Diversicare of Southaven

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure the Activities of Daily Living (ADL) care plan was implemented for personal hygiene and grooming (Resident #101 and Resident #119) and failed to implement a pain care plan (Resident #144) for three (3) of 31 care plans reviewed. Resident #101, #119, and #144. Findings Include: Record review of the facility policy titled Care Plans revealed under, Guideline: 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. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to ensure timely assessment and management of pain for one (1) of 16 residents residing on the rehabilitation unit (Resident #144), resulting in a delay of greater than three hours in treatment, prolonged unrelieved pain at a level ten (10), inability to eat, and unnecessary physical suffering.

Inspectors wroteBased on observations, resident interviews, staff interviews, record review, and facility policy review, the facility failed to ensure residents were treated with dignity and respect by maintaining privacy and providing personal care in a manner that preserved resident dignity for four (4) of 31 residents reviewed (Residents #20, #101, #111, #119). Findings Include: Review of facility policy, Resident Rights & Quality of Life Policy with an effective date of March 13, 2020, revealed, .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 . Resident #20 On 4/20/2026 at 10:32 AM, Resident #20 was observed in his room with a urinary catheter bag containing yellow urine. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to reasonably accommodate resident needs by not ensuring the call light was accessible (Resident #54) and by failing to timely address and replace an uncomfortable mattress (Resident #42) for two (2) of four (4) residents reviewed for accommodation of needs and preferences. Findings Include: Review of the facility policy titled Resident Rights & (and) Quality of Life Policy revealed under, Procedure: A patient or resident has the right: . To receive services in a center environment that is safe, clean, and comfortable. Review of facility policy titled Nurse Call System with effective date: 9/1/2014, revealed, .2. Each cord needs to be visible and reachable by the resident to which it operates for . [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to maintain a shower room in a safe manner to prevent potential hazards to residents and staff as evidenced by an obstructed floor drain resulting in water accumulation and flooding, for one (1) of three (3) shower rooms observed. East wing Findings Include:Review of the facility policy titled Resident Rights & (and) Quality of Life Policy revealed under, Procedure: A patient or resident had the right: . To receive services in a center environment that is safe, clean, and comfortable. An interview with Resident #138 on 4/21/26 at 3:01 PM revealed she received a shower the previous night on E hall. She stated the shower room drain was stopped up, causing water to stand on the floor. The resident reported the water accumulated to the point that she was afraid she might fall. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure nursing services were provided in accordance with professional standards of practice and physician orders for one (1) of seven (7) resident care observations (Resident #5). Findings Include: Review of the facility's Standards of Practice typed on letterhead revealed, The expectation set forth by (Proper Name) management is that nurses comply with current standards of practice by following physician orders for providing to peg site care. An observation on 04/21/26 at 2:55 PM of Resident #5's Percutaneous Endoscopic Gastrostomy (PEG) tube site revealed no dressing in place and there was a yellowish-brown substance beneath the external skin disk and extended out about one-fourth of an inch to surrounding skin. [...]

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure assistance with activities of daily living (ADLs), including bathing and personal hygiene, was provided in accordance with resident needs and preferences for two (2) of thirty-one (31) residents sampled. (Residents #101 and #119)

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to ensure percutaneous endoscopic gastrostomy (PEG) feedings were administered in a manner to prevent complications for two (2) of five (5) PEG feedings observed. (Residents #54 and #121)

Inspectors wroteBased on observation, record review, staff interview and facility policy review, the facility failed to ensure physician-ordered oxygen therapy for one (1) of four (4) residents requiring oxygen. Resident #145 Findings Include:Review of the facility policy titled Oxygen Guideline revealed under, Policy: Medical oxygen is classified by the Food and Drug Administration as a drug; therefore, it is provided in accordance with a health care provider's order and in accordance with acceptable standards of practice .On 4/21/2026 at 8:30 AM, observation of Resident #145 revealed the resident was sitting in a wheelchair in her room with an oxygen nasal cannula in place, with the concentrator set at two (2) liters. Record review of the Clinical Health Status Evaluation dated 4/14/26 revealed Resident #145 was on continuous oxygen. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement infection control practices to prevent the spread of infection by not maintaining aseptic technique and not providing dressing changes during 3 (three) of 7 (seven) care area observations. Resident #5, Resident #23, Resident #54. Findings Include: Review of the facility policy, Infection Control with effective date of 11/01/2017 revealed, This 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 staff and resident interviews, record reviews, the facility's investigation, and the facility clinical care system guidelines review, the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of three (3) residents reviewed for accident hazards (Resident #1). The facility's failure to provide supervision resulted in Resident #1 exiting the facility unnoticed and unsupervised. She was determined to have exited the facility on 2/14/26, at approximately 1:08 PM and was located by staff 0.4 miles from the facility at 1:33 PM. During the investigation, the SA identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 2/14/26, and existed at 42 CFR: [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure medications were available and administered as ordered for one (1) of three (3) resident reviewed for significant medication errors. (Resident #4). Findings Include:Record review of the facility Medication Availability form, identified by the Nurse Consultant as the facility protocol for missing medications, revealed, If medication is not available at administration time: Check E Kit (Emergency Medication Kit), call the pharmacy, obtain estimated time of delivery, notify supervisor. If greater than four (4) hours, call Medical Doctor (MD) to inform and obtain plan to address. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review the facility 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 for one (1) of three (3) residents care plans reviewed. Resident #1 Findings Include: Record review of the facility policy titled, Comprehensive Care Plans revealed Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . A record review of the facility investigation revealed that on 3/14/25, while Resident #1 was being transferred to bed by Certified Nursing Assistant (CNA) #1, the resident stated, ow, and CNA #1 eased the resident to the floor. CNA #1 immediately notified the nurse. Upon evaluation, no injury or complaint of pain was noted. [...]

Inspectors wroteRevised 6/4/25 After quality review by the Centers for Medicare and Medicaid Services Regional Office, the deficiency originally cited at F 600 has been moved to F 689. Based on staff interview, record review, and facility policy review, the facility failed to ensure a resident's environment was free from accident hazards when the facility staff failed to refer to the kiosk [NAME] to ensure staff transferred the resident with the required number of staff members and failed to use the proper assistive device for one (1) of three (3) residents reviewed. Resident #1 Findings Include: Record review of the facility policy titled, Lift 4 Care-Safe 4 All revealed Purpose: To provide team members guidance with assisting patients and residents to safely reposition or transfer . 7. [...]

Inspectors wroteBased on staff interview, record review, Payroll-Based Journal (PBJ) staffing data report review, and facility policy review, the facility failed to accurately submit staffing data into the PBJ system for one (1) of four (4) quarters reviewed. First Quarter 2025 (October-December 2024) Findings Include: Review of the facility policy titled Payroll Based Journal Entry Submission unrevised, revealed under, Policy: CMS (Centers for Medicare and Medicaid Services) regulations for Payroll Based Journal (PBJ) entries submission are adhered too. Record review of the PBJ Staffing Data Report revealed the facility submitted excessively low weekend staffing data for the 1st quarter 2025 (October 1-December 31). [...]

Inspectors wroteBased on observation, staff and resident interview, record review, and facility policy review, the facility failed to ensure that resident call lights were within reach, which limited a resident's ability to request assistance as needed for two (2) of 134 residents observed on survey.

Inspectors wroteBased on observations, resident and staff interviews, record review, and facility policy review, the facility failed to provide a safe, clean, and homelike environment for nine (9) of 134 residents residing in the facility. (Residents #14, # 17, #32, # 70,, #71, #79, #87, #93, and #95).

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to implement an activities of daily living (ADL) care plan for resident's dependent on staff assistance (Residents #12, #111, and #118) and failed to implement a care plan related to fluid restriction for (Resident #32) for four (4) of 45 resident care plans reviewed.

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide activities of daily living (ADL) care for resident's dependent on staff assistance for three (3) of five (5) residents reviewed for ADL's. (Residents #12, #111, and #118).

Inspectors wroteBased on observation, staff interview, Safety Data Sheet review, and facility policy review, the facility failed to safely store and lock hazardous cleaning chemicals on two (2) of three (3) housekeeping carts observed during survey.

Inspectors wroteResident #118 An observation and interview on 3/19/25 at 9:35 AM with CNA #1 performing Foley catheter care for Resident #118 revealed there was no observation of CNA #1 applying a gown as part of EBP. In a continued interview with CNA #1 she confirmed after seeing the EBP sign on the resident's door that she failed to wear a gown as part of EBP and confirmed that she should have worn the gown to reduce the risk of transmission of bacteria between the staff and resident. During an interview with the Infection Preventionist on 3/19/25 at 10:36 AM she revealed the purpose of EBP is to place a layer of protection between staff and residents to reduce the risk of spread of infection. She revealed that all residents who have devices like indwelling catheters, wounds, and other devices should be on enhanced barrier precautions. [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to secure electronic health records as evidenced by an Electronic Medication Administration Record (EMAR) visible while the medication cart was unattended on the [NAME] unit for two (2) of 58 residents residing on the [NAME] Hall.

Inspectors wroteBased on record reviews, staff interviews, and facility policy reviews, the facility failed to accurately monitor and document fluid intake for one (1) of six (6) residents receiving dialysis. Resident #32. Findings Include: Review of a statement, on company letter head, dated 3/19/25 and signed by the Administrator (ADM) revealed Standards of Practice, the expectation set forth by (Proper name of facility) management is that the nurses comply with current standards of practice in terms of following physician's orders and fluid restriction documentation. A record review of the Order Summary Report for Resident #32 revealed an order for a one liter (1L) fluid restriction. Nursing was to provide 150 cubic centimeters (cc) on the 7:00 AM-3:00 PM shift, 150 cc on the 3:00 PM-11:00 PM shift, and 100 cc on the 11:00 PM-7:00 AM shift. [...]

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

Inspectors wroteBased on observation, staff interview, record review and facility policy review the facility failed to ensure accurate documentation of the care and services provided for a resident with a Peripherally Inserted Central Catheter (PICC) for one (1) of three (3) residents receiving IV (Intravenous) therapy. Resident #430 Findings Include: Record review of the facility policy titled Purpose of the Patient Record revealed Process; clinical records are maintained to provide complete and accurate patient information for continuity of care . On 3/19/25 at 9:18 AM, an observation of Registered Nurse (RN) #4 revealed she flushed Resident #430's PICC located on the right upper arm with 10 ML (milliliters) normal saline and started Vancomycin (antibiotic) infusing via dial a flow. There was a transparent dressing over the residents' PICC line dated 3/14/25. [...]

Inspectors wroteBased on observation, resident and staff interview, and record review, the facility failed to maintain an effective pest control program to address and eliminate the presence of mice droppings in the resident's dresser drawers, posing a potential risk of contamination and health hazards for one (1) of 134 resident's rooms observed (Resident #70).

Inspectors wroteBased on staff and Resident Representative (RR) interview, record review and Administrator statement review the facility failed to ensure a resident received treatment and services in accordance with professional standards of practices as evidenced by failure to change the negative pressure wound therapy system dressing as ordered by the provider for one (1) of three (3) residents with wound care reviewed.

Inspectors wroteBased on staff interview, facility policy review, facility statement review and record review, the facility failed to implement an elopement/wandering risk plan of care for Resident #1 who had worn a wander guard since his admission on [DATE]. Resident #1 had a documented history of wandering and elopement attempts prior to his admission to the facility. Resident #1 was one (1) of four (4) residents identified by the facility, who were at risk for elopement and that wore a wander guard. On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. [...]

Inspectors wroteBased on observation, staff and family interviews, record review and facility policy review the facility failed to provide adequate supervision to prevent Resident #1, who was identified as an elopement and wandering risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1 On 3/31/24 Resident #1 exited the facility unsupervised and undetected by facility staff. It was determined that Resident #1 was missing from the facility for approximately ten to twenty minutes prior to discovery. No facility staff saw resident leave the facility and no facility staff were aware that Resident #1 was missing until approximately 10:40 PM when they received a verbal report from a friend of a staff member that Resident #1 was at an apartment complex parking lot, off the facility grounds, talking to the police. [...]

Inspectors wroteBased on observations, staff and resident interview, record review and facility policy review, the facility failed to provide a safe, clean, homelike environment as evidenced by damaged floors on the East Wing, trash build up, unclean floors and no clean linens for two (2) of three (3) wings. Findings Include: Review of the facility policy titled, 5-Step Daily Room Cleaning with no revision date revealed, Purpose .proper cleaning method to sanitize a patient room or any area in a healthcare facility .1. Empty Trash, 2. Horizontal Surfaces-disinfect, 3. Spot Clean Walls, 4. Dust Mop, 5. Damp Mop; The most important area of a patient's room to disinfect is the floor .When damp mopping floors pay close attention to any possible build up . Review of the facility policy titled, Structuring the Laundry System with a revision date of 10/25/18 revealed, .Stage 1: [...]

Inspectors wroteBased on observation, staff interview, record review and facility policy review, the facility failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside for one (1) of 11 residents on sample.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to implement a comprehensive care plan for a resident requiring assistance with Activities of Daily Living (ADLs) for three (3) of 11 residents sampled. Resident #1, Resident #3, and Resident #6.

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to provide assistance with Activities of Daily Living (ADL) for residents that required assistance for three (3) of seven (7) sampled residents. Resident # 6, #1, and #3. Cross Reference F725 Findings Include. A review of the facility policy titled ADL's Effective August 2021, revealed, 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. Resident #6 On 03/18/24 at 10:30 AM, observation/interview of Resident #6 with the Treatment Nurse present revealed the resident lying in bed and appeared disheveled wearing only a shirt and a brief. [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review, the facility failed to provide sufficient staff as evidenced by staff not providing assistance with bathing, grooming and personal hygiene for three (3) of seven (7) sampled residents residing in the facility. Resident #1, Resident #3,and Resident #6.

Inspectors wroteBased on observation, staff and resident interview and facility policy review, the facility failed to ensure that call lights were functioning in all resident rooms as evidenced by Resident #3 and Resident #6's call lights not functioning for two (2) of seven (7) residents sampled. Findings Include: Record review of the facility policy titled, Nurse Call System with a revision date of 9/1/14 revealed, Policy .To maintain center nurse call systems in an ideal mechanical condition to ensure optimum performance when residents request assistance from staff . An observation on 3/18/24 at 6:15 AM, of Resident #3's room revealed the call light outside the room door was on, but no noise was alerting staff. An interview on 3/18/24 at 6:16 AM with Licensed Practical Nurse (LPN) #3 confirmed that Resident #3's call light is not working and stays on all of the time, so they have bells. [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to develop/implement care plans for (2) two residents related to shaving Resident #90 and Resident #173; failed to ensure a call light was in reach of (1) one resident, Resident #102; failed to consult a physician for medication changes for (1) resident, Resident #15; and failed to apply a splint for (1) one of (4) four residents reviewed with assistive devices, Resident #108; for a total of five (5) residents out of 26 sampled residents.

Inspectors wroteBased on observation, resident/staff interview, record review, and facility policy review the facility failed to apply a hand splint that was recommended by Occupational Therapy to prevent worsening of a contracture for one (1) of three (3) residents with splints resulting in loss of Range of Motion (ROM) for the resident. Resident #108 Findings Include: A review of the facility policy titled, Splinting and orthotics, revealed: It is the policy of (Proper Name) Rehabilitation that therapists recommend, within their scope of practice, appropriate splinting and orthotics for patients currently receiving therapy services, as the need arises. An observation and interview, on 10/30/23 at 10:30 AM with Resident #108 confirmed that she was unable to open her left hand and that she could not move her left arm. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to clean the ice machine for one (1) of two (2) ice machines in the nursing facility, failed to check the water temperature of the dish water in the three-(3) compartment sink prior to use for six (6) days during September and October of 2023, and failed to label, date, clean, and remove expired food for three (3) of 3 resident nourishment refrigerators located on the nursing units. Findings Include: Review of the facility policy titled, Manuel Warewashing, with a revised date of 9/2017, revealed Policy Statement: All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed . Procedures: 1. The Dining Service staff will be knowledgeable in proper technique including: . Wash temperature at no less than 110 degrees F (Fahrenheit). [...]

Inspectors wroteBased on observation, staff, resident and responsible party interview, and facility policy review the facility failed to provide activities of daily living (ADL) care, shaving, for two (2) of 125 residents reviewed on initial tour.

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's call light was placed within reach as evidenced by the call light laying on the floor not in reach of the resident for (1) one of 26 sampled residents, Resident #102.

Inspectors wroteBased on record review and staff interview, the facility failed to notify the resident's physician of an elevated blood sugar of 466 for (1) one of 26 sampled residents reviewed for provider notification of change in condition.

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure a resident was free from accident hazards as evidenced by an unsecured free standing portable oxygen cylinder for one (1) of 12 residents with portable oxygen cylinders.

Inspectors wroteBased on observation, resident and staff interview, and facility policy review the facility failed to prevent the possible spread of infection when a residents oxygen tubing was laying on a resident's floor under her wheelchair and not stored in a plastic bag for (1) of 26 residents on oxygen therapy.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to provide a safe/functional/sanitary/comfortable environment as evidence by a gray/black residue on a residents room wall and dirty air conditioner filter for three (3) of four (4) days of survey, for one (1) of 75 resident rooms observed. Resident #83 Findings Include: A review of the facility policy titled Room Audit Effective Date: September 1, 2014, revealed: Purpose - To assess resident rooms to identify items that should be repaired, replaced, or addressed to ensure a home - like standard that meets acceptable standards. Guidelines: General Room Appearance - Housekeeping issues should be noted and reported to housekeeping. Damage drywall, furniture, or non-functioning equipment, etc. should be noted, a work order created and addressed according to priority. [...]