Inspection Reports for
Diversicare of Tylertown
200 Medical Circle, Tylertown, MS, 39667
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
39% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
92% occupied
Based on a July 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Routine
Deficiencies: 4
Date: Jan 14, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident rights, medication administration, infection control, and medication storage at Diversicare of Tylertown nursing home.
Findings
The facility failed to ensure residents receiving meals in their rooms were informed of meal choices, failed to obtain physician orders for flushing PEG tubes, improperly secured medications and wound care supplies, and did not consistently follow infection prevention protocols during wound care and medication administration.
Deficiencies (4)
F 0561: The facility failed to ensure residents eating in their rooms were informed of daily menu options and given meal choices for 2 of 14 residents reviewed.
F 0658: The facility failed to obtain a physician order to flush PEG tubes with water before and after medication administration for 1 of 6 residents with PEG tubes.
F 0761: The facility failed to properly secure medications and wound care supplies, as the wound care cart was observed unlocked and unattended on two occasions.
F 0880: The facility failed to prevent infection risk by not following proper hand hygiene and glove use during wound care and PEG tube medication administration for 3 residents.
Report Facts
Residents reviewed for meal choices: 14
Residents affected by meal choice deficiency: 2
Residents with PEG tubes reviewed: 6
Residents affected by flushing order deficiency: 1
Days wound care cart was unsecured: 2
Residents affected by infection control deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed administering medication and failing to perform hand hygiene during PEG tube medication administration |
| LPN #2 | Licensed Practical Nurse | Observed administering PEG tube medications and improper glove use |
| RN #1 | Registered Nurse | Observed locking wound care cart and confirmed storage protocols |
| RN #2 | Registered Nurse | Observed locking wound care cart and interviewed about storage |
| RN #3 | Wound Care Nurse | Observed providing wound care and interviewed about glove use |
| Director of Nursing | Director of Nursing | Interviewed regarding policies on meal choices, PEG tube flushing orders, medication storage, and infection control |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed working with Resident #22 and lack of meal choice process |
| Infection Preventionist Nurse | Infection Preventionist Nurse | Interviewed about infection prevention guidelines and glove use |
| Administrator | Administrator | Interviewed about ongoing meal choice issues |
Inspection Report
Routine
Census: 55
Deficiencies: 5
Date: Jul 1, 2025
Visit Reason
Routine inspection to assess compliance with health and safety regulations at Diversicare of Shelby nursing home.
Findings
The facility was found deficient in maintaining a safe and clean environment due to water damage and possible mold in a resident room, failure to implement a comprehensive care plan for nail care for one resident, failure to perform nail care for a resident requiring assistance, failure to submit accurate Payroll-Based Journal staffing data, and failure to use Enhanced Barrier Precautions during medication administration for a resident with a PICC line.
Deficiencies (5)
F 0584: The facility failed to maintain a clean, safe, and homelike environment in one of 55 resident rooms due to visible water damage and possible mold growth from a leaking roof.
F 0656: The facility failed to develop and implement a complete care plan for nail care for one of 28 sampled residents, Resident #10.
F 0677: The facility failed to perform nail care for Resident #10 who required assistance with activities of daily living, resulting in long, jagged fingernails.
F 0851: The facility failed to submit accurate Payroll-Based Journal staffing data to CMS for the 2nd quarter of 2025 due to manual entry errors and untimely data submission.
F 0880: The facility failed to use Enhanced Barrier Precautions during medication administration for Resident #206 with a PICC line, increasing infection risk.
Report Facts
Residents in room with deficiency: 1
Residents sampled for nail care: 28
Residents on Enhanced Barrier Precautions reviewed: 16
Quarters reviewed for PBJ data: 4
Quarter with inaccurate PBJ data: 2
Residents in facility during inspection: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Failed to use Enhanced Barrier Precautions during medication administration for Resident #206 |
| Certified Nurse Aide #1 | CNA | Confirmed Resident #10's long nails and responsibility of treatment nurse for nail care |
| Human Resource Coordinator | Explained payroll time clock system issues and manual time entry | |
| Workforce Manager | Discussed PBJ data submission discrepancies and review process | |
| Administrator | Confirmed deficiencies including roof leak, nail care issues, PBJ data inaccuracies, and failure to use EBP | |
| Infection Control Nurse | Verified water damage and possible mold in resident room | |
| Maintenance | Verified roof leak and water damage in resident room |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 5, 2024
Visit Reason
The inspection was conducted due to an investigation into allegations of misappropriation of resident funds in the facility's resident trust accounts.
Complaint Details
The complaint investigation was substantiated, confirming misappropriation of funds for nine residents. The Business Office Manager was implicated and resigned. The facility reimbursed residents for the misappropriated amounts.
Findings
The facility failed to ensure residents were free from misappropriation of funds for nine of 30 residents with resident trust funds. An internal investigation revealed fraudulent cash withdrawals linked to the Business Office Manager, who resigned after the findings. The facility reimbursed residents for identified discrepancies and no negative outcomes were reported.
Deficiencies (1)
F 0602: The facility failed to protect residents from misappropriation of their trust fund money involving nine residents. Fraudulent cash withdrawals were identified, and the Business Office Manager resigned following the investigation.
Report Facts
Residents affected: 9
Misappropriation amounts: 980
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Named in relation to misappropriation of resident funds and subsequent resignation | |
| Administrator | Interviewed regarding investigation details and signature discrepancies | |
| Regional Business Office Consultant | Conducted audits that identified discrepancies prompting investigation |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 5, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including continence care, feeding tube management, and infection prevention and control practices.
Findings
The facility was found deficient in providing appropriate perineal care to prevent urinary tract infections, ensuring tube feedings were administered as ordered, and maintaining infection control by improperly storing clean durable medical equipment in a biohazard room.
Deficiencies (3)
F 0690: The facility failed to provide perineal care in a manner to prevent urinary tract infection for one resident by wiping from back to front instead of front to back.
F 0693: The facility failed to ensure tube feedings were administered as ordered for one resident due to missing active physician orders in the electronic system.
F 0880: The facility failed to prevent possible transmission of infections by storing clean oxygen concentrators in a room designated for biohazard materials.
Report Facts
Residents reviewed for incontinent care: 4
Residents receiving enteral feedings: 7
Residents affected: 1
Residents affected: 1
Days of survey: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Observed providing perineal care incorrectly | |
| Director of Nursing (DON) | Interviewed regarding perineal care and feeding tube orders | |
| Maintenance #1 | Interviewed regarding storage of oxygen concentrators in biohazard room | |
| Registered Nurse (RN) #1 | Interviewed regarding infection control practices in biohazard room |
Inspection Report
Routine
Census: 60
Deficiencies: 5
Date: May 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations at Diversicare of Shelby nursing home.
Findings
The facility was found deficient in multiple areas including failure to maintain window blinds in good repair, inaccurate completion of resident assessments, incomplete care plans for residents with enteral feeding and antipsychotic medication, failure to administer enteral feeding according to physician orders, and inaccurate submission of staffing data to the Payroll-Based Journal system.
Deficiencies (5)
F 0584: The facility failed to provide window blinds or coverings in good repair for one of 60 resident rooms, with broken slats creating an opening.
F 0641: The facility failed to accurately complete section P of the Minimum Data Set for one of four residents with a wander alert bracelet, resulting in a data error.
F 0656: The facility failed to implement comprehensive care plans for two residents, one receiving enteral feeding and one receiving antipsychotic medication.
F 0693: The facility failed to administer enteral feeding according to physician's orders for one of 11 residents with a feeding tube, resulting in risk for weight loss and malnutrition.
F 0851: The facility failed to submit accurate direct care staffing information into the Payroll-Based Journal system for the first quarter of 2024 due to payroll data errors.
Report Facts
Residents observed: 60
Residents with wander alert bracelet: 4
Residents with feeding tube: 11
Care plans reviewed: 19
Staffing quarters reviewed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed Resident #1's feeding pump was turned off |
| Registered Nurse #1 | Registered Nurse | Notified maintenance staff about broken equipment and confirmed enteral feeding order issues |
| Director of Nursing | Director of Nursing | Provided expectations for accurate assessments and care plans; acknowledged feeding order errors |
| Administrator | Administrator | Verified maintenance notification practices and acknowledged payroll data errors |
| Minimum Data Set Nurse | MDS Nurse | Confirmed data error in Resident #24's quarterly MDS |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Reported staffing concerns on weekends |
| Workforce Manager | Workforce Manager | Described staffing call-in procedures and payroll data submission issues |
| Human Resources Staff | Human Resources | Responsible for payroll and explained payroll system limitations |
| Registered Dietician | Registered Dietician | Confirmed risk of weight loss for Resident #1 without prescribed enteral feeding |
Inspection Report
Routine
Census: 49
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident activities and respiratory care in the nursing home.
Findings
The facility failed to provide an ongoing resident-centered activities program during the absence of the Activity Director, affecting 9 sampled residents and potentially 49 residents overall. Additionally, the facility failed to post cautionary oxygen use signs for one resident receiving oxygen therapy.
Deficiencies (2)
F 0679: The facility failed to provide an ongoing resident-centered activities program for nine sampled residents during the Activity Director's absence, resulting in no scheduled activities taking place as per the activity calendar.
F 0695: The facility failed to post cautionary and safety signs indicating oxygen use for one sampled resident receiving oxygen therapy, which is required to ensure resident and staff safety.
Report Facts
Residents affected: 9
Residents potentially affected: 49
BIMS scores: 15
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Confirmed Activity Director was on vacation and Social Worker responsible for activities | |
| Social Worker | Reported inability to consistently oversee activities during Activity Director's absence | |
| Registered Nurse #1 | Registered Nurse | Confirmed resident was receiving oxygen and no oxygen use signage was posted |
| Director of Nursing | Confirmed oxygen use signage should have been posted for resident safety |
Inspection Report
Deficiencies: 1
Date: Jan 5, 2023
Visit Reason
The inspection was conducted to assess compliance with pre-admission screening and resident review (PASARR) requirements following an inpatient Geri-psych admission for Resident #16.
Findings
The facility failed to submit a Change in Status Form for Resident #16 after a Geri-psych inpatient admission with a new psychiatric diagnosis and new psychiatric medications. This failure potentially prevented Resident #16 from receiving a Level II PASARR screening and appropriate mental health services.
Deficiencies (1)
F0644: The facility failed to coordinate assessments with the pre-admission screening and resident review program by not submitting a required Change in Status Form for Resident #16 following a Geri-psych inpatient admission with a new diagnosis of Schizophrenia and new psychiatric medications.
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