Inspection Reports for
Diversicare of Moss Point
3401 Main Street, Moss Point, MS, 39563
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Inspection Report — Dec 5, 2024
Routine CMS
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding resident transfer notifications, bed hold policies, MDS submission, care planning, food safety, infection control, and trauma-informed care at Diversicare of Moss Point.
Findings
The facility failed to provide timely written notifications to residents and representatives regarding transfers and bed hold policies for three residents. One discharge MDS was not submitted timely. Care plans lacked specific PTSD triggers and failed to implement enhanced barrier precautions for two residents. Food safety violations were observed including unlabeled and exposed foods and an unclean ice machine. Infection control practices were not followed as an occupational therapist failed to wear a gown while providing care to a resident requiring enhanced barrier precautions.
Deficiencies (7)
F 0623: The facility failed to provide written notification of resident transfers to the resident or representative for three residents discharged to hospitals.
F 0625: The facility failed to notify residents or representatives in writing about bed hold policies at the time of transfer for three residents.
F 0640: The facility failed to timely transmit a discharge Minimum Data Set (MDS) assessment for one of twenty-one reviewed residents.
F 0656: The facility failed to develop care plan interventions identifying PTSD triggers for one resident and failed to implement enhanced barrier precautions for another resident.
F 0699: The facility failed to ensure trauma-informed care by not identifying PTSD triggers or resident-specific interventions for one resident.
F 0812: The facility failed to store food safely, including unlabeled and undated foods, exposed foods, a scoop left in flour, and an unclean ice machine.
F 0880: The facility failed to implement infection control by not requiring an occupational therapist to wear a gown while providing care to a resident on enhanced barrier precautions.
Report Facts
Residents reviewed for hospitalizations: 3
MDS assessments reviewed: 21
Residents sampled for care plan review: 21
Trays of unlabeled liquids: 6
Opened bags of food left exposed: 3
Spice jars with lids open: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist | Instructed by Regional Business Office Consultant to stop mailing transfer notifications | |
| Administrator | Unaware of stopped mailing notifications; committed to resume mailing | |
| Licensed Practical Nurse #3 | LPN | Confirmed corporate nurse failed to submit discharge MDS for Resident #86 |
| Registered Nurse #2 | RN | Confirmed failure to submit discharge MDS for Resident #86 |
| Director of Nursing | DON | Unaware of MDS non-submission; confirmed care plan and infection control deficiencies |
| Licensed Practical Nurse #1 | LPN | Unaware of PTSD triggers for Resident #27 |
| Occupational Therapist | OT | Did not wear gown while providing care to Resident #203 on enhanced barrier precautions |
| Social Services Director | SSD | Unaware of stopped mailing bed hold notifications; acknowledged importance of PTSD trigger identification |
| Dietary Director | DD | Confirmed food safety violations and unclean ice machine |
Inspection Report — May 19, 2023
Complaint Investigation CMS
Date: May 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation following an incident where Resident #1, identified as an exit-seeker and elopement risk, exited the facility unnoticed and unsupervised on 5/14/2023.
Complaint Details
The complaint investigation was substantiated. Resident #1, an identified elopement risk, exited the facility unnoticed on 5/14/2023 due to a malfunctioning door alarm and locking mechanism. The facility implemented a Removal Plan and corrective actions, which were validated and the immediate jeopardy was removed on 5/18/2023.
Findings
The facility failed to provide adequate supervision and maintain proper door security, allowing Resident #1 to elope unnoticed for approximately 10 minutes. The exit door alarm and locking mechanism were not functioning properly, placing residents at risk of serious injury or death. Immediate corrective actions and systemic changes were implemented, including staff education, door repairs, and monitoring.
Deficiencies (1)
F 0689: The facility failed to ensure the resident's environment was free from accident hazards and that Resident #1 received adequate supervision. Resident #1 exited the facility unnoticed and unsupervised through a malfunctioning exit door on 5/14/2023.
Report Facts
Residents affected: 4
Elapsed time outside facility: 10
Temperature: 68
Date of incident: May 14, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Returned Resident #1 to the facility and performed full body audit; notified responsible parties. |
| Director of Nursing Services | DNS | Validated Wander Guard bracelet function, performed elopement risk assessments, initiated staff education, and participated in QAPI meetings. |
| Maintenance Director | Maintenance Director | Assessed and repaired malfunctioning exit door locking mechanism and alarm. |
| Administrator | Facility Administrator | Notified of incident, initiated investigation and Root Cause Analysis, participated in QAPI meetings. |
Inspection Report — Apr 13, 2023
Complaint Investigation CMS
Date: Apr 13, 2023
Visit Reason
The inspection was conducted due to resident complaints about food quality, specifically cold, soggy, and unsavory food served at the facility.
Complaint Details
The complaint was substantiated based on observations, interviews, and record reviews confirming unresolved grievances about food quality and improper food storage practices.
Findings
The facility failed to resolve Resident Council grievances related to food concerns for nine residents. Additionally, the facility failed to properly seal dry goods, label and date refrigerated foods, and remove expired foods during kitchen observations.
Deficiencies (2)
F 0565: The facility failed to ensure Resident Council grievances about cold, soggy, and wrong foods were resolved for nine residents who attended the meetings over six months.
F 0812: The facility failed to properly seal dry goods, label and date refrigerated foods, and remove expired foods during one of three kitchen observations.
Report Facts
Residents affected: 9
Residents with BIMS score 15: 4
Residents with BIMS score 14: 2
Residents with BIMS score 12: 3
Expired food item: 8
Open undated food items: 5
Undated Styrofoam cups: 5
Undated hoagie buns: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker | Received resident complaints and notified the Administrator | |
| Dietary Manager | Attended Resident Council meetings and responsible for kitchen operations; confirmed food issues and food storage violations | |
| Administrator | Acknowledged awareness of resident complaints and food storage issues | |
| Dietary District Manager | Confirmed knowledge of resident complaints about food quality |
Inspection Report — Nov 14, 2019
Routine CMS
Date: Nov 14, 2019
Visit Reason
Routine inspection to assess compliance with regulatory requirements including resident rights, grievance resolution, notification of hospital transfers, bed hold notices, assessment accuracy, care plan adherence, and staffing qualifications.
Findings
The facility was found deficient in multiple areas including failure to assist residents to vote, unresolved grievances, failure to notify residents and representatives of hospital transfers and bed hold notices, inaccurate coding of Minimum Data Set assessments related to hospice, failure to follow care plans for catheter and enteral feeding pump care, and lack of a licensed social worker for the licensed bed capacity.
Deficiencies (9)
F 0550: The facility failed to assist two residents to vote in the general election despite policy to encourage voting.
F 0585: The facility failed to resolve grievances for one resident who reported missing money and was not informed of investigation results.
F 0623: The facility failed to notify residents, representatives, and Ombudsman in writing of hospital transfers for two residents.
F 0625: The facility failed to provide written bed hold notices to residents or representatives for three hospitalizations reviewed.
F 0637: The facility failed to accurately code Minimum Data Set assessments and initiate significant change assessments related to hospice for three residents.
F 0656: The facility failed to follow the care plan for catheter care by not securing catheter tubing, causing pain to one resident.
F 0658: The facility failed to follow professional standards by allowing CNAs to stop enteral feeding pumps instead of licensed nurses.
F 0690: The facility failed to provide catheter care to prevent infection and trauma by not anchoring tubing during care for one resident.
F 0850: The facility failed to employ a licensed social worker as required for a facility licensed for more than 120 beds.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 3
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Licensed beds: 160
Days without licensed social worker: 3
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