Inspection Reports for
Diversicare of Amory
1215 Earl Frye Drive, Amory, MS, 38821
Back to Facility Profile42 Reports
Inspection Report — May 26, 2026
Annual Inspection
Date: May 26, 2026
Visit Reason
On 05/26/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 04/16/26. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 05/22/26. No deficiencies were cited in this document.
Inspection Report — Apr 16, 2026
Annual Inspection
Date: Apr 16, 2026
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 4/13/26 through 4/16/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with multiple requirements including resident rights, safe environment, comprehensive care planning, ADL care, quality of care, incontinence care, medication storage, and infection control practices.
Deficiencies (8)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure a resident’s right to dignity during feeding when a nurse fed a resident while standing and did not sit at eye level.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to maintain a safe, clean, and homelike environment as evidenced by a large area of missing paint on a resident’s wall that was not repaired.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement comprehensive care plan interventions related to ADLs and wound care for three residents, including failure to provide nail care, timely toileting assistance, and wound treatments as ordered.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide necessary ADL services resulting in unmet care needs for two residents, including failure to provide nail care and delayed toileting assistance.
F0684 - Quality of Care. The facility failed to provide necessary care and services to promote healing and prevent complications of wounds, including failure to complete wound treatments as ordered and ensure accurate documentation.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide services to prevent possible complications for a resident with a suprapubic catheter by not changing the catheter as ordered.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure medications were securely stored and administered safely, leaving medications unattended at the bedside for two residents and storing prescription medication improperly for another resident.
F0880 - Infection Prevention & Control. The facility failed to implement infection control practices including failure to perform hand hygiene between residents during meal service, not maintaining aseptic technique during medication administration, and not securely storing biohazard waste.
Report Facts
Deficiencies cited: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Apr 16, 2026
Annual Inspection
Date: Apr 16, 2026
Visit Reason
The State Agency conducted an annual re-licensure survey at the facility from 4/13/26 through 4/16/26. During the survey, the SA determined the facility was not in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm.
Findings
The facility was found not in compliance with multiple licensure requirements including residents' rights, activities of daily living, urinary incontinence care, walls and ceilings maintenance, and infection control practices.
Deficiencies (5)
M0500 - Residents' rights. The facility failed to ensure a resident's right to dignity when a nurse fed a resident while standing instead of sitting at eye level.
M0610 - Activities of daily living. The facility failed to provide adequate ADL care including nail care and timely toileting assistance for two residents.
M0620 - Urinary incontinence. The facility failed to provide services to prevent complications by not changing a resident's suprapubic catheter as ordered.
M1210 - Walls and ceilings. The facility failed to maintain walls in good repair, with a large area of missing paint behind a resident's bed.
M1570 - Infection control. The facility failed to implement infection control practices including hand hygiene between residents during meal service, aseptic technique during medication administration, and secure storage of biohazard waste.
Report Facts
Deficiencies cited: 5
Inspection Report — Apr 14, 2026
Life Safety
Date: Apr 14, 2026
Visit Reason
The survey was conducted to assess compliance with the Life Safety Code and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Mar 2, 2026
Complaint Investigation
Date: Mar 2, 2026
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 02/05/26. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice and sustained compliance.
Findings
The facility was found to be in compliance as the State Agency recommended the facility be placed back in compliance effective 02/27/26.
Report Facts
Deficiencies cited: 0
Inspection Report — Feb 5, 2026
Complaint Investigation
Date: Feb 5, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2725776) at the facility from 2/4/26 through 2/5/26 for neglect, quality of care, and dietary.
Complaint Details
CI MS #2725776 investigated neglect, quality of care, and dietary allegations. Deficiency F0550 was cited for failure to protect resident rights, confirming the complaint was substantiated.
Findings
The facility failed to protect the resident's right to be treated with dignity and respect for one of ten residents sampled. Resident #1 experienced rude and disrespectful care from a Certified Nursing Assistant, which was confirmed by the Administrator.
Deficiencies (1)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure Resident #1 was treated with dignity and respect, as evidenced by rude and rough care from a staff member.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 1, 2025
Complaint Investigation
Date: Oct 1, 2025
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 08/21/25. The facility confirmed corrective measures were in place and compliance was sustained.
Complaint Details
CI MS#26995 complaint investigation completed on 08/21/25; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance as of 09/24/25 following the complaint investigation.
Report Facts
Complaint surveys reviewed: 1
Inspection Report — Aug 21, 2025
Complaint Investigation
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of verbal abuse by a Certified Nurse Assistant (CNA) towards a resident and concerns about newly hired nurses and CNAs not receiving skills competency checkoffs before providing resident care.
Complaint Details
The complaint investigation substantiated that CNA #1 verbally abused Resident #1 by threatening to slap him and stating she would put him in the morgue. Multiple residents corroborated the verbal abuse. The Administrator confirmed the allegation and deemed the conduct unprofessional and potentially harmful.
Findings
The facility substantiated verbal abuse by CNA #1 towards Resident #1, involving verbal threats and cursing. Additionally, the facility failed to ensure that newly hired licensed nurses and CNAs received required skills competency checkoffs before providing care, posing potential risks to resident safety.
Deficiencies (2)
F 0600: The facility failed to protect a resident from verbal abuse when CNA #1 verbally threatened Resident #1 and engaged in a verbal altercation. The abuse was substantiated by resident interviews and facility investigation.
F 0726: The facility failed to ensure newly hired licensed nurses and CNAs received skills competency checkoffs before providing care for three new hires reviewed. Skills checkoff forms were missing or incomplete, and staff reported inadequate training and supervision.
Report Facts
Residents reviewed for abuse: 7
New hires reviewed for skills competency: 3
BIMS score: 15
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in verbal abuse findings involving threats and cursing toward Resident #1. |
| Graduate Practical Nurse #1 | Graduate Practical Nurse | New hire nurse who reported lack of skills checkoff and inadequate training. |
| Clinical Educator | Clinical Educator | Confirmed lack of skills checkoffs and training for new hires. |
| Administrator | Administrator | Confirmed substantiation of verbal abuse and acknowledged missing skills checkoffs. |
Inspection Report — Aug 21, 2025
Complaint Investigation
Date: Aug 21, 2025
Visit Reason
The State Agency conducted complaint investigations (CI# 2564871, CI# 2568272, CI# 2574939, CI# 495947, and Incident # 495948) at the facility from 8/20/25 through 8/21/25. The SA determined the facility was not in compliance with Medicare and Medicaid requirements and cited deficiencies related to abuse and competent staffing.
Complaint Details
Complaint investigations CI# 2564871, CI# 2568272, CI# 2574939, CI# 495947, and Incident # 495948 were conducted. Deficiencies were cited for Incident # 495948 related to abuse (F0600) and for CI# 2568272 related to competent staffing (F0726). Other complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance due to verbal abuse by a staff member toward a resident and failure to ensure newly hired nursing staff received skills competency checkoffs before providing care.
Deficiencies (2)
F0600 - Free from Abuse and Neglect. The facility failed to ensure a resident was free from verbal abuse when a Certified Nurse Assistant threatened and cursed at the resident, causing psychosocial harm.
F0726 - Competent Nursing Staff. The facility failed to ensure newly hired licensed nurses and certified nurse assistants received skills competency checkoffs before providing resident care for three new hires reviewed.
Report Facts
Deficiencies cited: 2
Complaint investigations: 5
Inspection Report — Apr 22, 2025
Complaint Investigation
Date: Apr 22, 2025
Visit Reason
On 04/23/25 the State Agency (AG) conducted an onsite complaint investigation (CI) for MS #28409 for alleged verbal abuse.
Complaint Details
Complaint CI MS#28409 for alleged verbal abuse was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The State Agency determined that the facility was in compliance with the Standards for Participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Mar 19, 2025
Follow-Up
Date: Mar 19, 2025
Visit Reason
On 03/18/25 through 03/19/25 the State Agency conducted an onsite revisit for the annual survey that was completed on 02/13/25. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 03/14/25. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 14, 2025
Life Safety
Date: Mar 14, 2025
Visit Reason
On 03/14/25 the State Agency conducted a desk review of information related to the annual survey conducted on 02/12/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The facility was found to be in compliance with all applicable emergency preparedness and Life Safety Code requirements. No deficiencies were cited.
Inspection Report — Feb 13, 2025
Routine
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident safety, cleanliness, and restraint use in the nursing home.
Findings
The facility failed to maintain a safe, clean, and homelike environment as evidenced by unsanitary conditions and damaged equipment in resident rooms. Additionally, the facility failed to ensure a resident was free from physical restraints by restricting voluntary movement.
Deficiencies (2)
F 0584: The facility failed to provide a safe, clean environment as evidenced by an unsanitary toilet in room C-7, rusted and damaged overbed tables in residents' rooms, and wall disrepair affecting three residents.
F 0604: The facility failed to ensure a resident was free from physical restraints by restricting Resident #88's voluntary movement through body contact.
Report Facts
Residents affected: 3
Residents affected: 1
Resident rooms occupied: 73
BIMS score: 9
BIMS score: 9
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Aide | Named in physical restraint finding involving Resident #88 |
| Director of Nursing | Director of Nursing | Confirmed issues with wheelchair and overbed tables, and restraint incident |
| Administrator | Administrator | Confirmed awareness of restraint incident and maintenance responsibilities |
Inspection Report — Feb 13, 2025
Re-Inspection
Date: Feb 13, 2025
Visit Reason
The inspection was a recertification and complaint survey conducted to assess compliance with regulatory requirements and to verify correction of previously cited deficiencies.
Findings
The facility was found deficient in multiple areas including residents' rights, communication, environment cleanliness, restraint use, notification procedures, assessment accuracy, care planning, personal hygiene, medication management, infection control, and quality assurance. Several deficiencies were re-cited from a prior survey, indicating ongoing issues.
Deficiencies (17)
F 0550: The facility failed to ensure residents' right to participate in smoking during inclement weather, restricting residents from smoking outside during rain for multiple days.
F 0576: The facility failed to deliver resident mail on Saturdays for four of ten residents during the Resident Council meeting.
F 0584: The facility failed to provide a safe, clean, and homelike environment as evidenced by unsanitary toilet, torn wheelchair armrest, rusted overbed tables, and wall disrepair affecting multiple residents.
F 0604: The facility failed to ensure a resident was free from physical restraints as evidenced by staff physically restraining a resident's voluntary movement by body contact.
F 0623: The facility failed to mail written notification of hospital transfer to resident representatives for two residents.
F 0641: The facility failed to accurately complete an MDS assessment for medication, incorrectly coding an antiplatelet medication as an anticoagulant for one resident.
F 0655: The facility failed to develop a baseline care plan related to personal hygiene for one resident, missing instructions needed to provide effective and person-centered care.
F 0656: The facility failed to develop comprehensive care plans and implement care plans for multiple residents related to personal hygiene, medication, respiratory equipment storage, enhanced barrier precautions, TED hose use, and dialysis communication.
F 0677: The facility failed to provide care to maintain personal hygiene for three residents, including untrimmed, dirty fingernails and unkept facial hair.
F 0684: The facility failed to provide treatment and care according to orders and professional standards for two residents, including failure to use enhanced barrier precautions during wound care and improper storage of respiratory equipment.
F 0698: The facility failed to provide ongoing communication documentation with the hemodialysis center for one resident receiving dialysis, resulting in incomplete coordination of care.
F 0755: The facility failed to maintain accurate reconciliation and accounting for all controlled medications, failing to count narcotics stored in the medication refrigerator.
F 0761: The facility failed to store controlled drugs in a locked, permanently affixed compartment as evidenced by unsecured Lorazepam concentrate in the refrigerator.
F 0806: The facility failed to honor residents' beverage preferences during dining, denying a resident a large glass of tea and another resident coffee at lunch.
F 0758: The facility failed to ensure a PRN psychotropic medication had a stop date for one resident, resulting in an order without a stop date for Ativan.
F 0867: The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program, with ineffective follow-up on identified deficiencies and staff turnover impacting monitoring.
F 0880: The facility failed to prevent the spread of infection by not monitoring water sources for Legionella, improper storage of respiratory equipment, and failure to use enhanced barrier precautions during wound care and for residents with indwelling devices.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 6
Residents affected: 23
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Gave medication room keys to Medical Records nurse and failed to count narcotics in refrigerator |
| LPN #2 | Licensed Practical Nurse | Counted narcotics only on medication cart, not in refrigerator |
| RN #4 | Registered Nurse | Confirmed PRN psychotropic medication without stop date and beverage preference issues |
| DON | Director of Nursing | Confirmed multiple deficiencies including medication errors, infection control, and QAPI issues |
| Administrator | Administrator | Discussed QAPI program weaknesses and dialysis communication issues |
| CNA #7 | Certified Nursing Assistant | Forgot to use gown during wound care |
| RN #1 | Registered Nurse | Failed to use Enhanced Barrier Precautions during IV antibiotic administration |
| Maintenance #1 | Maintenance Staff | Described water system maintenance but lacked documentation |
| Medical Records Nurse | Medical Records Nurse | Accepted narcotic keys improperly and failed to complete dialysis communication paperwork |
Inspection Report — Feb 13, 2025
Annual Inspection
Date: Feb 13, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and four Complaint Investigations (CI) MS #27703, CI MS #27184, CI MS #27940, and CI MS #27952 at the facility from 2/10/25 through 2/13/25.
Complaint Details
Four Complaint Investigations (CI) MS #27703, CI MS #27184, CI MS #27940, and CI MS #27952 were conducted. Deficiencies were cited for CI MS #27703 (F584) and CI MS #27952 (F604). No deficiencies were cited for CI MS #27184 and CI MS #27940.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies including resident rights, communication, safe environment, care planning, quality of care, medication management, infection control, and QAPI program failures.
Deficiencies (17)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure residents had the right to participate in smoking during inclement weather for several residents.
F0576 - Right to Forms of Communication w/ Privacy. The facility failed to deliver resident mail on Saturdays for several residents.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide a safe, clean environment as evidenced by unsanitary toilet, torn wheelchair armrest, rusted overbed tables, and wall in disrepair affecting several residents.
F0604 - Right to be Free from Physical Restraints. The facility failed to ensure a resident was free from physical restraints as evidenced by restricting voluntary movement by body contact.
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to mail written notification of hospital transfer to resident representatives for two residents.
F0641 - Accuracy of Assessments. The facility failed to accurately complete an MDS assessment for an antiplatelet medication being entered as an anticoagulant medication for one resident.
F0655 - Baseline Care Plan. The facility failed to thoroughly develop a baseline care plan related to personal hygiene for one resident.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement comprehensive care plans for residents with personal hygiene needs, antiplatelet medication, respiratory equipment storage, enhanced barrier precautions, TED hose, and dialysis.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide care to maintain personal hygiene for three residents.
F0684 - Quality of Care. The facility failed to ensure residents received treatment and care in accordance with professional standards for treating skin concerns and application of TED hose for two residents.
F0698 - Dialysis. The facility failed to provide ongoing communication documentation with the hemodialysis center for one resident receiving hemodialysis.
F0755 - Pharmacy Services/Procedures/Pharmacist/Records. The facility failed to maintain a system of medication records that enables accurate reconciliation and accounting for all controlled medications as evidenced by narcotics stored unsecured in the refrigerator.
F0758 - Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to ensure a PRN psychotropic medication had a stop date for one resident medication reviewed.
F0761 - Label/Store Drugs and Biologicals. The facility failed to store controlled drugs in a locked permanently affixed compartment for storage as evidenced by narcotics stored unsecured in the refrigerator.
F0806 - Resident Allergies, Preferences, Substitutes. The facility failed to honor residents' beverage preferences during dining for two residents.
F0867 - QAPI/QAA Improvement Activities. The facility failed to maintain implemented procedures and monitor interventions following the previous survey, indicating a pattern of failure to sustain an effective QAPI program.
F0880 - Infection Prevention & Control. The facility failed to prevent the possibility of spread of infection by not monitoring water source for Legionella, storing respiratory equipment on the floor, and not using required enhanced barrier precautions for residents with wounds or indwelling devices.
Report Facts
Deficiencies cited: 18
Complaint investigations: 4
Inspection Report — Feb 12, 2025
Life Safety
Date: Feb 12, 2025
Visit Reason
The survey was conducted as a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility was found to have deficiencies in smoke barrier construction and smoke barrier doors that failed to resist the passage of smoke in multiple smoke compartments, affecting a majority of residents.
Deficiencies (2)
K0372 - The facility failed to provide a half-hour fire resistance rating in the smoke barrier walls due to unsealed holes around data cables and electrical piping at the A, C, and D Hall smoke barriers, affecting 98 of 113 residents.
K0374 - The facility failed to provide 20-minute fire resistance rating smoke barrier doors that properly closed upon activation of fire alarm and sprinkler systems at B Hall and C Hall smoke barrier doors, affecting 49 of 113 residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 19, 2024
Complaint Investigation
Date: Nov 19, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 26213 and CI MS #26563) related to resident neglect.
Complaint Details
Complaint numbers CI MS# 26213 and CI MS #26563 related to resident neglect were investigated and found to have no deficiencies cited.
Findings
The facility was found in compliance with the Minimal Standards of Operation for Institutions for the Aged or Infirm. No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 29, 2024
Complaint Investigation
Date: Jul 29, 2024
Visit Reason
On 07/29/2024 the State Agency (SA) conducted an on site complaint investigation (CI) for MS #24929 for neglect and MS #25648 for resident to resident abuse.
Complaint Details
Complaint investigation for MS #24929 for neglect and MS #25648 for resident to resident abuse; both complaints were not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate either complaints and no deficiencies were cited. The SA determined that the facility was in substantial compliance with the requirements for The Aged and Infirm.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 26, 2024
Complaint Investigation
Date: Mar 26, 2024
Visit Reason
On 03/26/24 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 02/13/24. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice; the complaint was substantiated but no deficiencies were cited in this review.
Findings
The State Agency found the facility in compliance and is recommending that the facility be placed back in compliance effective 03/20/24.
Report Facts
Deficiencies cited: 0
Inspection Report — Feb 13, 2024
Complaint Investigation
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician and resident representative of an unwitnessed fall of Resident #1.
Complaint Details
The complaint investigation revealed that Resident #1 fell on 01/16/24 and the family was not notified until they visited on 01/17/24. The resident's son stated the facility did not follow protocol and failed to keep him informed. The investigation found missing family contact information in the system and failure by staff to notify the family and Nurse Practitioner promptly.
Findings
The facility failed to notify the physician and resident representative of an unwitnessed fall for Resident #1. The fall was discovered by a Certified Nursing Assistant, but family contact information was missing from the system, resulting in delayed notification to the resident's family.
Deficiencies (1)
F 0580: The facility failed to notify the resident's physician and resident representative of an unwitnessed fall that occurred on 01/16/24. The nurse on duty did not contact the family or the On-Call Nurse Practitioner as required by protocol.
Report Facts
Residents affected: 3
Assessment Reference Date: Jan 18, 2024
Brief Interview for Mental Status (BIMS) Score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding the fall and notification process |
| Admissions Coordinator | Admissions Coordinator | Admitted fault for missing family contact information in the system |
| Administrator | Administrator | Confirmed missing family contact information and failure to notify family |
Inspection Report — Feb 13, 2024
Complaint Investigation
Date: Feb 13, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS #24010) at the facility on 02/13/24 regarding accidents related to an unwitnessed fall and failure to notify the family and physician in a timely manner.
Complaint Details
CI MS #24010 involved allegations related to accidents from an unwitnessed fall and failure to notify the family and physician timely. The complaint was substantiated with deficiencies cited.
Findings
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to notify the physician and resident representative of an unwitnessed fall for one of three residents reviewed. Resident #1 was found on the floor after a fall on 01/16/24, but the nurse on duty did not notify the resident representative or the On-Call Nurse Practitioner as required.
Deficiencies (1)
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to notify the physician and resident representative of an unwitnessed fall for one of three residents reviewed, Resident #1, resulting in delayed family notification despite the resident having visible injuries.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 30, 2023
Follow-Up
Date: Nov 30, 2023
Visit Reason
The State Agency conducted a revisit survey at the facility on 11/29/23 through 11/30/23 and placed the facility back into compliance for M500 related to Resident's Rights, M610 related to Activities of Daily Living, M815 related to food storage, M1010 related to Housekeeping Facilities and Services, and M1570 related to Infection Control.
Findings
The facility was found back in compliance for all previously cited deficiencies related to Resident's Rights, Activities of Daily Living, food storage, Housekeeping Facilities and Services, and Infection Control.
Report Facts
Deficiencies cited: 5
Inspection Report — Oct 19, 2023
Annual Inspection
Date: Oct 19, 2023
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 10/16/23 to 10/19/23. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F561, F584, F656, F677, F684, F761, F812 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Deficiencies were cited in resident self-determination, safe and clean environment, comprehensive care planning, ADL care, quality of care, medication storage, food safety, and infection prevention and control.
Deficiencies (8)
F0561 - The facility failed to ensure a resident's preference for coffee was honored for one resident, resulting in the resident not receiving coffee on multiple occasions.
F0584 - The facility failed to maintain a clean environment as evidenced by multiple areas of a circular black substance on two ceiling air vents in the memory care unit.
F0656 - The facility failed to develop and implement a comprehensive care plan for a resident on hospice services and failed to implement an ADL care plan for shaving and oral hygiene for another resident.
F0677 - The facility failed to provide necessary ADL services for shaving and oral hygiene for one resident dependent on staff.
F0684 - The facility failed to coordinate hospice care for one resident receiving hospice services, including failure to enter hospice orders timely.
F0761 - The facility failed to ensure a medication cart was locked while unattended, risking medication security.
F0812 - The facility failed to ensure opened food items stored in the refrigerator were dated and labeled, risking food safety.
F0880 - The facility failed to prevent the spread of infection as evidenced by improper nebulizer storage, failure to perform hand hygiene during incontinent care, and transporting an isolation cart into and out of a resident's room on transmission-based precautions.
Report Facts
Deficiencies cited: 8
Inspection Report — Oct 19, 2023
Annual Inspection
Date: Oct 19, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/16/23 through 10/19/23. During the survey, the SA determined the facility was not in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and a deficiency was cited at M0040 for staffing.
Findings
One deficiency was cited at M0040 for staffing on the Alzheimer's Disease/Dementia Care Unit. The facility failed to maintain the minimum required staffing ratio of 3.0 hours of nursing care per resident per 24 hours on the Alzheimer's Unit, and staff were unaware of the staffing requirements. Additionally, Resident #21 was observed with poor oral hygiene and facial hair not shaved as part of care.
Deficiencies (1)
M040 - Staffing. The facility failed to maintain the minimum staffing ratio of 3.0 hours of nursing care per resident per 24 hours on the Alzheimer's Unit and staff were unaware of the staffing requirements. Resident #21 was observed with poor oral hygiene and facial hair not shaved as part of care.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 19, 2023
Routine
Date: Oct 19, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care planning, environment cleanliness, medication storage, food safety, infection control, and hospice care coordination at Diversicare of Amory.
Findings
The facility was found deficient in honoring resident preferences, maintaining a clean environment, developing and implementing comprehensive care plans, ensuring medication cart security, labeling and dating food items, and infection prevention and control practices. Several residents were affected by these deficiencies, including issues with oral hygiene, hospice care coordination, medication security, food labeling, and infection control breaches.
Deficiencies (8)
F 0561: The facility failed to honor a resident's preference for receiving coffee, as Resident #70 did not receive coffee on multiple mornings despite requesting it.
F 0584: The facility failed to maintain a clean environment, evidenced by multiple areas of circular black substance on two ceiling air vents, potentially causing breathing issues.
F 0656: The facility failed to develop a comprehensive care plan for a resident on hospice services (Resident #50) and failed to implement an ADL care plan for shaving and oral hygiene for Resident #21.
F 0677: The facility failed to provide activities of daily living for a resident dependent on staff for shaving and oral hygiene, as Resident #21 had white buildup on her lower teeth and facial hair not removed.
F 0684: The facility failed to coordinate hospice care for Resident #50 by not entering a hospice order into the computer system upon admission, delaying care plan development.
F 0761: The facility failed to ensure a medication cart was locked while unattended, risking medication misappropriation.
F 0812: The facility failed to ensure opened food items stored in the refrigerator were dated and labeled, risking cross contamination and resident safety.
F 0880: The facility failed to prevent infection spread by improper nebulizer storage, lack of hand hygiene during incontinent care, and transporting an isolation cart in and out of a transmission-based precautions room.
Report Facts
Residents sampled: 20
Survey days: 4
BIMS score: 15
BIMS score: 13
BIMS score: 10
BIMS score: 11
BIMS score: 10
Nebulizer order frequency: 6
Nebulizer order duration: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Confirmed oral hygiene issues for Resident #21 and environmental concerns |
| Director of Nursing | DON | Confirmed multiple deficiencies including hospice care coordination, medication cart security, oral hygiene, and infection control issues |
| Certified Nurse Aide #2 | CNA | Observed infection control breaches during incontinent care for Resident #83 |
| Licensed Practical Nurse #3 | LPN | Observed leaving medication cart unlocked |
| Assistant Director of Nursing | ADON | Confirmed infection control issues with nebulizer storage |
| Licensed Social Worker | LSW | Responsible for developing hospice care plans, confirmed delay in Resident #50 hospice care plan |
| Dietary Manager | DM | Confirmed food labeling and dating deficiencies |
Inspection Report — Oct 17, 2023
Life Safety
Date: Oct 17, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Oct 3, 2023
Complaint Investigation
Date: Oct 3, 2023
Visit Reason
On 10/03/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/30/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 08/30/23; the facility was found in compliance after corrective measures were confirmed.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 09/25/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 30, 2023
Complaint Investigation
Date: Aug 30, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to implement care plans and provide timely incontinent care for residents dependent on staff assistance.
Complaint Details
The investigation was complaint-driven, focusing on allegations that residents were not receiving appropriate care related to Activities of Daily Living and incontinent care. The complaints were substantiated based on observations, interviews, and record reviews.
Findings
The facility failed to implement care plans related to Activities of Daily Living for two residents and did not provide timely incontinent care, resulting in residents remaining in soiled briefs for extended periods. Staff interviews and observations confirmed lapses in care and failure to follow established care plans.
Deficiencies (2)
F 0656: The facility failed to implement a care plan related to Activities of Daily Living for two residents dependent on staff for care. Resident #3 was not repositioned or changed as scheduled, and Resident #4 was not changed during a visit by her caretaker.
F 0677: The facility failed to provide timely incontinent care for two residents. Resident #3 was found with a saturated brief after not being changed for several hours, and Resident #4 was not changed until late in the day despite having a care plan for incontinence.
Report Facts
Residents reviewed: 5
Residents affected: 2
BIMS score: 99
BIMS score: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Confirmed failure to change Resident #3 at scheduled time | |
| Certified Nursing Assistant (CNA) #2 | Confirmed responsibility for Resident #4 and admitted failure to ensure timely changes | |
| Certified Nursing Assistant (CNA) #3 | Confirmed Resident #3 needed changing during observation | |
| Certified Nursing Assistant (CNA) #4 | Performed peri care for Resident #4 and noted saturated brief | |
| Director of Nursing (DON) | Acknowledged failure to follow care plans and expressed concern about quality of care |
Inspection Report — Aug 30, 2023
Complaint Investigation
Date: Aug 30, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI) on 8/30/23 at the facility for CI MS #21049 related to falls and residents being left wet.
Complaint Details
CI MS #21049 related to falls and residents being left wet. The SA found the facility in compliance related to assessments but not in compliance with participation requirements related to residents being left wet, citing deficiencies at F656 and F677.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements related to residents being left wet. Deficiencies were cited for failure to implement care plans and provide timely incontinent care for dependent residents.
Deficiencies (2)
F0656 - The facility failed to implement a care plan related to Activities of Daily Living for residents dependent on staff for care, as evidenced by Residents #3 and #4 not being checked and changed every two hours as required.
F0677 - The facility failed to provide timely incontinent care for Residents #3 and #4, resulting in residents being left wet and at risk for skin breakdown and pressure sores.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 9, 2022
Complaint Investigation
Date: Nov 9, 2022
Visit Reason
On 11/09/22 the State Agency (SA) conducted on site complaint investigation, CI MS #19444 for alleged neglect of a respite resident and for not providing oxygen ordered by the physician, and for over medicating a respite resident; and CI MS #19673 for alleged dirty floors, staff not wearing name tags, and diabetic diets not being honored.
Complaint Details
Complaint numbers CI MS #19444 and CI MS #19673 were investigated; the allegations were not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the allegations and no deficiencies were cited. The facility was found to be in substantial compliance with the standards for participation in Medicaid and Medicare.
Report Facts
Complaint investigations: 2
Inspection Report — Jul 26, 2022
Complaint Investigation
Date: Jul 26, 2022
Visit Reason
On 07/26/2022 the State Agency (SA) conducted an on site complaint investigation for CI MS #18717 for wrongful discharge of a resident and CI MS #18883 for facility not providing services to residents with mental health needs.
Complaint Details
Complaint investigation CI MS #18717 and CI MS #18883 for wrongful discharge and failure to provide services to residents with mental health needs; both complaints were not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate either complaints and no deficiencies were cited. The SA determined that the facility was in substantial compliance with the standards for participation in Medicare and Medicaid Services.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 4, 2022
Annual Inspection
Date: Apr 4, 2022
Visit Reason
On 04/04/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 2/3/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 03/28/22.
Inspection Report — Feb 3, 2022
Annual Inspection
Date: Feb 3, 2022
Visit Reason
The State Agency conducted an annual recertification survey and a complaint survey for CI MS #17922 at the facility from 1/31/22 through 2/03/22. The SA did not substantiate CI MS #17922 but cited F806, F880 and F921 during the recertification survey.
Complaint Details
CI MS #17922 was investigated during the survey but was not substantiated by the State Agency.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to failure to follow resident meal preferences, inadequate infection prevention practices during medication administration, and unsafe, unsanitary conditions of air conditioning/heating units in resident rooms.
Deficiencies (3)
F0806 - Resident Allergies, Preferences, Substitutes. The facility failed to ensure residents' meal preferences were followed as meal tickets did not match the food served for Residents #14, #37, and #84.
F0880 - Infection Prevention & Control. The facility failed to use a barrier during medication administration to prevent infection spread for Resident #43, as medications were placed on a dirty bedside table without a barrier.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to ensure proper installation and maintenance of air conditioning/heating units in five resident rooms on B hall, with open areas to the outside and debris on units, posing risks of pest entry, improper heating/cooling, and fire hazard.
Report Facts
Deficiencies cited: 3
Inspection Report — Feb 3, 2022
Routine
Date: Feb 3, 2022
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident food preferences, infection prevention and control, and safety of the nursing home environment including air conditioning and heating units.
Findings
The facility failed to ensure residents' meal preferences were followed as meal tickets did not match the food served for multiple residents. The facility also failed to use barriers during medication administration to prevent infection spread. Additionally, air conditioning and heating units were improperly installed with open areas allowing potential pest entry and fire hazards.
Deficiencies (3)
F 0806: The facility failed to ensure residents' food preferences were followed as meal tickets did not match the food served for Residents #14, #37, and #84.
F 0880: The facility failed to use a barrier during medication administration to prevent infection spread for Resident #43.
F 0921: The facility failed to ensure proper installation of air conditioning and heating units, resulting in open areas to the outside and debris accumulation in five of 14 resident rooms on B hall.
Report Facts
Residents affected: 3
Residents affected: 1
Residents affected: 5
Rooms observed: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #2 | Interviewed regarding meal ticket and food served discrepancy for Resident #37 | |
| Administrator (ADM) | Interviewed about past complaints and dietary management regarding meal tickets | |
| Dietary Department #1/Dietary Manager | Interviewed about lack of training on menus and meal tickets | |
| Registered Nurse (RN) #1 | Observed and interviewed regarding failure to use barrier during medication administration | |
| Director of Nurses (DON) | Interviewed about infection control policies and barrier use during medication administration | |
| Infection Preventionist (IP) | Interviewed confirming barrier use is required during medication administration | |
| Pharmacy Consultant | Interviewed confirming barrier use is required during medication administration | |
| Registered Nurse Consultant | Interviewed confirming barrier use is required during medication administration | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about air conditioning/heating unit conditions and replacements | |
| Maintenance Director | Interviewed and toured B-hall rooms regarding air conditioning/heating unit issues |
Inspection Report — Feb 1, 2022
Life Safety
Date: Feb 1, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Oct 27, 2020
Complaint Investigation
Date: Oct 27, 2020
Visit Reason
The State Agency conducted a complaint survey investigating MS CI 00017111 at the facility from 10/26/2020 to 10/27/2020.
Complaint Details
Complaint MS CI 00017111 was investigated and found to be unsubstantiated as the facility was in compliance with requirements.
Findings
The survey determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 1
Inspection Report — Oct 27, 2020
Routine
Date: Oct 27, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 10/26/20 through 10/27/20.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/24/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Nov 14, 2019
Complaint Investigation
Date: Nov 14, 2019
Visit Reason
On November 14, 2019 the State Agency (SA) conducted an on-sight complaint investigation for a facility self-reported incident, CI MS #16330.
Complaint Details
CI MS #16330 was unsubstantiated and no deficiencies were cited.
Findings
The complaint investigation CI MS #16330 was unsubstantiated and no facility deficiencies were cited. The facility was determined to be in substantial compliance with the requirements for Medicaid and Medicare.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 18, 2019
Annual Inspection
Date: Apr 18, 2019
Visit Reason
The State Agency (SA) conducted a recertification survey from 4/15/19 to 4/18/19. During the survey the SA determined the facility was not in compliance with the Minimum Standards for The Institutions For The Aged And Infirm. The SA cited the state statutes M610 and M620.
Findings
The facility failed to ensure that dependent residents unable to carry out activities of daily living received necessary assistance to maintain good personal hygiene for three of 25 sampled residents (Residents #1, #24, and #26). Observations and record reviews showed residents had untrimmed fingernails, facial hair growth, and inadequate personal care.
Deficiencies (1)
M610 - Activities of daily living. The facility failed to ensure dependent residents received necessary assistance with personal hygiene, including nail care and shaving, as evidenced by Residents #1, #24, and #26 having long or dirty fingernails and unshaved facial hair.
Report Facts
Deficiencies cited: 2
Report
7 CMS Surveys
CMS Survey — Aug 30, 2023
Aug 30, 2023
CMS Survey — Feb 13, 2024
Feb 13, 2024
CMS Survey — Feb 13, 2025
Feb 13, 2025
CMS Survey — Aug 21, 2025
Aug 21, 2025
CMS Survey — Feb 3, 2022
Feb 3, 2022
CMS Survey — Oct 19, 2023
Oct 19, 2023
CMS Survey — Feb 13, 2025
Feb 13, 2025
Viewing
Loading inspection reports...
