Diversicare of Southaven

    1730 Dorchester Dr, Southaven, MS 38671
    • Assisted Living
    • Memory Care
    • Skilled Nursing

    Compassionate care with excellent therapy

    I've been very satisfied with this Southaven facility - the staff are caring and professional, nurses and NP are excellent, therapy/rehab is effective, meals are good, and communication and activities (weekly trips, Sunday church, fenced courtyard) keep my loved one engaged. After years here, I feel they provide excellent, compassionate care and I would strongly recommend them.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    2.19·(68)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      1.8
    • Staff

      2.2
    • Meals

      2.1
    • Amenities

      2.6
    • Value

      1.6

    Pros

    • Compassionate and dedicated caregiving staff
    • Accessible and communicative nursing on some shifts
    • Successful short-term rehabilitation outcomes for many residents
    • Organized outings and on-site religious services
    • Engaging daily activities and social interaction opportunities
    • Outdoor courtyard and secure exterior spaces
    • Family-oriented communication and updates when provided
    • Ongoing facility renovations and maintenance efforts
    • Pleasant dining experiences reported by some families

    Cons

    • Inconsistent staffing levels and high staff turnover
    • Gaps in medication administration and clinical oversight
    • Sanitation and odor concerns in rooms and common areas
    • Delays in emergency response and call-button responsiveness
    • Unreliable meal-service continuity and limited therapeutic diets
    • Mishandling and poor tracking of resident belongings and documents
    • Inadequate care coordination and delayed family communication
    • Weak transfer-safety and fall-prevention practices
    • Insufficient dementia-specific training and limited night staffing
    • Administrative instability and resource-driven operational constraints

    Summary of reviews

    Reviews for Diversicare of Southaven present a mixed picture. Many families praise individual caregivers and some clinical staff as compassionate, attentive, and capable of producing good rehabilitative outcomes. Several accounts describe effective short-term therapy, helpful hour-by-hour rehabilitation support, organized social programming (including outings and Sunday services), and a pleasant outdoor courtyard that contributes positively to residents' quality of life. Ongoing renovation work is noted, and some visitors and relatives reported favorable impressions of the facility environment when those areas were maintained.

    At the same time, a substantial portion of feedback identifies recurring operational weaknesses. Staffing instability and periods of short staffing are frequent themes; reviewers reported high turnover among administrators and nursing leadership, reduced staff presence overnight, and stretched nurse-to-patient ratios. These workforce constraints are linked in multiple accounts to lapses in clinical care, including delayed or missed medication administration, abrupt medication changes without clear family communication, and inconsistent wound and personal-care practices. Several families also described hospital readmissions and serious clinical events that prompted additional concern about clinical oversight and escalation procedures.

    Hygiene and environmental maintenance emerged as another pattern. Multiple reviewers raised sanitation concerns, odor concerns in hallways and rooms, inconsistent linen and laundry handling, and housekeeping variability. These issues were often tied to staffing capacity and supervision. Related to operations, there are repeated accounts of difficulties with belongings and documentation management — missing or delayed personal items, and problems retrieving or tracking resident paperwork — which has eroded family trust in the facility's administrative processes.

    Dining and therapeutic nutrition appear inconsistent: some families praised meals and responsive dining staff, while many others reported cold meals, small portions, and inadequate provision of diet-specific menus (for example, limited diabetic or low-sodium options). Activity programming and social engagement receive mostly positive comments, though participation levels vary by resident and some families felt their loved ones were not encouraged to engage.

    Communication and leadership responsiveness are mixed. When staff communicate proactively, families report better experiences; conversely, delayed updates, limited case-management follow-through, and inconsistent incident reporting were cited as significant concerns. Several reviewers urged stronger dementia-care training and improvements to nighttime staffing to better support residents with cognitive impairment. A subset of reviews referenced infection-control and end-of-life care concerns that prompted calls for regulatory attention; these descriptions increased family distress and contributed to calls for improved oversight.

    In summary, prospective residents and families should weigh the facility's strengths in individualized caregiving, active programming, and some successful rehabilitation outcomes against recurrent operational challenges: inconsistent staffing, gaps in clinical and medication management, sanitation and laundry issues, dining variability, and administrative lapses in property/document handling. Visiting in person, asking for current staffing ratios and turnover data, reviewing care plans for medication and wound management, and clarifying policies for belongings and incident communication are recommended steps for families considering this facility.

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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

    Map showing location of Diversicare of Southaven

    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 numbernh-255109
    Facility typeNursing Home
    Special certificationMedicaid/Medicare – Dually certified

    Inspection Reports

    113

    Reports

    27

    Type A Citations

    0

    Type B Citations

    70

    Complaints

    6

    Years

    01 Jun 2026Revisit
    Determined that compliance was restored after corrective actions were implemented.
    01 Jun 2026Revisit
    Verified corrective actions were implemented and compliance was restored after a follow-up visit.
    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
    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
    Found no deficiencies related to life safety code or emergency preparedness. Compliance with applicable requirements was confirmed.
    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
    Investigated a complaint and found no deficiencies.
    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
    Confirmed compliance was restored after issues were addressed.
    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 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 Aug 2025Complaint
    Found no deficiencies during the complaint investigation.
    01 Aug 2025Complaint
    Found no deficiencies identified during the complaint investigation and survey.
    01 Apr 2025Revisit
    Verified corrective actions were implemented to address prior deficiencies and recommended placing back in compliance.
    01 Apr 2025Revisit
    Confirmed compliance after corrective actions were implemented and recommended restoration of participation.
    01 Apr 2025Revisit
    Concluded corrective actions restored compliance with the standards; recommended placing back in compliance.
    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
    Verified compliance with Medicare and Medicaid participation after issues were addressed; recommended return to compliance.
    01 Apr 2025Revisit
    Verified corrective actions were implemented and compliance restored as of 2025-04-16.
    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 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
    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
    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.
    • 483.10(e)(3)Reasonable Accommodations Needs/Preferences
    • 483.10(i)Safe Environment
    • 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
    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 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
    Found no deficiencies in emergency preparedness.
    01 Mar 2025Inspection
    Found no deficiencies cited. Compliance with applicable Life Safety Code provisions was documented.
    01 Mar 2025Inspection
    Found no deficiencies.
    01 Nov 2024Complaint
    Investigated complaints found no deficiencies.
    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
    Investigated a verbal abuse allegation and found no deficiencies related to the allegation.
    01 Sept 2024Complaint
    Investigated a complaint and found no deficiencies related to verbal abuse allegations.
    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
    Investigated two complaints; found no deficiencies from those complaints. However, the agency found ongoing noncompliance due to deficiencies cited in earlier surveys.
    01 May 2024Complaint
    Determined compliance with Medicare/Medicaid participation after a follow-up review.
    01 May 2024Complaint
    Investigated complaints and found no deficiencies.
    01 May 2024Complaint
    Investigated and noted ongoing noncompliance from earlier surveys despite no deficiencies identified in the complaint investigations.
    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
    Investigated two complaints and found no deficiencies in those investigations, but noted ongoing noncompliance due to deficiencies identified in prior surveys.
    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 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 Mar 2024Complaint
    Investigated a complaint and found multiple deficiencies across resident rights, environment, care planning, daily ADL care, staffing, and call systems.
    • CFR 483.10Resident Rights/Exercise of Rights
    • CFR 483.10(i)Safe/Clean/Comfortable/Homelike Environment
    • 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
    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
    Determined in compliance after follow-up and placed back in compliance effective 2024-06-03. No violations were cited.
    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
    Concluded the facility was placed back in compliance with the Life Safety Code as of December 13, 2023.
    01 Dec 2023Revisit
    Concluded that the facility was back in compliance and no deficiencies were cited.
    01 Dec 2023Revisit
    Verified continued compliance with Medicare/Medicaid participation and found no additional deficiencies during follow-up.
    01 Dec 2023Revisit
    Found no deficiencies; compliance was restored after a follow-up review.
    01 Dec 2023Revisit
    Verified compliance with emergency preparedness requirements; no deficiencies cited.
    01 Nov 2023Complaint
    Observed failures in care planning and ADL support, plus unsafe environmental conditions, during a survey.
    • §483.21(b)(1) and §483.21(b)(3)Develop/Implement Comprehensive Care Plan
    • §483.24(a)(2)ADL Care Provided for Dependent Residents
    • §483.90(i)Safe/Functional/Sanitary/Comfortable Environment
    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 2023Inspection
    Found multiple deficiencies across resident rights, care planning, diabetes management, mobility devices, oxygen safety, infection control, and food service.
    • CFR 483.10(e)(3)Reasonable Accommodations Needs/Preferences
    • CFR 483.10(g)(14)-(15)Notify of Changes
    • CFR 483.21(b)(1)Comprehensive Care Plans
    • CFR 483.21(b)(1)Comprehensive Care Plans
    • CFR 483.21(b)(1)(3)Comprehensive Care Plans
    • CFR 483.21(b)(1)Comprehensive Care Plans
    • CFR 483.25(c)(1)-(3)Mobility
    • CFR 483.25(d)(1)-(2)Accidents
    • CFR 483.60(i)(1)-(2)Food Safety
    • CFR 483.80(a)(1)-(2)(4)(e)(f); 483.80(e)Infection Prevention & Control
    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 2023Infection Control
    Determined incomplete COVID-19 reporting for a seven-day period.
    • CFR 483.80(g)(1)-(ix)(2)COVID-19 reporting
    01 Oct 2023Inspection
    Identified that the fire alarm system was not properly maintained, potentially affecting all residents.
    • NFPA 72 Chapter 10; NFPA 101 Section 9.6NFPA 101 Fire Alarm System- Installation
    01 Oct 2023Inspection
    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
    Found no deficiencies related to emergency preparedness. Confirmed compliance with all applicable emergency preparedness requirements.
    01 Aug 2023Infection Control
    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 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.
    • CFR 483.80(g); 483.80(g)(1)(i)-(ix)(2)COVID-19 reporting
    01 Jun 2023Complaint
    Found no deficiencies identified during the complaint investigations. The agency determined compliance with Medicare and Medicaid participation requirements.
    01 Jun 2023Complaint
    Investigated a complaint; found no deficiencies cited.
    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
    Found no deficiencies cited after a complaint investigation. The review covered allegations of pressure sores, neglect and accidents.
    01 Feb 2023Revisit
    Concluded that corrective actions placed the provider back in compliance with Medicare and Medicaid participation requirements.
    01 Feb 2023Revisit
    Verified no deficiencies were found after reviewing the complaint information; the information indicated compliance with minimum standards.
    01 Jan 2023Complaint
    Found no deficiencies. The complaint investigation concluded compliance with applicable Mississippi regulations.
    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
    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.
    • CFR 483.10(i)Safe/Clean/Comfortable/Homelike Environment
    01 Dec 2022Complaint
    Found no deficiencies cited after the complaint survey; the review determined compliance with applicable regulations.
    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
    Found no deficiencies.
    01 Nov 2022Complaint
    Found no deficiencies.
    01 Sept 2022Revisit
    Determined the provider was back in compliance after a desk review; no deficiencies cited.
    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
    Investigated and found no deficiencies; recommended placing back in compliance.
    01 Sept 2022Revisit
    Determined that compliance had been achieved and recommended placing the facility back in compliance.
    01 Aug 2022Complaint
    Investigated the complaint. Found no deficiencies related to neglect or abuse, but noted ongoing deficiencies from a prior survey.
    01 Aug 2022Complaint
    Investigated the complaint and found no deficiencies. It remained out of compliance due to deficiencies cited on a prior survey.
    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 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
    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.
    • §483.10(i)Safe/Clean/Comfortable/Homelike Environment
    • §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 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 Mar 2022Complaint
    Investigated allegations of abuse and found no deficiencies.
    01 Mar 2022Complaint
    Investigated the complaint and found no deficiencies cited for alleged abuse.
    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 2021Complaint
    Investigated complaints and found no deficiencies cited.
    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 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
    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
    Investigated complaints and found no deficiencies.
    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
    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 2021Complaint
    Found no deficiencies. The focused COVID-19 emergency preparedness survey determined compliance with requirements.
    01 Feb 2021Infection Control
    Found no deficiencies.
    01 Feb 2021Complaint
    Found no deficiencies. Investigations into complaints were not substantiated for quality of care or for pressure areas.
    01 Jan 2021Infection Control
    Confirmed compliance with infection control requirements during a COVID-19 focused review; no deficiencies were identified.
    01 Jan 2021Infection Control
    Found no deficiencies.
    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
    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 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 2020Infection Control
    Investigated a COVID-19 focused emergency preparedness assessment and found no deficiencies. Compliance with required emergency preparedness standards was confirmed.
    01 Nov 2020Infection Control
    Found no deficiencies during the focused infection control review.
    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 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
    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 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
    Verified compliance with COVID-19 infection control requirements; no deficiencies identified.
    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 Mar 2020Complaint
    Found a violation of residents' rights due to staff physical abuse toward a resident.
    • 45.17.2Residents' Rights
    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(i)Safe Environment / Clean, homelike environment
    • 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
    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
    Investigated four complaints and found no deficiencies in quality of care or pressure areas.

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