Diversicare Of Oxford

PM FLPN #31 confirmed she was terminated for allegations of taking resident medications.

She

Administrator (FADM) #14 verified she reviewed medications that were found in FLPN's #31 home.

and whether the medications were active orders. FADM #14 confirmed the medications were identified as belonging to facility residents but had been discontinued, with no replacement of medications required.On 04/08/2026 at 9:30 AM Former Director of Nursing (FDON ) stated the facility was first notified when police arrived and informed FADM #8 medications belonging to the facility had been found in the home of FLPN #31.

The police provided photographic evidence of medication cards that had been removed from the facility. FDON #22 confirmed that three non-narcotic medication cards belonging to the facility residents were identified in the possession of FLPN #31.

These medications had been discontinued; however, the medications remained resident/facility property and should not have been removed from the facility but destroyed per facility policy.

She acknowledged that discontinued medications were required to be secured and destroyed according to policy.

The medications found in FLPN #31's home should have been destroyed and not removed from the facility. On 04/08/2026 at 10:58 AM Director of Clinical Operations (DCO) #2 revealed she was notified by the Administrator and Director of Nursing Services after the police arrived at the facility reporting medications found in the home of FLPN #31 with photographic evidence that confirmed the presence of non-narcotic medication cards originating from the facility.

She confirmed the non-narcotic medications were discontinued and should have been secured and destroyed at least weekly or no later than monthly.

The medications found in FLPN's #31 home should have been destroyed and not removed from the facility.

She further acknowledged that medications prescribed to residents were found outside of the facility in the possession of FLPN #31, supporting the allegation of misappropriation of resident property.

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authorities.

Misappropriation, Exploitation Policy, and review of Facility Reported Incidents (FRIs), the facility

misappropriation to the SA within required timeframes.

These failures had the potential to delay initiation of investigations and implementation of protective measures to ensure resident safety and protection.Specifically:1.)

The facility failed to report an incident of physical abuse involving Resident Identifier (RI) #128 and RI #132 within two hours of the incident occurring. On 11/10/2025 around 11:35 AM RI # 132 entered the room of RI #128 and pinched him/her on the hand when RI #132 attempted to redirect RI #128 out of the room.

The facility reported this allegation to the SA on 11/10/2025 at 5:12 PM. 2.) The facility further failed to report an allegation of misappropriation involving RI #12, RI #130 and RI #129 within 24 hours of the incident occurring. On 11/18/2025 at 5:00 PM the facility became aware that Former Licensed Practical Nurse (FLPN) #31 had in her possession medication that belonged to RI #12, RI #130 and RI #129.

The facility reported this allegation to the SA on 11/19/2025 at 7:14 PM.

These failures affected five of 17 residents sampled for abuse and neglect.These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers 2667273 and 2683455.Findings Include:Cross Reference

change in the resident's condition.

ROM and/or mobility, unless a decline is for a medical reason.

record review, interview and policy titled Restorative Guidelines the facility failed to implement a

#60 one of one residents who experienced multiple falls.

This failure had the potential to contribute to decline in function and increased risk for further falls and had the potential to affect all residents requiring ongoing maintenance services due to the absence of a functional maintenance program.

This deficient practices were cited as a result of the investigations of facility reported incident/complaint/report number 2800273.Findings Include:Cross-Reference F-F689 and F725A review of a facility policy titled RESTORATIVE GUIDELINE with an effective date of 2024 revealed,PURPOSE:Restorative services refer to nursing interventions that assist the resident in sustaining function and/or continue to progress toward functional goals.RESTORATIVE PROGRAM:A successful restorative program is dependent on the collaboration of the Care Coordination team to identify residents who will benefit from the program utilizing the Restorative process flow chart below.The Director of Care Coordination (DCC) is the owner of the Restorative program. A Nurse Partner will be the backup.Each resident will be screened or evaluated by the DCC/IDT for inclusion into the appropriate center restorative program where there is a need identified .Restorative initial review completed in PCC.Restorative Plans of Care will be added to the Patient/Resident Care Plan .

The DCC/Nurse Partner will evaluate and document through the Restorative Monthly Review Evaluation in PCC this will include initiating and updating restorative care plans.Team members are trained in the Restorative Plan of Care .IMPLEMENTATATION AND ROLES OF THE RESTORATIVE PROGRAM When a resident is identified to have a functional change of condition, a restorative form is completed and given to the DCC/Nurse Partner.

Discussion in the Daily Clinical Start up will occur to determine next steps. A licensed therapy team will: Complete a Therapy Screen/Evaluation Be available to restorative team/nurse as a consultant.Administrator, DON, DCC /Nurse Partner will provide Restorative Program oversight .Nursing team members will be trained in restorative modules.

The DCC/ Nurse Partner will be responsible for assuring appropriate team members provide care.

Non-nursing team members . will be trained in select modules where approved .Key Elements: Residents will benefit from a Restorative Program in order to sustain function and /or to continue to progress toward functional goals after formalized therapy.When a resident is identified as a restorative participant, an individualized care plan will be developed to include measurable objectives and interventions .RI #60 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses to include: Muscle Weakness (Generalized), Bipolar Disorder, Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Right Dominant Side, and Lack of Coordination.RI #60 Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/29/2025 documented a Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicating intact cognitive function.On 04/07/2026 at 5:20 PM the Director of Therapy (DOT) stated RI #60 was treated by the therapy department from 02/10/2026 to 03/27/2026 due to decline in strength and mobility.

The DOT said the facility did not have a restorative nurse and RI #60 was not being followed by an FMP. On 04/07/2026 at 6:10 PM the Assistant Director of Nursing (ADON) stated RI #60 did not have a restorative care plan.

The ADON further stated the facility did not have a restorative nurse, restorative program, or an FMP. On 04/08/2026 at 6:09 PM the Registered Nurse Assessment Coordinator/ MDS Coordinator stated the facility did not have a restorative nurse nor a restorative program.

She further stated the facility did not have enough staff for a restorative nurse and the restorative program had not been in place for at least eight years.

When asked about the concern of not following the facility policy for FMP with residents with decline in mobility and frequent falls, she stated a resident could get hurt or not reach their rehab potential.On 04/09/2026 at 9:59 AM the Staffing Coordinator stated the facility did not currently have a restorative nurse and had not had one for four years.

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outside and was escorted to the porch. FDON #24 did not recall how long he/she remained on the

jeopardy to resident health or monitoring. FDON #24 stated he was notified of the incident when a staff member informed him that safety RI #127 had left the facility. RI #127 was located down the street in front of the facility, on the main highway, on the shoulder of the road, approximately 100 feet from the highway. FDON #24 described

presents a safety risk due to traffic. FDON #24 stated the weather was sunny, with no rain. FDON #24 reported that upon assessment, RI #127 did not appear overheated, was not in distress, and was not complaining of any symptoms.

When asked if the incident could have been prevented, FDON #24 stated yes the incident could have been avoided if RI #127 had not been taken outside and left unattended.

On 04/01/2026 at 10:50 AM during a telephone interview FADM #8 reported he was made aware RI #127 had left the facility while attending a morning meeting, when a staff member informed him RI #127 was on the highway.

When asked how RI #127 exited the facility, FADM #8 stated that the FDON #24 had taken RI #127 outside to sit on the porch. FADM #8 reported that RI #127 was found on the roadway but was safe and without apparent injury. FADM #8 stated there were no observed physical injuries, including bruising, fractures, or signs of heat exhaustion and he/she did not appear frightened or in distress at the time of retrieval.

When asked how the weather was, FADM #8 stated the weather was nice, not raining.

On 03/22/2026 at 10:26 AM, the surveyor

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Diversicare of Oxford 1130 South Hale Street Oxford, AL 36203

Based on the resident/patient population and their needs for care and support, describe the general approach to staffing to ensure there are sufficient team members to meet the needs of the residents/patients at any given time.Our approach to determine the staffing needs to care for and support our patients and residents, along with the information provided in Section 1.8 above, begins at the bedside.

The administrator facilitates the coordination of care needed each day with the interdisciplinary team.

The care team evaluates the resident/patient population and acuity as well as center layout to determine the number of team members needed to provide care and service to the patients/residents.

This then creates our center staffing ladder. If the profile of the resident/patient population changes throughout the year, the number of team members changes accordingly, and the staffing ladder is adjusted.

The center has internal approaches that are utilized should non-emergent staffing needs arise; On-Call licensed staff coverage, overtime by internal staff, shift pick up for staff who volunteer to work additional hours, region nurses are utilized in various centers to assist with openings, or clinical leadership work as floor nurses.On 03/26/2026 at 3:56 PM RN #40 reported she was working on 03/05/2026.

When asked if Certified Nursing Assistant (CNA) #39 informed her that Resident Identifier (RI) #60 had been found on the floor, RN #40 stated she could not recall her exact words.

When asked if she assessed RI #60 after being informed, RN #40 stated the situation was not significant enough to disrupt the medication pass. RN #40 reported she was responsible for approximately 50 -55 residents during the shift.

When questioned regarding a call light for RI #60 being activated for a prolonged period on 03/05/2025 she stated she did not observe that. RN #40 stated she would assist with answering call lights if she was nearby; however, she reported she was unable to respond while counting narcotics or receiving report. RN #40 stated that while administering medications, she was unable to keep up with alarms.On 04/08/2026 at 6:09 PM the MDS Coordinator stated the facility did not have a restorative program.

The MDS Coordinator reported the facility did not have sufficient staff to support a restorative nurse position and indicated it had been eight or more years since the facility last had a restorative nurse.

The MDS Coordinator further stated that although the facility previously had three restorative nurses, the program was not maintained after their departure due to inadequate staffing.

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Diversicare of Oxford 1130 South Hale Street Oxford, AL 36203

corrective plans of action.

Performance Improvement (QAPI), the QAPI committee failed to identify all causal factors related to

corrective actions needed to be taken to prevent any further resident safety concerns.This deficient practice affected RI #119, RI #88, RI #127 and RI #106.These deficient practices were cited as a result of the investigations of facility reported incident/complaint/report numbers 447995, 447964, 2629802 and 2603429.Findings Include: Cross-Reference F-F689 and F-F725, A review of a facility policy titled, Quality Assurance and Performance Improvement, dated March 2025 revealed: Purpose The center develops, implements, and maintains an effective, comprehensive, data-driven QAPI program that focus on indicators of the outcomes of care and quality of life and addresses all the care and unique services the center provides.

Definitions Adverse Event is an untoward, undesirable and usually unanticipated event that causes death or serious injury, or the risk thereof.

High Risk Areas refers to care of service areas associated with significant risk to the health or safety of patient/resident .

Performance Improvement (PI) is the continuous study and improvement of processes with the intent to improve services or outcomes, and prevent or decreased the likelihood of problems, by identifying areas of opportunity and testing new approaches to fix underlying causes of persistent/systemic problems or barriers to improvement.

Quality Assurance (QA) is the specification of standards for quality of service and outcomes, and systems throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why center performance is at risk or has failed to meet standards.

Quality Assurance and Performance Improvement (QAPI) refers to the coordinated application of two mutually reinforcing aspects of a quality management system: (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing home, .

Procedure .c.

Develop and implement appropriate plans of action to correct identified quality deficiencies . 3.

The QAPI plan will address the following elements: . c.

Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies.

Key components of this process include, but are not limited to, the following: .

Tracking and measuring performanceEstablishing goals and thresholds for performance improvements.Identifying prioritizing quality deficienciesSystematically analyzing underlying cause of systemic quality deficiencies.Developing and implementing corrective action or performance improvement activities.Monitoring and evaluating the effectiveness of corrective action/performance improvement activities and revising as needed. 4.

The center will maintain documentation and demonstrate evidence of its ongoing QAPI program.

Documentation may include, but is not limited to: . b.

Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. d.

Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. On 04/09/2026 at 2:47 PM the Director of Clinical Operations (DCO) #2 said the facility identified the issues/problems with elopements. DCO #2 was asked what the root cause of the elopements were and why elopements continued to occur in the facility after the first elopement in January of 2024.

She said because each elopement was different and different interventions were put in place but was not a pattern. On 04/09/2026 at 4:34 PM a follow- up interview was conducted with DCO #2.

She said insufficient staffing or lack of supervision was not considered as a factor for the root cause of the elopements.

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Diversicare of Oxford 1130 South Hale Street Oxford, AL 36203