Inspection Reports for Diversicare of Meridian

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

No deficiencies were cited related to the two complaint investigations regarding nursing services, quality of care/treatment, resident neglect, and abuse. However, during the annual recertification survey, the facility was found not in compliance with state licensure requirements and cited for deficiencies M 225, M 815, and M 1020.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The facility was found deficient in staffing levels, food safety and storage, and housekeeping/maintenance issues. Specifically, insufficient nursing staff were available during shift changes, food items were overly ripe or improperly stored, and several resident rooms had exposed sheetrock and other maintenance issues.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The complaint investigations regarding nursing services, quality of care, neglect, and abuse resulted in no deficiencies cited. However, the annual recertification survey found the facility not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment and resident/patient client neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The facility was found deficient in multiple areas including resident/family group response, safe and homelike environment, accuracy of assessments, care plan timing and revision, sufficient nursing staff, food procurement and storage, and payroll based journal reporting. Deficiencies included failure to promptly resolve resident grievances, unsafe and unclean environment in some rooms, inaccurate MDS coding, outdated care plans, insufficient nursing staff during shift changes, improper food storage, and inaccurate staffing data submission.

The facility was found deficient in multiple areas including failure to promptly resolve resident grievances related to condiments and call light response times, failure to maintain a safe and homelike environment in resident rooms, inaccurate Minimum Data Set (MDS) assessments, failure to revise care plans according to current resident needs, insufficient nursing staff during shift changes, improper food storage and handling, and inaccurate Payroll Based Journal (PBJ) staffing data submission.

The facility failed to provide complete and proper documentation of fire drills for the calendar year 2024 and the first and second quarters of 2025. A 100% audit was conducted, and fire drills were subsequently performed on each shift between 5/29/25 and 5/30/25. The Administrator provided in-service training to the Maintenance Director on fire drill policies and documentation.

The facility met emergency preparedness requirements but failed to meet several Life Safety Code standards, including smoke barrier doors not properly closing and latching, incomplete fire drill documentation, and inadequate documentation of generator testing. These deficiencies affected multiple smoke compartments and all 98 residents.

Five complaint investigations were conducted (CI MS #27547, CI MS #27597, CI MS #28040, CI MS #28066, and CI MS #28088). CI MS#28040 was substantiated with deficiencies related to improper medical equipment and pain management. CI MS#27547 and CI MS#27597 involved issues such as call bells, resident care, dietary, and quality of care. CI MS#28066 and CI MS#28088 investigated neglect and resident rights with no deficiencies cited.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to provide effective and timely pain management for one resident with multiple cancer diagnoses, resulting in unmanaged pain and delayed medication administration. Other complaint investigations related to neglect and resident rights found no deficiencies.

The complaint investigation revealed that Resident #5 was admitted on 2/14/25 with a prescription for hydromorphone (Dilaudid) that was not available in the facility's emergency medications. The resident experienced unmanaged pain overnight until a new order for Hydrocodone-Apap was obtained and administered on 2/15/25. Family members and staff interviews confirmed the delay and the resident's distress. The resident later succumbed to his illness on 2/20/25.

The facility failed to ensure effective and timely pain management for Resident #5, who did not receive prescribed PRN opioid pain medication for approximately twelve hours after admission, resulting in unmanaged pain and subsequent transfer to hospital. Interviews and record reviews confirmed delays in medication availability and administration.

The facility was found not in compliance with residents' rights and activities of daily living standards. Deficiencies included staff using cell phones in resident rooms and failure to provide shaving assistance to a resident who required it. The facility implemented corrective actions including staff education, resident council meetings, and ongoing monitoring.

The facility was found not in compliance with several requirements including resident rights, accuracy of assessments, comprehensive care planning, ADL care, and activities programming. Deficiencies included staff using cell phones in resident rooms, inaccurate MDS coding for medications, failure to implement care plans for activities, failure to provide shaving for a dependent resident, and failure to assist a resident with activities.

The visit was complaint-related, triggered by resident complaints about staff using cell phones in resident rooms and failure to provide adequate care and activities. The complaints were substantiated based on observations, interviews, and record reviews.

The facility was found to have multiple deficiencies including staff using cell phones in resident rooms, inaccurate coding of medication in resident assessments, failure to implement care plans related to resident activities, failure to provide personal care such as shaving, and failure to assist a dependent resident to group activities. These issues affected a few residents and were confirmed through observations, interviews, and record reviews.

The complaint investigation was triggered by resident complaints of poor quality food, meals not served timely, cold meals, and meal preferences not honored. The Ombudsman reported ongoing unresolved issues despite assurances from facility leadership. Multiple grievances were documented from January to October 2023, all related to dietary concerns. The complaint was substantiated with deficiencies cited.

The facility failed to immediately honor and resolve food/meal grievances and requests from residents, with multiple residents reporting cold food, lack of meat at breakfast, and untimely meal service. Observations confirmed uncovered and cold food served, late meal delivery, and discrepancies between menu and food served. The facility had not posted meal service times and had unresolved grievances dating back several months. The Administrator acknowledged the need for improvement and implemented corrective actions.

Complaint Investigation MS #23089 was triggered by ongoing unresolved resident complaints about poor quality food, untimely meal service, cold meals, and unhonored meal preferences. The investigation confirmed deficiencies related to food quality and grievance resolution. Other complaint investigations (MS #23450 and MS #23479) concerning resident rights for dignity and privacy were not cited.

The facility failed to promptly resolve food and meal grievances from residents, with multiple residents reporting cold food, lack of meat at breakfast, and untimely meal delivery. Observations confirmed uncovered and cold food served, inaccurate tray contents, and lack of posted meal service times. The facility acknowledged deficiencies and implemented corrective actions including serving breakfast meat, in-servicing staff, and monitoring meal service.

The complaint investigation was substantiated by multiple resident interviews, observations, and record reviews showing unresolved grievances about cold food, lack of meat at breakfast, untimely meal delivery, and poor food quality. The Ombudsman had raised concerns and met with facility leadership who promised a 90-day improvement plan starting 10/18/23, but residents reported no improvements by the survey date.

The facility failed to promptly honor and resolve residents' food and meal grievances, resulting in many residents receiving cold, poorly prepared breakfasts without requested meat. Observations confirmed late meal delivery, uncovered food trays, and lack of proper temperature control. The facility had not resolved these issues despite a planned 90-day improvement initiated in October 2023.

The facility was found not in compliance with residents' rights and urinary incontinence care standards. Deficiencies included failure to maintain resident dignity during incontinent care and improper catheter insertion technique, affecting two residents.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident dignity during care, failure to follow comprehensive care plans, improper incontinent and catheter care, and infection prevention and control issues.

The visit was complaint-related, triggered by allegations of failure to maintain resident dignity, improper care plan implementation, inadequate incontinent and catheter care, and infection control breaches. Substantiation is implied by detailed findings and interviews confirming the issues.

The facility failed to maintain resident dignity during care, did not follow care plans for incontinent and catheter care for residents #1 and #87, and failed to implement proper infection prevention practices, including improper handling of COVID-19 specimens and inadequate hand hygiene and use of barriers during care.

Complaint Investigations #17832 for Quality of Care (resident not transferred), #16756 for Quality of Care (resident grooming), #17316 for Neglect (resident reported mean treatment), and #17040 for unqualified personnel. CI #17040 was substantiated and cited; others were unsubstantiated.

The facility was found not in compliance with Minimum Standards of Operation Institutions for the Aged or Infirm and State Licensure requirements. One complaint regarding unqualified personnel was substantiated involving a Certified Nursing Assistant who falsely represented herself as a Licensed Practical Nurse. Other complaints were unsubstantiated.

The complaint investigation substantiated that CNA #1 was incompetent nursing staff, falsely representing herself as an LPN. Other complaints regarding quality of care, grooming, and neglect were not substantiated.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to employing an incompetent nursing staff member who falsely represented herself as a Licensed Practical Nurse (LPN). The complaint regarding incompetent nursing staff was substantiated, while other complaints were not substantiated.

The complaint was substantiated for failure to provide continued CPR on a resident with a full code status. Immediate Jeopardy and Substandard Quality of Care were identified beginning 8/15/2019. The facility failed to continue CPR until EMS arrival, resulting in resident death.

The facility failed to continuously provide CPR per American Heart Association guidelines on Resident #1, who had a full code status, resulting in the resident's death and placing other residents at risk. An Immediate Jeopardy was identified and later removed after corrective actions including staff suspension, audits, education, and policy reinforcement.

The complaint was substantiated for failure to provide continued CPR on a resident with a full code status until EMS arrival or without a Do Not Resuscitate order. The facility was found noncompliant with Medicare and Medicaid participation requirements.

The facility failed to continuously provide CPR to Resident #1, who had a full code Advance Directive, resulting in the resident's death. The facility also failed to develop an accurate Baseline Care Plan reflecting the resident's code status. The facility took corrective actions including staff education, audits, and suspension/termination of responsible staff.

Complaint investigation (CI MS #15730) was conducted and found to be unsubstantiated.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to notice requirements before transfer/discharge, coordination and certification of assessments, and food procurement and sanitation. The complaint investigation was unsubstantiated.

The facility was found not in compliance due to failure to store and handle food in a sanitary manner, including personal items being stored on kitchen prep tables causing potential cross-contamination and wet nesting of dishes. The dietary manager acknowledged these issues and corrective actions were planned.