DIVERSICARE OF MOSS POINT
For profit - Limited Liability company
160 Beds
DIVERSICARE HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
41/100
#112 of 200 in MS
Photo by Diversicare of Moss Point
Photo by Diversicare of Moss Point
Photo by Diversicare of Moss Point
1 / 5 photos
Last Inspection: December 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Diversicare of Moss Point has received a Trust Grade of D, indicating below-average performance with some concerning issues. It ranks #112 out of 200 facilities in Mississippi, placing it in the bottom half, though it is the top facility out of six in Jackson County. The facility is worsening, with the number of issues found increasing from 3 in 2023 to 7 in 2024. Staffing is a relative strength, with a rating of 3 out of 5 stars and a turnover rate of 37%, which is below the state average of 47%. However, there are significant concerns, including a critical incident where a resident identified as an elopement risk left the facility unsupervised for about ten minutes before staff were alerted. Additionally, the kitchen failed to properly store and label food items, which raises hygiene concerns. Overall, while there are some strengths in staffing, the facility has critical safety issues and a declining trend that families should consider.
- Trust Score
- D
- In Mississippi
- #112/200
- Safety Record
- High Risk
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Mississippi's 48% average. Typical for the industry.
- Penalties ✓ Good
- $9,318 in fines. Lower than most Mississippi facilities. Relatively clean record.
- Skilled Nurses ○ Average
- Each resident gets 39 minutes of Registered Nurse (RN) attention daily — about average for Mississippi. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
41/100
Bottom 44%
Review needed
3 → 7 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2023: 3 issues
2024: 7 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Mississippi average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Mississippi average (2.6)
Below average - review inspection findings carefully
Staff Turnover: 37%
Near Mississippi avg (46%)
Typical for the industry
Federal Fines: $9,318
Below median ($33,413)
Minor penalties assessed
Chain: DIVERSICARE HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 19 deficiencies on record
1 life-threatening
Dec 2024
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of resident transfers to the resident or the resident representative (RR) for t...
Read full inspector narrative →
Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of resident transfers to the resident or the resident representative (RR) for three (3) of (3) residents reviewed for hospitalizations. (Residents #47, #65, and #69).
Findings included:
A review of the facility's policy titled Transfer & Discharge, revised November 1, 2016, revealed, (Proper Name of Facility) shall permit each resident to remain at the center and not transfer or discharge the resident from the center except in accordance with federal and state laws and as directed in this policy .Notice Requirements .4 .Before (Proper Name of 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 .
During an interview on 12/04/2024 at 10:30 AM, the Receptionist explained she was instructed by the Regional Business Office Consultant not to mail written notification of transfers to the RRs. She stated the company policy required calling the representatives instead. She confirmed she had stopped mailing written notification of transfer approximately six (6) months ago.
During an interview on 12/05/2024 at 9:00 AM, with the Administrator, he explained he was unaware the receptionist had stopped mailing transfer letters. He acknowledged the regulation requiring written notification to representatives in a language they understand and stated the facility would resume mailing transfer notifications to representatives immediately.
Resident #47
A record review of the admission Record revealed the facility initially admitted Resident #47 on 03/26/2020 and she had current diagnoses including Sepsis.
A record review of Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2024 revealed Resident #47 was discharged from the facility to an acute hospital.
Resident #65
A record review of the admission Record revealed the facility initially admitted Resident #65 on 05/04/2023 with diagnoses including Acute Respiratory Failure.
A record review of Resident #65's Discharge MDS with an ARD of 10/09/2024 revealed Resident #65 was discharged to an acute hospital.
Resident #69
A record review of the admission Record revealed the facility admitted Resident #69 on 05/13/2024 with diagnoses including Paraplegia.
A record review of the Discharge MDS with an ARD of 08/15/2024 revealed Resident #69 was discharged to an acute hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of the facility's bed hold policies and information at the time of the transfer...
Read full inspector narrative →
Based on staff interview, record review, and facility policy review, the facility failed to provide written notification of the facility's bed hold policies and information at the time of the transfer to the resident or the Resident Representative (RR) for three (3) of (3) residents reviewed for hospitalizations. (Residents #47, #65, and #69).
Findings included:
A review of the facility's Bed Hold Policy, revised November 1, 2016, revealed, (Proper Name of Facility) shall permit each resident to remain at the center and not transfer or discharge the resident from the center except in accordance with federal and state laws and as directed in this policy .Notice Requirements .4 .Before (Proper Name of 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 .
During an interview on 12/04/2024 at 10:30 AM, the Social Services Director explained she was told by the Regional Business Office Consultant not to mail or provide the RR's with written notification regarding the facility's bed hold policies and information. She stated she was told the company policy did not require written notification and that representatives could be contacted by phone. The Social Services Director reported she had stopped mailing bed hold notifications six (6) months ago.
During an interview on 12/05/2024 at 9:00 AM, the Administrator revealed he was unaware the Social Services Director had stopped mailing bed hold notification information to RRs. He stated the facility would resume mailing bed hold notification to RR's immediately.
Resident #47
A record review of the admission Record revealed the facility initially admitted Resident #47 on 03/26/2020 and she had current diagnoses including Sepsis.
A record review of Discharge Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/2024 revealed Resident #47 was discharged from the facility to an acute hospital.
Resident #65
A record review of the admission Record revealed the facility initially admitted Resident #65 on 05/04/2023 with diagnoses including Acute Respiratory Failure.
A record review of Resident #65's Discharge MDS with an ARD of 10/09/2024 revealed Resident #65 was discharged to an acute hospital.
Resident #69
A record review of the admission Record revealed the facility admitted Resident #69 on 05/13/2024 with diagnoses including Paraplegia.
A record review of the Discharge MDS with an ARD of 08/15/2024 revealed Resident #69 was discharged to an acute hospital.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one (1) of twenty-one (21) MDS...
Read full inspector narrative →
Based on staff interview, record review, and facility policy review, the facility failed to transmit a discharge Minimum Data Set (MDS) assessment in a timely manner for one (1) of twenty-one (21) MDS assessments reviewed. (Resident #86)
Findings included:
A review of the facility's policy MDS and Care Plan, effective August 2019, revealed, .Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines.
A record review of the admission Record revealed the facility admitted Resident #86 on 7/2/24 with current diagnoses including Spastic Hemiplegia Affecting Left Non-Dominant Side.
A record review of the Discharge Minimum Data Set (MDS) in the electronic medical record with an Assessment Reference Date (ARD) of 08/06/2024 revealed Resident #86 discharged home, however, it was not electronically submitted.
During an interview on 12/05/2024 at 10:05 AM, Licensed Practical Nurse (LPN) #3 stated that the corporate nurse was responsible for submitting the discharge MDS. LPN #3 confirmed the corporate nurse completed the discharge MDS but failed to submit it to Centers for Medicare and Medicaid Services (CMS).
During an interview on 12/05/2024 at 10:30 AM, Registered Nurse (RN) #2 confirmed she failed to submit the discharge MDS for Resident #86. RN #2 stated she did not know how she missed it.
During an interview on 12/05/2024 at 10:45 AM, the Director of Nursing (DON) stated she did not know the MDS was not submitted and expected MDS assessments to be submitted timely.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to develop care plan interventi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and facility policy review, the facility failed to develop care plan interventions related to triggers for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD) (Resident #27) and failed to implement care plan interventions related to enhanced barrier precautions (EBP)(Resident #203) for two (2) of (21) sampled residents.
Findings included:
A review of a statement provided by the facility titled MDS (Minimum Data Set) and Care Plans, effective August 2019, revealed, Policy: Care plans and MDS will be developed and maintained per RAI (Residential Assessment Instrument) Guidelines.
A review of the facility's Social Services Manual, undated, revealed, .Trauma-informed care is an approach to providing care to trauma survivors .Incorporating their story into the care plan and daily care is key to successfully caring for patients and residents who have experienced trauma .
Resident #27
A record review of Resident #27's Comprehensive Care Plan with a date initiated of 7/5/2017 revealed the care plan included forgetfulness, memory loss, and short-term memory impairment related to PTSD, but no triggers were identified in the interventions.
During an observation and interview on 12/02/2024 at 12:11 PM, Resident #27 was lying in bed and reported he had PTSD due to his service in the Vietnam War. He explained that his triggers included gunfire and hearing people grunting or moaning as if being hurt.
During an interview on 12/03/2024 at 11:55 AM, Licensed Practical Nurse (LPN) #1 stated Resident #27 had always been pleasant and cooperative with medications. She reported being unaware of the resident's PTSD triggers and noted that the care plan only mentioned a history of PTSD but did not include specific triggers.
A record review of the admission Record revealed the facility admitted Resident #27 on 07/01/2016 with current diagnoses including Post-Traumatic Stress Disorder (PTSD), chronic, with an onset date of 08/09/2016.
A record review of the Order Summary Report with active orders as of 12/5/2024 revealed Resident #27 had a Physician's Order, dated 5/31/2023 for Ritalin (5) milligrams (mg) twice daily for PTSD.
A record review of a Behavioral Health Progress Note, dated 6/29/2023, revealed Resident #27 had Subjective Interim History completed that indicated he had .PTSD that stemmed from serving in Vietnam war in the [NAME] Corp .
Resident #203
A record review of Resident #203's Comprehensive Care Plan with a review start date of 11/26/2024, included enhanced barrier precautions related to tracheostomy status, with interventions requiring staff to wear gowns and gloves when rendering care.
During an observation on 12/02/2024 at 10:55 AM, an Occupational Therapist (OT) was in Resident #203's room and was providing hand therapy and applying moisturizer to the resident's lips. The resident, who was non-verbal, had a tracheostomy in place and a feeding pump infusing. A sign on the resident's door indicated Enhanced Barrier Precautions, with a picture of the required Personal Protective Equipement (PPE) to wear during care. PPE, including gowns and gloves, was available on the hall and at other residents' doors. The OT was observed wearing gloves and a surgical mask but no gown.
During an interview on 12/03/2024 at 12:15 PM, the OT confirmed providing therapy for Resident #203 on 12/02/2024, including hand exercises and oral care. She admitted she did not wear a gown while providing care.
On 12/03/2024 at 3:00 PM, during an interview with LPN #3/Care Plan nurse, she confirmed that Resident #27's care plan did not identify any PTSD triggers. She was unaware of the need to list or identify triggers on the care plan. She stated that care plans are the guide for providing care and staff are expected to follow the care plan to provide the highest functional care for residents. She also confirmed Resident #203 had a care plan intervention for EBP to include wearing a gown while providing care.
During an interview on 12/03/2024 at 3:20 PM, the Director of Nursing (DON) stated social services was responsible for evaluating PTSD and identifying triggers. She was unaware that Resident #27's care plan did not include PTSD triggers. She acknowledged that triggers must be identified to provide quality care and prevent re-traumatization of the resident. The DON also confirmed the OT did not implement the care plan intervention to wear a gown as EBP when providing care to Resident #203.
A record review of the admission Record revealed the facility admitted Resident #203 on 08/26/2024 with diagnoses including Gastrostomy Status and Encounter for Attention to Tracheostomy.
A record review of the Order Summary Report revealed Resident #203 had a Physician's Order, dated 11/20/24 for OT and a Physician's Order dated 12/3/24 for enteral feedings.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0699
(Tag F0699)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility Social Services Manual review, the facility failed to ensure triggers and resid...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review, and facility Social Services Manual review, the facility failed to ensure triggers and resident-specific interventions were identified and initiated for a resident with Post-Traumatic Stress Disorder (PTSD) for one (1) of 21 sampled residents, Resident #27.
Findings included:
A review of the facility's Social Services Manual, undated, revealed, .Trauma-informed care is an approach to providing care to trauma survivors. Trauma-informed care recognizes the experiences endured by survivors, responds to their needs, and helps them on their path . Safety .Survivors of trauma need to feel safe and have a low-stress environment . Care for the Traumatized Patient .Recognizing the many experiences of a trauma survivor is essential to their care .Incorporating their story into the care plan and daily care is key to successfully caring for patients and residents who have experienced trauma .
A record review of the admission Record revealed the facility admitted Resident #27 on 07/01/2016 with current diagnoses including Post-Traumatic Stress Disorder (PTSD), chronic, with an onset date of 08/09/2016.
A record review of the Order Summary Report revealed Resident #27 had a Physician's Order, dated 5/31/2023 Ritalin 5 milligrams (mg) twice daily for PTSD.
A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/2024 revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of eleven (11), which indicated moderate cognitive impairment. Section I-Active Diagnoses listed PTSD as an active diagnosis.
A record review of Resident #27's Certified Nurse Aide (CNA) [NAME] revealed there were no triggers listed for PTSD.
A record review of Resident #27's medical record revealed no documentation indicating the resident was evaluated to identify triggers and resident-specific interventions related to PTSD.
A record review of a Behavioral Health Progress Note, dated 6/29/2023, revealed Resident #27 had Subjective Interim History completed that indicated he had .PTSD that stemmed from serving in Vietnam war in the [NAME] Corp .
On 12/02/2024 at 12:11 PM, during an observation and interview, Resident #27 was lying in bed and reported he had PTSD due to his service in the Vietnam War. He explained that his triggers included gunfire and hearing people grunting or moaning as if being hurt.
On 12/03/2024 at 11:20 AM, during an interview with CNA #1, she stated Resident #27 did not have problems receiving care and was always cooperative. She reported being unaware of any PTSD triggers for the resident and confirmed that no triggers were listed on the [NAME] or care plan in his electronic medical record.
At 11:55 AM on 12/03/2024, during an interview with Licensed Practical Nurse (LPN) #1, she stated Resident #27 had always been pleasant and cooperative with medications. She reported being unaware of the resident's PTSD triggers and noted that the care plan only mentioned a history of PTSD but did not include specific triggers.
On 12/03/2024 at 2:45 PM, during an interview with the Social Services Director (SSD), she explained that when a resident is diagnosed with PTSD, assessments regarding PTSD are the responsibility of nursing. She stated she refers residents with PTSD for one-on-one consultations and to the psychiatrist if needed. She acknowledged the importance of identifying PTSD triggers to prevent re-traumatization.
On 12/03/2024 at 3:20 PM, during an interview with the Director of Nursing (DON), she stated social services was responsible for evaluating PTSD and identifying triggers. She was unaware that Resident #27's care plan did not include PTSD triggers. She acknowledged that triggers must be identified to provide quality care and prevent re-traumatization of the resident.
On 12/05/2024 at 2:00 PM, during an interview with the Administrator, he stated residents diagnosed with PTSD are expected to receive trauma-informed care to prevent re-traumatization.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to foods not labeled, food with n...
Read full inspector narrative →
Based on observation, staff interview, and facility policy review, the facility failed to store food in accordance with professional standards for food safety related to foods not labeled, food with no identified date, exposed foods, a scoop left in the flour bin, and an unclean ice machine for one (1) of two (2) kitchen observations.
Findings included:
A record review of the facility's policy, Refrigerated Storage, effective June 1, 2013, revealed, It is the policy of this facility to store, prepare, and serve foods in accordance with federal, state, and local sanitary codes . 7. All foods will be properly wrapped and/or stored in sealed containers and dated and labeled.
A record review of the facility's policy, Dry Storage, effective August 1, 2012, revealed, .8. Scoops will not be stored in bulk containers.
On 12/02/2024 at 10:22 AM, during an observation and interview of the kitchen with the Dietary Director (DD), the ice machine revealed dirt-like stains along the interior, in contact with the ice. When the DD wiped the soiled areas with a white towel, the smudge transferred onto the towel. An observation of Refrigerator #2 revealed six (6) trays containing portioned glasses of various liquids with no label or date. Freezer #1 was observed to contain one (1) opened bag of breaded chicken strips, leaving the food exposed, with no date. An observation of the pantry revealed one (1) opened bag containing six (6) hamburger buns, left exposed, and a scoop left in the flour bin, touching the flour. Additionally, one (1) opened bag of dehydrated onions was left exposed. On the spice rack, three (3) spice jars were noted with the lids open, leaving the spices exposed. A bottle of lemon juice was noted with manufacturer's instructions to refrigerate after opening, but it was left unrefrigerated. The DD confirmed the dirt-like stains inside the ice machine, undated food, exposed foods, and the scoop left in the flour bin. She stated she was responsible for monitoring food safety but admitted she had tried to clean the ice machine unsuccessfully. The DD reported she did not know the nature of the stains and had not tested the machine for bio-growth, as the Maintenance Director was responsible for such checks.
On 12/02/2024 at 10:52 AM, during an interview, [NAME] #1 stated that cooks are responsible for monitoring food safety and labeling. The cook confirmed that staff are in-serviced monthly on food safety.
On 12/05/2024 at 9:08 AM, during an interview, the Administrator he had been told of the issues observed in the kitchen. He stated he would ensure, through self-monitoring, that the DD maintains food quality and sanitation in the kitchen. He also stated he would implement a strong plan of correction to address unsafe food storage.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) fo...
Read full inspector narrative →
Based on observation, staff interviews, record reviews, and facility policy reviews, the facility failed to follow infection control practices by not implementing Enhanced Barrier Precautions (EBP) for a resident at high risk for Multidrug-resistant Organisms (MDRO) for one (1) of 21 sampled residents. (Resident #203)
Findings included:
A review of the facility's policy Transmission Based Precaution, dated 2022, revealed, .Enhanced Barrier Precautions recommendation is to consider expanding the use of PPE (Personal Protective Equipment) and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk .
A record review of the admission Record revealed the facility admitted Resident #203 on 08/26/2024 with diagnoses including Gastrostomy Status and Encounter for Attention to Tracheostomy.
A record review of the Order Summary Reportwith active orders as of 12/4/24 revealed Resident #203 had a Physician's Order, dated 11/20/24 for Occupational Therapy (OT) and a Physician's Order dated 12/3/24 for enteral feedings.
On 12/02/2024 at 10:55 AM, observed an Occupational Therapist in Resident #203's room. The Occupational Therapist was providing hand therapy and applying moisturizer to the resident's lips. The resident, who was non-verbal, had a tracheostomy in place and a feeding pump infusing. A sign on the resident's door indicated Enhanced Barrier Precautions, with a picture of the required PPE to wear during care. PPE, including gowns and gloves, was available on the hall and at other residents' doors. The OT was observed wearing gloves and a surgical mask but no gown.
On 12/02/2024 at 2:30 PM, during an interview with Registered Nurse (RN) #1, she explained all residents with wounds, gastrostomy tubes, tracheostomies, or catheters were on EBP, which are designed to protect residents from infections brought in by staff. She confirmed all staff, including therapy staff, had been in-serviced on enhanced barrier precautions and stated the OT should have worn a gown while providing care for Resident #203.
On 12/03/2024 at 12:15 PM, during an interview with the OT, she confirmed providing therapy for Resident #203 on 12/02/2024, including hand exercises and oral care. She admitted she did not wear a gown while providing care. She stated she was aware of the enhanced barrier signage and had been educated on the purpose of enhanced barrier precautions, which is to prevent residents from contracting infections from staff. She explained she only wears PPE when the PPE is located on the resident's door itself, but confirmed PPE was readily available on the hall.
On 12/03/2024 at 3:20 PM, during an interview with the Director of Nursing (DON), she confirmed that staff are expected to follow proper infection precautions while providing care. She stated the OT should have worn a gown while providing therapy at the bedside for a resident with a gastrostomy tube and tracheostomy. She reported that PPE was readily available on the hall, noting that the absence of PPE hanging on the door was not a valid reason to omit proper precautions.
May 2023
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Accident Prevention
(Tag F0689)
Someone could have died · This affected 1 resident
Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was previously identified as an exit-seeker...
Read full inspector narrative →
Based on observation, interviews, record review, and facility policy review, the facility failed to provide adequate supervision to prevent Resident #1, who was previously identified as an exit-seeker and elopement risk, from exiting the facility unnoticed and unsupervised for one (1) of four (4) residents reviewed. Resident #1.
Resident #1 exited the facility on 5/14/2023 without the knowledge of staff and was unsupervised approximately 10 minutes until a driver passing by the street entered the facility and notified the staff that a resident was outside of the facility at 6:45 AM. Resident #1 was last observed inside of the facility by staff at approximately 6:40 AM and was located at 6:50 AM approximately 100 yards from the facility walking on the sidewalk in front of a local business.
The facility's failure to provide adequate supervision to prevent the elopement of Resident #1 placed this resident, and other residents at risk for wandering and elopement, in a situation that was likely to cause serious injury, harm, impairment, or death.
The situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 5/14/23 and existed at 42 CFR(s): 483.25(d)(1)(2) Free of Accidents Hazards/Supervision/Devices (F689) - Scope and Severity of J. The SA notified the facility's Administrator of the IJ and SQC on 5/18/2023 at 3:10 PM and provided the Administrator with the IJ template. The facility submitted an acceptable Removal Plan on 5/18/2023, in which they alleged all corrective actions to remove the IJ were completed and the IJ removed on 5/18/2023.
The SA validated the Removal Plan on 5/19/2023 and determined the IJ was removed on 5/18/2023, prior to exit. Therefore, the scope and severity of CFR 483.25(d)(1)(2) Free of Accidents Hazard/Supervision/Devices (F689) was lowered to a Scope and Severity of D while the facility develops a plan of correction to monitor the effectiveness of systemic changes to ensure the facility sustains compliance with regulatory requirements.
Findings include:
Review of the facility's policy, Elopement, dated April 2017, revealed, .To establish a process that identifies risk and establishes interventions to mitigate the occurrence of elopements .Door Alarm Protocol .Once Doors/exit alarms are activated a resident search is completed ensuring there is no missing resident .Tools Resource List for Interventions to Address Elopement Risk .Utilize alarmed doors at time of meals to prevent wandering off units .
On 5/17/23 at 5:00 PM, observations revealed the facility was located on the main street through town. There were local businesses on both sides of the street on each side of the facility. There were thirty (30) automobiles traversing the three (3) lane street (turn lane in the middle) in a five-minute period. The front door faced the street directly and was approximately sixty (60) feet from the street. There was an exit door perpendicular to the main street at the end of each of two wings which ran north and south of the front entrance. There was a four (4) foot wide, well-maintained sidewalk in front of the facility which separated the parking lot and grassy yard from the street. From the front, southern corner of the building of the facility where the East Hall exit door was located to the railroad tracks which intersect the street that the facility was located on was approximately one hundred (100) yards. The condition of the parking lot and yard was well maintained.
Record review of the facility's Investigation Template, dated 5/17/23, revealed, .Description of the Allegation: At approximately 6:50 am, resident was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes. A full body assessment was performed on resident, no issues or injuries noted .Center response: Resident was redirected back inside. A full body assessment was performed on resident, no issues or injuries noted. Building administration was notified, incident called into Reporting line at 5:25 pm. Abuse/Neglect & Elopement in-servicing started for all staff. The resident was dressed appropriately wearing slacks, a blouse and a light jacket, and not at risk for weather related issues Investigation Summary: At approximately 6:50 am, resident was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes .Summary of interview: At 0635 (6:35 AM) I saw (Proper Name of Resident #1) on South wing talking to the nurse .a lady came to the door at 0645 (6:45 PM) and asked if we had anyone missing. She said a lady with long gray was walking down the road .The nurse got in the car with the lady and I got in my car. She was right up the street .We returned to the facility .Person interviewed: (Proper Name of Certified Nurse Aide (CNA) #1 .Summary Investigation . (Proper Name of Resident #1) was walking with another resident at 6:40a (AM) .(Proper Name of CNA #1) ran up the hallway and notified me that (Proper Name of Resident) had gotten outside the building .Body assessment was completed upon returned, no skin tears or lacerations noted. All doors were checked, side door on East wing was the only door unlocked. Staff also completed a head count of every resident in the building .Person Interviewed: (Proper Name of Licensed Practical Nurse (LPN) #1 .
On 5/17/23 at 5:50 PM, in an interview with the Director of Nursing Services (DNS) and the Administrator, the DNS confirmed that Resident #1 was last observed in the facility at 6:40 AM, walking down the hall on the South Hall with another resident. At 6:45 AM, the report of a passerby alerted staff that Resident #1 was outside the facility unaccompanied approximately one hundred yards down the street from the facility. The DON stated that an investigation revealed that the exit door on the North end of the East Hall had an alarm and a magnetic locking mechanism that was not working properly. The resident was returned to the facility at 6:50 AM.
On 5/17/23 at 6:00 PM, observation and an interview with Resident #1 revealed she was in her room sitting on her bed with call light in reach. She was not able to answer questions but was polite and pleasant.
On 5/17/23 at 7:00 PM, during an observation, the exit door at the North end of the East Hall opened with a push by the DNS without the numeric code being entered into the wall mounted keypad beside the door.
On 5/17/23 at 11:30 PM, during a telephone interview with LPN #1 revealed she was working at the facility on the morning of 5/14/23.At 6:40 AM she observed Resident #1 and Resident #2 walking together on the North Hall. She stated she was not aware that Resident #1 had exited the facility until a passerby entered the facility and notified her that she was concerned that a resident was walking down the sidewalk in front of the facility. She stated the nursing staff immediately called a Code Adam per facility protocol for a missing resident using the overhead announcement system and conducted a 100% headcount of all residents. Resident #1 was not accounted for. She stated she located Resident #1 down the street, on the same side of the street as the facility and assisted the resident back to her room in the facility. She stated that the nursing staff had checked all exit doors and determined that the side exit door at the end of East Hall had a locking mechanism issue and the alarm had failed. She said that the door should not have opened without a numeric code being entered into the keypad beside the door. If the door opened, an alarm should have sounded to alert the staff, but the door opened without the code and the alarm did not sound upon opening the door.
On 5/18/23 at 11:34 AM, during an interview with the Maintenance Director, he said he reported to the facility on Sunday (5/14/23) after he was notified of the elopement of Resident #1. He stated that he assessed the side door at the end of the East Hall and determined that the door alarm, nor the locking mechanism operated correctly. He confirmed that on 5/14/23 the side door at the end of the East Hall opened without the numeric code being entered into the wall mounted keypad beside the door and the alarm did not sound upon opening of the door.
Record review of local website weather information revealed the weather for the city on 5/14/2023 at 6:31 AM was 68 degrees Fahrenheit, foggy, with no wind.
Record review of the admission Record revealed the facility admitted Resident #1 on 10/05/21 (with an original admission date listed as 9/19/16) and she had diagnoses including Alzheimer's Disease and Dementia.
Record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/07/23 revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 1, which indicated she had severe cognitive impairment. MDS review also revealed that Resident #1 was ambulatory without assistance.
Record review of the Clinical Health Status Evaluation .Section 11. Elopement, dated 5/9/23, indicated that Resident #1 had a history of wandering or elopement, wanders aimlessly about the facility and/or exhibits night wandering, and was determined to be at risk for elopement.
Record review of the Care Plan for Resident #1 revealed she had a Focus of .Exhibits Exit seeking behavior R/T (related to) periods of confusion with a Goal of .will not attempt to leave the facility without being accompanied by staff or family member , and Interventions included .Wander Guard to left ankle, check placement each shift .
The facility provided the following Removal Plan:
At approximately 6:40 am, Resident #1 was noted to be outside of the facility. Staff were able to redirect and bring resident inside within a few minutes. A full body assessment was performed on resident, no issues or injuries noted. The resident was dressed appropriately wearing slacks, a blouse and a light jacket, and not at risk for weather related issues. The temp was 69 degrees according to the National Weather Association at the time the resident was out of the building. Based on interviews with the staff and timeline, the resident was out of the building for a brief 10 minutes. We were able to redirect easily. Resident #1 was last seen prior to incident at 6:40 a.m. in hallway ambulating with another resident. Upon investigation and door securement checks the East Wing North door released for Administrator and deemed the point of exit for Resident #1. F 689 The facility failed to ensure the resident's environment was free from accident hazards and that Resident #1 received adequate supervision. Resident #1, who was determined by the facility to be an elopement risk, left the faciity on 5/14/2023 at 6:40 AM unnoticed and unsupervised through an exit door that was not functioning properly.
Immediate Corrective Actions for Resident # 1:
Resident #1 returned to the facility 5/14/23 @ 6:50 a.m. by Licensed Practical Nurse (LPN) #1 and placed 1:1 supervision with LPN #1.
Wander guard bracelet placement and function verified immediately by Director of Nursing 5/14/23. Resident #1's bracelet in place and functioning properly.
Full body audit was completed of Resident #1 on 5/14/23 @ 6:55 a.m.by LPN #1 with no injuries noted.
Responsible Party (RP) notified 5/14/23 @ 7:10 a.m. by LPN #1.
Medical Doctor (M.D) notified 5/14/23 @ 7:20 a.m. by LPN #1
Administrator notified by LPN #2 5/14/23 @ 6:45 a.m.
Director of Nursing Services(DNS) was notified by Administrator on 5/14/23 @ 6:50 a.m.
Elopement risk assessments performed on all residents 5/14/23 by Director of Nursing Services (DNS).
Care plan reviewed and updated 5/14/23 by DNS with continued monitoring of resident's whereabouts.
State Agency notified by Administrator 5/14/23 @ 5:25 p.m.
Attorney General Compliant completed online by DNS 5/14/23 @ 4:57 p.m.
Immediate Action take to Identify Others at Risk:
Staff completed a room to room audit of all residents to assure all were safe and accounted for on 5/14/23 @ 6:40 - 7:00 a.m. by nursing staff.
All residents with Wander guard bracelets were checked for functionality and positioning with all in place noted on 5/14/23 @ 7:10 a.m. by DNS. All Wander guard bracelets were in place and functioning properly.
All residents at risk for wandering had their care plan and elopement book reviewed on 5/14/23 by DNS with pictures and current care plans in place.
Administrator (ADM) began an investigation and Root Cause Analysis on 5/14/23 @ 6:45 a.m. to determine how resident went outside; East Wing North End door was not locking and employee placed at door to monitor and ensure no one enters or exits center through door. Employee remained at door through 3-11 shift 5/15/23 when parts were obtained and door demonstrated proper locking function when repeatedly check by Maintenance Supervisor.
All doors were checked for proper function and operation 5/14/23 by Maintenance Director. All doors secure and functioning properly except East Wing North End door noted to not properly lock. Repair to East Wing North End door on 5/15/23 by Maintenance Director.
Systemic Changes and Education Completed to Avoid Reoccurrence:
DNS and Director of Clinical Education Immediately initiated an in-service with all staff regarding our elopement policy guideline (including nursing, maintenance, office personnel, dietary, housekeeping, therapy, and any volunteers) on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time will be educated prior to working.
Education for all staff on abuse, neglect, prevention of accidents and supervision of residents by DNS and Director of Clinical Education on 5/14/23 and completed on 5/15/23 Any staff member that was not educated on this date will be educated prior to starting next shift.
Social Services Director (SSD) conducted an elopement drill on all three shifts beginning 5/14/23-5/16/23.
Licensed Nursing Staff to check for proper function and placement of Wander guard bracelets every shift beginning 5/14/23, with documentation on the Treatment Administration Record (TAR).
Door checks will be conducted on each shift for three days, then daily to assure proper function by Director of Maintenance/Assistant Director of Maintenance/Licensed Nurse or Administrator beginning 5/14/23.
Door monitored by staff member 5/14/23 through 5/15/23
The Administrator, Maintenance Director or Nurse will assure that all exit doors will be checked after any power failure to assure they are in proper working order beginning on 5/17/23.
On 5/17/23 when East Wing North door opened without disarming alarm, a staff member was place at the door for monitoring and to remain until repaired.
QAPI:
A focused/Adhoc Quality Assessment Performance Improvement (QAPI)meeting addressing the findings was initiated and completed on May 15, 2023 with participation of the Administrator, Medical Director, DNS, Assistant DNS, Unit Manager. Evaluation of process with placement of staff member at door until parts obtained and placed 5/15/23 and proper door function noted.
After the door malfunctioned on 5/17/23, a 2nd QAPI meeting was held to re evaluate processes and additional corrective action to check all doors after electrical storms or power outages. The QAPI meeting was completed on May 17, 2023, with the participation of the Administrator, Medical Director, DNS, Assistant DNS, Infection Preventionist/DCE. Reevaluated process also included placing a staff member at door for monitoring to remain in place until repaired.
Diversicare of Moss Point alleges all corrective actions were completed on 5/17/23 with IJ removal 5/18/23.
The SA validated the facility's investigation of the incident and implementation of the Removal Plan through observations, facility record review, and interviews.
SA validated that Resident #1 returned to the facility 5/14/23 at 6:50 AM, by Licensed Practical Nurse (LPN) #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and record review of the Facility Investigation.
SA validated that Wander Guard bracelet placement and function was validated immediately by the DNS on 5/14/23 with Resident #1's bracelet in place and functioning properly during an interview with the DNS on 5/18/23 at 11:10 AM.
SA validated that a full body audit was completed for Resident #1 on 5/14/23 at 6:55 AM by LPN #1 with no injuries noted during a telephone interview with LPN #1 on 5/17/23 at 11:30 AM and record review of the Progress Notes for Resident #1 dated 5/14/23 18/23 and the Facility Investigation.
SA validated that the Responsible Party (RP) for Resident #1 was notified on 5/14/23 at 7:10 AM by LPN #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM.
SA validated that the Medical Doctor (MD) of Resident #1 was notified on 5/14/23 at 7:20 AM by LPN #1 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM.
SA validated that the facility Administrator was notified on 5/14/23 at 6:45 AM by LPN #2 during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and during an interview with the Administrator on 5/18/23 at 10:55 AM. and during an interview with the DNS on 5/18/23 at 11:10 AM.
SA validated that the DNS was notified by the Administrator on 5/14/23 at 6:50 AM during an interview with the Administrator on 5/18/23 at 10:55 AM and during an interview with the DNS on 5/18/23 at 11:10 AM.
SA validated that elopement risk assessments were performed on all residents 5/14/23 by the DNS and during an interview with the DNS on 5/18/23 at 11:10 AM and record review of the elopement risk assessments for Resident #1, Resident #2, Resident #3 and Resident #4.
SA validated that the Care Plan for Resident #1 was reviewed and updated on 5/14/23 by DNS with continued monitoring of resident's whereabouts by record review of Resident #1's Care Plan.
SA validated that State Agency (SA) was notified by the Administrator on 5/14/23 at 5:25 PM during an interview with the Administrator on 5/18/23 at 10:55 AM.
SA validated that an Attorney General Compliant was completed online by the DNS on 5/14/23 at 4:57 PM during an interview with the DNS on 5/18/23 at 11:10 AM.
SA validated that Staff completed a room-to-room audit of all residents to assure all were safe and accounted for on 5/14/23 at 6:40 - 7:00 AM by nursing staff during an interview with the DNS on 5/18/23 at 11:10 AM and during a telephone interview with LPN #1 on 5/17/23 at 11:30 PM.
SA validated that all residents with Wander Guard bracelets were checked for functionality and bracelet positioning with all in place noted on 5/14/23 at 7:10 AM by DNS and that all Wander guard bracelets were in place and functioning properly a telephone interview with LPN #1 on 5/17/23 at 11:30 PM and during an interview with the DNS on 5/18/23 at 11:10 AM.
SA validated that all residents at risk for wandering had their care plan and elopement book reviewed on 5/14/23 by DNS with pictures and current care plans in place during an interview with the DNS on 5/18/23 at 11:10 AM and record review of the elopement books at the nurses stations.
SA validated that the Administrator began an investigation and Root Cause Analysis on 5/14/23 at 6:45 AM to determine how resident went outside; East Wing North End door was not locking and employee placed at door to monitor and ensure no one enters or exits center through door and that an employee remained at door through 3-11 shift 5/15/23 when parts were obtained and door demonstrated proper locking function when repeatedly check by Maintenance Director during an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM.
SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that all doors were checked for proper function and operation on 5/14/23 by the Maintenance Director. All doors were secure and functioning properly except East Wing North End door noted to not properly lock and that repair to East Wing North End door was performed on 5/15/23 by the Maintenance Director.
SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that the DNS and the Director of Clinical Education Immediately initiated an in-service with all staff regarding elopement policy guideline (including nursing, maintenance, office personnel, dietary, housekeeping, therapy, and any volunteers) on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time to be educated prior to working. The SA also validated through staff interviews that all staff received the in-service including with Cook, on 5/19/23 at 1:27 PM, Housekeeper on 5/19/23 at 1:30 PM, LPN #2 on 5/19/23 at 1:38 PM, LPN #3 on 5/19/23 at 1:40 PM, and OT on 5/19/23 at 1:42 PM, and the Director of Clinical Education (and Infection Preventionist) on 5/19/23 at 1:48 PM.
SA validated through an interview with the DNS on 5/18/23 at 11:10 AM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM. that the DNS and the Director of Clinical Education initiated an in-service with all staff regarding abuse, neglect, prevention of accidents and supervision of residents on 5/14/23 and completed on 5/15/23. Any staff member that was not educated at that time to be educated prior to working. The SA also validated through staff interviews that all staff received the in-service including with Cook, on 5/19/23 at 1:27 PM, Housekeeper on 5/19/23 at 1:30 PM, LPN #2 on 5/19/23 at 1:38 PM, LPN #3 on 5/19/23 at 1:40 PM, and OT on 5/19/23 at 1:42 PM, and the Director of Clinical Education (and Infection Preventionist) on 5/19/23 at 1:48 PM.
SA validated through record review of Patient/Resident Elopement Drill Worksheets dated 5/14/23, 5/15/23 and 5/16/23 that the Social Services Director (SSD) conducted an elopement drill on all three shifts beginning 5/14/23-5/16/23.
SA validated through record review of the Treatment Administration Record (TAR) that Licensed Nursing Staff were to check for proper function and placement of Wander guard bracelets every shift beginning 5/14/23, with documentation on the TAR.
SA validated through record review of LOGBOOK DOCUMENTATION sheets that door checks were conducted on each shift for three days, then daily to assure proper function by Director of Maintenance/Assistant Director of Maintenance/Licensed Nurse or Administrator beginning 5/14/23.
SA validated through record review of the Door Monitor schedule and during an interview with the DNS on 5/18/23 at 11:10 AM, an interview with CNA #2 on 5/18/23 at 10:00 AM and CNA #3 on 5/18/23 at 4:00 PM and during an interview with the Maintenance Director on 5/18/23 at 11:34 AM that the East Wing North door was monitored by staff member 5/14/23 through 5/15/23.
SA validated through observation on 5/17/23 at 7:00 PM that after East Wing North door opened without the numeric code entered into the wall mounted keypad, a staff member was placed at the door for monitoring and to remain until repaired on 5/19/23. SA validated through observation and interview with the alarm repairman on 5/19/23 at 12:48 PM that the repairman performed maintenance on the East Wing North door and repeatedly tested the door to ensure proper functioning of the locking mechanism.
SA validated through record review of the Quality Assurance and Performance Improvement (QAPI) Meeting sheet dated 5/15/23, including sign-in of committee members that a focused/Adhoc Quality Assessment Performance Improvement (QAPI)meeting addressing the findings was initiated and completed on May 15, 2023, with participation of the Administrator, Medical Director, DNS, Assistant DNS, Unit Manager. Evaluation of process with placement of staff member at door until parts obtained and placed 5/15/23 and proper door function noted.
SA validated through record review of the Quality Assurance and Performance Improvement (QAPI) Meeting sheet dated 5/17/23, including sign-in of committee members that after the door malfunctioned on 5/17/23, a 2nd QAPI meeting was held to reevaluate the processes and additional corrective action to check all doors after electrical storms or power outages. The QAPI meeting was completed on May 17, 2023, with the participation of the Administrator, Medical Director, DNS, Assistant DNS, Infection Preventionist/DCE. The reevaluated process also included placing a staff member at door for monitoring to remain in place until repaired.
The SA validated through observation, record reviews, policy reviews and interviews that the facility completed all corrective actions on 5/17/23 with IJ removal 5/18/23.
Apr 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected 1 resident
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident Council grievances were resolved related to food concerns for nine (9) of nine resi...
Read full inspector narrative →
Based on observations, interviews, record review, and facility policy review, the facility failed to ensure Resident Council grievances were resolved related to food concerns for nine (9) of nine residents who attended the Resident Council meeting.
Findings include:
Review of the facility's, Customer Concern (Grievance) Policy dated July 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 . Our Grievance Official is the center Administrator .Process . Customer concerns will have a prompt response. The concern will be recorded on the Customer Concern Form either by the team member who has received the concern or by the customer (patient/resident) . The Administrator will ensure a thorough investigation is conducted and will respond to the customer (patient/resident) . In resolving the concern, both the Administrator and the customer will develop a plan of action which will be specific about what is to occur . The Administrator shall follow up on the correction of the problem and finalize the Customer Concern Form validating the resolution of the concern including who did what, when, and where. The Administrator shall contact the customer to assure him/her that it has been resolved . The completed Customer Concern Form will be retained in the Administrator's office for a period of three years .
Record review of the Resident Council Minutes, dated 1/18/23 at 3:00 PM, revealed .Concerns: Dietary .Cold food, soggy food because of putting foods together veggies and fruits in bowl .
Record review of the Resident Council Minutes, dated 2/15/23 at 3:00 PM, revealed, .Concerns: Dietary .still being served dislikes, cold food, still getting soggy foods, wrong foods on tray .
Record review of the Resident Council Minutes, dated 3/15/23 at 3:00 PM, revealed, .Old Business .food still being cold in cafeteria and room soggy buns from wet food .Concerns: Dietary: cold, soggy, and wrong foods .
During a Resident Council meeting on 4/11/23 at 10:00 AM, the residents stated they had complained for six (6) months that the food was cold and did not taste good. The residents explained they had complained to the Social Worker (SW), who then notified the Administrator. The Dietary Manager (DM) attended several of their meetings in which they expressed their concerns related to the cold temperature and the lack of taste with the food. The DM said he would make sure the food was hot and that the food was seasoned, however, the residents remarked that nothing had changed, and the food continued to be cold and unsavory.
Review of the most recent Minimum Data Sets (MDSs) for the residents who attended the Resident Council meeting, on 4/11/23, revealed a Brief Interview of Mental Status (BIMS) score of 15 for four (4) of the residents and a BIMS score of 14 for two (2) residents, which indicated no cognitive impairment, and a BIMS score of 12 for three (3) of the residents, which indicated moderate cognitive impairment.
During an interview on 04/11/23 at 10:40 AM, with the SW, she confirmed the residents had complained that the food was cold and unsavory. The SW advised that she presented the grievances to the Administrator and the Dietary Manager, and the DM was invited and attended some resident council meetings.
During an interview on 04/12/233 at 12:24 PM, the DM confirmed he had attended Resident Council meetings when he was invited, however, he was unable to explain why the grievances had not been resolved.
During an interview on 04/13/23 at 10:53 AM, with the Administrator, he confirmed he was aware of the complaints from the resident council about the food being cold and unsavory.
During an interview on 04/13/23 at 11:15 AM, with the Dietary District Manager, he confirmed he knew the residents had been complaining about the food lacking taste and being cold.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interviews and facility policy review the facility failed to properly seal dry goods, label, and date refrigerated foods, and remove expired foods for one (1) of three (3) kitche...
Read full inspector narrative →
Based on observation, interviews and facility policy review the facility failed to properly seal dry goods, label, and date refrigerated foods, and remove expired foods for one (1) of three (3) kitchen observations.
Findings include:
A record review of the facility's policy, Food Storage: Dry Goods, with a revision date of 9/2017, revealed, . All dry goods will be appropriately will be appropriately stored in accordance with the FDA Food Code . All packaged and canned food items will be kept clean, dry, and properly sealed .
A record review of the facility's policy, Food Storage: Cold Food, with a revision date of 4/2018, revealed, . All Time/Temperature Control for Safety (TCS) foods, frozen and refrigerated, will be appropriately stored in accordance with guidelines of the FDA (Food and Drug Administration) Food Code . All foods will be stored wrapped or in covered containers, labeled, and dated, and arranged in a manner to prevent cross contamination .
On 4/10/23 at 10:55 AM, in an initial tour of the kitchen with Dietary Manager (DM), observation of the dry goods storage room, revealed there was a five (5) pound bag of egg noodles open and undated in a plastic clear bin without a lid. There were five (5) eight (8) ounces Styrofoam cups in the refrigerator, unlabeled and undated. The DM confirmed the cups contained fortified white pudding. Observation of the items in the refrigerator also revealed three (3) packs of six (6) count, undated hoagie buns and an unlabeled and undated piece of meat wrapped in saran wrap. It was noted that the piece of meat had a yellow sticker on it that said, use first. The DM stated it was a chicken breast. In the cooler, there were also eight (8) 32-ounce cartons of Debel® Liquid Egg whites, with an expiration date of 11/25/22.
On 4/11/23 at 3:00 PM, in an interview with the DM, he stated, as the manager of the department, it is his responsibility to oversee the operations of the department. He revealed that although he expects the staff to check foods for expiration dates and remove them, it is his responsibility to oversee the staff and make sure that they complete their assigned tasks. The DM stated he expects his staff to pull food expired foods and dispose of them, as consumption could cause residents to become ill.
On 4/13/23 at 2:15 PM, in an interview with the Administrator, he confirmed the egg whites should have been removed from the refrigerator. He stated the egg whites should have been removed from the refrigerator on their expiration date and all the opened foods that had been observed, should have been sealed and labeled.
Nov 2019
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on interviews, record review, and facility policy review, the facility failed to assist two (2) of three (3) residents to vote in the general election. Resident #92 and Resident #3.
Findings inc...
Read full inspector narrative →
Based on interviews, record review, and facility policy review, the facility failed to assist two (2) of three (3) residents to vote in the general election. Resident #92 and Resident #3.
Findings include:
Review of the facility policy, Voting and Community/ Citizenship Activities, dated 11/2017, revealed the Center will encourage and assist, where appropriate and reasonable, the resident to participate in the resident's community and citizenship activities of choice (i.e., voting .).
Resident #92
On 11/14/19 at 10:00 AM, interview with Resident #92 revealed he did not get to vote in the Governor's election on 11/5/19. Resident #92 stated she would have voted, if taken to vote. The facility admitted Resident #92 on 5/29/1998, and her most recent Brief Interview for Mental Status (BIMS), dated 10/18/19, revealed a score of 15, which indicated Resident #92 had no cognitive impairment.
Resident #3
On 11/14/19 at 10:55 AM, interview with Resident #3 revealed she did not get to vote in the recent 11/5/19 general election. Resident #3 stated, No, and I like to vote. Usually they drive us to vote. The facility admitted Resident #3 on 9/11/2014. Review of the most recent BIMS assessment, dated 10/17/19, revealed Resident #3 scored 15, which indicated no cognitive impairment.
On 11/14/19 at 10:09 AM, in a phone interview, Social Worker #1 stated she did not know if the residents got to vote, because she had been out on sick leave since October 18, 2019.
On 11/14/19 at 11:54 and 11:58 AM, interview with Administrator revealed he was not sure if the residents got to vote on 11/5/2019, for the Governor's election. The Administrator confirmed he was responsible since the Social Worker was on medical leave.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
Based on staff interview, record review, and facility policy review, the facility failed to resolve grievances for one (1) of 21 Residents interviewed for grievances, Resident #65.
Findings Include:
R...
Read full inspector narrative →
Based on staff interview, record review, and facility policy review, the facility failed to resolve grievances for one (1) of 21 Residents interviewed for grievances, Resident #65.
Findings Include:
Review of the facility policy Investigating Grievances, dated April 2018, revealed the facility will investigate all grievances filed and make a prompt effort to resolve all complaints/grievances.
The department Director of the involved employee or practice will be notified of the nature of the grievance and that an investigation is underway. The resident, or person acting on behalf of the resident, will be verbally informed of the findings of the investigation, as well as any corrective actions recommended, within a reasonable time of filing of the grievance.
Resident #65
Review of the September 2019 Grievance Log, revealed a grievance filed on 9/25/19, and closed on 9/30/19 for Resident #65. Review of the facility's investigation form for the grievance, revealed Resident #65 reported missing money and a credit card holder from the pouch of her wheel chair, to the Social Worker, either on 9/21/19 or 9/22/19. The investigation revealed the resident's wheelchair was removed from her room for cleaning on the 11-7 shift. There was no documented evidence the resident was made aware of the results and/or that the grievance was resolved to the satisfaction of the resident. There was no documented evidence the resident's money was refunded.
Interview on 11/13/19 at 12:00 PM, with Resident #65, revealed the Certified Nursing Assistants (CNAs) on night shift removed her wheelchair to wash it a couple of times and did not inform her. Resident #65 also stated when her wheelchair was returned, the money pouch did not have her $20.00 in it. Resident #65 stated she reported the missing money to the Social Worker and the Administrator. Resident #65 said she was not told the outcome of the investigation and no one offered to give her money back.
Telephone interview on 11/14/19 at 12:17 PM, with the Social Worker, revealed the grievance for Resident #65's missing money was turned over to the Risk Manager to resolve. The Social Worker said the Administrator and the Risk Manager was responsible for that grievance.
Interview on 11/14/19 at 12:30 PM, with The Administrator, confirmed facility staff removed the wheelchair on night shift to clean it and did not wake the resident up and let her know the wheelchair was going to be washed. The Administrator said the staff will be in-serviced to let cognitive residents know when their wheelchairs will be removed for cleaning purposes. The Administrator said he thought the Risk Manager had given the resident her money. The Administrator did not have a receipt. The Administrator presented a receipt dated November 14, 2019 for $20.00 to Resident #65.
Review of Resident #65's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/20/2019, revealed Resident #65 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to notify the resident/Responsible Part...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and facility policy review, the facility failed to notify the resident/Responsible Party, and Ombudsman, in writing, of hospital transfers, including the reasons for transfer, for two (2) of five (5) residents reviewed for hospitalization, Resident #20 and Resident #32.
Findings include:
Review of the Facility Policy, Documentation of Transfers/Discharges, dated November 2001, revealed: When a resident is transferred or discharged , his or her medical records shall be documented as to the reasons why such action was taken. Documentation from the care planning team concerning all transfers or discharges must include, as a minimum, and as they may apply: A. The reason for the transfer. B. That an appropriate notice was provided to the resident/representative.
Resident #32
Review of Resident #32's medical record revealed there was no documented evidence the resident/representative or the Ombudsman was notified, in writing, of a hospital transfer for Resident #32, on 8/14/19.
Review of the Physician Orders, dated 8/14/2019, revealed orders to send Resident #32 to the emergency room of the local hospital, related to increased confusion, incontinent episodes, unlike behavior.
On 11/13/19 at 2:11 PM, interview with the Director of Nursing revealed Resident #32 was transferred and admitted to the hospital on [DATE], and returned on 8/16/2019.
On 11/14/19 at 10:56 AM, interview with the Administrator confirmed the facility did not mail a letter to the Responsible Party regarding Resident #32's hospital transfer on 8/14/2019.
Resident #20
Review of Resident #20's medical record revealed there was no documented evidence the facility had provided the resident, Resident Representative and/or Ombudsman, of written transfer notices when the resident was sent to the hospital on five (5) different occasions.
Review of the Minimum Data Set (MDS), with Assessment Reference Dates (ARDs) of 7/31/2019, 8/20/2019, 8/26/2019, 8/29/2019, and 9/5/2019, revealed they all documented acute hospital and/or unplanned discharge, with anticipation to return back to the facility.
Interview on 11/14/19 at 11:54 AM, with the Administrator, confirmed the facility failed to send the hospital transfer notices to the family and Ombudsman for Resident #20 and Resident #32. The Administrator stated it was the responsibility of the Social Worker to make sure the letters go out. The Administrator confirmed he was responsible for the duties of the Social Worker for the last four (4) weeks, because she was out on Family Medical Leave (FMLA).
During a telephone interview, on 11/14/19 at 12:31 PM, the Social Worker confirmed she was responsible for the Ombudsman letter for resident transfers. The Social Worker said she was not responsible for sending out the hospital transfer letters to family/resident. The Social Worker said the facility had not decided who would be responsible for the hospital transfer letters.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #76
Review of the Quarterly MDS, with an ARD of 10/3/2019, revealed Hospice Care was not checked for Resident #76. Ther...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #76
Review of the Quarterly MDS, with an ARD of 10/3/2019, revealed Hospice Care was not checked for Resident #76. There was no documented SC MDS for Resident #76, related to hospice services, when the resident was admitted to hospice on 2/21/19.
Review of the Physician Orders, dated 2/21/2019, revealed an order to admit Resident #76 to Hospice.
On 11/13/2019 at 11:04 AM, an interview with Registered Nurse #1 revealed that the Quarterly MDS for Resident #76 was not coded correctly, nor was a significant change completed with an admission to Hospice, following the Physician Order on 2/21/2019. RN #1 stated they have 14 days to complete the Significant Change, but it was not performed.
On 11/13/19 at 1:32 PM, an interview with the Director of Nursing (DON) revealed she would expect the MDS to be completed in a timely manner and to be accurate to reflect the resident's current status.
On 11/13/19 at 3:20 PM, an interview with RN #1 revealed if the facility does not complete a SCSA when the resident goes on or come off of hospice services, then the MDS does not accurately reflect the resident's current status.
Based on record review, staff interview, and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) and initiate a significant change in status assessment (SCSA) MDS, related to hospice for three (3) of (26) resident Minimum Data Set (MDS) assessments reviewed, Resident #45, Resident #71, and Resident #76.
Findings include:
A review of the facility's policy, Resident Assessment, dated November 2017, revealed a comprehensive assessment of a resident's needs shall be made following the guidelines set forth in the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. (The RAI manual, October 2017, documents anytime a resident is admitted to Hospice, changes Hospice Services, or discharges from Hospice, a SC MDS must be initiated.)
Resident #45
Review of the medical record revealed there was no Significant Change in Status Assessment (SCSA) MDS completed after Resident #45 was admitted to hospice services on 1/15/19.
A review of the facility's Face Sheet revealed, Resident #45 was admitted on [DATE].
Review of the Physician's Order Sheet, revealed Resident #45 had hand-written orders to admit to Hospice, dated 1/15/19, for a diagnosis of Chronic Obstructive Pulmonary Disease (COPD).
On 11/13/19 at 3:11 PM, an interview with Registered Nurse (RN) #1 confirmed Resident #45 did not have a SCSA MDS assessment completed after she was admitted to hospice services.
Resident #71
Record review revealed the most recent quarterly MDS assessment, with an ARD of 10/1/19, and a SCSA MDS, with an ARD of 7/1/19, did not include Resident #71's admission or discharge from Hospice services.
Review of the physician orders, dated 7/07/19, revealed an order for Resident 71's admission to Hospice. A physician order dated 9/3/19, indicated to discharge Resident #71 from Hospice.
On 11/13/19 at 10:31 AM, interview with RN #1 revealed there was not a SCSA completed for the admission of Resident #71 to hospice services on 7/7/19. RN #1 also stated there should be a SCSA MDS completed anytime a resident goes on hospice services and comes off of hospice services, and there was not a SCSA completed after Resident #71 was discharged from hospice services on 9/3/19.
On 11/13/19 at 10:37 AM, an interview with RN #2 revealed she would expect the MDS to be coded accurately.
On 11/13/19 at 11:22 AM, an interview with LPN #1 revealed she did not complete a SCSA MDS assessment when Resident #71 had gone on hospice services, but knows she should have. She stated she didn't think she needed to complete a SCSA MDS when the resident comes off hospice. LPN #1 stated she used the RAI manual for completing the MDS assessment and there was not a SCSA completed after the resident was discharged from hospice services.
On 11/14/19 at 10:45 AM, interview with LPN #1 revealed, she attends a yearly state MDS training and yes, a SCSA should have been done for when Resident #71 was admitted on hospice services 7/7/19.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and policy review, the facility failed to follow the care plan, related to catheter care, for one (1) of (23) resident care plans reviewed, Reside...
Read full inspector narrative →
Based on observation, staff interview, record review, and policy review, the facility failed to follow the care plan, related to catheter care, for one (1) of (23) resident care plans reviewed, Resident #44.
Findings Include:
Review of the Care Plan-Comprehensive policy, dated November 2017, revealed a comprehensive care plan is developed and maintained for each resident.
Review of the Comprehensive Care Plan, initiated 6/12/19, revealed Resident #44 at risk for infection, related to the Foley catheter, with an intervention to provide Foley catheter care as ordered and to monitor for pain/discomfort due to catheter care.
Observation on 11/13/19 at 2:15 PM, revealed Certified Nursing Assistant (CNA) #3 failed to hold the tip of the catheter tubing (close to the insertion site), to prevent trauma to the meatus, while providing catheter care to Resident #44. CNA #3 pulled the catheter outward, without securing the tubing, and Resident #44 stated it hurt.
During an interview, on 11/13/19 at 2:26 PM, CNA #3 confirmed she failed to hold the catheter tubing close to the insertion site while providing catheter care to Resident #44. CNA #3 stated she was told to hold the head of the penis.
During an interview, on 11/14/19 at 11:28 AM, Registered Nurse (RN) #2 stated she expected the staff to follow the care plan (which would include providing care the correct way). RN #2 stated CNA #3 should have held the catheter tubing while providing care, to keep the catheter tubing from coming out.
During an interview, on 11/14/19 at 11:46 AM, the Director of Nursing (DON) confirmed CNA #3 failed to follow the care plan by not securing the tubing, which is part of catheter care. The DON said the tubing could come out by pulling on it.
A review of the facility's face sheet revealed the facility admitted Resident #44 on 4/10/2019, with diagnoses, which included Retention , Urinary Tract infection (UTI), Hematuria and Benign Prostatic Hyperplasia.
Review of Resident #44's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/3/2019, revealed Resident #44 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated the resident is cognitively impaired.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0658
(Tag F0658)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and facility statement review, the facility failed to follow standards of practice, related to enteral feeding pumps, in accordance to the care pl...
Read full inspector narrative →
Based on observation, staff interview, record review, and facility statement review, the facility failed to follow standards of practice, related to enteral feeding pumps, in accordance to the care plan, for one (1) of nine (9) resident care observations, Resident #25. This was as evidenced by a Certified Nursing Assistant (CNA) turned off a feeding pump, instead of getting a licensed nurse to turn the pump off, during care of the resident.
Findings include:
Review of a statement, documented on facility letterhead, dated 11/14/19, revealed: We follow the practices of Mississippi State guidelines of CNAs not turning off enteral feeding pumps.
Review of the Mississippi Nurse Aide Candidate Handbook, dated March 2017, revealed no documentation of any directive for the CNA to turn on/off feeding tube pumps.
Review of Resident #25's care plan, initiated 10/19/18, revealed the nurse was designated as the staff member, to hold or turn off the tube feeding, while giving ADL (Activity of Daily Living) care or anytime the bed is flat in position.
On 11/13/19 at 4:06 PM, during catheter care observation, Certified Nursing Assistant (CNA) #1 stopped the enteral feeding pump before laying the bed in a flat position and providing catheter care on Resident #25.
On 11/13/19 at 4:25 PM, interview with CNA #1, with CNA #2 present, revealed it was ok for them to pause the enteral feeding to care for the resident, but they could not restart it. CNA #1 said she had to let the nurse know when care was completed. CNA #1 and CNA #2 both said they had competency training during orientation related to care of catheters. Neither of the CNA's could identify any deficiency.
On 11/14/19 at 11:09 AM, interview with the Director of Nursing (DON) revealed she was made aware of the CNA's stopping the feeding pump during the care, which was not in their scope of practice; the nurse should have stopped the feeding. The DON stated the CNAs have not been told in training they can stop the feeding pumps.
On 11/14/19 at 11:14 AM, interview with Licensed Practical Nurse (LPN)/Staff Development (SD) Nurse, revealed the CNA's were not to touch or adjust feeding pumps, because it was the responsibility of the nurses. She said both CNA #1 and CNA #2 had competency training related to peri/catheter care, but it wouldn't have addressed the tube feeding because they are not responsible. The SD Nurse said she would check to see if any education had been provided on the care of a resident with an enteral tube to the CNAs.
Review of the competency Skills Check list for CNA #1, dated 8/27/19, and CNA #2, dated 5/31/19, related to perineal care and catheter care, did not reveal any documentation related to the care of resident with an enteral tube.
On 11/14/19 at 12:56 PM, The SD Nurse confirmed care of a enteral tube was not on the competency check list for CNA #1 or CNA #2. She also said no in-services were provided, prior to 11/13/19, related to care of a resident with a feeding tube.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent infection and trauma to the meatus for one (1) of ...
Read full inspector narrative →
Based on observation, staff interview, record review, and facility policy review, the facility failed to provide catheter care in a manner to prevent infection and trauma to the meatus for one (1) of two (2) catheter care observations, Resident #44, as evidenced by not anchoring the tubing to prevent pulling on/pulling out the catheter, while providing care.
Findings Include:
Review of the facility's policy, Catheter Care, Urinary, dated July 2015, revealed the purpose of the procedure was to prevent infection of the resident's urinary tract, which included to retract the foreskin on the penis and maintain the position of the hand throughout the procedure.
Observation on 11/13/19 at 2:15 PM, revealed Certified Nursing Assistant (CNA) #3 provided catheter care to Resident #44. The CNA failed to hold the tip of the catheter tubing, next to the foreskin of the penis, to prevent trauma to the meatus. CNA #3 pulled the catheter outward, without securing the tubing. Resident #44 said it hurt when she pulled the tubing.
In an interview, on 11/13/19 at 2:26 PM, CNA #3 confirmed she failed to hold the catheter tubing while she provided catheter care to Resident #44. CNA #3 said she was taught to hold the head of the penis.
In an interview, on 11/14/19 at 11:46 AM, the Director of Nursing (DON) confirmed CNA #3 failed to prevent possible infection and trauma to the meatus, by not securing the tubing, while providing catheter care to Resident #44. The DON said the tubing could have come out when the CNA pulled outward on the tube.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Social Worker
(Tag F0850)
Could have caused harm · This affected 1 resident
Based on staff interview and review of the facility license, the facility failed to employ a Licensed Social Worker (LSW), to provide social services, for three (3) of three (3) days of survey.
Findin...
Read full inspector narrative →
Based on staff interview and review of the facility license, the facility failed to employ a Licensed Social Worker (LSW), to provide social services, for three (3) of three (3) days of survey.
Findings include:
During an interview, on 11/14/19 at 11:54 and 11:58 AM, the Administrator revealed their employed Social Services person is out on medical leave, and he was responsible for doing the social services duties while she was out. The Administrator stated they do not have a LSW working at the facility and they are licensed for 160 beds. The Administrator stated they have a current census of 100 residents.
Review of the facility license revealed the facility is licensed for 160 beds until March 2020.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide a written bed hold notice to the resi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to provide a written bed hold notice to the resident and/or resident representative, at the time of transfer to an acute care setting, for three (3) of five (5) hospitalizations reviewed, Resident #20, Resident #32, and Resident #69.
Findings include:
Review of the facility's Bed Hold Policy, dated 2/1/2005, revealed: The resident/responsible party/will be asked to sign a bed hold authorization. The authorization will be specific to the length of time the authorization is valid and the daily rate for the bed hold. A new bed hold authorization will be completed for each absence from the facility.
Resident #20
Review of the Minimum Data Set (MDS) Assessments, for Resident #20, revealed Assessment Reference Dates (ARDs) of 9/5/2019, 8/29/2019, 8/26/2019, and 8/20/2019, when the resident was discharged to an acute care hospital, and 7/31/2019 for an unplanned discharge; all with anticipation to return back to the facility.
During an interview, on 11/14/19 at 11:54 AM, the Administrator confirmed the facility failed to send the written Bedhold letters to the resident/family. The Administrator said it was the responsibility of the Social Worker (SW) to make sure the letters go out. The Administrator stated he was, however, responsible for the duties of the SW for the last four (4) weeks, due to the SW had been out on Family Medical Leave.
During a telephone interview, on 11/14/19 at 12:31 PM, the SW stated she was not responsible for sending out the bedhold letters or the hospital transfer letters. The SW stated the facility had not decided who would be responsible for the Bedhold and hospital transfers letters, that she was aware of.
Resident #32
Review of the Physician Orders, dated 8/14/2019, revealed an order to send Resident #32 to the local emergency room (ER) for increased confusion, incontinent episodes, and unlike behavior.
During an interview, on 11/13/19 at 2:11 PM, the Director of Nursing confirmed Resident #32 was admitted to hospital on [DATE], and returned to the facility on 8/16/2019.
On 11/14/19 at 10:56 AM, an interview with the Administrator revealed the facility did not provide a written bedhold notice to the resident and/or resident representative for Resident #32's hospital transfer/admission, on 8/14/19.
Resident #69
Review of the medical record revealed Resident #69 was transferred to the hospital on 9/13/2019, and was re-admitted to the Nursing home on 9/14/2019. There was no evidence in chart of notification to the resident and/or resident representative, in writing, of the bed hold agreement.
During an interview, on 11/13/19 at 4:14 PM, the Staff Development Nurse revealed they could not find the bed hold authorizations/notifications for Resident #69's hospital transfer on 9/13/19.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • 37% turnover. Below Mississippi's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), Payment denial on record. Review inspection reports carefully.
- • 19 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (41/100). Below average facility with significant concerns.
Bottom line: Trust Score of 41/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Diversicare Of Moss Point's CMS Rating?
CMS assigns DIVERSICARE OF MOSS POINT an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Mississippi, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Diversicare Of Moss Point Staffed?
CMS rates DIVERSICARE OF MOSS POINT's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 37%, compared to the Mississippi average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Diversicare Of Moss Point?
State health inspectors documented 19 deficiencies at DIVERSICARE OF MOSS POINT during 2019 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 18 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Diversicare Of Moss Point?
DIVERSICARE OF MOSS POINT is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by DIVERSICARE HEALTHCARE, a chain that manages multiple nursing homes. With 160 certified beds and approximately 99 residents (about 62% occupancy), it is a mid-sized facility located in MOSS POINT, Mississippi.
How Does Diversicare Of Moss Point Compare to Other Mississippi Nursing Homes?
Compared to the 100 nursing homes in Mississippi, DIVERSICARE OF MOSS POINT's overall rating (2 stars) is below the state average of 2.6, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Diversicare Of Moss Point?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Diversicare Of Moss Point Safe?
Based on CMS inspection data, DIVERSICARE OF MOSS POINT has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Mississippi. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Diversicare Of Moss Point Stick Around?
DIVERSICARE OF MOSS POINT has a staff turnover rate of 37%, which is about average for Mississippi nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Diversicare Of Moss Point Ever Fined?
DIVERSICARE OF MOSS POINT has been fined $9,318 across 1 penalty action. This is below the Mississippi average of $33,172. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Diversicare Of Moss Point on Any Federal Watch List?
DIVERSICARE OF MOSS POINT is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.