Active social programming (field trips, Sunday church)
Accessible outdoor courtyard and outdoor access
Ongoing facility renovations and maintenance
Successful short-term rehabilitation outcomes
Engaging physical and occupational therapy services
Individual staff who go above-and-beyond
On-site dining service with prepared meals
Experience with long-term memory care
Approachable nursing practitioners and select clinicians
Cons
Inconsistent staffing levels and inadequate night coverage
Gaps in medication administration and medication continuity
Inconsistent cleanliness and sanitation practices
Unreliable call-response and emergency-alert responsiveness
Poor communication and care-coordination processes
Unreliable dietary accommodations and meal consistency
Weak personal-care and hygiene protocols
Lax belongings and documentation controls
Inconsistent therapy scheduling and rehabilitation continuity
High staff turnover and leadership instability
Odor concerns in some common areas
Safety and transfer-practice weaknesses
Insufficient post-discharge coordination with home health
Regulatory scrutiny and allegations of serious incidents
Summary of reviews
The reviews present a mixed picture: many families praise individual caregivers and certain clinical staff for compassion, hands-on rehabilitation success, and strong family communication, while a substantial number of accounts describe operational weaknesses that have affected care continuity and safety. Positive descriptions emphasize staff who are attentive, proactive with family updates, and able to deliver effective short-term rehab; the facility offers regular activities (including outings and church services), an accessible outdoor courtyard, and ongoing renovation efforts intended to improve the environment.
Care and staffing: There is evidence of dedicated staff members and clinicians who provide attentive, recovery-focused care for some residents, and a subset of reviewers described significant rehab progress and positive long-term memory-care experiences. At the same time, persistent concerns center on inconsistent staffing levels—especially overnight—and high nursing workloads that limit time at bedside. Several families described delayed responses to call lights or emergency alerts and uneven personal-care delivery (including inconsistent bathing, linen changes, and skin-care practices). These patterns suggest variable caregiver availability and situations where staffing constraints can affect day-to-day resident support.
Clinical management and safety: Reviews raise important clinical concerns about medication management, medication-timing errors, and breaks in medication continuity; these issues are tied to hospital readmissions or acute clinical deterioration in some accounts. There are also reports of safety and transfer-practice weaknesses (including difficulties with safe transfer equipment and timed assistance), and feeding-related safety events noted by families. A number of reviews referenced serious outcomes and concerns following a resident's death; that feedback indicates the need for careful clinical review, clearer incident documentation, and transparent family communication.
Dining, therapy, and activities: Experiences with meals are mixed. Some families praised prepared meals and accommodating staff, while others noted inconsistent portioning, lack of tailored dietary options (for example, limited diabetic or low-sodium choices), and cold food delivery to rooms. Therapy services receive both praise for hands-on, hour-by-hour rehab assistance and criticism for inconsistent scheduling or early termination of services. Activity programming (outings, church, courtyard access) is a clear strength when residents participate and staff support engagement.
Facilities and logistics: The facility is undergoing renovations that some families find positive and minimally disruptive, and the outdoor courtyard is valued. However, multiple reviews describe cleanliness and sanitation concerns in certain areas, odor issues in common spaces, problems with laundry timeliness, and maintenance gaps such as inconsistent climate control. There are also recurring complaints about belongings management and document security, indicating weaknesses in inventory controls and discharge procedures.
Management and patterns: Reviewers describe a combination of caring frontline staff and broader operational challenges tied to staffing levels, turnover, and administrative instability. Several accounts cite leadership turnover and state-level scrutiny or investigation, which contributes to family unease. Families recommend close review of medication processes, staffing models (particularly night coverage), hygiene and linen protocols, incident documentation, and post-discharge coordination.
Bottom line: Prospective residents and families should weigh the presence of committed caregiving staff, active programming, and some successful rehab cases against consistent patterns of operational risk: variable staffing, medication and safety process gaps, uneven cleanliness, and communication shortfalls. Those considering this facility may want to ask for current staffing ratios, medication-safety audits, recent inspection outcomes, examples of care-coordination at discharge, and a tour of renovated areas to assess how the facility is addressing the documented concerns.
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Medicare Ratings
1·/ 5
Overall
Health Inspection
Staffing
Quality Measures
Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov
Location
Diversicare of Southaven is located at 1730 Dorchester Dr, Southaven, MS, 38671.
About Diversicare of Southaven
Diversicare of Southaven is a Skilled Nursing Facility at 1730 Dorchester Drive in Southaven, Mississippi, and it has 140 beds for residents who need different levels of care, so there are people there who might need long-term care, short-term rehab after surgery or illness, or even more advanced help like hospice care, memory care, or assisted living. The staff have training in helping those with mobility and memory problems, and they support people who have trouble with daily activities or face cognitive challenges. There are physical, occupational, respiratory, and speech therapies on site, and they try to help residents gain back their strength and skills when they can, which can mean working on moving, speaking, or doing basic tasks again. Residents have personal care plans so their needs get attention, and there's a large team to guide them with medical care and daily support. Some programs provide support for emotional needs, too, and there's an effort to help everyone feel comfortable, connected, and respected. Even though their office hours aren't posted and not all details about services are public, the center aims for a warm, home-like setting with cozy rooms and group activities, and they keep up with updating their information so families know what's current, but they're not accepting new patients right now. The facility falls under the Mississippi Health Care Association and holds accreditation, and while many staff may speak more than one language, there aren't details about which. Overall, Diversicare of Southaven blends healthcare with a focus on dignity and everyday living for seniors needing different types of care.
People often ask...
Diversicare of Southaven offers assisted living, memory care, and skilled nursing.
There are 1 photos of Diversicare of Southaven on Mirador.
The full address for this community is 1730 Dorchester Dr, Southaven, MS 38671.
No, Diversicare of Southaven does not offer respite care.
Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.
Safety & Compliance
In Mississippi, the State Department of Health licenses care facilities and publishes the survey, complaint, and infection-control reports from its inspections.
License number
nh-255109
Facility type
Nursing Home
Special certification
Medicaid/Medicare – Dually certified
Inspection Reports
115
Reports
27
Type A Citations
0
Type B Citations
72
Complaints
6
Years
01 Oct 2026Complaint
01 Oct 2026Complaint
Determined that residents were not treated with dignity and respect when a staff member blocked a resident from leaving for a smoking break with a plastic box.
45.17.2Residents' Rights
01 Oct 2026Complaint
01 Oct 2026Complaint
Cited a violation of resident rights where a staff member blocked a resident from exiting for a smoking break using a plastic box, denying dignity and respect.
42 CFR 483.10Resident Rights/Exercise of Rights
01 Jun 2026Revisit
01 Jun 2026Revisit
Verified corrective actions were implemented and compliance was restored after a follow-up visit.
01 Jun 2026Revisit
01 Jun 2026Revisit
Determined that compliance was restored after corrective actions were implemented.
01 Apr 2026Inspection
01 Apr 2026Inspection
Identified multiple deficiencies across care planning, pain management, infection control, ADL support, privacy, tube feeding, oxygen administration, and environmental safety.
Type A§483.21(b)(1)Comprehensive Care Plans
Type A§483.25(k)Pain Management
Type A§483.10(a)-(b)Resident Rights/Exercise of Rights
Type A§483.10(e)(3)Reasonable Accommodations Needs/Preferences
Type A§483.10(i)Safe Environment
Type A§483.24(a)(2)ADL Care Provided for Dependent Residents
Type A§483.25(g)(4)-(5)Tube Feeding Mgmt/Restore Eating Skills
Type A§483.25(i)Respiratory Care and Suctioning
Type A§483.80Infection Prevention & Control
01 Apr 2026Inspection
01 Apr 2026Inspection
Identified multiple deficiencies in resident privacy, ADL support, PEG tube care, oxygen management, infection control, shower safety, and waste handling during the survey.
45.17.2 Residents' RightsResidents' Rights
45.21.2 Activities of daily livingActivities of daily living
45.21.7 Gastric feedingGastric feeding
45.21.11 Special needsSpecial needs
45.34.3 Medical Waste Management PlanMedical Waste Management Plan
45.35.2 Bathtubs, Showers, and LavatoriesBathtubs, Showers, and Lavatories
48.58.1 Infection ControlInfection Control
01 Apr 2026Inspection
01 Apr 2026Inspection
Found no deficiencies related to life safety code or emergency preparedness. Compliance with applicable requirements was confirmed.
01 Mar 2026Revisit
01 Mar 2026Revisit
Verified corrective actions were implemented to address the deficiency and recommended that compliance be reinstated as of 2026-03-06.
01 Mar 2026Complaint
01 Mar 2026Complaint
Investigated a complaint and found no deficiencies.
01 Mar 2026Complaint
01 Mar 2026Complaint
Determined that no deficiencies were cited after the complaint investigation. The survey occurred on 2026-03-17 with a census of 139.
01 Mar 2026Revisit
01 Mar 2026Revisit
Confirmed compliance was restored after issues were addressed.
01 Feb 2026Complaint
01 Feb 2026Complaint
Investigated a wandering/elopement incident where a resident at risk exited without staff supervision. Found inadequate supervision and elopement precautions that placed residents at risk.
45.21.8Accidents
01 Feb 2026Complaint
01 Feb 2026Complaint
Investigated elopement attributed to inadequate supervision and found medication administration errors for a resident.
42 CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
42 CFR 483.45(f)(2)Residents are Free of Medication Errors
01 Aug 2025Complaint
01 Aug 2025Complaint
Found no deficiencies during the complaint investigation.
01 Aug 2025Complaint
01 Aug 2025Complaint
Found no deficiencies identified during the complaint investigation and survey.
01 Apr 2025Revisit
01 Apr 2025Revisit
Verified corrective actions were implemented to address prior deficiencies and recommended placing back in compliance.
01 Apr 2025Revisit
01 Apr 2025Revisit
Confirmed compliance after corrective actions were implemented and recommended restoration of participation.
01 Apr 2025Revisit
01 Apr 2025Revisit
Concluded corrective actions restored compliance with the standards; recommended placing back in compliance.
01 Apr 2025Revisit
01 Apr 2025Revisit
Determined that corrective actions were in place and compliance was restored for the earlier findings. The revisit confirmed correction as of mid-April 2025.
01 Apr 2025Revisit
01 Apr 2025Revisit
Verified compliance with Medicare and Medicaid participation after issues were addressed; recommended return to compliance.
01 Apr 2025Revisit
01 Apr 2025Revisit
Verified corrective actions were implemented and compliance restored as of 2025-04-16.
01 Mar 2025Complaint
01 Mar 2025Complaint
Investigated several complaints and found violations related to residents' rights, daily living assistance, hydration monitoring, and unsafe environmental conditions, including inaccessible call lights and unaddressed room repairs.
Type A45.17.2 Residents' RightsResidents' Rights
Type A45.21.2 Activities of daily livingActivities of daily living
Type A45.21.10 HydrationHydration
Type A45.31.3 Screens and Outside OpeningsScreens and Outside Openings
Type A45.35.1 Housekeeping Facilities and ServicesHousekeeping Facilities and Services
Type A45.40.7 Walls and CeilingsWalls and Ceilings
01 Mar 2025Complaint
01 Mar 2025Complaint
Investigated a complaint regarding a resident transfer injury and found failures to follow transfer Kardex guidance and proper lifting procedures, resulting in a fracture; deficiencies identified related to abuse/neglect and care planning.
CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
CFR 483.21(b)(1)(3)Comprehensive Care Plans
01 Mar 2025Inspection
01 Mar 2025Inspection
Investigated numerous deficiencies across resident rights, environment, care planning, ADL assistance, infection control, medication handling, and pest control, affecting multiple residents.
Type ACFR 483.10(e)(3)Reasonable Accommodations Needs/Preferences
Type ACFR 483.10(h)Personal Privacy/Confidentiality of Records
Type ACFR 483.10(i)Safe Environment
Type ACFR 483.21(b)Develop/Implement Comprehensive Care Plan
Type ACFR 483.24(a)(2)ADL Care Provided for Dependent Residents
Type ACFR 483.25(d)Safe/Accident Hazards/Supervision/Devices
Type ACFR 483.25(g)Hydration/Nutrition
Type ACFR 483.45(h)Label/Store Drugs and Biologicals
Type ACFR 483.20(f)(5), 483.70(h)Resident Records - Identifiable Information
Type ACFR 483.70(p)Payroll-Based Journal (PBJ) Submission
Type ACFR 483.80Infection Control
Type ACFR 483.90Pest Control
01 Mar 2025Complaint
01 Mar 2025Complaint
Investigated a complaint and found neglect related to transfer procedures and Kardex adherence, resulting in a resident sustaining a fracture after a transfer.
45.17.2Residents' Rights
01 Mar 2025Complaint
01 Mar 2025Complaint
Identified multiple deficiencies related to resident care, environment, and hydration management, including inaccessible call lights, unsafe room conditions, incomplete care plans, and inadequate ADL support.
483.21(b)Develop/Implement Comprehensive Care Plan
483.24(a)(2)ADL Care Provided for Dependent Residents
483.25(g)Nutrition/Hydration Status Maintenance
01 Mar 2025Inspection
01 Mar 2025Inspection
Investigated multiple deficiencies related to residents' rights, daily living assistance, hydration, safety, infection control, and environmental care, with several care and facility practices found deficient.
45.17.2Residents' Rights
45.21.2Activities of daily living
45.21.8Accidents
45.21.10Hydration
45.24.2Policies and procedures
45.31.3Screens and Outside Openings
45.33.4Control of insects, rodents, etc.
45.40.7Walls and Ceilings
45.40.7Walls and Ceilings
48.58.1Infection Control
01 Mar 2025Inspection
01 Mar 2025Inspection
Found no deficiencies.
01 Mar 2025Inspection
01 Mar 2025Inspection
Found no deficiencies cited. Compliance with applicable Life Safety Code provisions was documented.
01 Mar 2025Inspection
01 Mar 2025Inspection
Found no deficiencies in emergency preparedness.
01 Nov 2024Complaint
01 Nov 2024Complaint
Investigated complaints found no deficiencies.
01 Nov 2024Complaint
01 Nov 2024Complaint
Found no deficiencies. Investigated complaints related to dietary services, funds misappropriation, quality of care, administration, environment, falls, and nursing services.
01 Sept 2024Complaint
01 Sept 2024Complaint
Investigated a complaint and found no deficiencies related to verbal abuse allegations.
01 Sept 2024Complaint
01 Sept 2024Complaint
Investigated a verbal abuse allegation and found no deficiencies related to the allegation.
01 May 2024Complaint
01 May 2024Complaint
Investigated and found a failure to change a prescribed NPWT dressing for a resident, resulting in the dressing remaining on the wound and foam fragments adhering to the wound bed, with improper documentation.
CFR 483.25Quality of care
01 May 2024Complaint
01 May 2024Complaint
Investigated and noted ongoing noncompliance from earlier surveys despite no deficiencies identified in the complaint investigations.
01 May 2024Complaint
01 May 2024Complaint
Investigated complaints and found no deficiencies.
01 May 2024Complaint
01 May 2024Complaint
Determined compliance with Medicare/Medicaid participation after a follow-up review.
01 May 2024Complaint
01 May 2024Complaint
Investigated two complaints; found no deficiencies from those complaints. However, the agency found ongoing noncompliance due to deficiencies cited in earlier surveys.
01 Apr 2024Complaint
01 Apr 2024Complaint
Investigated two complaint investigations and found no deficiencies in the complaint process. Noted ongoing noncompliance due to deficiencies cited in earlier surveys.
01 Apr 2024Complaint
01 Apr 2024Complaint
Investigated two complaints and found no deficiencies in those investigations, but noted ongoing noncompliance due to deficiencies identified in prior surveys.
01 Apr 2024Complaint
01 Apr 2024Complaint
Concluded no deficiencies were cited on this review, but deficiencies from a March 2024 survey left the operation out of compliance.
01 Apr 2024Complaint
01 Apr 2024Complaint
Investigated two complaints and found no deficiencies related to the allegations. Concluded the provider remained out of compliance due to deficiencies cited on the 3/20/2024 survey.
01 Mar 2024Complaint
01 Mar 2024Complaint
Investigated a complaint and found multiple deficiencies across resident rights, environment, care planning, daily ADL care, staffing, and call systems.
CFR 483.21(b)Develop/Implement Comprehensive Care Plan
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
CFR 483.35(a)(1)-(2)Sufficient Nursing Staff
CFR 483.90(g)Resident Call System
01 Mar 2024Complaint
01 Mar 2024Complaint
Investigated seven complaints and identified multiple deficiencies in staffing, resident rights, ADL care, call systems, and facility conditions.
45.4.1Nursing Facility Staffing
45.17.2Residents' Rights
45.21.2Activities of Daily Living
45.40.6Floors
45.40.11Call System
01 Mar 2024Revisit
01 Mar 2024Revisit
Determined in compliance after follow-up and placed back in compliance effective 2024-06-03. No violations were cited.
01 Mar 2024Revisit
01 Mar 2024Revisit
Determined that compliance with Medicare/Medicaid participation requirements was achieved on follow-up, and recommended return to compliance effective 2024-06-03.
01 Dec 2023Revisit
01 Dec 2023Revisit
Concluded that the facility was back in compliance and no deficiencies were cited.
01 Dec 2023Revisit
01 Dec 2023Revisit
Concluded the facility was placed back in compliance with the Life Safety Code as of December 13, 2023.
01 Dec 2023Revisit
01 Dec 2023Revisit
Verified continued compliance with Medicare/Medicaid participation and found no additional deficiencies during follow-up.
01 Dec 2023Revisit
01 Dec 2023Revisit
Found no deficiencies; compliance was restored after a follow-up review.
01 Dec 2023Revisit
01 Dec 2023Revisit
Verified compliance with emergency preparedness requirements; no deficiencies cited.
01 Nov 2023Inspection
01 Nov 2023Inspection
Regulators identified deficiencies in ROM management, kitchen operations, and infection control, leading to cited violations.
45.21.5Range of motion
45.32.2Kitchen
48.58.1Infection Control
01 Nov 2023Complaint
01 Nov 2023Complaint
Identified deficiencies in activities of daily living care, specifically shaving, for some residents. Staff did not consistently provide shaving per care plans.
45.21.2Activities of daily living
01 Nov 2023Inspection
01 Nov 2023Inspection
Found multiple deficiencies across resident rights, care planning, diabetes management, mobility devices, oxygen safety, infection control, and food service.
Found that the fire alarm system had a trouble signal and could not be reset.
NFPA 101 Fire Alarm System - Installation; NFPA 72; NFPA 70Fire Alarm System - Installation
01 Oct 2023Inspection
01 Oct 2023Inspection
Found no deficiencies related to emergency preparedness. Confirmed compliance with all applicable emergency preparedness requirements.
01 Aug 2023Infection Control
01 Aug 2023Infection Control
Investigated COVID-19 reporting to NHSN and found incomplete information during a seven-day period; CMS data showed missing and incomplete COVID-19 data.
Identified a failure to report complete COVID-19 information to NHSN during a required weekly period, potentially affecting resident safety.
CFR 483.80(g)(1)(i)-(ix)(2); §483.80(g)Reporting - National Health Safety Network
01 Jun 2023Complaint
01 Jun 2023Complaint
Investigated a complaint; found no deficiencies cited.
01 Jun 2023Complaint
01 Jun 2023Complaint
Found no deficiencies identified during the complaint investigations. The agency determined compliance with Medicare and Medicaid participation requirements.
01 May 2023Complaint
01 May 2023Complaint
Found no deficiencies after investigating a complaint and performing the site visit. The investigation concluded compliance with applicable regulations.
01 May 2023Complaint
01 May 2023Complaint
Found no deficiencies cited after a complaint investigation. The review covered allegations of pressure sores, neglect and accidents.
01 Feb 2023Revisit
01 Feb 2023Revisit
Verified no deficiencies were found after reviewing the complaint information; the information indicated compliance with minimum standards.
01 Feb 2023Revisit
01 Feb 2023Revisit
Concluded that corrective actions placed the provider back in compliance with Medicare and Medicaid participation requirements.
01 Jan 2023Complaint
01 Jan 2023Complaint
Found no deficiencies. The complaint investigation concluded compliance with applicable Mississippi regulations.
01 Jan 2023Complaint
01 Jan 2023Complaint
Investigated a complaint; found no deficiencies in this assessment, but ongoing noncompliance remains due to deficiencies cited in a prior complaint.
01 Dec 2022Complaint
01 Dec 2022Complaint
Investigated a complaint about the environment and found pink and black residues in toilets and around a bathtub drain in multiple bathrooms, indicating unsanitary conditions.
Found no deficiencies cited after the complaint survey; the review determined compliance with applicable regulations.
01 Dec 2022Revisit
01 Dec 2022Revisit
Verified no additional deficiencies were cited during the follow-up survey. Compliance was restored for participation with a census of 131 of 140.
01 Nov 2022Complaint
01 Nov 2022Complaint
Found no deficiencies.
01 Nov 2022Complaint
01 Nov 2022Complaint
Found no deficiencies.
01 Sept 2022Revisit
01 Sept 2022Revisit
Determined that compliance had been achieved and recommended placing the facility back in compliance.
01 Sept 2022Revisit
01 Sept 2022Revisit
Investigated and found no deficiencies; recommended placing back in compliance.
01 Sept 2022Revisit
01 Sept 2022Revisit
Determined that compliance with Medicare/Medicaid participation was reinstated and recommended placing back in compliance effective 2022-09-09.
01 Sept 2022Revisit
01 Sept 2022Revisit
Determined the provider was back in compliance after a desk review; no deficiencies cited.
01 Aug 2022Complaint
01 Aug 2022Complaint
Investigated the complaint and found no deficiencies. It remained out of compliance due to deficiencies cited on a prior survey.
01 Aug 2022Complaint
01 Aug 2022Complaint
Investigated the complaint. Found no deficiencies related to neglect or abuse, but noted ongoing deficiencies from a prior survey.
01 Jul 2022Complaint
01 Jul 2022Complaint
Found multiple deficiencies: unsafe environment due to disrepair, delayed reporting of an elopement, inadequate nail care for a dependent resident, and a malfunctioning call system.
483.10(i)Safe Environment
483.12(c)(1)-(4)Reporting of Alleged Violations
483.24(a)(2)ADL Care Provided for Dependent Residents
483.90(g)(2)Resident Call System
01 Jul 2022Complaint
01 Jul 2022Complaint
Identified deficiencies in nail care for a resident, unsafe housekeeping conditions, and an inoperative nurse call system.
45.21.2Activities of daily living
45.35.1Housekeeping Facilities and Services
45.40.11Call System
01 Jul 2022Inspection
01 Jul 2022Inspection
The survey identified multiple deficiencies across resident safety, care planning, wound care, medication handling, and call systems, indicating failures to maintain a safe, compliant environment and adequate resident care.
§483.15(c)(3)-(6)(8)Notice Requirements Before Transfer/Discharge
§483.21(b)Develop/Implement Comprehensive Care Plan
§483.24(a)(2)ADL Care Provided for Dependent Residents
§483.25(b)(1)(i)(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
§483.45(g)(h)(1)(2)Label/Store Drugs and Biologicals
§483.90(g)(2)Resident Call System
01 Jul 2022Inspection
01 Jul 2022Inspection
Investigative findings identified multiple deficiencies: inadequate nail care for a resident, missing RN wound assessments, deteriorating facility environment, and an malfunctioning call system.
45.21.2Activities of daily living
45.21.3Pressure sores
45.35.1Housekeeping Facilities and Services
45.40.11Call System
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated allegations of abuse and found no deficiencies.
01 Mar 2022Complaint
01 Mar 2022Complaint
Investigated the complaint and found no deficiencies cited for alleged abuse.
01 Oct 2021Complaint
01 Oct 2021Complaint
Investigated a complaint and concluded the allegation of abuse, quality of care/treatment, and resident rights were unsubstantiated, with no deficiencies cited.
01 Oct 2021Revisit
01 Oct 2021Revisit
Concluded the provider was in compliance with Medicare/Medicaid participation after a follow-up review. Record reviews showed discharge summaries audits were completed, nursing staff in-services were completed, and discharge summaries were monitored for complete information.
01 Oct 2021Complaint
01 Oct 2021Complaint
Investigated complaints and found no deficiencies cited.
01 Oct 2021Revisit
01 Oct 2021Revisit
Determined back-to-compliance with Medicare/Medicaid participation after a follow-up review. Audits of discharge summaries for medication reconciliation and nursing staff in-services were completed, with ongoing monitoring for complete information.
01 Sept 2021Complaint
01 Sept 2021Complaint
Investigated a discharge medication reconciliation issue and found failures to reconcile discharge medications on three resident discharge summaries.
CFR 483.21(c)(2)Discharge Summary
01 Sept 2021Complaint
01 Sept 2021Complaint
Investigated complaints and found no deficiencies.
01 Feb 2021Complaint
01 Feb 2021Complaint
Investigated COVID-19 infection control practices; found improper mask use by two dietary staff in the kitchen.
CFR 483.80Infection control
01 Feb 2021Infection Control
01 Feb 2021Infection Control
Cited improper mask use by two dietary staff in the kitchen, raising risk of COVID-19 transmission.
§483.80 Infection ControlInfection Prevention & Control
01 Feb 2021Infection Control
01 Feb 2021Infection Control
Found no deficiencies.
01 Feb 2021Complaint
01 Feb 2021Complaint
Found no deficiencies. Investigations into complaints were not substantiated for quality of care or for pressure areas.
01 Feb 2021Complaint
01 Feb 2021Complaint
Found no deficiencies. The focused COVID-19 emergency preparedness survey determined compliance with requirements.
01 Jan 2021Infection Control
01 Jan 2021Infection Control
Found no deficiencies.
01 Jan 2021Infection Control
01 Jan 2021Infection Control
Confirmed compliance with infection control requirements during a COVID-19 focused review; no deficiencies were identified.
01 Nov 2020Revisit
01 Nov 2020Revisit
Investigated a COVID-19 infection control concern and found violations related to infection prevention, including two positive staff not quarantining and others not following masking and distancing guidelines.
42 CFR 483.80(a)(1)(2)(4)(e)(f)Infection Control
01 Nov 2020Revisit
01 Nov 2020Revisit
Found infection control deficiencies related to delays in notifying two COVID-positive employees and failure to follow masking and distancing guidelines, with an initial jeopardy identified and later removed.
42 CFR 483.80Infection Control
01 Nov 2020Revisit
01 Nov 2020Revisit
Identified noncompliance with infection control requirements related to COVID-19, including delayed notification of positive test results and improper PPE use, with an immediate jeopardy that was later removed.
42 CFR 483.80(a)(1)(2)(4)(e)(f)Infection control
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Found no deficiencies during the focused infection control review.
01 Nov 2020Infection Control
01 Nov 2020Infection Control
Investigated a COVID-19 focused emergency preparedness assessment and found no deficiencies. Compliance with required emergency preparedness standards was confirmed.
01 Aug 2020Infection Control
01 Aug 2020Infection Control
Found failures in infection control, including improper PPE use and delays in sharing COVID-19 test results, risking resident and staff safety.
42 CFR 483.80Infection Prevention & Control
01 Aug 2020Complaint
01 Aug 2020Complaint
Found infection control failures: improper use of PPE and delays in notifying staff of positive COVID-19 test results, creating exposure risk with an Immediate Jeopardy identified and later removed.
42 CFR 483.80Infection Prevention & Control
01 Aug 2020Infection Control
01 Aug 2020Infection Control
Identified infection control deficiencies during a COVID-19 focused inspection, including delayed notification of positive test results and failures to quarantine, plus improper masking and distancing by staff.
42 CFR 483.80(a)(1)(2)(4)(e)(f)Infection Control
01 Aug 2020Complaint
01 Aug 2020Complaint
Investigated COVID-19 infection control issues and found noncompliance, including delayed notification of positive test results and improper mask use and distancing.
42 CFR 483.80(a)(1)(2)(4)(e)(f) Infection Prevention and ControlInfection Prevention and Control
01 Jun 2020Infection Control
01 Jun 2020Infection Control
Verified compliance with COVID-19 infection control requirements; no deficiencies identified.
01 Mar 2020Complaint
01 Mar 2020Complaint
Found a violation of residents' rights due to staff physical abuse toward a resident.
45.17.2Residents' Rights
01 Mar 2020Complaint
01 Mar 2020Complaint
Investigated a complaint alleging abuse; found evidence of abuse and cited a deficiency for freedom from abuse and neglect; found no deficiencies related to quality of care.
CFR(s): 483.12(a)(1)Free from Abuse and Neglect
01 Feb 2020Inspection
01 Feb 2020Inspection
Investigated multiple deficiencies found in care, safety, and record-keeping, including unsafe environment conditions, improper use of restraints, inaccurate assessments, incomplete care plans, and issues with respiratory care and life safety.
CFR 483.10(e)Right to be free from physical restraints
CFR 483.20(g)Accuracy of Assessments
CFR 483.21(b)Comprehensive Care Plans
CFR 483.24(a)(2)ADL Care Provided for Dependent Residents
CFR 483.25(i)Respiratory care and related equipment
NFPA 101 / NFPA 72Fire Alarm System - Testing and Maintenance
NFPA 101 19.7.1.2Fire Drills
NFPA 110 / NFPA 70Electrical Systems - Generator testing and maintenance
01 Feb 2020Inspection
01 Feb 2020Inspection
Found deficiencies related to restraint evaluation, activities of daily living support, and nebulizer equipment care.
M190 45.2.33 RestraintRestraint
M610 45.21.2 Activities of daily livingActivities of daily living
M655 45.21.11 Special needsSpecial needs
01 Feb 2020Infection Control
01 Feb 2020Infection Control
Investigated four complaints and found no deficiencies in quality of care or pressure areas.
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