
Failure to provide scheduled showers to Resident Identifier #43 as documented in ADL sheets and resident interviews.
Cross contamination potential due to dust build-up on ceiling vents and dirty blade on manual can opener in the kitchen.
No temperature monitored refrigerator available for staff to store food items brought in by family/friends, risking food-borne illness.
Walk-in freezer door not closing securely causing ice/frost build-up and potential safety hazards.
Report Facts
Residents affected: 1 Residents affected: 107 Residents affected: 8

Employees mentioned
NameTitleContext
CNAEmployee Identifier #4 CNA admitted not giving baths/showers to RI #43 due to assumption resident bathed independently
Director of NursingEmployee Identifier #2 DON confirmed shower schedule and lack of showers for RI #43
Dietary AideEmployee Identifier #12 Dietary Aide acknowledged manual can opener was not cleaned properly
District ManagerEmployee Identifier #11 District Manager for contract food company noted cross contamination risks and assisted with can opener cleaning
Maintenance AssistantEmployee Identifier #7 Maintenance Assistant discussed maintenance requests and cleaning schedules
Dietary Manager/Account ManagerEmployee Identifier #6 Dietary Manager discussed dust build-up, can opener cleaning, and refrigerator temperature monitoring issues
Licensed Practical NurseEmployee Identifier #8 LPN reported lack of nourishment refrigerator and food distribution practices
Activity AssistantEmployee Identifier #9 Activity Assistant reported lack of nourishment refrigerator on North Hall
Unit ManagerEmployee Identifier #3 Unit Manager for South Hall discussed food storage procedures and refrigerator issues
AdministratorEmployee Identifier #1 Administrator discussed refrigerator use and food safety concerns
Dietary AideEmployee Identifier #13 Dietary Aide unable to close walk-in freezer door properly

Inspection Report

Complaint Investigation
Census: 108 Deficiencies: 4 Date: Apr 5, 2023

Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaint/report numbers regarding failure to provide scheduled showers, missing survey reports, and food safety concerns.

Complaint Details
The complaint investigation was triggered by complaint/report numbers AL00042152, AL00042579, AL00042786, and AL00042969 related to failure to provide scheduled showers and other care concerns.
Findings
The facility failed to ensure survey results for the last three years were available for residents, failed to provide scheduled showers to a resident, had food safety issues including cross contamination risks from dirty kitchen equipment and lack of temperature monitoring for resident food storage, and had maintenance issues with the walk-in freezer door causing frost build-up and safety hazards.

Deficiencies (4)
Failed to ensure survey results for the last three years were available for residents or visitors to review.
Failed to ensure Resident Identifier #43 received showers as scheduled, affecting one of eight residents sampled.
Failed to prevent potential cross contamination due to dust build-up on ceiling vents and dirty blade on manual can opener; failed to ensure temperature monitored refrigerator was available for resident food storage.
Failed to maintain walk-in freezer in proper operating condition; door did not close securely causing ice/frost build-up and safety hazards.
Report Facts
Residents affected by missing survey results: 108 Residents affected by shower deficiency: 1 Residents affected by food safety deficiencies: 107

Employees mentioned
NameTitleContext
AdministratorResponsible for maintaining the survey binder and interviewed regarding missing survey reports and food storage refrigerator.
Director of Nursing (DON)Interviewed regarding shower schedule and ADL documentation for Resident #43.
CNA (Employee Identifier #4)Interviewed about bathing care provided to Resident #43.
Dietary Aide (Employee Identifier #12)Interviewed about cleaning of manual can opener.
District Manager (Employee Identifier #11)Contract food company representative interviewed about kitchen equipment and walk-in freezer door.
Maintenance Assistant (Employee Identifier #7 and #9)Interviewed about maintenance requests and cleaning schedules for kitchen equipment and walk-in freezer door.
Dietary Manager/Account Manager (Employee Identifier #6)Interviewed about kitchen equipment cleaning, food storage, and walk-in freezer door issues.
Unit Manager for South Hall (Employee Identifier #3)Interviewed about handling of food brought in by family/friends and nourishment refrigerators.
Licensed Practical Nurse (LPN) (Employee Identifier #8)Interviewed about nourishment refrigerator and food storage.
Activity Assistant (Employee Identifier #9)Interviewed about nourishment refrigerator and food storage.

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Jul 22, 2021

Visit Reason
The inspection was conducted due to an allegation of verbal abuse by a Certified Nursing Assistant (EI #4) toward Resident Identifier #22 on 4/19/2021, which was reported to the State Agency and investigated by the facility.

Complaint Details
The complaint involved verbal abuse of resident RI #22 by CNA EI #4 on 4/19/21 at 2:00 AM. The allegation was substantiated based on statements from two employees (EI #2 LPN and EI #3 CNA) who witnessed the incident, the resident's statement, and the Director of Nursing's investigation. EI #4 was terminated due to the substantiated verbal abuse.
Findings
The facility substantiated the allegation of verbal abuse where EI #4 was heard cursing at RI #22, causing emotional distress. Additionally, the facility failed to ensure proper hand hygiene and sanitization procedures in the dietary department, including improper hand washing by dietary staff and insufficient sanitizing time for pots and pans.

Deficiencies (3)
Verbal abuse of resident RI #22 by CNA (EI #4) using profanity and unacceptable language.
Dietary staff failed to wash hands properly after touching dirty dishes and before touching clean dishes.
Dietary staff failed to properly sanitize metal cook wares by not immersing them in sanitizing solution for the recommended time.
Report Facts
Residents affected by verbal abuse: 1 Residents affected by dietary deficiencies: 69 Sanitizing contact time required: 7 Sanitizing contact time observed: 2 Sanitizing contact time observed: 3 Hand dip time in sanitizer: 5 Date of verbal abuse incident: Apr 19, 2021

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN)EI #2 witnessed verbal abuse and intervened
Certified Nursing Assistant (CNA)EI #3 witnessed verbal abuse
Certified Nursing Assistant (CNA)EI #4 alleged perpetrator of verbal abuse
Director of Nursing (DON)EI #1 conducted investigation and substantiated verbal abuse
Dietary AidEI #7 observed improperly sanitizing pots and pans
Dietary AidEI #8 observed touching dirty and clean dishes without proper hand washing
DietitianEI #6 interviewed about sanitizing procedures
Dietary Manager, Account ManagerEI #5 interviewed about dietary staff practices and policies

Inspection Report

Complaint Investigation
Deficiencies: 3 Date: Jul 22, 2021

Visit Reason
The inspection was conducted due to a complaint alleging verbal abuse of Resident Identifier (RI) #22 by Employee Identifier (EI) #4, a Certified Nursing Assistant (CNA), on 4/19/2021 at 2:00 AM.

Complaint Details
The complaint was substantiated. The verbal abuse allegation against EI #4 was confirmed by statements from multiple employees and the resident. EI #4 was terminated due to the substantiated verbal abuse.
Findings
The facility substantiated the allegation of verbal abuse against EI #4, who was heard cursing at RI #22. The CNA was terminated due to this behavior. Additionally, the facility failed to ensure proper hand hygiene and sanitization procedures in the dietary department, including improper hand washing by dietary staff and insufficient sanitizing time for pots and pans.

Deficiencies (3)
Verbal abuse of resident RI #22 by CNA EI #4 using profanity and unacceptable language.
Dietary staff failed to wash hands after touching dirty dishes and before touching clean dishes.
Dietary staff improperly sanitized metal cook wares by not immersing them in sanitizing solution for the required time.
Report Facts
Residents affected: 1 Residents affected: 69 Sanitizing time required: 7 Sanitizing time observed: 2 Sanitizing time reported: 60 Sanitizing time observed: 3 Sanitizing time observed: 5 Sanitizing time observed: 10

Employees mentioned
NameTitleContext
EI #4Certified Nursing Assistant (CNA)Named in verbal abuse finding and terminated for the incident
EI #2Licensed Practical Nurse (LPN)Witnessed verbal abuse and intervened during incident
EI #3Certified Nursing Assistant (CNA)Witnessed verbal abuse incident
EI #1Director of Nursing (DON)Conducted interviews and substantiated verbal abuse allegation
EI #7Dietary AidObserved improperly sanitizing pots and pans
EI #8Dietary AidObserved failing to wash hands properly between handling dirty and clean dishes
EI #5Dietary Manager, Account ManagerInterviewed regarding dietary hand hygiene and sanitization policies
EI #6DietitianInterviewed regarding sanitizing procedures and times

Inspection Report

Complaint Investigation
Census: 115 Deficiencies: 8 Date: Dec 5, 2019

Visit Reason
The inspection was conducted based on complaints received by the Alabama State Survey Agency regarding multiple deficiencies including failure to provide discharge notices, bed hold notices, and refusal to allow a resident to return after hospitalization.

Complaint Details
The complaint investigation was triggered by allegations that the facility discharged resident #264 without providing a 30-day notice, failed to provide bed hold notice, and refused to accept the resident back after hospitalization. The investigation confirmed these deficiencies.
Findings
The facility was found deficient in multiple areas including privacy breaches during medication administration, unsafe environmental conditions, failure to provide timely discharge and bed hold notices, refusal to allow a resident to return after hospitalization, unsafe storage of sharps, expired medications in storage, and improper food storage practices.

Deficiencies (8)
Failed to ensure resident's personal information was not visible during medication administration.
Failed to ensure vents did not hang down from bathroom ceilings in two resident rooms.
Failed to issue a 30-day notice of discharge to resident #264 upon discharge.
Failed to provide written notice specifying bed hold duration and conditions to resident #264 upon transfer to hospital.
Failed to allow resident #264 to return to the facility after hospitalization.
Sharps box in shower room was full with razors protruding, posing injury risk.
Medication storage room contained expired medication prescribed for resident #265.
Styrofoam cup was stored inside the flour bin in the kitchen, risking cross contamination.
Report Facts
Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 110 Residents affected: 115 Sharps protruding: 5 Expired medication containers: 3

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN) Unit ManagerHandled discharge of resident #264 and documented progress notes
Director of Nursing Service (DNS)Made decision to not allow resident #264 to return to facility
Social Service DirectorInterviewed regarding discharge process for resident #264
Social Services AssistantInterviewed regarding discharge process for resident #264
Business Office ManagerResponsible for issuing bed hold notices, did not issue notice for resident #264
Registered Nurse (RN) Unit ManagerInterviewed regarding sharps box hazard
Registered NurseAcknowledged expired medication in storage
Evening CookObserved Styrofoam cup in flour bin

Inspection Report

Complaint Investigation
Census: 115 Deficiencies: 8 Date: Dec 5, 2019

Visit Reason
The inspection was conducted based on complaints received by the Alabama State Survey Agency regarding multiple deficiencies including failure to provide proper discharge notices, bed hold notices, and refusal to allow a resident to return after hospitalization.

Complaint Details
The complaint investigation focused on allegations that the facility discharged resident #264 without proper notice, failed to provide bed hold notices, and refused to accept the resident back after hospitalization. The investigation confirmed these deficiencies and cited the facility accordingly.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy during medication administration, unsafe environmental conditions such as hanging vents and full sharps boxes, failure to provide timely discharge and bed hold notices to a resident, refusal to allow a resident to return after hospitalization, storage of expired medications, and improper food storage practices.

Deficiencies (8)
Failed to ensure resident's personal information was not visible during medication administration.
Failed to ensure vents did not hang down from bathroom ceilings in two resident bathrooms.
Failed to issue a 30-day notice of discharge to resident #264 upon discharge.
Failed to provide written notice of bed hold policy and duration to resident #264 upon transfer to hospital.
Failed to allow resident #264 to return to the facility after hospitalization.
Sharps box in shower room was full with razors protruding, posing injury risk.
Medication storage room contained expired medication prescribed for resident #265.
Styrofoam cup was stored inside the flour bin in the kitchen, risking cross contamination.
Report Facts
Residents affected: 6 Rooms with hanging vents: 2 Residents affected: 1 Residents affected: 1 Residents affected: 1 Razors protruding: 5 Expired medication containers: 3 Resident census: 115 Residents fed by tube feeding: 5

Employees mentioned
NameTitleContext
Licensed Practical Nurse (LPN)EI #6 named in privacy violation during medication administration
Director of Nursing ServiceEI #2 interviewed regarding privacy and discharge decisions
Housekeeping SupervisorEI #5 interviewed about hanging vents
Social Service DirectorEI #15 interviewed regarding discharge process
Social Services AssistantEI #14 interviewed regarding discharge process
LPN Unit ManagerEI #4 responsible for resident #264 discharge
MDS CoordinatorsEI #20 and EI #21 interviewed about discharge planning
Business Office ManagerEI #16 interviewed about bed hold notice issuance
Registered Nurse (RN) Unit ManagerEI #3 interviewed about sharps box hazard
Registered NurseEI #20 interviewed about expired medication
Evening CookEI #7 interviewed about food storage violation

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