Diversicare of Eupora

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to ensure licensed nursing staff followed professional standards of practice related to accurate and individualized documentation of as needed (PRN) pain medication administration for 13 of 25 residents reviewed on the B-hall medication cart. This deficient practice resulted in repetitive clustered documentation of PRN narcotic pain medications at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation of care provided. Resident #9, #12, #22, #27, #38, #43, #44, #47, #61, #65, #68, #95 and unsampled Resident D. Findings Include:Record review of the facility policy tilted Medication Administration with a review date of 4/23 revealed under, Policy; [...]

Inspectors wroteBased on staff interview, record review, monthly pharmacy reviews, and facility policy review, the facility failed to ensure its pharmacy services and drug regimen review process identified and addressed irregularities in as needed (PRN) opioid medication documentation for 13 of 25 residents on medication cart B. Resident #9, #12, #22, #27, #38, #43, #44, #47, #61, #65, #68, #95 and unsampled Resident D. Findings Include:Review of the facility policy titled Drug Regimen Review reviewed 4/23, revealed under, Policy: Drug Regimen Review consists of a review and analysis of prescribed medication therapy and medication use, including nursing documentation, medication ordering, and administration. The Consultant Pharmacist reviews the medication regimen and medical record of each resident at least monthly. [...]

Inspectors wroteBased on resident, resident representative, and staff interviews, along with facility policy review, the facility failed to ensure residents were treated with dignity and respect by providing timely toileting assistance and honoring residents right for two (2) of 25 sampled residents reviewed. Resident #5 and Resident #18. Findings Include: Review of the facility policy titled Resident Rights & Quality of Life Policy, with an effective date of March 13, 2020, revealed, It is the policy of 'Proper name of facility' that all patients and residents have the right to a dignified existence, self-determination, and communication with access to people and services inside and outside the center. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to provide a safe, clean environment as evidenced by overbed tables with a thick black substance on the metal base for three (3) of sixty-three resident rooms observed. (room [ROOM NUMBER], #18, and #28) Findings Include: Review of the facility policy titled Resident Rights & Quality of Life Policy, with an effective date of March 13, 2020, revealed, It is the policy of 'Proper name of facility' that all patients and residents have the right to a dignified existence .To receive services in a center environment that is safe, clean, and comfortable . On 2/23/2026, between 3:25 PM and 4:00 PM, observations on B Wing revealed that Rooms #16, #18, and #28 contained overbed tables with a thick black substance scattered across the metal bases. [...]

Inspectors wroteBased on staff and family interview, record review, and facility policy review, the facility failed to ensure a resident who was dependent on staff for incontinent care received timely assistance with activities of daily living (ADLs) for one (1) of 25 sampled residents. Resident #18Findings Include:Review of the facility policy titled ADL's (Activities of Daily Living) dated 2025 revealed under, Policy: Ensure ADLs are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences .An interview with a family member on 2/24/26 at 2:10 PM revealed she entered the facility around 1:05 PM to visit Resident #18, whose call light was sounding because she was wet and needed to be changed. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure residents were protected from accident hazards related to unsafe possession and storage of smoking materials for three (3) of nineteen residents identified as smokers. (Resident #88, Unsampled Residents A, and B)Findings Include:Review of the Facility policy titled Safe Tobacco Use with a revision date of November 3, 2022, revealed under, Purpose: 1. To maximize our ability to provide a safe environment for all residents/patients who smoke, while taking into account non-smoking residents. 4. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to ensure a medication cart was secured to prevent unauthorized access for one (1) of four (4) medication carts observed (B Wing). Findings Include: Review of the facility policy titled, Proper Name, Inc. Policies and Procedures, revised 04/22, stated, It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use . During an observation on 2/24/26 at 2:35 PM, the medication cart on B Wing was observed unlocked and unattended. Licensed Practical Nurse (LPN) #2 stated she got busy and forgot to lock her cart before sitting down to chart. She stated the cart should always be secured for the safety of the residents. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy reviews, the facility failed to implement infection prevention and control practices to prevent the transmission of infections. Specifically, the facility failed to ensure oxygen delivery devices were stored in a sanitary manner when not in use for one (1) of four (4) days of survey and failed to ensure staff used Enhanced Barrier Precautions (EBP) during wound care during 1 of 4 resident care opportunities. (Residents #3 and #12)

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure residents were free from abuse when a Licensed Practical Nurse (LPN) used profanity toward a resident diagnosed with Alzheimer's disease and was observed to have applied physical force during an incident, where the resident was laying flat on her back on the floor and the LPN forcefully pushed the resident's legs into her chest and used profanity toward the resident. This placed the resident at risk for humiliation, intimidation, and harm. This was identified for one (1) of six (6) residents reviewed for abuse (Resident #1).

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to ensure that all allegations of abuse were immediately reported to the State Agency, failed to report allegations involving a licensed nurse to the appropriate licensing board, and failed to ensure staff recognized and reported abuse. This deficient practice was identified for one (1) of three (3) residents reviewed for abuse allegations. (Resident #1)

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to identify and provide needed care and services that were resident centered, in accordance with the resident's preferences, goals for care, and professional standards of practice to meet resident's physical needs for one (1) of five (5) residents reviewed for quality of care.

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that a resident's rights were honored when a staff member refused to assist a resident with toileting for one (1) of four (4) survey days.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to resolve grievances related to food concerns and bed linens not being changed for five (5) of seven (7) residents with grievances. Resident #3, #19, #26, #88, and #108. Findings Include: Review of the Facility policy titled Customer Concern (Grievance) Policy dated 7/2018, revealed Purpose: Support each customer's (patient's/resident's) right to voice concerns (grievances) and to ensure after receiving a concern, the center actively seeks a resolution and keeps the customer appropriately apprised of its progress toward resolution .Process . [...]

Inspectors wroteBased on resident and staff interviews, record view, facility policy review, the facility failed to implement a care plan for nail care for Resident #41 and failed to develop a care plan for the application of leg braces for Resident #51 and failed to develop a behavior monitoring care plan for Resident #113 for three (3) of 26 resident care plans reviewed.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to provide personal hygiene as evidenced by failure to provide nail care for one (1) of 24 sampled residents. Resident #41 Findings Include: Review of the facility policy titled ADL's dated 8/2021 revealed Policy: Ensure ADL's (Activities of Daily Living) are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences . An observation and interview with Resident #41 on 8/26/2024 at 11:36 AM, revealed, she was sitting in her wheelchair in her room. She held up her hands and stated, I need my nails cut. I keep scratching myself. The resident revealed her nails had not been cut in a long time and stated she was a diabetic. [...]

Inspectors wroteBased on staff interview, record review and facility behavior monitoring document review, the facility failed to ensure a resident with a new diagnosis of Binge Eating Disorder received appropriate behavioral monitoring and interventions to address the disorder for (1) one of (3) residents reviewed with behaviors. (Resident #113)

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review the facility failed to ensure foods were palatable, attractive and at a safe and appetizing temperature, for seven (7) of 12 residents sampled for dining. Resident #19, #41, #52, #88, #101, #102, and #108.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for two (2) of twenty-six MDS reviewed. Resident #46 and Resident #96.

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain or improve mobility for one (1) of three (3) residents reviewed for range of motion.

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility medication checklist review, the facility failed to store an inhalant medication in a locked storage compartment as evidenced by medication being left at the resident's bedside for one (1) of seven (7) medication observations.

Inspectors wroteBased on resident and staff interviews and snack program document review, the facility failed to provide residents with a bedtime snack for six (6) of six (6) residents interviewed during the resident council meeting. Resident #3, #13, #19, #88, #94, and #108 Findings Include: Review of the H.S. (Bedtime) Basic Snack Program: Evening undated, revealed, Basic snack program items delivered between 7:30 pm -8:00 pm. Bulk snack cart should include (2-3) basic choices for the residents. A resident council meeting was held on 8/27/2024 at 3:05 PM, in which Resident #3, #13, #19, #88, #94, and #108 revealed they were not receiving a bedtime snack. Resident #88 revealed the kitchen did bring snacks out at night, but they left them at the desk and they were not passed out to the residents. He revealed the residents that were able to go to the desk had been getting their snacks. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility failed to address dietary recommendations to change and/or increase a peg (percutaneous gastrostomy) tube feedings and water flushes to meet the nutritional needs for one (1) of three (3) residents reviewed who received enteral nutrition. (Resident #112)

Inspectors wroteBased on observation, resident and staff interviews, record review and facility policy review the facility failed to honor a resident's privacy as evidenced by a sign posted over the resident's bed that read two (2) stool samples needed with the resident's name and date, for one (1) of 111 residents reviewed for dignity.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to reevaluate the Advance Directive information for a resident and to provide the information to the resident directly once she was able to cognitively receive the information for one (1) of 32 residents' Advance Directives reviewed.

Inspectors wroteBased on resident representative and staff interview, record review and facility policy review the facility failed to resolve a grievance as evidenced by the resident representative not being reimbursed for missing clothing for one (1) of 23 residents sampled.

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed to develop a person-centered care plan for a resident who smokes for one (1) of 23 resident care plans reviewed.

Inspectors wroteBased on observations, staff interview, record review and facility policy review the facility failed to provide services to maintain hygiene for a resident who was dependent on the staff as evidenced by long nails with a brown substance under each nail and 1/4-inch-long gray hair on the resident's chin for one (1) of 111 resident's reviewed.

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed to perform a safe smoking assessment for one (1) of five (5) residents reviewed for smoking.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to develop a person centered care plan for Post Traumatic Stress Disorder (PTSD) for one (1) of 23 care plans reviewed, Resident # 66.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to prevent the possible spread of infection as evidenced by staff failed to sanitize a multi-use resident blood pressure cuff after each use, sanitize a multi-use stethoscope prior to use, to sanitize hands after administering eye drops and prior to administering percutaneous endoscopic gastrostomy (PEG) medication, and failed to rinse and dry a PEG tube syringe after use to prevent the growth of bacteria for two (2) of five (5) residents reviewed during medication and treatment administration. Resident #65 and Resident #91.