Inspection Reports for
Diversicare of Riverchase
2500 River Haven Dr, Birmingham, AL 35244, Birmingham, AL, 35244
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
81% worse than Alabama average
Alabama average: 3.6 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations involving allegations of misappropriation of resident property, missed physician appointments, medication administration issues, inaccurate resident assessments, incomplete care plans, pressure ulcer care deficiencies, and inaccurate documentation.
Complaint Details
This deficiency report was cited as a result of investigations of complaint/report numbers AL00042818, AL00043987, and AL00043925.
Findings
The facility was found deficient in protecting resident property, ensuring accurate resident assessments and care plans, following physician orders including missed appointments and oxygen therapy, proper medication administration and documentation, and providing appropriate pressure ulcer care. Several residents were affected by these deficiencies, with issues ranging from missing personal belongings to falsified medical records.
Deficiencies (8)
Failed to protect Resident Identifier (RI) #5 from misappropriation of resident property when personal belongings were placed in an unlocked closet and went missing.
Failed to ensure Resident Identifier (RI) #15's Quarterly Minimum Data Set (MDS) assessment accurately reflected continuous oxygen use.
Failed to implement care plan interventions for Resident Identifier (RI) #4's padded side rails and failed to develop oxygen and pressure ulcer care plans for Resident Identifier (RI) #14.
Failed to ensure licensed nurses did not leave medications unattended at the bedside of Resident Identifier (RI) #2.
Missed cardiology appointment for Resident Identifier (RI) #1 despite physician orders and lack of communication among staff.
Failed to provide appropriate pressure ulcer care for Resident Identifier (RI) #14, including failure to elevate heels and prevent worsening of a Stage II pressure ulcer.
Failed to accurately document administration of pain medication for Resident Identifier (RI) #2, with discrepancies between narcotic log and medication administration record (MAR).
Falsified documentation of oxygen administration for Resident Identifier (RI) #14 when oxygen was not being administered.
Report Facts
Deficiencies cited: 8
Norco doses signed out: 76
Norco doses documented: 13
Pressure ulcer measurement length: 5.4
Pressure ulcer measurement width: 3.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Care Coordinator | Interviewed regarding missing personal belongings of Resident Identifier #5. | |
| Director of Nursing (DON) | Interviewed regarding missing personal belongings of Resident Identifier #5, care plan deficiencies, medication administration, and oxygen therapy documentation. | |
| Administrator | Interviewed regarding missing personal belongings of Resident Identifier #5 and medication administration issues. | |
| MDS Assistant | Interviewed regarding inaccurate MDS assessment for Resident Identifier #15 and care plan development for Resident Identifier #14. | |
| Registered Nurse (RN)/Unit Manager | Interviewed regarding care plan implementation for Resident Identifier #4 and medication administration. | |
| Licensed Practical Nurse (LPN)/Minimum Data Set (MDS) Assistant | Interviewed regarding care plan development for Resident Identifier #14. | |
| Nurse Practitioner | Interviewed regarding pressure ulcer care for Resident Identifier #14. | |
| Registered Nurse (RN)/Assistant Director of Nursing (ADON) | Interviewed regarding medication administration and oxygen therapy documentation. | |
| Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and oxygen therapy documentation. | |
| Social Service Director | Interviewed regarding missed cardiology appointment for Resident Identifier #1. |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Apr 28, 2023
Visit Reason
The inspection was conducted as a result of complaint investigations regarding multiple issues including failure to include residents and representatives in care planning, misappropriation of resident property, medication administration concerns, missed physician appointments, and inadequate discharge planning.
Complaint Details
This deficiency was cited as a result of investigations of complaint/report numbers AL00042883, AL00042818, AL00043987, and AL00043925.
Findings
The facility failed to ensure resident participation in care planning, protect resident belongings, accurately assess residents, develop timely comprehensive care plans, administer medications properly, follow physician orders for oxygen and appointments, and create individualized discharge plans. Multiple residents were affected with minimal harm or potential for actual harm.
Deficiencies (9)
Failure to include residents and representatives in care planning meetings for Resident Identifiers #3 and #10.
Failure to protect Resident Identifier #5's personal belongings resulting in misappropriation when items were placed in an unlocked closet and went missing.
Inaccurate coding of Resident Identifier #15's Quarterly Minimum Data Set assessment regarding continuous oxygen use.
Failure to develop a comprehensive care plan timely for Resident Identifier #3.
Failure to ensure medications were not left unattended at bedside for Resident Identifier #2, resulting in medications being left in a bottle in the resident's room.
Failure to follow physician orders for continuous oxygen use for Resident Identifier #14.
Failure to follow physician orders for cardiology appointment for Resident Identifier #1, resulting in missed appointment.
Failure to provide evidence of removal and reapplication of Scopolamine patch as ordered for Resident Identifier #4.
Failure to develop individualized discharge plans for Resident Identifiers #3, #10, and #16.
Report Facts
Residents sampled for abuse concerns: 3
Residents sampled for MDS assessments: 17
Residents sampled for comprehensive care plans: 3
Medications observed in resident's bottle: 6
Oxygen order liters per minute: 3
Missed appointment date: Apr 10, 2023
Scopolamine patch application interval: 72
Residents sampled for discharge planning: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Responsible for scheduling care plan meetings and discharge planning; interviewed regarding care plan meeting scheduling and discharge planning. | |
| Director of Care Coordination | Interviewed regarding scheduling care plan meetings and discharge planning responsibilities. | |
| Licensed Practical Nurse, Minimum Data Set and Care Plan Assistant | Interviewed regarding care plan development, MDS assessments, and discharge planning. | |
| Director of Nursing | Interviewed regarding care plan meetings, medication administration, and missed appointments. | |
| Administrator | Interviewed regarding medication administration concerns and observations. | |
| Registered Nurse/Assistant Director of Nursing | Interviewed regarding medication administration and oxygen order compliance. | |
| Licensed Practical Nurse | Interviewed regarding medication administration and oxygen order compliance. | |
| Certified Nursing Assistant/Medication Aide | Interviewed regarding medication administration and documentation of Scopolamine patch application. | |
| Registered Nurse/Unit Manager | Interviewed regarding medication administration and documentation of Scopolamine patch application. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 1, 2021
Visit Reason
The inspection was conducted due to a complaint regarding improper incontinent care practices by a Certified Nursing Assistant (CNA), specifically failure to wash or sanitize hands between glove changes and improper handling of clean briefs and cloth pads during care.
Complaint Details
The complaint was substantiated based on observation, interviews, and policy review. The CNA admitted to not washing hands between glove changes and using the same gloves to place clean items under the resident. The Director of Nursing confirmed this was against facility policy and could cause contamination.
Findings
The facility failed to ensure the CNA washed or sanitized her hands between glove changes and improperly used the same gloves to place a clean cloth and brief under the resident after cleaning bowel movement, potentially causing contamination and infection risk. Interviews with the CNA and Director of Nursing confirmed these practices violated facility hand hygiene policies.
Deficiencies (1)
Failure to wash or sanitize hands between glove changes during incontinent care, and placing a clean cloth and brief under the resident with the same gloves used to clean bowel movement.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| EI #3 | Certified Nursing Assistant (CNA) | Named in incontinent care hand hygiene deficiency and interview regarding handwashing practices. |
| EI #2 | Director of Nursing (DON), Infection Preventionist | Interviewed regarding facility hand hygiene policies and risks of contamination. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 3, 2019
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements and ensure resident safety and care quality.
Findings
The facility was found to have multiple deficiencies including failure to provide appropriate care for residents (e.g., range of motion devices not used as ordered), improper catheter care, incomplete narcotic destruction logs, improper food preparation and storage practices, inadequate infection control practices, and a non-functioning call system on the east wing affecting resident safety.
Deficiencies (7)
Failure to ensure Resident #47 wore a prescribed palm guard to maintain range of motion.
Certified Nursing Assistant failed to remove soiled gloves and wash hands prior to catheter care for Resident #76; Resident #86 lacked a catheter order.
Prescription Drug Destruction Inventory log lacked required three signatures for controlled substance destruction.
Pureed foods were not prepared according to recipe instructions, resulting in watery and flavorless meals.
Food preparation sink drain pipe extended into floor drain, ceiling of walk-in cooler had removable dark matter, shelving in dry storage less than six inches from floor, expired shredded chicken salad present, staff with facial hair not wearing beard guards, and staff chewing gum in kitchen.
Certified Nursing Assistants failed to wash hands after glove removal during incontinence care; Licensed Nurse stored bandage scissors in pocket during wound care.
Call system on east wing was not working properly, with no audible alerts, affecting 60 residents.
Report Facts
Residents sampled for Range of Motion: 11
Residents sampled with urinary catheters: 4
Months of narcotic destruction logs reviewed: 13
Residents receiving pureed diets: 16
Residents affected by food safety deficiencies: 108
Residents affected by call system failure: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant | EI #11 named in failure to apply palm guard and hand hygiene deficiencies | |
| Director of Nursing | EI #3 interviewed regarding catheter order and narcotic destruction process | |
| Licensed Practical Nurse | EI #2 assisted with catheter care while wearing soiled gloves | |
| Dietary Manager | EI #6 interviewed about food preparation and sanitary practices | |
| Registered Dietitian | EI #5 interviewed about food preparation and safety | |
| Certified Nursing Assistant | EI #12 observed and interviewed for hand hygiene failure during incontinence care | |
| Licensed Nurse/Wound Nurse | EI #13 observed storing bandage scissors improperly during wound care | |
| Unit Manager | EI #10 interviewed about call system failure | |
| Administrator | EI #4 interviewed about call system failure and maintenance |
Inspection Report
Deficiencies: 1
Date: Nov 15, 2018
Visit Reason
The inspection was conducted to assess compliance with food safety standards, specifically to ensure that pureed foods were served at safe and sanitary temperatures according to facility policy.
Findings
The facility failed to ensure pureed foods were consistently served at or above the recommended temperature of 135 degrees Fahrenheit. Pureed casserole and fortified mashed potatoes were served at substandard temperatures, potentially affecting 15 residents.
Deficiencies (1)
Failed to ensure pureed foods were served at recommended safe and sanitary temperatures of 135 degrees Fahrenheit or higher.
Report Facts
Residents affected: 15
Food temperature: 125
Food temperature: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| morning Cook | Interviewed regarding food temperature and failure to reheat food |
Report
April 28, 2023
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April 28, 2023
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July 1, 2021
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October 3, 2019
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November 15, 2018
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