Inspection Reports for
Diversicare of Oneonta
215 Valley Road, Oneonta, AL, 35121
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
3% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of resident-to-resident sexual abuse occurring on 2023-01-14 involving Resident #21 and Resident #2, focusing on the facility's failure to implement abuse policies and procedures.
Complaint Details
The complaint investigation was related to report #AL00043048 concerning resident-to-resident sexual abuse on 2023-01-14. The allegation was substantiated, with findings that staff failed to protect residents and report the incident immediately, causing immediate jeopardy to resident health and safety.
Findings
The facility failed to ensure staff reported and responded appropriately to the sexual abuse allegation, resulting in immediate jeopardy to resident health and safety. Staff did not separate the residents or report the incident timely, and corrective actions were implemented only after several days, including staff termination and mandatory in-service training.
Deficiencies (1)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, and failure to report and respond to an allegation of resident-to-resident sexual abuse in a timely manner.
Report Facts
Date of incident: Jan 14, 2023
Date incident reported to Administrator: Jan 16, 2023
Date of survey completion: Jul 23, 2023
BIMS score Resident #21: 4
BIMS score Resident #2: 12
BIMS score Resident #2 follow-up: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Observed the abuse incident but failed to take immediate protective action and delayed reporting |
| LPN #3 | Licensed Practical Nurse | Responded to CNA #2's report but did not report the incident or separate residents |
| RN #4 | Registered Nurse | Was informed about the incident but did not report it |
| CNA #37 | Certified Nursing Assistant | Aware of the incident but did not report it |
| CNA #1 | Certified Nursing Assistant | Reported the incident to the Administrator on 2023-01-16 |
| Administrator | Interim Administrator | Notified of the incident on 2023-01-16 and provided statements on staff failures and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jul 23, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of resident-to-resident sexual abuse that occurred on 01/14/2023 involving Resident #21 and Resident #2, and failure of staff to report and prevent further abuse.
Complaint Details
The complaint investigation was triggered by an allegation of resident-to-resident sexual abuse on 01/14/2023 involving Resident #21 and Resident #2. The facility failed to report the incident immediately and did not protect residents from further abuse until 01/20/2023. The Immediate Jeopardy began on 01/14/2023 and was abated on 01/20/2023 after corrective actions were implemented.
Findings
The facility failed to implement its abuse policies and procedures by not immediately reporting the sexual abuse allegation and not protecting residents from further potential abuse. Staff delayed reporting the incident to the Administrator for two days, during which the residents remained roommates without protective measures. Corrective actions were implemented by 01/20/2023, including staff termination and in-service training. Additional deficiencies included failure to complete PASARR screenings after new mental illness diagnoses, failure to provide treatment per physician orders for compression bandages, failure to ensure vision services per physician orders, and failure to document clinical rationale for continuing PRN psychotropic medication beyond 14 days.
Deficiencies (6)
Failure to develop and implement policies and procedures to prevent abuse, neglect, and theft, specifically failure to report and protect residents from resident-to-resident sexual abuse.
Failure to complete a new PASARR Level I after a resident was diagnosed with a new mental illness.
Failure to update PASARR screening with newly developed mental illness for a resident.
Failure to provide treatment per physician's orders for compression bandages for edema.
Failure to ensure resident was seen by in-house optometrist as ordered by physician.
Failure to ensure physician documented clinical rationale for continuing PRN psychotropic medication beyond 14 days and failure to indicate duration on PRN order.
Report Facts
Deficiencies cited: 6
Residents affected: 2
Dates of incident: Jan 14, 2023
Dates of reporting: Jan 16, 2023
Dates of corrective actions: Jan 20, 2023
BIMS scores: 4
BIMS scores: 12
BIMS scores: 8
PRN Xanax days administered: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #2 | Observed the sexual abuse incident but failed to take immediate protective action and delayed reporting. | |
| Licensed Practical Nurse (LPN) #3 | Observed the incident, instructed resident to return to bed, but failed to report the incident. | |
| Registered Nurse (RN) #4 | Was informed about the incident but did not report it. | |
| Certified Nursing Assistant (CNA) #37 | Aware of the incident but did not report it. | |
| Certified Nursing Assistant (CNA) #1 | Reported the incident to the Administrator on 01/16/2023. | |
| Interim Administrator | Notified of immediate jeopardy findings and oversaw corrective actions. | |
| Director of Nursing (DON) | Notified of immediate jeopardy findings and oversaw corrective actions. | |
| Licensed Practical Nurse (LPN) #11 | Documented treatment of compression bandages that were not provided. | |
| Social Services (SS) | Responsible for PASARR assessments and optometrist scheduling. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Dec 10, 2019
Visit Reason
The inspection was conducted based on complaints regarding failure to provide privacy during medication administration and failure to follow infection prevention and control procedures.
Complaint Details
The complaint investigation found substantiated issues related to privacy violations during medication administration and inadequate infection control practices by licensed nurses.
Findings
The facility failed to ensure privacy for Resident Identifier #20 during medication administration by a licensed nurse who left the door and privacy curtain open. Additionally, the facility failed to ensure a Licensed Practical Nurse removed gloves and performed hand hygiene between administering oral medications and a nebulizer treatment for Resident Identifier #61.
Deficiencies (2)
Failure to provide privacy during medication administration for Resident Identifier #20.
Failure to remove gloves and perform hand hygiene between oral medication administration and nebulizer treatment for Resident Identifier #61.
Report Facts
Residents observed during medication administration: 4
Licensed nurses observed during medication administration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse | EI #1 observed failing to provide privacy during medication administration for RI #20 | |
| Licensed Practical Nurse | EI #3 observed failing to remove gloves and perform hand hygiene between medication administration and nebulizer treatment for RI #61 | |
| Infection Control Preventionist/Registered Nurse | EI #4 interviewed regarding hand hygiene policy and concerns |
Inspection Report
Routine
Deficiencies: 2
Date: Oct 25, 2018
Visit Reason
The inspection was conducted to assess compliance with infection prevention and control practices, specifically focusing on peri-care procedures and hand hygiene during medication administration and incontinent care.
Findings
The facility failed to ensure proper peri-care technique to prevent cross contamination, as a staff member wiped from back to front instead of front to back, risking urinary tract infections. Additionally, staff did not turn off faucets with a clean paper towel after handwashing, increasing the risk of bacterial contamination.
Deficiencies (2)
Failure to provide peri-care in a manner to prevent cross contamination by wiping from back to front instead of front to back.
Failure to implement infection prevention and control program, including improper hand hygiene such as turning off faucets with bare hands and wiping front to back during peri-care.
Report Facts
Residents observed during peri care: 2
Residents observed during medication pass: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee Identifier #3 wiped resident from back to front during peri-care | ||
| Infection Control Nurse | Employee Identifier #2 interviewed regarding proper hand hygiene and peri-care | |
| Employee Identifier #1 observed turning faucet off with bare hands after medication administration |
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