Deficiencies (last 6 years)
Deficiencies (over 6 years)
16 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
321% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
97% occupied
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility based on complaint investigation numbers CI #2569723, CI #500417, and CI #500419.
Complaint Details
Complaint investigation based on CI #2569723, CI #500417, and CI #500419; facility found compliant with no deficiencies.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Census: 136
Total Capacity: 140
Inspection Report
Re-Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the complaint investigation that was completed on 03/26/25 to verify correction of previously identified deficiencies.
Complaint Details
This visit was a follow-up complaint investigation confirming correction of deficiencies identified in the complaint investigation completed on 03/26/25.
Findings
The information reviewed confirmed the facility had put measures in place to correct the deficient practice as of 04/16/25. The State Agency is recommending the facility be placed back in compliance with Medicare and Medicaid participation requirements for the prior surveys.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Follow-Up
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the complaint investigation that was completed on 2025-03-26 to verify correction of previously identified deficiencies.
Complaint Details
This visit was a follow-up to a complaint investigation completed on 2025-03-26. The findings confirmed correction of deficiencies and compliance was restored as of 2025-04-16.
Findings
The facility had put measures in place to correct the deficient practice as of 2025-04-16, and the State Agency recommended the facility be placed back in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Annual Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 2025-03-20.
Complaint Details
The visit included a complaint investigation completed on 2025-03-20; the revisit confirmed correction of deficiencies.
Findings
The review confirmed the facility had implemented measures to correct the deficient practices and sustain compliance with Medicare and Medicaid participation requirements. The facility was recommended to be placed back in compliance effective 2025-04-16.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility on 3/26/2025 due to allegations of failure to implement a resident's care plan and improper transfer techniques resulting in injury.
Complaint Details
The complaint investigation (CI MS# 28356) substantiated that the facility failed to implement Resident #1's care plan, resulting in improper transfer and a right femur fracture.
Findings
The facility was found non-compliant for neglecting to follow the resident's care plan during transfers, resulting in a resident sustaining a right femur fracture. The facility failed to ensure staff used the proper assistive device and number of staff members for transfers as required by the care plan and Kardex.
Deficiencies (2)
Failure to ensure a resident's right to be free from neglect when staff failed to refer to the Kardex and used improper transfer methods causing injury.
Failure to develop and implement a comprehensive care plan consistent with resident needs, resulting in improper transfer and injury.
Report Facts
Census: 134
Total Capacity: 140
Residents reviewed: 3
Staff observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in neglect finding for improper transfer of Resident #1 |
| Administrator | Verified facility investigation and expectations for care plan adherence | |
| Nurse Practitioner | Nurse Practitioner | Notified of resident's injury and ordered transfer to hospital |
| Registered Nurse | Registered Nurse | Assessed resident after improper transfer |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a resident's care plan, specifically related to improper transfer methods and insufficient staff assistance during transfers for Resident #1.
Complaint Details
The complaint investigation found that Resident #1 was transferred improperly on 3/14/25, resulting in a fracture. The investigation included staff interviews, record reviews, and policy reviews. CNA #1 admitted to not following the care plan and using the wrong transfer method. The Administrator confirmed expectations for staff to follow care plans and use the kiosk for guidance. Resident #1 was diagnosed with dementia and required maximal assistance for transfers.
Findings
The facility failed to follow the care plan for Resident #1, resulting in the resident being transferred using an incorrect method without the required number of staff or proper assistive devices. This led to the resident sustaining a right femoral shaft fracture. Interviews and record reviews confirmed staff did not adhere to the care plan instructions, and the facility's policies and procedures were not properly followed.
Deficiencies (2)
Failed to implement a resident's care plan when Resident #1 was transferred without the required number of staff members and the use of the proper assistive devices.
Failed to ensure a resident's environment was free from accident hazards by not referring to the kiosk to ensure proper transfer methods and staff assistance.
Report Facts
Residents care plans reviewed: 3
Residents affected: 1
Date of incident: Mar 14, 2025
Date of fracture diagnosis: Mar 20, 2025
Date of admission: Apr 10, 2018
Assessment Reference Date: Feb 9, 2025
Lift Transfer Evaluation Date: Apr 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Admitted to transferring Resident #1 using the wrong method and not following the care plan |
| Administrator | Verified the investigation findings and confirmed expectations for staff to follow care plans and use the kiosk | |
| Registered Nurse (RN) | Registered Nurse | Assessed Resident #1 after the fall and found no immediate injury |
| Nurse Practitioner (NP) | Nurse Practitioner | Notified of Resident #1's condition and ordered transfer to hospital after fracture diagnosis |
Inspection Report
Annual Inspection
Census: 134
Capacity: 140
Deficiencies: 10
Date: Mar 20, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and seven Complaint Investigations at the facility from 3/17/25 through 3/20/25 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm.
Complaint Details
Seven complaint investigations were conducted (CI MS #27183, CI MS #27690, CI MS #27865, CI MS #28043, CI MS #28193, CI MS #28208, and CI MS #28282). Non-compliance was identified in several complaints related to activities of daily living, hydration, and environment. Three complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with multiple standards including residents' rights, activities of daily living, hydration, medication storage, housekeeping, infection control, and environmental safety. Deficiencies included call lights not within reach, inadequate ADL care, improper fluid intake monitoring, unsecured medication carts, pest control issues, maintenance deficiencies, and failure to follow infection control precautions.
Deficiencies (10)
Resident call lights were not within reach for two residents, limiting their ability to request assistance.
Facility failed to provide activities of daily living care for three residents dependent on staff assistance.
Housekeeping carts were not locked and hazardous chemicals were accessible to residents.
Resident's window had a 3-inch gap with no screen, exposing the room to outside elements.
Presence of mice droppings in resident's dresser drawers posing contamination risk.
Resident rooms had housekeeping issues including stained curtains, cluttered floors, broken bed rails, and unclean equipment.
Hole in resident's wall with vent cover hanging out posing injury hazard.
Facility failed to maintain an effective infection control program including improper use of enhanced barrier precautions and improper disposal of contaminated materials.
Facility failed to accurately monitor and document fluid intake for a resident on dialysis, resulting in exceeding fluid restrictions.
Medication cart was left unlocked with medications unsecured, posing risk to residents.
Report Facts
Residents observed: 134
Licensed capacity: 140
Deficiency count: 10
Fluid restriction: 1
Medication cart audit frequency: 3
Housekeeping cart audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication cart unlocked and unsecured medication finding |
| Director of Nursing | DON | Named in multiple findings including call light accessibility, ADL care, fluid restriction monitoring, medication storage, infection control |
| Director of Clinical Education | Provided staff education on call light accessibility, ADL care, chemical storage, medication cart security, maintenance reporting, and infection control | |
| Housekeeping Supervisor | Named in chemical storage and infection control cleaning findings | |
| Maintenance Director | Named in findings related to environmental repairs and maintenance | |
| Infection Preventionist | Named in infection control findings regarding enhanced barrier precautions and communication failures |
Inspection Report
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess the facility's 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 with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 4
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, care, environment, and care plan implementation at Diversicare of Southaven.
Findings
The facility failed to ensure call lights were within reach for residents, maintain a safe and clean environment, provide timely maintenance and repairs, implement complete care plans for activities of daily living, and accurately monitor and document fluid intake for residents on fluid restrictions.
Deficiencies (4)
Failed to ensure resident call lights were within reach, limiting ability to request assistance for 2 of 134 residents.
Failed to provide a safe, clean, and homelike environment for 9 of 134 residents, including issues with leaking air conditioner, broken furniture, pest droppings, holes in walls, and clutter.
Failed to implement activities of daily living (ADL) care plans for 3 of 5 residents dependent on staff assistance, including inadequate oral and nail care.
Failed to accurately monitor and document fluid intake for 1 of 6 residents receiving dialysis, resulting in exceeding fluid restriction on multiple days.
Report Facts
Residents observed: 134
Residents affected by call light deficiency: 2
Residents affected by environment deficiency: 9
Residents reviewed for ADL care plans: 45
Residents with failed ADL care plan implementation: 4
Days fluid intake exceeded 1 liter: 9
Length of sagging mattress area: 12
Length of peeling mattress area: 36
Hole size in wall: 24
Length of Resident #111's fingernails: 1.5
Length of Resident #118's fingernails: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed staff are expected to ensure call lights are within reach and acknowledged failures in care plan implementation and fluid monitoring. |
| CNA #4 | Certified Nursing Assistant | Confirmed call light was inaccessible to Resident #42. |
| RN #2 | Registered Nurse | Verified call light was out of reach for Resident #32 and exposed wires on bed remote control. |
| CNA #2 | Certified Nursing Assistant | Admitted leaving call light out of reach for Resident #32. |
| Housekeeper #2 | Housekeeper | Reported air conditioner leaking and towels changed daily. |
| Maintenance Supervisor | Maintenance Supervisor | Unaware of some maintenance issues including leaking air conditioner and broken headboard. |
| RN #1 | Registered Nurse | Confirmed mice droppings, broken equipment, and clutter in resident rooms. |
| Maintenance Director | Maintenance Director | Confirmed lack of notification about maintenance issues and bed/mattress disrepair. |
| CNA #6 | Certified Nurse Aide | Confirmed poor oral care for Resident #12. |
| LPN #1 | Licensed Practical Nurse | Admitted incomplete monitoring of Resident #32's fluid intake. |
| Nurse Practitioner | Nurse Practitioner | Agreed failure to monitor fluid intake could exacerbate resident's condition. |
| CNA #5 | Certified Nurse Aide | Assigned to Resident #111 and confirmed long jagged fingernails not reported. |
| LPN #3 | Licensed Practical Nurse | Confirmed responsibility for trimming nails of diabetic Resident #111. |
Inspection Report
Routine
Census: 134
Deficiencies: 10
Date: Mar 17, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure resident call lights were within reach, failure to secure electronic health records, unsafe and unclean resident environments, failure to implement care plans for activities of daily living and fluid restrictions, unsafe storage of hazardous chemicals, inaccurate staffing data submission, failure to follow infection prevention protocols including enhanced barrier precautions, and ineffective pest control.
Deficiencies (10)
Failure to ensure resident call lights were within reach, limiting residents' ability to request assistance (Residents #32 and #42).
Failure to secure electronic health records as evidenced by visible EMAR information on unattended medication carts (Residents #86 and #104).
Failure to provide a safe, clean, and homelike environment including leaking air conditioner, broken furniture, pest droppings, and unsafe room conditions affecting multiple residents.
Failure to implement activities of daily living care plans for dependent residents and failure to implement fluid restriction care plan for Resident #32.
Failure to safely store and lock hazardous cleaning chemicals on housekeeping carts.
Failure to accurately submit staffing data into the Payroll-Based Journal system for the first quarter of 2025.
Failure to ensure medication cart was locked and medications secured when unattended.
Failure to ensure accurate documentation of care and services for a resident with a PICC line (Resident #430).
Failure to implement infection prevention and control practices including improper use of enhanced barrier precautions and improper disposal of contaminated materials (Residents #4, #118, and #125).
Failure to maintain an effective pest control program to address mice droppings in resident's dresser drawers (Resident #70).
Report Facts
Residents observed: 134
Residents affected by call light deficiency: 2
Residents affected by EMAR privacy deficiency: 2
Residents affected by unsafe environment: 9
Residents reviewed for ADL care plans: 45
Residents with deficient ADL care plans: 4
Days fluid intake exceeded 1 liter: 9
Residents on dialysis reviewed: 6
Survey days medication cart unsecured: 1
Quarters with inaccurate PBJ data: 1
Residents on contact isolation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed EMAR visibility on medication cart and fluid intake documentation issues |
| DON | Director of Nursing | Confirmed multiple deficiencies including call light accessibility, EMAR privacy, infection control, medication cart security, and fluid intake monitoring |
| CNA #4 | Certified Nursing Assistant | Confirmed call light accessibility issues for Resident #42 |
| RN #2 | Registered Nurse | Confirmed call light accessibility and exposed wires on bed remote control |
| Housekeeper #5 | Housekeeper | Confirmed housekeeping cart lock issues and chemical storage |
| Administrator | Facility Administrator | Acknowledged deficiencies in environment, staffing data, infection control, and housekeeping |
| RN #1 | Registered Nurse | Confirmed mice droppings and infection control lapses |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged unreported maintenance issues including mice droppings and broken equipment |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 140
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 11/25/2024 related to dietary services, misappropriation of funds, quality of care, administration, environment, falls, nursing services, and quality of care.
Complaint Details
Complaint investigation for CI MS #26562 related to dietary services, misappropriation of funds, quality of care, and administration; and CI MS #26598 related to environment, falls, nursing services, and quality of care. No deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Census: 130
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 131
Capacity: 140
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 25402) at the facility related to allegations of verbal abuse.
Complaint Details
Complaint investigation CI MS# 25402 regarding allegations of verbal abuse was not substantiated; no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. No deficiencies were cited related to the allegations of verbal abuse.
Report Facts
Census: 131
Total Capacity: 140
Inspection Report
Follow-Up
Census: 125
Capacity: 140
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The State Agency conducted a follow-up survey at the facility on 6/4/24 related to the complaint survey conducted from 3/18/24 through 3/20/24.
Complaint Details
The follow-up survey was related to a prior complaint survey conducted from 3/18/24 through 3/20/24. The facility was found compliant during the follow-up.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm, and the State Agency recommended the facility be placed back in compliance effective 6/3/24.
Report Facts
Facility census: 125
Total bed capacity: 140
Inspection Report
Complaint Investigation
Census: 133
Capacity: 140
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 05/30/2024 to investigate facility staffing, infection control, misappropriation of property, and nursing services.
Complaint Details
Complaint investigations CI MS #25064 and CI MS #25066 were conducted, focusing on staffing, infection control, misappropriation of property, and nursing services. No deficiencies were cited during this investigation.
Findings
No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with Medicare and Medicaid participation requirements due to deficiencies cited in prior surveys on 03/20/2024 and 05/08/2024.
Report Facts
Census: 133
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 123
Capacity: 140
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 5/8/2024 related to two complaint investigations (CI MS #24852 and CI MS #25031). The investigation focused on compliance with Medicare and Medicaid Services requirements, specifically regarding quality of care and discharge.
Complaint Details
The complaint investigation MS #24852 was substantiated with a deficiency cited for failure to provide services according to professional standards. Complaint investigation MS #25031 related to discharge had no deficiencies cited.
Findings
The facility was found non-compliant for failure to provide services in accordance with professional standards of practice, specifically failing to change a negative pressure wound therapy system dressing as ordered for one resident. No deficiencies were cited related to discharge for the second complaint. The wound vac dressing was not changed as ordered, leading to foam adherence to the wound and potential harm.
Deficiencies (1)
Failure to change the negative pressure wound therapy system dressing as ordered for one resident with wound care.
Report Facts
Census: 123
Total Capacity: 140
Deficiency Completion Date: Jun 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding wound vac dressing and documentation |
| Director of Clinical Education | Director of Clinical Education | Provided education to licensed nurses on treatment and documentation |
| Director of Nursing Services | Director of Nursing Services | Responsible for reviewing treatment documentation and auditing compliance |
| Administrator | Administrator | Interviewed and agreed wound vac dressing should have been changed as ordered |
| Wound Care Nurse Practitioner | Nurse Practitioner | Provided progress notes and verified wound vac dressing adherence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was conducted following a complaint regarding failure to change the negative pressure wound therapy system dressing as ordered for Resident #1.
Complaint Details
Complaint investigation confirmed failure to change wound vac dressing as ordered. Resident Representative notified staff about the need for dressing change. The deficiency was substantiated with actual harm to the resident.
Findings
The facility failed to ensure that Resident #1's wound vac dressing was changed as ordered, resulting in the foam dressing adhering to the wound bed and causing actual harm. Interviews and record reviews confirmed the dressing was not changed on scheduled dates and fragments remained in the wound after removal.
Deficiencies (1)
Failure to change the negative pressure wound therapy system dressing as ordered for Resident #1, resulting in foam dressing adhered to the wound bed and actual harm.
Report Facts
Residents affected: 3
Residents affected: 1
Dates wound vac dressing not changed: 3
Wound vac pressure: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding wound vac dressing and documentation |
| NP #1 | Wound Care Nurse Practitioner | Completed progress note and interviewed regarding wound vac dressing adherence and harm |
| Director of Nursing | Director of Nursing | Involved in wound vac removal and responsible for wound care at the time |
| Administrator | Administrator | Interviewed and agreed wound vac dressing should have been changed as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by the elopement of Resident #1, who exited the facility unsupervised and undetected on 03/31/24, posing immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was initiated due to Resident #1 eloping from the facility on 03/31/24, remaining missing for approximately 10-20 minutes. The State Agency identified Immediate Jeopardy and Substandard Quality of Care beginning on 03/31/24. The facility implemented corrective actions by 04/01/24, and the Immediate Jeopardy was removed on 04/02/24 prior to the State Agency's entrance on 04/05/24.
Findings
The facility failed to implement an effective elopement/wandering risk care plan for Resident #1, who had a documented history of wandering and elopement attempts. Resident #1 exited the facility through an unsecured kitchen door that lacked an alarm, resulting in a 10-20 minute unsupervised absence. The facility initiated corrective actions including staff in-services, installation of new door locks and alarms, 24/7 door monitoring, and updated care plans. The immediate jeopardy was removed after corrective actions were validated by the State Agency.
Deficiencies (2)
Failed to implement an elopement/wandering risk plan of care for Resident #1 who wore a wander guard.
Failed to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Times wander guard not checked: 28
Residents at risk for elopement: 4
Distance from facility to apartment complex: 200
Date of elopement: Mar 31, 2024
Date of corrective action completion: Apr 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse Supervisor | Assessed Resident #1 after elopement, notified administration, and participated in investigation and staff in-services. |
| ADM | Administrator | Received Immediate Jeopardy template, led investigation, contacted State Agency and Attorney General's Office, and oversaw corrective actions. |
| ADON | Assistant Director of Nursing / Interim Director of Nurses | Confirmed kitchen door was unsecured, participated in staff in-services, and confirmed care planning for Resident #1. |
| RN #2 | MDS/Care Plan Nurse | Completed and revised care plan for Resident #1 including elopement risk. |
| Maintenance Director | Checked and confirmed malfunctioning kitchen door alarms, coordinated installation of new locks and alarms. | |
| CNA #3 | Certified Nursing Assistant | Participated in locating Resident #1 after elopement and reported Resident #1's wandering behavior. |
| CNA #4 | Certified Nursing Assistant | Assigned to Resident #1, redirected him before elopement, and participated in locating Resident #1. |
| Resident Representative | Provided background on Resident #1's wandering history and consented to behavioral health evaluation. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The inspection was conducted on 4/2/2024 as two complaint investigations related to abuse and physical environment, maintenance of equipment, and falls.
Complaint Details
Two complaint investigations were conducted: CI MS #24633 related to abuse and CI MS #24634 related to physical environment, maintenance of equipment, and falls. Both complaints were found to be unsubstantiated as no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited during this visit. However, the facility remains out of compliance due to deficiencies cited on the 3/20/2024 survey.
Report Facts
Licensed beds: 140
Resident census: 134
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 5
Date: Mar 20, 2024
Visit Reason
The State Agency conducted seven complaint investigations related to various complaint investigation numbers and found the facility was not in compliance with state licensure requirements and Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was triggered by seven complaint investigations (CI MS #23878, #23901, #23910, #24000, #24186, #24221, #24352). Non-compliance was found in multiple complaint investigations with citations issued. The facility was in compliance related to CI MS #24000 and CI MS #23901.
Findings
The facility failed to provide sufficient nursing staff, failed to provide assistance with activities of daily living for several residents, failed to maintain a safe and clean environment including damaged floors and unclean areas, failed to provide adequate linens and blankets, and failed to ensure call lights were functioning properly for residents.
Deficiencies (5)
Failed to provide sufficient staff as evidenced by staff not providing assistance with bathing, grooming and personal hygiene for three sampled residents and failed to meet the state minimum nursing care hours per resident.
Failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside.
Failed to provide assistance with activities of daily living including bathing, grooming, dressing, toileting for three sampled residents.
Failed to maintain floors in a safe, clean, and homelike environment as evidenced by damaged floors on the East Wing, trash buildup, unclean floors, and no clean linens for two of three wings.
Failed to ensure call lights were functioning in all resident rooms as evidenced by call lights not functioning for two sampled residents.
Report Facts
Resident census: 135
Total bed capacity: 140
Staffing ratio: 2.69
Staffing ratio: 2.7
Number of complaint investigations: 7
Floor repair completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Confirmed Resident #2's condition and staffing issues |
| Licensed Practical Nurse #2 | LPN | Confirmed bathing schedule and shaving for Resident #6 |
| Licensed Practical Nurse #5 | LPN | Confirmed staffing issues and resident care concerns |
| Director of Nurses | DON | Confirmed staffing and care deficiencies, call light issues |
| Administrator | Acknowledged staffing, linen, and environmental issues | |
| Certified Nurse Assistant #1 | CNA | Reported staffing shortages and resident care delays |
| Certified Nurse Assistant #3 | CNA | Confirmed linen shortages and resident care issues |
| Maintenance Staff #2 | Confirmed floor damage and washer repair details | |
| Housekeeper #4 | Confirmed cleaning deficiencies in resident rooms | |
| Laundry Staff #3 | Assistant Supervisor | Reported washer breakdown and staffing issues |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, staffing, environment, and call system functionality at Diversicare of Southaven nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide adequate linens and blankets to residents, unsafe and damaged flooring, unclean environment, insufficient assistance with activities of daily living (ADLs) for several residents, inadequate staffing levels impacting resident care, and malfunctioning call light systems in resident rooms.
Deficiencies (6)
Failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside.
Failed to provide a safe, clean, homelike environment as evidenced by damaged floors, trash buildup, unclean floors, and no clean linens for two of three wings.
Failed to implement a comprehensive care plan for residents requiring assistance with ADLs for three residents.
Failed to provide assistance with ADLs for residents requiring help for three residents.
Failed to provide enough nursing staff to meet the needs of residents, resulting in inadequate assistance with bathing, grooming, and personal hygiene for three residents.
Failed to ensure that call lights were functioning in all resident rooms as evidenced by two residents' call lights not functioning.
Report Facts
Residents on sample: 11
Residents affected: 1
Residents affected: 2
Residents affected: 3
Nurse aides on night shift: 3
Residents per nurse aide: 20
Square feet of flooring ordered: 470.86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Resident #2's nurse, confirmed lack of linens and open window |
| Certified Nurse Assistant #3 | CNA | Resident #2's CNA, confirmed lack of linens and frequent occurrence |
| Administrator | Confirmed issues with linens, window open, laundry problems, and floor hazards | |
| Director of Nurses | DON | Confirmed resident rights violations and staffing issues |
| Laundry Staff #1 | Confirmed no clean linens or blankets available | |
| Licensed Practical Nurse #4 | LPN | Confirmed floor hazards and use of yellow poles |
| Maintenance Staff #2 | Confirmed floor damage and washer issues | |
| Certified Nurse Assistant #5 | CNA | Reported complaints about cleanliness and garbage buildup |
| Environmental Manager | New manager, unaware of washer breakdown and linen issues | |
| Licensed Practical Nurse #5 | LPN | Reported staffing issues and inadequate showers |
| Workforce Manager | Untrained in staffing scheduling, unaware of staffing shortages |
Inspection Report
Follow-Up
Census: 131
Capacity: 140
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The State Agency conducted a Follow-up Survey from 12/4/23 to 12/6/23 to verify compliance after the Annual Survey conducted from 10/30/23 to 11/2/23.
Findings
The facility was placed back in compliance with the Mississippi Regulation for Minimum Standards for Institutions for Aged and Infirm with no additional deficiencies cited during this survey effective 11/27/2023.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day period, specifically between 10/30/2023 and 11/05/2023, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 7
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 10/30/23 through 11/2/23 to determine compliance with Medicare and Medicaid requirements.
Complaint Details
The complaint investigation (Cl MS #22673) found noncompliance related to environment and Activities of Daily Living, citing deficiencies F677 and F921.
Findings
The facility was found not in compliance with multiple regulatory requirements including reasonable accommodations, notification of changes, comprehensive care plans, range of motion/mobility, accident hazards, food safety, and infection prevention and control. Deficiencies were cited related to call light accessibility, failure to notify physician of elevated blood sugar, incomplete care plans, failure to apply splints, unsecured oxygen cylinders, unclean ice machine, improper dishwashing temperatures, and unsanitary resident nourishment refrigerators.
Deficiencies (7)
Failed to ensure a resident's call light was placed within reach.
Failed to notify the resident's physician of an elevated blood sugar of 466.
Failed to develop/implement comprehensive care plans for multiple residents including shaving, call light accessibility, medication changes, and assistive devices.
Failed to apply a hand splint recommended by Occupational Therapy to prevent worsening of contracture.
Failed to ensure a resident was free from accident hazards due to unsecured free standing portable oxygen cylinder.
Failed to clean the ice machine, failed to check dishwashing water temperature, and failed to label, date, clean, and remove expired food in resident nourishment refrigerators.
Failed to prevent possible spread of infection when a resident's oxygen tubing was laying on the floor and not stored in a plastic bag.
Report Facts
Deficiencies cited: 7
Census: 125
Total licensed capacity: 140
Elevated blood sugar: 466
Oxygen flow rate: 3
BIMS score: 6
BIMS score: 12
BIMS score: 9
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to notify physician of elevated blood sugar for Resident #15. |
| CNA #3 | Certified Nurse Assistant | Confirmed Resident #102's call light was on the floor and not in reach. |
| Director of Nursing | Director of Nursing | Assessed residents, confirmed deficiencies, and provided oversight of corrective actions. |
| District Dietary Manager | Dietary Manager | Confirmed improper dishwashing temperatures and unclean ice machine. |
| Maintenance Director | Maintenance Director | Responsible for ice machine cleaning. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Removed oxygen tubing from floor and replaced it for Resident #49. |
| Occupational Therapist | Occupational Therapist | Evaluated Resident #108 and confirmed splint was not applied. |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Diversicare of Southaven.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, failure to notify physicians of critical blood sugar levels, incomplete care plans for residents, failure to apply prescribed splints, unsecured oxygen cylinders, unclean ice machine and resident nourishment refrigerators, and improper infection control practices related to oxygen tubing.
Deficiencies (7)
Failed to ensure a resident's call light was placed within reach.
Failed to notify the resident's physician of an elevated blood sugar of 466.
Failed to develop/implement care plans for shaving, call light accessibility, medication consultation, and splint application for multiple residents.
Failed to apply a hand splint recommended by Occupational Therapy resulting in loss of range of motion.
Failed to ensure a resident was free from accident hazards due to unsecured portable oxygen cylinder.
Failed to clean the ice machine, check dish water temperature, and properly label, date, clean, and remove expired food in resident nourishment refrigerators.
Failed to prevent possible spread of infection by allowing oxygen tubing to lay on the floor and not stored in a plastic bag.
Report Facts
Residents sampled: 26
Blood sugar level: 466
Water temperature: 90
Water temperature: 110
Water temperature: 135
Water temperature range: 135-150
Water temperature range: 150-185
BIMS score: 6
BIMS score: 12
BIMS score: 9
BIMS score: 15
Resident nourishment refrigerators: 3
Ice machine cleaning frequency: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding blood sugar notification and care plan compliance |
| Licensed Practical Nurse #2 | LPN | Confirmed unsecured oxygen cylinder and oxygen tubing on floor |
| Licensed Practical Nurse #3 | LPN | Did not notify NP of elevated blood sugar for Resident #15 |
| Certified Nurse Assistant #1 | CNA | Interviewed about shaving residents and refrigerator cleanliness |
| Certified Nurse Assistant #2 | CNA | Confirmed resident nourishment refrigerator uncleanliness |
| Certified Nurse Assistant #3 | CNA | Confirmed call light placement issue for Resident #102 |
| Certified Nurse Assistant #4 | CNA | Interviewed about shaving Resident #90 |
| Director of Nursing | DON | Multiple interviews confirming deficiencies and care plan issues |
| Occupational Therapist | OT | Confirmed splint not applied to Resident #108 and worsening contracture |
| District Dietary Manager | Manager | Confirmed ice machine uncleanliness and dishwashing temperature issues |
| Administrator | Administrator | Confirmed multiple deficiencies including ice machine and nourishment refrigerators |
| Minimum Data Set Nurse | MDS Nurse | Confirmed care plan non-compliance and impact on resident care |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The State Agency conducted a desk review on 12/14/2023 of information related to the annual survey conducted on 10/30/2023 to verify correction of deficient practices.
Findings
The facility provided information confirming measures were put in place to correct deficient practices and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 12/13/2023.
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding the fire alarm system functionality and maintenance.
Findings
The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, evidenced by a trouble signal on the fire alarm panel that could not be reset during the inspection. The deficiency affected all smoke compartments and all residents on the day of the survey.
Deficiencies (1)
Facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal on the fire alarm panel that could not be reset.
Report Facts
Date of fire alarm panel reset: Oct 30, 2023
Scheduled repair completion date: Dec 1, 2023
Date of fire alarm system inspection: Nov 9, 2023
Quality Assurance meeting date: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Unable to reset fire alarm panel to normal mode; verified observation during exit interview | |
| Administrator | Acknowledged the finding and educated Maintenance Director and Assistant on fire alarm panel importance | |
| Maintenance Director | Performed manual fire alarm panel reset to normal on 10/30/2023 and received education on fire alarm panel importance | |
| Maintenance Assistant | Educated on importance of ensuring fire alarm panel transmits normally |
Inspection Report
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no Life Safety Code deficiencies cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/07/2023 to 08/13/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Census: 129
Capacity: 140
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The State Agency conducted three complaint investigations at the facility from 2023-06-21 through 2023-06-22, investigating Dietary services, Nursing Services Quality of Care, Treatment, Physical Environment, and Neglect.
Complaint Details
Three complaint investigations (CI MS #21612, CI MS #21816, and CI MS #21887) were conducted with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, with no deficiencies cited in the investigated areas.
Report Facts
Licensed beds: 140
Census: 129
Inspection Report
Complaint Investigation
Census: 129
Capacity: 140
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 6/21/2023 through 6/22/2023 to investigate Dietary Services, Nursing Services, Quality of Care Treatment, Physical Environment, and Neglect.
Complaint Details
Complaint Investigation (CI MS #21612, CI MS #21816, and CI MS #21887) was conducted with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 129
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 5/9/23 through 5/10/23 to investigate pressure sores, neglect, and accidents.
Complaint Details
Complaint Investigation (CI MS #21424 and CI MS #20962) regarding pressure sores, neglect, and accidents was conducted and found no deficiencies.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, with no deficiencies cited during the investigation.
Report Facts
Licensed beds: 140
Census: 134
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2022-12-28 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey completed on 2022-12-28. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation for compliance reinstatement.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-01-31.
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a complaint survey from 1/18/23 to 1/19/23 to investigate complaint MS #20454 regarding Quality of Care/Treatment and Accidents/Unwitnessed Fall Resident #1.
Complaint Details
Complaint MS #20454 was not substantiated for Quality of Care/Treatment Call Bell Not Answered In A Timely Manner By Staff and Accidents/Unwitnessed Fall Resident #1.
Findings
The State Agency did not substantiate the complaint and determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 136
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility from January 18 to January 19, 2023, to investigate allegations related to Quality of Care/Treatment, Call Bell response times, and Accidents/Unwitnessed Falls.
Complaint Details
Complaint survey MS CI #20454 was conducted; the complaint for Quality of Care/Treatment, Call Bell Not Answered In A Timely Manner By Staff, and Accidents/Unwitnessed Fall was not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited during this survey; however, the facility remains out of compliance due to deficiencies cited in a prior complaint survey conducted on December 28, 2022.
Report Facts
Licensed beds: 140
Census: 135
Inspection Report
Complaint Investigation
Census: 138
Capacity: 140
Deficiencies: 1
Date: Dec 28, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility on 12/28/2022 due to a complaint regarding the physical environment.
Complaint Details
The complaint was substantiated for physical environment issues related to cleanliness and sanitation.
Findings
The facility failed to maintain a clean, comfortable environment as evidenced by thick, pink and black substances in and around toilets and bathtub drains in four of 75 bathrooms observed. Interviews with staff confirmed the unsanitary conditions and acknowledged the potential risk to residents.
Deficiencies (1)
Facility failed to maintain a safe, clean, comfortable, and homelike environment due to thick, pink and black substances in and around toilets and bathtub drains in four bathrooms.
Report Facts
Licensed beds: 140
Census: 138
Bathrooms observed: 75
Bathrooms with deficiencies: 4
Rooms monitored: 5
Monitoring frequency: 5
Monitoring frequency: 3
Monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Confirmed black and pink substances in bathtub and toilet in room W24 |
| Housekeeping Supervisor | Confirmed presence of black substances around toilets and acknowledged cleaning issues | |
| Housekeeping District Manager | Confirmed unsanitary conditions and potential resident risks; responsible for in-service training and monitoring | |
| Administrator | Confirmed unsanitary conditions and potential resident risks; involved in monitoring and corrective action | |
| Floor Technician #1 | Confirmed dried black and pink substances in bathroom |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a complaint survey from 11/28/22 to 11/30/22 related to complaints MS #19768 and MS #19808 concerning resident rights, environment, responsible party, notification, and resident assessment.
Complaint Details
Complaints MS #19768 and MS #19808 were investigated and found not substantiated for resident rights, environment, responsible party, notification, and resident assessment.
Findings
The State Agency did not substantiate the complaints and determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 135
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-07-27 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-09-09.
Report Facts
Annual survey completion date: Jul 27, 2022
Compliance effective date: Sep 9, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2022
Visit Reason
The State Agency conducted a complaint survey CI MS #19487 on 8/22/22 to investigate allegations of Neglect and Abuse.
Complaint Details
Complaint CI MS #19487 was investigated and found not substantiated for allegations of Neglect and Abuse.
Findings
The complaint was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 7/27/2022 survey.
Report Facts
Complaint ID: 19487
Previous survey date: Jul 27, 2022
Inspection Report
Annual Inspection
Census: 118
Capacity: 140
Deficiencies: 7
Date: Jul 27, 2022
Visit Reason
The State Agency conducted an annual recertification and complaint investigations from 07/17/22 to 07/21/22, with a return visit on 07/27/22 for investigation of possible abuse which was not substantiated.
Complaint Details
The survey included complaint investigations CI MS #19370, CI MS #19362, CI MS #19225, CI MS #18823, and CI MS #19414. Abuse investigation was not substantiated. Complaints substantiated included call light system, ADLs, environment, and timely notification to State Agency.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated complaints related to call light system, ADLs, environment, and other care issues. Multiple deficiencies were cited including safe environment, notice of transfer/discharge, care planning, pressure ulcer treatment, medication storage, and resident call system.
Deficiencies (7)
Failed to provide a safe, clean, comfortable, and homelike environment evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords in resident rooms.
Failed to provide notice of transfer to the hospital to the responsible party for one resident.
Failed to develop a comprehensive care plan for refusal of Activities of Daily Living (ADL) care for one resident.
Failed to provide ADL care including nail care for a dependent resident.
Failed to ensure Registered Nurse assessment and measurement of pressure ulcers; LPNs were performing wound measurements without RN verification.
Failed to store narcotics in permanently affixed locked compartments inside medication room refrigerators.
Failed to maintain a properly functioning resident call system on the East Wing; audible alarm was not working leading to potential delays in resident assistance.
Report Facts
Deficiencies cited: 9
Census: 118
Total licensed capacity: 140
Call light system malfunction report dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in findings related to environmental repairs and medication storage lock box installation. | |
| Administrator | Named in findings related to transfer notification and call light system issues. | |
| Registered Nurse #1 | RN | Named in findings related to refusal of care and nail care deficiencies. |
| Licensed Practical Nurse #3 | LPN | Named in findings related to pressure ulcer treatment and wound measurements. |
| Social Services | Named in findings related to failure to notify family of hospital transfer. | |
| Director of Nursing | DON | Named in findings related to wound care oversight and medication storage. |
| Assistant Director of Nursing | ADON | Named in findings related to wound care and medication storage. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 07/27/22 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 09/09/22.
Report Facts
Survey completion date: Jul 27, 2022
Inspection Report
Routine
Deficiencies: 7
Date: Jul 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, and facility environment, including observations of environmental conditions, resident care plans, medication storage, wound care, and call system functionality.
Findings
The facility was found deficient in maintaining a safe and clean environment, timely notification of hospital transfers, comprehensive care planning, nail care provision, pressure ulcer assessment by qualified staff, secure storage of narcotics, and proper functioning of the call system in the East Wing.
Deficiencies (7)
Failed to provide a clean and safe environment as evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords in resident rooms.
Failed to provide timely notification to the resident's responsible party of transfer to hospital for one of three residents.
Failed to develop a comprehensive care plan for refusal of Activities of Daily Living (ADL) care for one of 27 residents reviewed.
Failed to provide nail care for one dependent resident, with fingernails dirty with brownish material.
Failed to provide a Registered Nurse for assessment of pressure ulcers; Licensed Practical Nurses performed wound measurements without RN verification.
Failed to store narcotics in a permanently fixed locked box in two of three medication rooms reviewed.
Failed to maintain a properly functioning call system in the East Wing; audible alarm was not working though lights were on.
Report Facts
Rooms observed with environmental issues: 2
Residents transferred to hospital: 3
Residents care plans reviewed: 27
Residents reviewed for nail care: 5
Residents reviewed for wound assessments: 8
Medication rooms reviewed: 3
Wings observed for call system: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance rounds and call system repairs. | |
| Licensed Practical Nurse #8 | LPN | Interviewed about electronic reporting system for repairs and housekeeping. |
| Facility Administrator | Administrator | Confirmed environmental issues, call system problems, and notification policies. |
| Housekeeping Supervisor | Reported ongoing environmental issues and communication with maintenance. | |
| Licensed Practical Nurse #7 | LPN | Confirmed safety hazards and housekeeping cleaning schedules. |
| Registered Nurse #1 | RN | Confirmed resident care refusals and nail care needs. |
| Minimum Data Set Nurse | Confirmed lack of care plan for refusal of ADL care. | |
| Assistant Administrator | Confirmed documentation requirements for care refusals. | |
| Certified Nursing Assistant #1 | CNA | Reported on call system audible alarm and resident assistance. |
| Licensed Practical Nurse #3 | LPN | Performed wound treatments and measurements. |
| Nurse Practitioner | NP | Provided guidance on wound assessments. |
| Assistant Director of Nursing | ADON | Discussed wound care responsibilities and narcotics storage. |
| Director of Nursing | DON | Discussed wound care oversight and narcotics storage. |
| Licensed Practical Nurse #1 | LPN | Observed medication storage and narcotics lock box. |
| Licensed Practical Nurse #2 | LPN | Interviewed about narcotics lock box requirements. |
| Licensed Practical Nurse #5 | LPN | Reported call system audible alarm failure. |
| Licensed Practical Nurse #6 | LPN | Reported call system issues and resident bell distribution. |
| Licensed Practical Nurse #7 | LPN | Reported call system audible alarm failure and resident bell use. |
| Certified Nursing Assistant #3 | CNA | Reported call system audible alarm failure and resident bell use. |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 140
Deficiencies: 0
Date: Mar 21, 2022
Visit Reason
A complaint investigation was conducted by the State Agency on 3/21/22 regarding allegations of abuse.
Complaint Details
Complaint Investigation (CI) #18558 was unsubstantiated with no deficiencies cited for allegations of abuse.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited, and the facility was found to be in compliance with Mississippi Long Term Care regulations.
Report Facts
Licensed beds: 140
Census: 125
Inspection Report
Follow-Up
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The State Agency conducted a follow-up survey to verify the facility's compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance. Record reviews showed completion of an audit of discharge summaries for medication reconciliation, nursing staff in-services were completed, and discharge summaries are being monitored for completeness.
Inspection Report
Follow-Up
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The State Agency conducted a follow-up survey to verify the facility's compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance. Record reviews showed completion of audits on discharge summaries for medication reconciliation, nursing staff in-services were completed, and discharge summaries are being monitored for completeness.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The State Agency conducted a complaint investigation on 10/27/21 for complaints #MS18197, #MS18179, and #MS18217.
Complaint Details
The allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. Allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Report Facts
Complaint numbers: 3
Inspection Report
Complaint Investigation
Census: 114
Capacity: 140
Deficiencies: 1
Date: Sep 3, 2021
Visit Reason
The State Agency conducted a complaint investigation from 9/2/21 to 9/3/21 related to multiple complaint numbers concerning assessment and monitoring, quality of care, resident rights, and discharge medications.
Complaint Details
The complaint investigation involved three complaint numbers (MS #17617, MS #17876, MS #18025). The agency was unable to substantiate most allegations except for MS #18025 related to Admission, Discharge, and Transfer concerning discharge medications.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to properly reconcile discharge medications for three residents. No deficiencies were substantiated for other complaint areas. The facility failed to ensure medication reconciliation was completed and reviewed with residents or their representatives at discharge.
Deficiencies (1)
Failure to properly reconcile discharge medications for three resident discharge summaries reviewed.
Report Facts
Census: 114
Total licensed capacity: 140
Residents with medication reconciliation deficiencies: 3
Medication bubble packs given: 8
Medication bubble packs given: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Spoke with Resident #1's husband about medication errors and confirmed reconciliation failures |
| Licensed Practical Nurse #1 | LPN | Discharged Resident #1 and did not reconcile medications properly |
| Licensed Practical Nurse #2 | LPN | Discharged Resident #1 and confirmed failure to reconcile medications |
| Licensed Practical Nurse #3 | LPN | Discharged Resident #15 and confirmed failure to check medication reconciliation box |
Inspection Report
Routine
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2/8/2021 through 2/24/2021 to assess compliance with federal regulations related to emergency preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2/8/2021 through 2/24/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 2/8/2021 through 2/24/2021, including complaint investigations related to infection control, pressure areas, and quality of care.
Complaint Details
Complaint investigations MS #17256, #17501, #17196, #16871, and #17195 were conducted. CI #16871, #17195, #17196 were not substantiated for quality of care. CI #17501 was not substantiated for infection control notification. CI #17256 was not substantiated for pressure areas.
Findings
The facility was found not in substantial compliance with infection control practices, specifically improper mask use by two dietary employees, leading to repeated deficient practice citations at severity level 'F'. Multiple complaint investigations were not substantiated. The facility implemented re-education and daily monitoring to ensure compliance.
Deficiencies (1)
Failure to prevent the likelihood of the spread of COVID-19 as evidenced by improper mask use by two dietary employees while working in the kitchen.
Report Facts
Census: 109
Total licensed capacity: 140
Number of dietary employees observed with improper mask use: 2
Number of dietary employees in mask in-service: 2
Duration of daily monitoring: 28
Duration of thrice-weekly monitoring: 28
Duration of weekly monitoring: 28
QAPI committee monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff #1 | Identified for improper mask use; educated and placed in disciplinary process | |
| Dietary Staff #2 | Identified for improper mask use; educated and placed in disciplinary process | |
| District Manager for Healthcare Services Group | Educated dietary staff on 2/9/2021 and 2/10/2021 regarding PPE compliance | |
| Director of Clinical Education | Started education with all team members on proper PPE use on 2/10/2021 | |
| Director of Nurses | Director of Nursing (DON) | Confirmed facility failed to ensure proper infection control practices |
Inspection Report
Abbreviated Survey
Census: 105
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 1/13/21 to assess compliance with infection control regulations and COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report
Abbreviated Survey
Census: 118
Capacity: 140
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 11/13/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Complaint Investigation were conducted due to concerns about infection control practices and delayed notification of positive COVID-19 test results among employees.
Complaint Details
Complaint Investigation MS #16968 was not substantiated related to Quality of Care. Complaint Investigation MS #17013 was substantiated related to Infection Control.
Findings
The facility failed to follow CDC guidelines for mask use and timely communication of positive COVID-19 test results to employees, resulting in two COVID-positive employees working with symptoms and potentially exposing 135 staff and 105 residents. Immediate Jeopardy was identified and later removed after corrective actions including education, monitoring, and weekly testing were implemented.
Deficiencies (2)
Failure to follow CDC guidelines for use of face masks and PPE in healthcare setting to prevent pathogen transmission.
Failure to communicate and report employee COVID-19 test results timely, resulting in positive employees working with symptoms and exposing others.
Report Facts
Positive COVID-19 employees not informed timely: 2
Facility census: 124
Facility licensed capacity: 140
Positive residents: 21
Positive employees: 25
Deaths: 3
Pending staff test results: 58
Pending resident test results: 42
Total team members: 135
Additional health care services team members: 25
Team members tested negative: 66
Residents tested negative: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed not wearing mask properly; received verbal correction and re-education. |
| LPN #2 | Licensed Practical Nurse | Observed not wearing mask properly; received verbal correction and re-education. |
| Social Worker | Tested positive for COVID-19 but was not informed timely; worked in close proximity to others without masks. | |
| MDS Nurse #4 | MDS Nurse | Worked in close proximity to COVID-positive Social Worker without mask; had not received test results. |
| Human Resources Officer | Tested positive for COVID-19 but was not informed timely; worked while symptomatic. | |
| Administrator | Facility Administrator | Delayed obtaining COVID test results from lab, failed to notify employees of positive results, suspended pending investigation. |
| Director of Nursing (DON) | Director of Nursing | Involved in infection control oversight; confirmed staff noncompliance with mask use. |
| Assistant Director of Nursing Services (ADNS) | Assistant Director of Nursing Services | Provided re-education to staff on proper PPE use. |
| Director of Clinical Operations (DCO) | Director of Clinical Operations | Provided education on PPE and infection control. |
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
The inspection was conducted due to a complaint investigation related to COVID-19 infection control practices and delayed communication of positive COVID-19 test results among staff.
Complaint Details
The complaint investigation revealed that two employees tested positive for COVID-19 but were not informed of their results due to administrative delays, leading to potential exposure of 135 staff and 105 residents. Immediate Jeopardy was identified on 08/26/2020 and removed on 08/28/2020 after corrective actions.
Findings
The facility failed to follow CDC guidelines for PPE use, including improper mask wearing by staff and failure to timely communicate positive COVID-19 test results to employees, resulting in two COVID-positive employees working while symptomatic and exposing residents and staff. Immediate Jeopardy was identified and later removed after corrective actions including staff education, increased testing, and monitoring were implemented.
Deficiencies (2)
Failure to follow CDC guidelines for use of face masks and PPE in a healthcare setting to prevent pathogen transmission.
Failure to communicate and report employee COVID-19 test results to positive employees in order to quarantine and prevent further exposure.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Total team members: 135
Additional health care services team members: 25
Team member COVID test results received: 66
Residents tested: 105
Residents with negative test results: 75
Days delayed in notifying positive employees: 25
Deaths: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Failed to timely obtain and communicate COVID-19 test results, resulting in delayed notification of positive employees and suspension. | |
| Assistant Director of Nursing Services (ADNS) | Provided re-education to staff on proper PPE use after deficiencies were identified. | |
| Director of Nursing Services (DNS) | Involved in education and monitoring of staff PPE compliance and COVID-19 testing. | |
| Licensed Practical Nurse (LPN) #1 | Observed not wearing mask properly and received verbal correction. | |
| Licensed Practical Nurse (LPN) #2 | Observed not wearing mask and received verbal correction. | |
| Social Worker | Tested positive for COVID-19 but was not informed of results for weeks. | |
| Human Resources Officer | Tested positive for COVID-19 but was not informed of results for weeks. | |
| MDS Nurse #4 | Observed working without mask in close proximity to Social Worker. |
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 08/20/2020 through 08/28/2020 to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. Infection control guideline violations were also observed.
Deficiencies (2)
Failure to inform two COVID-19 positive employees of their test results, leading to potential exposure of staff and residents.
Two employees not following infection control guidelines, including improper mask use and lack of social distancing.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 1
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted along with Complaint Investigations MS #16968 and MS #17013 to assess compliance with infection control and quality of care during the COVID pandemic.
Complaint Details
Complaint Investigation MS #16968 related to Quality of Care was not substantiated. Complaint Investigation MS #17013 related to Infection Control was substantiated with citation F880.
Findings
The facility was found non-compliant with infection control practices recommended by CMS and CDC, substantiating complaint MS #17013 related to infection control with citation F880. An Immediate Jeopardy was identified due to failure to notify two COVID-positive employees, resulting in potential exposure to 135 staff and 105 residents. The Immediate Jeopardy was removed after the facility submitted and implemented a removal plan.
Deficiencies (1)
Failure to follow infection control safety practices during COVID-19 pandemic, including delayed notification of positive COVID-19 employees and improper use of face masks and social distancing.
Report Facts
Positive COVID-19 employees not informed: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 08/20/2020 through 08/28/2020 to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. The Immediate Jeopardy was removed on 08/27/2020 after corrective actions.
Deficiencies (2)
Failure to inform two COVID-19 positive employees of their test results, resulting in potential exposure to staff and residents.
Two employees not following infection control guidelines, including improper mask use and failure to social distance.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Routine
Census: 110
Capacity: 140
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 110
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 128
Capacity: 140
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The State Agency conducted a complaint survey from 03/03/2020 to 03/05/2020 investigating complaints MS #16639 and MS #16676. The survey was triggered by allegations of resident abuse and quality of care concerns.
Complaint Details
The complaint investigation was substantiated for resident abuse (MS #16676). The facility investigated an incident on 02/22/2020 where CNA #1 shoved Resident #1 into a chair after Resident #1 used racial slurs. The incident was reported to the State Agency and local police. CNA #1 was suspended and terminated. Resident #1 had no lasting physical injuries but received a psychosocial evaluation.
Findings
The survey substantiated the complaint MS #16676 for resident abuse involving a physical altercation between CNA #1 and Resident #1. The facility failed to ensure Resident #1 was protected from physical abuse. The facility took immediate action by suspending and terminating CNA #1. Psychosocial evaluation and staff education were implemented as corrective actions.
Deficiencies (1)
Facility failed to ensure one of seven residents reviewed was protected from physical abuse; Resident #1 was shoved by CNA #1 into a chair causing injury.
Report Facts
Census: 128
Total Capacity: 140
Deficiencies cited: 1
Psychosocial evaluation date: Feb 24, 2020
Incident date: Feb 22, 2020
CNA #1 hire date: Apr 24, 2017
MDS Assessment Reference Date: Jan 29, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and intervened in the abuse incident, assessed Resident #1 for injuries, notified Administrator and Director of Nursing |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Perpetrator of physical abuse against Resident #1, suspended and terminated after substantiation |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Witnessed and attempted to calm Resident #1 during the incident |
| Director of Nursing | Director of Nursing | Confirmed psychosocial evaluation and medication changes for Resident #1, commented on CNA #1's work history |
| Dietary Worker #1 | Dietary Worker | Witnessed initial incident involving Resident #1 in the kitchen and reported Resident #1's behavior |
Inspection Report
Annual Inspection
Census: 130
Capacity: 140
Deficiencies: 9
Date: Feb 6, 2020
Visit Reason
Annual recertification survey conducted from 02/03/2020 to 02/06/2020 to assess compliance with Medicare and Medicaid requirements.
Findings
The facility was found not in compliance with several regulatory requirements including safe environment, restraint evaluation, accuracy of assessments, comprehensive care planning, ADL care, respiratory care, fire alarm system maintenance, fire drills, and emergency electrical system maintenance.
Deficiencies (9)
Failed to provide a clean, homelike environment in 9 of 32 resident rooms on the East Wing, including dirty bathrooms, brown rings in toilets, debris, and unclean floors.
Failed to provide ongoing evaluation of Resident #70's restraint; restraint evaluation was 29 days overdue.
Failed to accurately reflect discharge status on Resident #125's MDS assessment; discharge coded incorrectly as hospital instead of home.
Failed to develop and implement comprehensive care plans for respiratory care (Resident #99), ADL care (Residents #54, #76, #106), and restraint evaluation (Resident #70).
Failed to provide necessary ADL assistance including nail care, toileting assistance, and showers for Residents #54, #76, #93, and #106.
Failed to provide proper cleaning and storage of respiratory equipment for Resident #99, risking infection spread.
Failed to properly maintain fire alarm system; smoke detector sensitivity testing documentation missing for 2017 and 2019.
Failed to conduct and document fire drills quarterly on all shifts during 2019.
Failed to properly test emergency generator weekly and monthly as required; missing documentation for several months in 2019.
Report Facts
Deficiencies cited: 9
Residents affected: 9
Fire drill frequency: 4
Generator test frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed restraint evaluation overdue, acknowledged unclean rooms, and discussed care plan deficiencies. | |
| Administrator | Directed housekeeping and maintenance actions, confirmed fire alarm and fire drill deficiencies, and oversaw corrective actions. | |
| Director of Clinical Education | Provided education on care plans, restraint assessments, and nebulizer equipment handling. | |
| Registered Nurse Assessment Coordinator (RNAC) | Conducted audits of restraint evaluations, care plans, and discharge assessments. | |
| Certified Nursing Assistant (CNA) #3 | Failed to respond timely to call light for Resident #106 and turned off call light without assistance. | |
| Certified Nursing Assistant (CNA) #4 | Aware of Resident #76's long fingernails but did not report to nurse. |
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