Diversicare of Amory

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement infection control practices to prevent the spread of infection for four (4) of four (4) days of survey, which included not performing hand hygiene between residents during meal service (4/13/26 and 4/14/26), not maintaining aseptic technique during medication administration (4/15/26), and not ensuring biohazard waste was securely stored (4/16/26). Findings Include: Review of the facility's Policies and Practices - Infection Control dated 11/01/17 revealed, The center's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections . [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident's right to dignity for one (1) of six (6) residents observed for dining, Resident #4.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the resident's right to a safe, clean, and homelike environment for one (1) of twenty-three (23) sampled residents, Resident #124.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions related to Activities of Daily Living (ADLs) (Resident #108 and #102) and wound care (Resident #3) for three (3) of 23 sampled residents. Findings Include: Review of the facility's policy Care Plans dated October 2021 revealed, Care plans will be developed and implemented for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines Resident #108 A record review of the Clinical Care Plan Detail revealed Resident #108 had a Focus of I have a Self Care Deficit. with Interventions/Tasks including Nail, hair, and oral care daily and as needed. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide Activities of Daily Living (ADL) services resulting in unmet care needs for two (2) of 4 residents reviewed for ADL care, Resident #108 and Resident #102.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure necessary care and services were provided to promote healing and prevent complications of a non-pressure wound, including failure to complete wound treatments as ordered and ensure accurate documentation of care for one (1) of two (2) residents reviewed for wounds, Resident #3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services to prevent possible complications for one (1) of one (1) resident reviewed with an indwelling urinary catheter, Resident #11.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications were securely stored and administered in a manner that prevented them from being left unattended at the bedside for two (2) of twenty-three (23) sampled residents, Residents #35 and #44.

Inspectors wroteBased on resident and staff interviews facility policy review, and record review, the facility failed to protect the resident's right to be treated with dignity and respect for one (1) of ten (10) residents sampled.

Inspectors wroteBased on staff interviews and record review, the facility failed to ensure that newly hired licensed nurses and certified nurse assistants (CNAs) received skills competency checkoffs before providing resident care for three (3) of three (3) new hires reviewed.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that a resident was free from verbal abuse when one (1) of seven (7) residents reviewed for abuse was subjected to verbal threats by a staff member. (Resident #1)

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 10/19/23. This was for deficiencies re-cited during a recertification and complaint survey on 2/13/25. The re-cited deficiencies included F 584, F 656, F 677, F 684, F 761, and F 880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAPI program. This was for six (6) of 18 deficient practice citations. Findings Include: This citation is cross-referenced to: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to prevent the possibility of the spread of infection as evidenced by: 1) not having procedures in place to monitor and test the water source for Legionella's Disease which had the potential to affect all residents in the facility; 2) storing of respiratory equipment on the floor for Resident #82, and 3) not using required Enhanced Barrier Precautions (EBP) Resident #11 and Resident #157 for three (3) of 23 sampled residents.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to provide a safe, clean environment as evidenced by an unsanitary toilet in room C-7, resident wheelchair (Resident #60), overbed tables, and wall in disrepair affecting three (3) residents in the seventy-three resident occupied rooms observed. Resident #48, Resident #60 and Resident #99 Findings Include: Review of the facility policy titled, Resident Rights and Quality of Life Policy, dated 3/13/20, revealed, A patient or resident has the right: . to receive services in a center environment that is safe, clean, and comfortable . Review of the facility policy titled, Resident/Patient Room Cleaning, last reviewed 2/1/2025, revealed Policy: Room Cleaning: [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to develop a comprehensive care plan for residents with personal hygiene needs (Resident #62, #74, #253), taking an antiplatelet medication (Resident #25), storage of respiratory equipment (Resident #82), and failed to implement a care plan for a resident on Enhanced Barrier Precautions (EBP) (Resident #11), Thromboembolic Deterrent (TED) (Resident #253), and receiving dialysis (Resident #8) for six (6) of 23 sampled residents. Residents #8, #11, #62, #74, #82, and #253 Findings Include Record review of facility policy titled, Care Plans with effective date of October 2021, revealed, Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide care to maintain personal hygiene for three (3) of 23 residents reviewed for Activities of Daily Living (ADL) care. Resident #62, #74 and #253.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for treating skin concerns (Resident #303) and application of TED (thromboembolic deterrent) compression hose for two (2) of 23 sampled residents.

Inspectors wroteBased staff interview, record review, and facility policy review the facility failed to store controlled drugs in a locked permanently affixed compartment for storage as evidenced by an unopened box of Lorazepam Concentrate 30 milliliters sitting on a shelf in the refrigerator among other non-narcotic medications for one (1) of three (3) narcotics refrigerator storage observed.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents had the right to participate in smoking during rainy or inclement weather for two (2) of four (4) survey days. Resident #60, 65, A, and B.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure a resident was free from physical restraints as evidenced by restricting a resident's voluntary movement by body contact for one (1) of 23 sampled residents. Resident #88 Findings Include: Review of the facility policy titled Residents' Rights Summary unrevised, revealed under, Examples of Violations: . 12. Restraining a resident without a physician's order for the convenience of staff, or as a disciplinary measure. An observation on the Memory Care Unit on 2/11/25 at 3:49 PM revealed Resident #88 sitting in a wheelchair in the activity room and Certified Nurse Aide (CNA) #4 was standing in front of the resident with her right knee in between the residents' legs. The resident was anxious and asked the aide to take her to the bathroom. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to thoroughly develop a baseline care plan related to personal hygiene for (1) one of three (3) baseline care plans reviewed. (Resident #253)

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to provide ongoing communication documentation with the hemodialysis center for one (1) of one (1) residents receiving hemodialysis reviewed. Resident #8.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain a system of medication records that enables accurate reconciliation and accounting for all controlled medications for (1) one of (3) three narcotic storage areas reviewed.

Inspectors wroteBased on staff interview and record review the facility failed to ensure a PRN (as needed) psychotropic medication had a stop date for one (1) of six (6) resident medications reviewed. Resident #69 Findings Include: The facility provided a statement on letterhead, (Proper name of the facility) follows the guidance of CMS (Centers for Medicare and Medicaid Services) as psychotropic medications ordered for PRN (as needed) usage shall not exceed past 14 days without further medical provider assessment in the facility for continuation of medication for each reinstatement of the order. Record review of Resident #69's February 2025 Medication Administration Record (MAR) revealed an order dated 12/17/24, Ativan (antianxiety) Oral Tablet 1 MG (milligram) (Lorazepam) give 1 tablet by mouth every 24 hours as needed for anxiety and agitation with no stop date. [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to honor a resident's beverage preference during dining for two (2) of three (3) residents reviewed for dining observation. Resident #13 and Resident #303 Findings Include: Review of the facility policy titled Dining and Food Preferences with a revision date of 9/17, revealed Policy Statement: Individual dining, food, and beverage preferences are identified for all residents/patients. An observation of Resident #13 on 2/10/25 at 11:44 AM, revealed she was lying in bed. Registered Nurse (RN) #4 entered the resident's room with her meal tray. The resident voiced she wanted to eat in the dining room and wanted a large glass of tea. [...]

Inspectors wroteBased on resident and staff interviews, record review and facility policy review, the facility failed to deliver resident mail on Saturdays for four (4) of ten (10) residents present during the Resident Council meeting. Resident #8, #14, #25, and #38.

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to mail a written notification of hospital transfer notice to a resident's Resident Representative (RR) for two (2) of two (2) residents reviewed for hospitalization. Resident #63 and #102 Findings Include: Review of the facility policy titled Transfer & Discharge unrevised, revealed under, Notice Requirements: 4. Before 'Proper name of the facility' transfers or discharges the Resident, it shall notify the Resident and the Resident's Representative of the basis for the transfer or discharge in a language and manner they understand . Record review of Resident #63's Progress Notes dated 1/3/25 revealed the resident was transferred to the hospital following a fall. [...]

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to accurately complete an assessment for the Minimum Data Set (MDS) medication section as evidenced by an antiplatelet medication being entered as an anticoagulant medication for one (1) of 23 sampled residents.

Inspectors wroteBased on interview, record review and facility policy review the facility failed to notify the physician and resident representative of an unwitnessed fall for one (1) of three (3) residents reviewed. Resident #1. Findings Include: Record review of the facility policy on Falls dated February 2017 revealed Purpose To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls .Post fall .The physician and resident's representative are notified of the fall . Record review of the Investigation Template dated 1/18/24 revealed that Resident #1 was found on the floor sitting on her buttocks beside her bed on 1/16/24 at approximately 10:50 PM by a Certified Nursing Assistant who was passing by the room and saw her foot beside the bed. [...]

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure that opened food items stored in the refrigerator were dated and labeled for two (2) of four (4) kitchen tours.

Inspectors wroteBased on resident and staff interviews and facility policy review the facility failed to ensure a resident's preferences was honored for one (1) of 20 sampled residents.

Inspectors wroteBased on observation, staff interviews, and facility policy review, the facility failed to ensure a clean environment as evidenced by multiple areas of a circular black substance on two ceiling air vents for two (2) of four (4) survey days.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to develop a comprehensive care plan for a resident on hospice services (Resident #50) and failed to implement an Activity of Daily Living (ADL) care plan for shaving and oral hygiene for Resident #21, for two (2) of 20 residents reviewed.

Inspectors wroteBased on observations, staff interview, record review and facility policy review, the facility failed to provide activities of daily living (ADLs) for a resident dependent on staff for shaving and oral hygiene for one (1) of 20 residents sampled. Resident #21.

Inspectors wroteBased on staff interviews, record review and facility policy review the facility failed to coordinate the hospice care for one (1) of four (4) residents receiving hospice services.

Inspectors wroteBased on observation, staff interviews and facility policy review, the facility failed to ensure a medication cart was locked while unattended for one (1) of four (4) survey days.

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to prevent the likelihood of the spread of infection as evidenced by a nebulizer and tubing not properly stored, hand hygiene not performed with incontinent care, and an isolation cart being transported in and out of a transmission-based precautions room for two (2) of 20 sampled residents reviewed.