Inspection Reports for
Diversicare of Amory
1215 Earl Frye Drive, Amory, MS, 38821
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
132% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 2
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
Routine
Census: 73
Deficiencies: 2
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
Re-Inspection
Deficiencies: 17
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
Complaint Investigation
Deficiencies: 1
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
Routine
Deficiencies: 8
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
Complaint Investigation
Deficiencies: 2
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
Routine
Deficiencies: 3
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 |
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