Diversicare of Shelby

Inspectors wroteBased on staff interview, record review, Payroll-Based Journal (PBJ) staffing data review and facility policy review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 2nd Quarter 2025 (January 1, 2025, through March 31, 2025)

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to maintain a clean, safe, and homelike environment in one (1) of fifty-five (55) resident rooms observed. This deficient practice resulted in a room environment with visible water damage and possible mold growth, which may pose a health risk to the resident occupying the room. room [ROOM NUMBER] B.

Inspectors wroteBased on observation, resident/staff interview, and record review, the facility failed to implement a comprehensive care plan for nail care for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead with an effective date of October 2024 that revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Record review of Resident #10's Care Plan Report revealed under, Focus: Self-care deficit due to: Recent surgery for trans metatarsal amputation of left foot. Additionally revealed under, Interventions/Tasks: Nail, hair, and oral care daily as needed. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to perform nail care for a resident requiring assistance with activities of daily living (ADLs) for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead that read, Policy: Proper name of the facility uses Clinical Nursing Skills and Techniques, [NAME]. [NAME], as a supplementary policy and procedure care guide. An observation and interview with Resident #10 on 6/29/25 at 11:55 AM revealed she was lying in bed with long fingernails bilaterally that measured approximately three-eighths (3/8) of an inch long and were jagged. She admitted that staff had told her they would trim them, but no one ever came. She stated that her nails had never been as long as they are now and she wanted them trimmed. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to use Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for one (1) of 16 residents on EBP reviewed.(Resident #206).

Inspectors wroteBased on staff interviews, record review and facility document review, the facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for one (1) of four quarters reviewed. First quarter 2024 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator (LNHA) revealed Staffing: It is the practice of (Proper name of the facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staffing expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment. The center conducts work force management meetings daily to discuss open positions, open shifts and call ins as related to patient needs. [...]

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to provide blinds or window coverings in good repair for one (1) of 60 resident rooms observed for a clean, comfortable, and homelike environment. room [ROOM NUMBER]. Findings Include: Review of the facility policy Work Orders and Paging, effective September 1, 2014, revealed, Purpose, To establish a productive procedure for communicating and coordinating the needs of the residents and employees from the Maintenance Department . Work Orders, TELS . is a Computerized Maintenance Management System (CMMS). Employees shall complete Work Orders through TELS. When a verbal request for maintenance is received from center personnel, maintenance staff should request that a work order be submitted . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident receiving an enteral feeding (Resident #1), and failed to develop a comprehensive care plan for a resident receiving antipsychotic medication (Resident #54) for two (2) of nineteen care plans reviewed. Findings Include: Review of the facility policy titled Care Plans with a revision date of October 2021 revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. This document was dated 5/21/24 and signed by the Licensed Nursing Home Administrator. Resident #1 Record review of Resident #1's care plan revealed, Focus: [...]

Inspectors wroteBased on observation, staff interview, and record review and facility document review, the facility failed to ensure a resident who received enteral nutrition received appropriate treatment and services, as evidenced by, the facility's failure to administer an enteral feeding according to the physician's order for one (1) of 11 residents with a feeding tube. Resident #1 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator revealed, Standards of Practice: The expectation set forth by (Proper Name of the facility) is that nurses comply with current standards of practice in terms of following physician's orders. This includes following orders for medication and enteral feedings. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to accurately complete section P of the Minimum Data Set (MDS) for one (1) of four (4) residents residing in the facility with a wander alert bracelet. Resident #24 Findings Include: Review of the facility policy titled RAI (Resident Assessment Instrument) Process Guideline undated, revealed Process: The CMS (Centers for Medicare and Medicaid Services) Long-Term Care Facility Resident Assessment User's Manual 3.0 will provide the framework and directions to completing the RAI process. All items in the MDS are to be coded per the instructions of the CMS Long-Term Care Facility Assessment User's Manual MDS 3.0. An observation of Resident #24, on 5/19/2024 at 12:16 PM, revealed she was sitting on the edge of the bed. A wander alert bracelet was observed on her left ankle. [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to refer a resident to the appropriate agency for a Level II Preadmission Screening and Resident Review (PASARR) following an inpatient Geri-psych admission with a new psychiatric diagnosis and new psychiatric medications for one (1) of four (4) sampled residents reviewed for PASARR. Resident #16.