Inspection Reports for
Diversicare of Quitman
191 Highway 511 East Kenyatta Pearson, Quitman, MS, 39355
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
4.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
24% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 18, 2024
Visit Reason
The inspection was conducted following a complaint regarding inadequate supervision that led to a resident-on-resident altercation resulting in injury.
Complaint Details
The complaint investigation found that Resident #61 wandered into another resident's room, leading to an altercation and injury. The incident was substantiated with medical records and staff interviews confirming the event and subsequent interventions.
Findings
The facility failed to provide adequate supervision to prevent a resident-on-resident altercation where Resident #61 was injured and required emergency department care. Interventions such as stop signs and increased monitoring were implemented after the incident.
Deficiencies (1)
F 0689: The facility failed to provide supervision to prevent a resident-on-resident altercation resulting in Resident #61 sustaining a hematoma and requiring emergency department treatment.
Report Facts
Sampled residents: 22
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Informed of the incident and discussed interventions | |
| Director of Nursing (DON) | Reported the incident to the State Agency and started an investigation | |
| Floor Tech | Observed the incident and assisted in removing Resident #61 | |
| Training Center Account Manager (TCAM) | Assisted in removing Resident #61 from Resident #91's room | |
| Registered Nurse (RN) #3 | Reported the incident to DON and Nurse Practitioner and performed neurological checks |
Inspection Report
Routine
Deficiencies: 5
Date: Dec 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to residents' rights, care planning, implementation of physician orders, accident prevention, and staffing adequacy at Diversicare of Quitman nursing home.
Findings
The facility failed to ensure residents' rights to privacy, develop comprehensive care plans for certain residents, implement physician orders for CPAP and catheter care, provide adequate supervision to prevent resident-on-resident altercations, and maintain sufficient nursing staff to meet residents' needs safely.
Deficiencies (5)
F550: The facility failed to ensure residents' rights to privacy by allowing wandering residents to enter rooms without permission and failing to cover a urinary drainage bag for three of 22 sampled residents.
F0656: The facility failed to develop care plans related to a CPAP machine and an indwelling catheter for two of 22 sampled residents.
F0658: The facility failed to implement physician orders for the use of a CPAP machine and an indwelling catheter for two of 22 sampled residents.
F0689: The facility failed to provide supervision to prevent a resident-on-resident altercation resulting in a hematoma and emergency department visit for one of 22 sampled residents.
F0725: The facility failed to ensure sufficient nursing staff to provide nursing and related services to meet residents' needs safely for one of four staffing quarters reviewed.
Report Facts
Sampled residents: 22
Staffing quarters reviewed: 4
BIMS score: 12
BIMS score: 15
BIMS score: 4
Staffing levels: 16
Staffing levels: 6
Staffing levels: 5
Staffing levels: 4
Staffing levels: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Placed indwelling catheter for Resident #74 and acknowledged responsibility to verify orders |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed failure to follow hospital discharge orders related to CPAP usage for Resident #2 |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported Resident #5's door closure to prevent wandering residents and staffing shortages |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Pulled to cover short staffing and confirmed low staffing levels |
| Nurse Practitioner | Nurse Practitioner | Expressed concerns about Resident #2's obstructive sleep apnea diagnosis and CPAP non-implementation |
| Director of Nursing | Director of Nursing | Acknowledged communication breakdowns, staffing shortages, and confirmed investigation of resident altercation |
| Administrator | Administrator | Confirmed staffing challenges and discussed interventions for resident altercation |
| Floor Tech | Floor Technician | Assisted in removing Resident #61 during altercation and cleaning water on floor |
| Training Center Account Manager | Training Center Account Manager | Assisted in removing Resident #61 during altercation |
| Registered Nurse #3 | Registered Nurse | Reported incident of resident altercation and performed neurological checks |
| Registered Nurse #2 | Registered Nurse | Responsible for developing Resident #74's care plan and acknowledged lack of orders |
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported staffing shortages and resident assignments |
| Workforce Manager | Workforce Manager | Provided staffing grid data and confirmed low staffing alerts |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 28, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding verbal abuse by a Certified Nurse Assistant (CNA) towards a resident.
Complaint Details
The complaint was substantiated. The CNA admitted to verbal abuse using profanity towards Resident #1. The facility reported the incident to the State Agency, Medicaid Fraud Control Unit, and local police. Corrective actions were implemented and the deficiency was corrected prior to the State Agency's entrance.
Findings
The facility failed to protect a resident from verbal abuse by a CNA who used profanity and a loud tone. The CNA was terminated, and the facility implemented corrective actions including staff in-services and a Quality Assurance Performance Improvement meeting.
Deficiencies (1)
F 0600: The facility failed to protect a resident from verbal abuse by a CNA who used profanity and a loud tone while addressing the resident. The CNA admitted to the verbal abuse and was terminated.
Report Facts
Residents sampled: 4
Residents affected: 1
Date of incident: Oct 20, 2023
Date of investigation template: Oct 24, 2023
Date of admission: Jun 28, 2021
Assessment Reference Date: Sep 16, 2023
Date of QAPI meeting: Oct 21, 2023
Date of report validation: Nov 28, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #1 | Employee who verbally abused Resident #1 and was terminated | |
| Administrator | Conducted investigation, reported incident, and provided in-services | |
| Registered Nurse (RN) #1 | Witnessed investigation and confirmed CNA's admission of verbal abuse | |
| Director of Nursing (DON) | Attended QAPI meeting discussing abuse policies | |
| Social Services Director | Attended QAPI meeting discussing abuse policies | |
| Infection Preventionist (IP) | Absent from emergency QAPI meeting | |
| Medical Director | Attended QAPI meeting via phone |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations related to resident care, infection control, respiratory care, dental services, and food safety at Diversicare of Quitman nursing home.
Findings
The facility was found deficient in multiple areas including improper care of peg feeding tubes, unsafe storage of respiratory equipment, failure to provide recommended dental services, presence of expired and spoiled food items in the kitchen, and failure to implement proper infection prevention practices during medication administration via peg feeding tube.
Deficiencies (5)
F 0693: The facility failed to provide proper care for a resident's peg feeding tube, including inadequate cleansing technique that could cause infection for Resident #64.
F 0695: The facility failed to store a nebulizer mask properly, leaving it on the floor and exposing Resident #74 to contamination risk.
F 0791: The facility failed to ensure recommended dental services were provided for Resident #79, resulting in untreated dental abscess due to insurance and payment issues.
F 0812: The facility failed to remove expired, undated, and spoiled food items from storage areas, potentially affecting all residents receiving food from the dietary department.
F 0880: The facility failed to prevent infection spread when a nurse flushed and administered medication via a peg feeding tube without wearing gloves for Resident #64.
Report Facts
Residents reviewed with peg feeding tubes: 3
Residents sampled for dental services: 20
Kitchen observations: 4
Residents affected by peg feeding tube care deficiencies: 1
Residents affected by respiratory care deficiencies: 2
Residents affected by dental service deficiencies: 1
Residents affected by food storage deficiencies: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection prevention deficiency for not wearing gloves during peg feeding tube medication administration |
| LPN #2 | Licensed Practical Nurse | Named in deficiencies related to peg feeding tube care and respiratory equipment storage |
| RN #1 | Registered Nurse | Named in dental service deficiency related to Resident #79 |
| Director of Nursing | Director of Nursing | Provided interviews confirming deficiencies and standard practices |
| Dietary Manager | Dietary Manager | Interviewed regarding expired food removal responsibilities |
| Cook | Cook | Interviewed regarding expired food removal responsibilities |
| Dietary Aide | Dietary Aide | Interviewed regarding expired food removal responsibilities |
| Administrator | Administrator | Interviewed regarding food safety and dental service deficiencies |
| Social Worker | Social Worker | Interviewed regarding dental service follow-up |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 19, 2020
Visit Reason
The inspection was conducted to investigate a complaint regarding the facility's failure to ensure that Resident #68 was free from the use of physical restraints, specifically the failure to monitor and release her lap buddy restraint every two hours as ordered.
Complaint Details
The complaint was substantiated as the facility failed to follow the care plan and physician's orders regarding the use and timely release of physical restraints for Resident #68.
Findings
The facility failed to follow Resident #68's Care Plan and Medical Doctor's orders to remove the lap buddy restraint every two hours. Observations and staff interviews confirmed that the restraint was not released for over two hours, violating the facility's physical restraint policy and care plan requirements.
Deficiencies (2)
F 0604: The facility failed to ensure Resident #68 was free from physical restraint use by not releasing her lap buddy every two hours as required by policy and care plan.
F 0656: The facility failed to develop and implement a complete care plan meeting Resident #68's needs, specifically failing to follow the care plan to release the lap buddy restraint every two hours.
Report Facts
Residents affected: 1
Care plans reviewed: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Confirmed failure to remove lap buddy restraint every two hours as per care plan. |
| Registered Nurse (RN) #1 | Staff Development Nurse | Stated nursing staff and CNAs are responsible for removing restraints every two hours. |
| Director of Nursing (DON) | Director of Nursing | Confirmed responsibility of nurses and CNAs to remove restraints and acknowledged care plan and MD orders were not followed. |
Viewing
Loading inspection reports...
