Diversicare of Tupelo

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from sexual abuse for one (1) of 32 initial pool residents. Resident #14 Findings Include:Review of the facility policy titled Abuse Policy, unrevised, revealed under Policy Statement: It is the policy of the center to take appropriate steps to prevent the occurrence of abuse, neglect, injuries of unknown origin, and misappropriation of resident/patient property .Record review revealed the facility reported an allegation of abuse to the State Agency on 1/10/26 at 11:30 AM after a staff member witnessed Resident #56 touching Resident #14 inappropriately. The residents were immediately separated and Resident #56 denied the allegation, and an investigation was initiated. [...]

Inspectors wroteBased on staff interview, record review, and facility policy review, the facility failed to notify the State Long-Term Care Ombudsman of a resident's transfer to the hospital, which did not ensure compliance with required notification procedures for resident transfers for one (1) of four (4) hospitalizations reviewed. Resident #46 Findings Include:Record review of facility policy titled, Transfer and discharge date d 11/1/16, revealed 4. Before (Proper name of facility removed) 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; and will also notify the State Long-Term Care Ombudsman . [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to implement the comprehensive care plan for two (2) of 28 residents sampled. (Resident #39 and Resident #58)

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to revise the comprehensive care plan, following a fall, on one (1) of 28 residents sampled. (Resident #83)

Inspectors wroteBased on observation, staff interview, resident interview, record review, and facility policy review, the facility failed to ensure a resident who required assistance received activities of daily living (ADL) care, including grooming and personal hygiene services such as hair washing, in accordance with the resident's assessed needs, for one (1) of 29 residents. (Resident #58) Findings Include: Review of facility policy titled Activities of Daily Living (ADLs), with an effective date of August 2021, revealed the facility policy is to ensure activities of daily living are provided in accordance with accepted standards of practice, the resident's care plan, and reasonable accommodation of the resident's choices and preferences. The policy further identified hygiene activities of daily living to include bathing, dressing, grooming, and oral care. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility failed to ensure adequate supervision and monitoring for one (1) of 28 residents reviewed following expressions of suicidal ideation, despite receiving post-emergency room recommendations for psychiatric follow-up. (Resident #8)

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure catheter care was performed correctly for one (1) of six (6) residents with an indwelling urinary catheter. Resident #70. Findings Include: Record review of the facility's Peri Care Audit Tool (undated) revealed, 11. If Foley catheter present, must wash catheter tube first before starting the peri care. Washes from the meatus up the tube about 6 inches X2 (times two) with changing position of cloth. An observation of Resident #70's catheter care with Certified Nurse Aide (CNA) #4 on 1/12/26 at 3:40 PM revealed she prepared to provide catheter care and filled one pan with clean water. CNA #4 wet a washcloth and applied Dynacare shampoo and body wash directly to the cloth. [...]

Inspectors wroteBased on staff interview, facility record review, and facility policy review, the facility failed to ensure ongoing monitoring for adverse effects of a medication for one (1) of five (5) residents reviewed for medication review. (Resident #39).

Inspectors wroteBased on observation, staff interview, facility policy review, the facility failed to ensure infection prevention and control practices were consistently implemented in accordance with accepted standards of practice. Specifically, the facility failed to maintain oxygen equipment by not dating the oxygen tubing and oxygen humidifier water bottles for Residents #37 and #93 and failed to ensure staff followed Enhanced Barrier Precautions (EBP) by not wearing a gown during Foley catheter care for a resident requiring EBP (Resident #70). These failures affected three (3) of twenty nine sampled residents. Findings Include: [...]

Inspectors wroteBased on observation, staff and resident interviews, record review, and facility policy review, the facility failed to ensure that staff followed the resident's Kardex requiring two-person assistance for bed mobility and toileting. This failure resulted in Resident #1 falling from the bed and sustaining actual harm in the form of a skin tear, facial swelling, bruising, and maxillary hematoma, with increased pain requiring a new order for tramadol, an opioid analgesic, for one (1) of three (3) residents reviewed for accidents. ( Resident # 1)

Inspectors wroteBased on resident representative interviews, staff interviews, record review, and facility policy review, the facility failed to provide pharmacy services for obtaining medications timely for two (2) of four (4) residents sampled.

Inspectors wroteBased on staff and resident interviews, record review, and facility policy review, the facility failed to honor residents' right to vote in the 2024 election for three (3) of six (6) residents sampled for resident's rights. Residents #4, #5, and #6 Findings Include: Record review of facility policy titled, Resident's Rights and Quality of Life, dated 5/1/12, revealed, It is the policy of (proper name removed) that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. A resident has the right to exercise his/her rights as a resident of the facility and a citizen or resident of the U.S. and be free of interference, coercion, discrimination, or reprisal by (proper name removed) or its employees for the exercise of such rights. [...]

Inspectors wroteBased on observation, resident and staff interviews, and record review, the facility failed to be administered in a manner that allowed it to use its resources effectively to ensure the well-being of its residents for four (4) of the four (4) days of the survey. Findings Include This tag is cross referenced to F 565, F 677, F 689, F 761, and F 880 A review of the typed statement on facility letterhead revealed that the facility did not have an Administration Policy and was signed by the Administrator. F 565 On 9/17/24 at 3:05 PM, during the resident council meeting held Resident #25 revealed that the food is terrible. She has complained about it in the resident council before, but nothing has improved. Resident #3 confirmed that they have complained about the food in resident council meetings every month and nothing is done. [...]

Inspectors wroteBased on observations, staff and resident interviews, record review, and facility policy review, the facility Quality Assurance and Assessment (QAA) committee failed to maintain implemented procedures and monitor interventions that the committee put into place following the recertification survey of 6/22/23. This was for deficiencies recited during a recertification survey on 9/16/24. The recited deficiencies included F 550, F565, F584, F656, F677, F689, F761, and F880. The continued failure of the facility during two state surveys indicates a pattern of the facility to sustain an effective QAA program. This was for eight (8) of 18 deficient practice citations. Findings Included: This citation is cross-referenced to: [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide dignity to residents, as evidenced by leaving urinary catheter bags uncovered for two (2) of four (4) residents with a catheter. Resident #52 and Resident #190.

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed to ensure that all residents were made aware of the resident council meetings each month in order to make the choice to attend (Resident #27 and Resident #50) for two (2) of 16 residents reviewed. The facility also failed to resolve grievances for seven (7) of eight (8) resident council meetings. CROSS REFERENCE F804??????? Findings Include: Review of the facility policy titled Resident Council with an effective date of 5/1/12 revealed under Procedure .#4. Activity Director/SS Designee will provide written answers to questions, requests and grievances to the Resident Council. #5. The Activity Director/SS Designee shall communicate to all residents when and where resident council meetings are held . [...]

Inspectors wroteBased on observation, resident and staff interviews, statement on facility letterhead and facility policy review, the facility failed to maintain a clean and safe environment, as evidenced by a dirty wheelchair, (Resident #71) and electrical wires exposed on a bed control (Resident #12) for two (2) of the 22 residents sampled residents. Findings Include: A review of the statement on facility on letterhead signed by the Administrator and dated September 18, 2024, revealed, (Proper Name) utilizes the Embrace Program for our wheelchair cleaning and inspection of bed controls and electrical connections. A review of the facility policy titled Resident's Right and Quality of Life, dated May 1, 2012, revealed, A resident has the right: to receive services in a facility environment that is safe, clean, and comfortable . [...]

Inspectors wroteBased on observation, resident and staff interview, record review, facility policy review, the facility failed to implement a comprehensive care plan related to Activity of Daily Living (ADL) for Resident #58, Resident #59 and for Resident #22 for smoking . For three (3) of 22 care plans reviewed. Findings Include: Facility policy titled, Care Plans, with no date, revealed, Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Resident #22 Record review of Resident #22's Care Plans with a date initiated of 5/29/21 revealed , Focus: At risk for smoking related injury related to: [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to provide the necessary assistance with Activities of Daily Living (ADL) care for a resident requiring nail care (Resident #58, #59) and incontinent care (Resident #7) for three (3) of 22 sampled residents. Findings Include: Review of the facility policy ADL's (Activities of Daily Living) dated August, 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodation of the resident's choices and preferences. An observation on 9/17/24 at 8:15 AM, revealed Resident #7 was lying in bed with eyes open, alert but confused and it was noted a very strong odor of urine in the room. [...]

Inspectors wroteBased on observation, resident and staff interview, and facility policy review, the facility failed to ensure that a residents' environment was free from accident hazards, as evidenced by, medications left at bedside and smoking paraphernalia in rooms for two (2) of 22 sampled residents.

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure that medications were stored securely in a locked medication cart or locked storage room for two (2) of four (4) medication carts used in the facility. Findings Include Record review of a typed statement on facility letterhead, dated September 18, 2024 and signed by the Administrator revealed (Proper name of facility) does not have a policy for Storage of Medications on top of the medication cart. An observation on 9/16/24 at 9:04 AM, revealed an unattended medication cart sitting outside the dining room near the beginning of the B Hall. The top of the cart contained a medicine cup full of a red liquid, a bottle of magnesium, Colace and calcium sitting on the top of the medication cart. [...]

Inspectors wroteBased on observation, staff interviews, record review and facility policy review, the facility failed to fully implement Enhanced Barrier Precautions (EBP) precautions and failed to follow infection control measures while providing resident care for two (2) of four (4) survey days that had the potential to affect 11 residents on EBP and Resident #2 and Resident #20. Findings Include Review of the facility policy titled, Policies and Practices - Infection Control with an effective date of 11/1/17 revealed .Policy Statement: 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 observation, resident and staff interview, meal ticket review, and facility policy review, the facility failed to honor a resident's choice for sweet tea with meals for one (1) of twenty-two sampled residents. Resident #44 Findings Include: Review of the facility policy titled Resident's Rights and Quality of Life with a revision date of 5/1/12 revealed under, Policy Statement: It is the policy of (Proper Name) that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility. An interview with Resident #44 on 9/16/24 at 11:06 AM revealed, she wanted sweet tea with meals, and it had been over a month since she had gotten it. She stated she had told them, but they keep sending unsweet tea and she just cannot drink it. [...]

Inspectors wroteBased on staff and resident interviews, record reviews, and facility policy reviews, the facility failed to ensure advance directives were addressed or correct for three (3) of the 22 sampled residents. Resident #43, Resident #63, and Resident #84 Findings Included: Record review of facility policy titled, Advance Directives, dated [DATE], revealed, Policy Statement, (Proper Name) recognizes the dignity and value of each Resident's right to make health care decisions and to be fully informed of his or her complete health status. Furthermore, (Proper name) recognizes the right of each Resident to issue Advance Directives regarding his or her health care . 8. (Proper name) will provide education and training to its staff regarding its policies and procedures regarding Advance Directives. [...]

Inspectors wroteBased on observation, staff interview and facility policy review the facility failed to ensure resident information was kept confidential and not accessible to the public for one (1) of four (4) survey days. Findings Include: Review of the facility policy titled, Resident Rights and Quality of Life with an effective date of 5/1/2012 revealed under, The resident has the right to .personal privacy and confidentiality of personal and clinical records. An observation on 9/16/24 at 9:04 AM, revealed a medication cart sitting outside the dining room door leading to the B Hall with a visible list of resident names, room numbers, code status and if they were on hospice or dialysis laying on top of the medication cart for anyone to see. [...]

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to ensure that a new employee had a background check completed prior to working for one (1) of five (5) new employee personnel records reviewed. Findings Include: Review of the facility policy titled, (Facilities Proper Name) Background Check Policy with a revision date of 2/13/17 revealed under, Policy .It is the policy of (Facilities Proper Name) Management Services, as part of its hiring procedures, to conduct criminal background checks on all applicants offered employment to support workplace productivity, safety and security. Record review of Registered Nurse (RN) Unit Manager's personnel file revealed she was hired by the facility on 8/13/24 and her background check was completed on 6/10/22 and was outdated. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to ensure that a resident's comprehensive care plan was revised and updated for one (1) of 22 sampled residents. Resident #33 Findings Include: Record review of the facility policy titled, Care Plans with a revision date of 10/21 revealed under, Policy: . Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. An observation of Resident #33 on 9/16/24 at 9:38 AM and on 09/17/24 at 8:30 AM revealed, she was lying in bed with a raised perimeter air mattress intact to the bed. An interview with the Director of Nursing (DON) on 9/17/24 at 10:30 AM revealed, Resident #33 had a raised perimeter air mattress to keep her from rolling out of the bed. [...]

Inspectors wroteBased on resident and staff interview, record review, and facility policy review, the facility failed to follow nursing standards of practice for a resident with a physician order for intravenous (IV) antibiotics for one (1) of 22 sampled residents. Resident #20 Findings Include: Record review of a typed statement on facility letterhead, dated September 19, 2024, and signed by the Administrator revealed (Proper name of facility) does not have a policy on Standards of Practice. Record review of the August 2024 Medication Administration Record (MAR) for Resident #20 revealed, an order dated 8/4/24, Meropenem Intravenous Solution Reconstituted 500 MG (milligrams) use 500 MG (milligrams) intravenously every day shift for infection Urinary Tract Infection (UTI) for 5 (five) days in sodium chloride 0.9% (percent) 100 ml (milliliters) IVPB (intravenous piggyback). [...]

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to ensure residents were properly assessed and consent obtained for bed rails for two (2) of 22 sampled residents. Resident #33 and #60 Findings Include: Record review of the Facility policy titled, Restraint with an effective date of 11/28/16 revealed Process: . When a patient/resident is determined to need a restraint, an evaluation will be completed at least on a quarterly basis or with a significant change in the patients/residents condition. This evaluation will assist in determining continued need or possible reduction/elimination . Resident #33 An observation of Resident #33 on 9/16/24 at 9:38 AM, revealed, she was lying in bed, arousable with one-half (1/2) side rails that were up on both sides of the bed and a raised perimeter air mattress was intact to the bed. [...]

Inspectors wroteBased on observation, resident and staff interview, record review, and facility policy review, the facility failed to serve food that met the residents' choices and failed to serve the food in an attractive and palatable manner for four (4) of twelve residents reviewed for dining. Resident #20, #27, #43, and #50. Findings Include: CROSS REFERENCE F565 Record review of the facility policy Menus revised 10/2022 revealed Menus will be planned in advance to meet the nutritional needs of the residents .6. Menus will be served as written, unless a substitution is provided in response to preference . Resident #20 An interview on 9/16/24 at 10:57 AM, with Resident #20 revealed, she did not like the food that she was served. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review the facility failed to ensure that a resident was treated with dignity when she asked for assistance with toileting and a staff member refused for one (1) of eight (8) residents reviewed. Resident #1. Findings Include: Record review of the facility policy, Resident's Rights and Quality of Life dated May 1, 2012, revealed It is the policy of Advocate that all residents have the right to a dignified existence, self-determination, and communication with an access to people and services inside and outside the facility . On 06/11/24 at 10:30 AM, an observation and interview with Resident #1 revealed her sitting in a wheelchair propelling herself in her room. She revealed that she was not able to walk, that she wore briefs and required help to use the bathroom. [...]

Inspectors wroteBased on observation, interview, record review and facility policy review the facility failed to implement Activities of Daily Living (ADL) care plans for two (2) of eight (8) residents reviewed. Resident #1 and Resident #8. Findings Included: Record review of the facility policy, 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. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. [...]

Inspectors wroteBased on observation, interviews, record review and facility policy review the facility failed to provide oral care for a resident (Resident #8) and failed to shave residents (Resident #1 and Resident #8) for two (2) of eight (8) residents reviewed. Findings Include: Record review of the facility policy, ADL's (Activities of Daily Living) dated August 2021, revealed, Policy: Ensure ADL's are provided in accordance with accepted standards of practice, the care plan, and reasonable accommodations of the resident's choices and preferences . RESIDENT #1 On 06/12/24 at 10:20 AM, an observation and interview with Resident #1 revealed facial hair, one approximately two (2) inches long on her left lower jaw and there was an area approximately three inches by three inches with scattered black hairs that measured approximately one-half inch to three-fourths inch on her lower chin. [...]

Inspectors wroteBased on observation, interviews, record reviews and facility policy review the facility failed to ensure that a comprehensive care plan was implemented for one (1) of nine (9) residents reviewed for Activities of Daily Living (ADLs). Resident #1 Findings Include: Record review of the facility policy, MDS (Minimum Data Set) and Care Plans with effective date of August, 2019 revealed,Policy: Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of Resident #1's Care Plan initiated on 05/11/2023 revealed Focus: Self-Care Deficit related to: decreased functional abilities, impaired cognition/dementia, pain, weakness .Interventions . Assist with bathing as needed . Nail, hair, and oral care daily and as needed. [...]

Inspectors wroteBased on observation, resident, family, and staff interviews, record review, and facility policy review the facility failed to ensure that a resident received her scheduled baths in January and failed to provide nail care for one (1) of nine (9) residents reviewed for Activities of Daily Living (ADLs). Resident #1 Findings Include: Record review of the facility policy titled, ADL's (Activities of Daily Living), with effective date August 2021, revealed Policy: Ensure ADLs (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 . On 02/07/24 at 10:30 AM, an observation and interview with Resident #1, revealed her lying in bed in her room. Resident #1's right hand was closed tightly and resting on the bed down by her side. [...]

Inspectors wroteBased on observation, resident and staff interviews the facility failed to provide enough staff to meet the needs of the residents for four (4) of 4 days of survey.

Inspectors wroteBased on observation, staff and resident interview, and facility policy review, the facility failed to promote the dignity of a resident as evidenced by failure to change a brief when wet for one (1) of sixty-seven residents with incontinence.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to maintain call lights within reach of the resident for two (2) of twenty-six residents reviewed.

Inspectors wroteBased on resident and staff interviews, record review and facility policy review the facility failed to resolve a resident grievance in a timely manner for five (5) of 17 residents reviewed for unresolved grievances in the resident council meeting. Resident #26, 38, 51, 55 and 80 Findings Include Review of the facility policy titled, Customer Concern Grievance Policy with a revision date of July 2018 revealed under 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. The goal is to encourage open communication of customer concerns in an environment free from reprisal, retaliation, or discrimination. We have a commitment to customer service and have systems in place to address concerns. [...]

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review, the facility failed to create a clean and safe environment as evidenced by a dirty wheelchair and black substance on a resident's refrigerator for two (2) of 26 residents sampled. Resident #26 and #77.

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to send a written transfer/discharge notice to a resident or resident representative for a hospital transfer for one (1) of five (5) residents reviewed for hospitalization. Resident #84 Findings Include: Review of the facility policy titled, Transfer & Discharge with a revision date of November 1, 2016, 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; and will also notify the State Long-Term Care Ombudsman. Record review of Resident #84's electronic record revealed there was no discharge/transfer notice for the resident's hospital stay on 5/1/23. [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to notify the resident or resident representative of the bedhold amount for a hospital discharge for one (1) of five (5) residents reviewed for hospitalization. Resident #84 Findings Include Review of the facility policy titled, Bed Hold Policy with a revision date of November 1, 2016 revealed under Policy Statement .(the facilities proper name) will, in accordance with Federal and State regulations, hold a Resident's bed during a temporary hospitilazation or therapautic leave. This review revealed under Procedure .#1 Before the Center transfers a Resident to a hospital or the Resident goes on therapeutic leave, the Center shall provide Resident or his or her Resident Representative this Bed Hold Policy. [...]

Inspectors wroteBased on staff interviews, facility policy review and record review the facility failed to develop or implement a care plan for four (4) of 26 care plans reviewed. Resident #6, 20, 25, 30.

Inspectors wroteBased on observations, resident and staff interviews, facility policy review, and record review the facility failed to provide care to maintain hygiene as evidenced by failure to provide shower, and nail care for two (2) of twenty-six residents reviewed. Resident #25 and Resident #30.

Inspectors wroteBased on observation, resident and staff interviews, and facility policy review the facility failed to ensure the safety of resident as evidenced by failure to secure smoking materials for one (1) of 18 smokers in the facility. Resident #57.

Inspectors wroteBased on observation, resident and staff interviews the facility failed to provide incontinent care in a timely manner to a resident that was incontinent for one (1) of sixty seven incontinent residents. Resident #6.

Inspectors wroteBased on observation, staff interview, facility policy review, the facility failed to store controlled medications in a separately locked permanently affixed compartment in the medication room refrigerator for one (1) of (1) medication storage rooms observed.

Inspectors wroteBased on observation, staff interviews and facility policy review the facility failed to prevent the possibility of the spread of infection as evidenced by failure to use a barrier during medication administration of a respiratory inhaler, for one (1) of 37 medications observed.