Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Diversicare Of Eupora during CMS and state inspections, most recent first.
An LPN repeatedly documented PRN opioid pain medications for multiple residents at identical, preset times during routine med passes, rather than based on individualized pain assessment and actual administration times. One cognitively intact resident with a history of stroke consistently denied pain and stated he did not take pain medication, while other staff confirmed he did not request analgesics; however, the LPN documented frequent Norco administration and high pain scores for him, and later admitted giving medication without his consent and falsely recording pain levels. Review of MARs and narcotic logs for 13 residents showed large clusters of PRN Norco and oxycodone entries at the same times across different rooms, and the LPN acknowledged that the records did not accurately reflect real administration times and that she sometimes entered pain scores without asking residents, contrary to facility policy and professional standards.
PRN opioid documentation was not accurately reviewed or identified by pharmacy services and nursing leadership. An LPN documented PRN Norco and oxycodone administrations for multiple residents at the same set times across many dates instead of recording real-time administration, and a controlled substance record showed frequent narcotic sign-outs by the same nurse. The consultant pharmacist had observed that the nurse did not check meds against the MAR before giving them and did not document immediately after administration, but no narcotic discrepancies were identified during monthly reviews.
Two cognitively intact residents experienced undignified care when staff failed to provide timely toileting assistance and used disrespectful communication. One resident, with multiple chronic conditions, reported that a CNA questioned her need to use the bathroom at night and later left her sitting on the toilet for about 30 minutes until she used the bathroom call light, after which the CNA stated she had to make her rounds. Another resident with cerebral palsy, incontinent and fully dependent on staff for toileting and hygiene, was found by a family member with the call light sounding, wet, and with three soiled, spaghetti-covered towels left on her chest from lunch; when a CNA entered, she removed the towels and told the resident she was "just showing out" because her sister was present. The DON and nursing staff interviews confirmed expectations that residents be treated with dignity and respect and receive timely toileting.
Dirty and rusted overbed tables were observed in three resident rooms, with a thick black substance on the metal bases that was readily visible upon entering the rooms. CNAs reported the tables appeared very rusty and in poor condition, one CNA had not noticed the issue or submitted a work order, and the DON stated the tables looked bad and did not represent a homelike environment. The Maintenance Supervisor said no work orders had been received and noted multiple overbed tables on the wing were rusted and in need of replacement.
Delayed Incontinent Care and ADL Assistance: A cognitively intact resident with cerebral palsy who was dependent on staff for toileting and personal hygiene was left wet and soiled for an extended period while the call light sounded. Family and staff reported the resident had a saturated brief, bowel movement, and wet bed sheets, and interviews confirmed incontinent rounds were not completed timely and the resident remained unchanged despite multiple staff contacts.
Unsafe possession and storage of smoking materials led to an accident hazard for three smokers. A cognitively intact resident with emphysema, AFib, and ASHD was observed with cigarettes and a lighter on a bedside table and chest of drawers, and two other residents were seen with cigarettes visible while seated near the exit door to the smoking area. The DON stated residents are not supposed to keep cigarettes or lighters on their person and that smoking materials should be kept in a locked box and issued at designated smoke times, while the Administrator acknowledged residents were observed with these items.
An unlocked and unattended medication cart was observed on B Wing, despite facility policy requiring medication carts to remain locked and secure when not in use. An LPN stated she got busy and forgot to lock the cart before charting, and the DON stated medication carts should never be left unlocked when not in use.
Infection control practices were not followed for two residents. One resident’s oxygen tubing was observed lying on the floor instead of being stored in the bag attached to the concentrator, despite manufacturer guidance and staff confirmation that this was an infection control concern. Another resident with exposed right ankle hardware and an open wound was on EBP, but during wound care the ADNS did not wear a gown as required for high-contact care activities.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff failed to immediately report an incident where an LPN used profanity and applied force to a resident. Two CNAs who witnessed the event delayed reporting, assuming others had done so, and another LPN did not recognize the behavior as abuse. The incident was reported to the State Agency but not to the Board of Nursing, contrary to policy, despite staff having received recent training on abuse reporting.
A resident with insulin-dependent diabetes and a diabetic foot ulcer was admitted without orders for insulin or wound care, despite repeatedly informing staff that her insulin had been discontinued in error and requesting provider notification. Nursing staff did not obtain clarification or new orders for insulin or wound care, and the resident self-administered insulin without assessment or documentation. Wound care was delayed and not documented until several days after admission, contrary to facility policy requiring prompt intervention and physician notification.
The facility failed to resolve grievances related to food quality and bed linen changes for several residents. Despite repeated complaints in resident council meetings, issues such as lack of food variety, poor taste, and infrequent linen changes were not addressed. The Administrator and Dietary Manager were aware of the complaints but did not document or follow up effectively, leading to ongoing resident dissatisfaction.
The facility failed to provide palatable, attractive, and appropriately heated meals to residents, leading to dissatisfaction among several residents. Complaints included cold, flavorless, and improperly cooked food, with limited meal options that did not meet dietary needs. Despite raising these issues with the Dietary Manager, the concerns remained unaddressed.
A resident with an overactive bladder and other medical conditions was denied assistance with toileting due to staff being occupied with meal tray distribution. Staff interviews revealed a misunderstanding of policy, believing they could not assist residents during mealtimes due to cross-contamination concerns. The DON acknowledged the resident's right to use the bathroom but needed to review the policy.
The facility failed to implement and develop care plans for three residents, resulting in deficiencies in their care. A resident's nail care was neglected, another resident did not have a care plan for necessary leg brace use due to communication failures, and a third resident lacked a care plan for Binge Eating Disorder after readmission. Staff interviews confirmed these oversights.
A resident with diabetes and moderate cognitive impairment did not receive necessary nail care, resulting in long nails that caused self-scratching. Facility staff acknowledged that diabetic nail care was not scheduled or documented, although it was expected to be performed as needed.
A facility failed to monitor a resident with a new diagnosis of Binge Eating Disorder. Despite the resident's frequent requests for snacks and taking food from carts, staff were unaware of the diagnosis. The Medication Administration Record lacked monitoring for this behavior, focusing on other issues. The DON confirmed the absence of monitoring, noting its importance for managing the resident's condition.
A facility failed to implement dietary recommendations for a resident receiving enteral nutrition via PEG tube. The RD's recommendations to adjust tube feeding and water flushes were not acted upon due to a communication lapse. The DON did not notice the recommendations in the email, and the LPN did not act on them without instruction. Consequently, the resident's nutritional needs were not met.
The facility inaccurately completed Section N of the MDS for two residents, leading to incorrect documentation of anticoagulant and antibiotic medications. One resident was documented as receiving anticoagulants but was on antiplatelet medication, while another was documented as receiving anticoagulants but was on antibiotics. These errors were confirmed by the MDS Coordinator and attributed to a remote MDS worker.
A resident with limited mobility did not receive necessary services to maintain or improve mobility due to staff failing to apply leg braces as per the therapy plan. The resident's therapy was discontinued, and the facility did not enter the order for brace application into the system, resulting in no tasks for staff to follow. Miscommunication and misunderstanding of the agreed schedule led to the resident not wearing the braces, impacting his mobility improvement efforts.
A resident's inhalant medication was left unsecured at the bedside by an LPN after administration, contrary to the facility's policy requiring medications to be stored in a locked compartment. The resident, who has COPD and Asthma, was assessed for supervised medication administration. The DON confirmed the risk posed by the unsecured medication.
The facility failed to provide bedtime snacks to residents, including those with diabetes, as snacks were left at the nurse's desk and not distributed. Mobile residents could retrieve snacks, but those who were not mobile were left without. Staff interviews confirmed the issue, with the Administrator unaware and the Dietary Manager stating that aides were responsible for distribution.
Clustered False Documentation and Non-Individualized PRN Opioid Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure licensed nursing staff followed professional standards of practice for accurate, individualized assessment and documentation of PRN opioid pain medications for 13 residents on one medication cart. Facility policies required medications to be administered as prescribed, in accordance with good nursing principles, and clinical records to be complete and accurate for continuity of care, including consistent evaluation, management, and documentation of pain. Despite these requirements, record review of January and February 2026 MARs and controlled substance records showed repetitive, clustered documentation of PRN narcotic administration at identical times for multiple residents, which did not reflect individualized assessment or real-time documentation. One resident reported concerns that an LPN attempted to administer medications without allowing her to visually verify them, that she questioned whether her Norco was present, and that she did not experience expected pain relief; on one occasion she observed a pill that did not resemble her usual Norco and was told it was broken. Resident #9 was a cognitively intact resident with hemiplegia and hemiparesis following cerebral infarction, whose MDS indicated frequent pain affecting sleep and daily activities. However, during interviews he consistently denied pain, stated he did not take pain medication, and reported refusing pain medication when offered. Other LPNs confirmed that he did not usually take pain medication and had never reported pain or requested PRN analgesics from them. In contrast, MARs and the controlled substance inventory showed that one LPN (LPN #3) documented Norco administration to this resident at highly consistent times (around 7:01 AM, 12:31 PM, and 6:31–6:49 PM) and recorded pain scores of 8–9 on her shifts, while other shifts documented pain scores of zero. LPN #3 later admitted she did not ask this resident about pain, administered medication without his consent, and falsely documented high pain scores. Across all 13 residents with PRN opioid orders (primarily Norco and one resident with oxycodone), MAR review revealed a pattern of clustered documentation by LPN #3, with large groups of residents recorded as receiving PRN pain medication at the exact same times on multiple dates. In January and February, PRN doses were repeatedly documented at standardized times such as 7:01 AM, 11:01 AM, 12:31 PM, 3:01 PM, and clustered evening times between 6:31 PM and 6:49 PM, sometimes for as many as 12 residents at once. LPN #3 acknowledged in a telephone interview that she administered all PRN pain medications during routine med passes and intentionally selected one set time for all residents so they could receive subsequent doses based on order frequency, and that the medical records did not accurately reflect actual administration times. She further admitted she did not always ask residents about their pain, sometimes entered pain levels without asking them, and recognized that this practice and her documentation were not in accordance with nursing standards. The DON confirmed that review of the 13 residents’ MARs showed a pattern of documentation inconsistencies related to this nurse, and the nurse had a history of prior medication documentation and narcotic handling issues identified through progressive discipline and consultant pharmacist review.
PRN Opioid Documentation Irregularities Not Identified
Penalty
Summary
Pharmaceutical services failed to meet resident needs because the facility did not identify or address irregularities in PRN opioid documentation for 13 residents on medication cart B, including residents receiving Norco and one resident receiving oxycodone. Review of January and February 2026 MARs showed repeated documentation of PRN pain medication administration to multiple residents at identical times on numerous dates, including a cluster on 2/21 and 2/22 when 12 residents were documented as receiving PRN pain medication at 7:01 AM. The documentation did not reflect real-time medication administration times. The consultant pharmacist reported that monthly drug regimen reviews were completed and that MARs were reviewed for appropriate documentation and PRN medication use, but no narcotic discrepancies or concerns with the PRN pain medications were identified during those reviews. The pharmacist also stated that she had observed a medication pass with LPN #3 in October 2025 and noted that the nurse did not compare medications to the MAR before administration and did not document them immediately after giving them. She further stated that she had noticed LPN #3 frequently signed out narcotics and had raised that concern to the DON. A controlled substance inventory record for Resident #9 showed 58 of 60 Norco doses signed out by LPN #3, with sign-out times of 0700, 1230, and 1830. LPN #3 stated she administered PRN pain medication during routine medication passes and used one set time for all residents so they could receive medication again depending on physician orders, confirming the records did not reflect actual administration times. The DON confirmed that a pattern of documentation inconsistencies related to LPN #3 was identified after review of the 13 residents' MARs and that the facility failed to identify narcotic documentation irregularities. The affected residents included individuals with a range of cognitive status, from cognitively intact to severely cognitively impaired, and one unsampled resident admitted with a sacral pressure ulcer.
Failure to Provide Dignified, Timely Toileting and Respectful Care
Penalty
Summary
The deficiency involves failure to ensure residents were treated with dignity and respect by providing timely toileting assistance and by using respectful communication. One resident, cognitively intact and dependent on staff for assistance, reported that around 11:00 PM she activated her call light to request help to the bathroom. CNA #1 responded by questioning whether someone had already taken her to the bathroom and, after being informed the resident had been asleep and needed to go at that time, did assist her. Later, at approximately 3:00 AM, the same resident again required toileting assistance. Although CNA #1 assisted her to the toilet, the resident stated she was left sitting there for about 30 minutes without supervision. When CNA #1 did not return, the resident activated the bathroom call light, and upon returning, CNA #1 told her, "I told you I was coming back. I had to make my rounds." The resident reported telling CNA #1 she could not sit on the toilet for that length of time and should not have to remain there for an extended period, and further reported she notified the night nurse, who said the issue would be reported to RN #2. RN #2 later stated she was not made aware of any complaints or concerns about this resident on Monday morning. The DON acknowledged CNA #1 could be gruff in tone, had multiple prior write-ups, including for leaving a resident on the toilet longer than appropriate, and confirmed the expectation that residents receive timely toileting. A second cognitively intact resident with cerebral palsy, always incontinent of bladder, frequently incontinent of bowel, and dependent on staff for toileting and personal hygiene, was also involved. A family member reported arriving shortly after 1:00 PM and finding the resident’s call light sounding because she was wet and needed to be changed, with three soiled towels from lunch, covered in spaghetti, left on her chest. The family member stated the call light had been going off for some time before day-shift CNA #5 entered the room, removed the soiled towels, and said to the resident, "You're just showing out because your sister is here." CNA #5 later confirmed that dirty towels had been left on the resident’s chest and that the family was upset, and stated she left the room to allow time for the situation to deescalate. The DON confirmed her expectation that all residents have the right to be treated with dignity and respect.
Dirty and Rusted Overbed Tables in Resident Rooms
Penalty
Summary
The facility failed to provide a safe, clean environment when overbed tables in Rooms #16, #18, and #28 were observed with a thick black substance on the metal bases. The condition was readily visible upon entering the rooms and was documented during multiple observations on B Wing. The facility policy titled Resident Rights & Quality of Life Policy stated that residents have the right to receive services in a center environment that is safe, clean, and comfortable. During interviews, CNA #6 stated the table bases appeared very rusty and in poor condition and explained that staff are expected to notify nursing when equipment needs replacement, after which nursing notifies maintenance. CNA #2 stated that staff submit work orders through the kiosk system when items need repair, but she had not submitted a work order and had not noticed the condition of the tables. The DON confirmed the tables had a thick black substance on the metal bases and stated they looked bad and did not represent a homelike environment. The Maintenance Supervisor stated he had not received any work orders for cleaning or replacement and, after inspecting B Wing, observed multiple overbed tables that were rusted and in need of replacement.
Delayed Incontinent Care and ADL Assistance
Penalty
Summary
The facility failed to ensure timely ADL assistance for a resident who was dependent on staff for incontinent care. Resident #18, who had cerebral palsy, was cognitively intact with a BIMS score of 13, and was always incontinent of bladder and frequently incontinent of bowel, was found by family and staff to be wet and soiled while waiting for care. The resident’s call light was sounding when the family member entered the room, and the family member reported the resident had been left over an hour before being changed, with a bowel movement in the brief, a saturated brief, and wet bed sheets. Staff interviews confirmed the resident remained soiled for an extended period. Evening shift CNAs stated they found the resident soaked in urine, with a bowel movement and wet sheets, and said rounds were not being made timely to keep residents clean and dry. RN #3 stated she answered the call light, was told the resident was wet, and returned multiple times while the resident still had not been changed. CNA #5 stated the last incontinent round had been completed around 10:00 AM, that rounds should occur every two hours and as needed, and that she left the resident soiled when tensions escalated with the family member. The DON confirmed that any staff member could provide incontinent care and that rounds should be completed every two hours and as needed.
Unsafe possession and storage of smoking materials
Penalty
Summary
The facility failed to ensure residents were protected from accident hazards related to unsafe possession and storage of smoking materials for three of nineteen residents identified as smokers, including Resident #88 and two unsampled residents. The facility policy titled Safe Tobacco Use stated that staff members would monitor or obtain fire igniting materials such as matches and lighters for smokers at the nurses' station or another designated location, but observations showed smoking materials left in resident-accessible areas and on residents' persons. Resident #88, who was admitted with diagnoses including emphysema, atrial fibrillation, and atherosclerotic heart disease and had a BIMS score of 15, was observed with cigarettes on a chest of drawers, then later with two boxes of cigarettes and a red lighter on a bedside table and another box of cigarettes on a chest of drawers. Resident #88 stated the cigarettes and lighter could be kept in the room and that they had been placed on the table after returning from smoking. During a scheduled smoke break, two unsampled residents were observed seated near the exit door to the outside smoking area with cigarettes visible, and one resident stated they could keep cigarettes and lighters with them while another stated she always kept her cigarettes with her and took them to her room. The DON stated the facility expectation was that residents do not keep cigarettes or lighters on their person and that smoking materials are to be kept in a locked box and provided at designated smoke times, while the Administrator acknowledged residents were observed in possession of these items and stated the presence of smoking materials constitutes an accident hazard.
Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure a medication cart was secured to prevent unauthorized access for one of four medication carts observed on B Wing. The facility policy titled, Proper Name, Inc. Policies and Procedures, revised 04/22, stated that it is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use. During an observation on 2/24/26 at 2:35 PM, the medication cart on B Wing was observed unlocked and unattended. An LPN stated she got busy and forgot to lock her cart before sitting down to chart, and she stated the cart should always be secured for the safety of the residents. On 2/25/26 at 2:30 PM, the DON stated medication carts should never be left unlocked when not in use and are to be locked at all times when not in use for the safety of the residents.
Infection Control Failures With Oxygen Tubing Storage and Wound Care Precautions
Penalty
Summary
The facility failed to implement infection prevention and control practices related to oxygen equipment storage. For Resident #3, review of the manufacturer’s guidelines for oxygen tubing stated that tubing not currently in use should be contained in a clean, sealed plastic bag or container to protect it from dust, pet dander, and other contaminants. During observations on 2/23/2026 at 10:45 AM and again at 3:41 PM, the resident’s oxygen tubing was lying on the floor. RN #1 later confirmed the tubing should not be on the floor and should be stored in the bag attached to the concentrator, and the DON also confirmed that tubing on the floor was an infection control concern. Resident #3 was admitted with a diagnosis of displaced intertrochanteric fracture of the left femur and had a BIMS score of 9, indicating moderate cognitive impairment. The facility also failed to use Enhanced Barrier Precautions during wound care for Resident #12. The facility’s Infection Control Guide stated that gown and gloves are indicated for high-contact resident care activities for residents with wounds and/or indwelling medical devices when Contact Precautions do not otherwise apply. Resident #12 had a sign outside the doorway indicating EBP and reported exposed orthopedic hardware at the right ankle with a history of antibiotics, hospitalization for sepsis, and a recommendation for hardware removal. The treatment order directed daily wound care for exposed surgical hardware on the right medial ankle. During observed wound care, the ADNS did not wear a gown, and later confirmed the resident was on EBP due to an open wound and acknowledged that she did not wear a gown.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Immediately Report and Recognize Abuse Allegations Involving Licensed Staff
Penalty
Summary
The facility failed to ensure that all allegations of abuse were immediately reported to the State Agency and the appropriate licensing board, as required by facility policy and regulations. Specifically, an incident involving a licensed nurse using profanity and applying force to a resident was witnessed by two CNAs, but both delayed reporting the incident until the following day, assuming another staff member had already reported it. Additionally, another LPN who overheard the use of profanity did not consider it abuse and did not report the incident. The incident was eventually reported to the State Agency, but not to the Board of Nursing, as the facility did not substantiate the abuse despite having statements from both CNAs. Interviews with staff confirmed a lack of immediate reporting and a failure to recognize the incident as abuse. The Administrator and DON acknowledged that staff did not follow the policy requiring immediate reporting of abuse allegations and that the required notification to the Board of Nursing was not made. Record review showed that all involved staff had attended a recent in-service training on abuse and neglect, which emphasized the importance of immediate reporting of any suspicion of abuse.
Failure to Provide Resident-Centered Care and Timely Physician Notification for Insulin and Wound Care
Penalty
Summary
The facility failed to identify and provide needed care and services that were resident-centered and in accordance with the resident's preferences, goals for care, and professional standards of practice for one resident. Upon admission, the resident, who had a history of insulin-dependent diabetes mellitus and a diabetic ulcer, informed staff that her insulin had been discontinued in error at the hospital and requested that the provider be contacted to clarify and reinstate her insulin orders. Despite repeated requests from the resident over several days, the nursing staff did not contact the provider for clarification or obtain new orders for insulin or wound care. The resident continued to self-administer her own insulin using a personal insulin pen, without an assessment for self-administration, and without facility orders or documentation for this medication. Additionally, the resident had a diabetic ulcer on her toe that was covered with a dressing upon admission. She requested wound care and dressing changes, but was told there were no orders for wound care. Although the dressing was changed by nurses on two occasions, the resident was unsure of the treatment used, and there was no documentation of wound care orders or treatments until several days after admission. The RN Treatment Nurse did not assess the wound until several days after admission, at which point a new wound care order was obtained from the Nurse Practitioner. Documentation revealed that the facility's policy required immediate implementation of resident-specific interventions and prompt notification of the physician when an open area was identified, which was not followed in this case. Interviews with facility staff, including the DON and RN Treatment Nurse, confirmed that the resident's requests for insulin and wound care were not addressed in a timely manner, and that appropriate notifications to providers were not made. The DON acknowledged that the resident had the right to necessary treatments and medications, and that the facility failed to obtain orders for both wound care and insulin, resulting in a lack of appropriate treatment and care according to the resident's needs and preferences.
Unresolved Grievances on Food Quality and Linen Changes
Penalty
Summary
The facility failed to adequately address grievances related to food quality and bed linen changes for several residents. Despite the facility's policy to actively seek resolution and keep residents informed, grievances from five residents regarding food concerns and infrequent linen changes were not resolved. Interviews with residents and staff revealed ongoing dissatisfaction with the food, including lack of variety, poor taste, and inadequate vegetarian options. Residents reported these issues repeatedly in resident council meetings, but no effective action was taken to address their concerns. The facility's Administrator and Dietary Manager were aware of the food complaints, yet failed to document or follow up on the grievances. The Administrator acknowledged the residents' dissatisfaction but did not complete a formal grievance process. The Dietary Manager claimed to have addressed the concerns but lacked documentation to support this. Additionally, the Social Services staff did not complete grievances for food complaints, believing them to be outside their responsibility. Residents also expressed concerns about the infrequency of bed linen changes, which were reportedly only done every two weeks or during deep cleaning. Despite these issues being raised in resident council meetings, there was no documentation or evidence of corrective actions taken. The facility's failure to resolve these grievances highlights a lack of effective communication and follow-up on resident concerns, leading to ongoing dissatisfaction among the residents.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and served at a safe and appetizing temperature for seven of the twelve residents sampled. Residents reported issues such as food being cold, lacking flavor, and not being cooked thoroughly. For instance, one resident mentioned receiving cornbread that was too hard to chew, while another resident complained about the lack of gravy on rice, which was a personal preference that was not accommodated despite discussions with the Dietary Manager. Several residents expressed dissatisfaction with the quality and variety of meals provided. One resident, who is diabetic, noted that the meal options were not suitable for their dietary needs, as they included multiple starchy items. Another resident, who is a vegetarian, reported a lack of appropriate meal options and described the food as disgusting and lacking seasoning. Additionally, there were instances where residents received incorrect meal items, such as being served a chicken salad sandwich instead of the requested tuna salad. Observations by the State Agency confirmed the residents' complaints, noting that sample trays from the kitchen contained food that was not warm and lacked flavor. The Dietary Manager acknowledged receiving complaints from residents about the food quality and confirmed that there were ongoing concerns. Despite these issues being raised in resident council meetings and directly with the Dietary Manager, the problems persisted, indicating a failure to address the residents' dietary needs and preferences adequately.
Failure to Assist Resident with Toileting During Mealtime
Penalty
Summary
The facility failed to honor a resident's right to a dignified existence and self-determination when a staff member refused to assist a resident with toileting. On one of the survey days, a resident expressed an urgent need to use the bathroom after returning from an appointment. Despite using the call light to request assistance, the resident was informed by a Registered Nurse (RN) that assistance could not be provided because staff were occupied with passing meal trays. The RN and the Director of Nursing (DON) did not return to assist the resident, leaving the resident in distress. Interviews with staff, including the DON and Certified Nurse Aides (CNAs), revealed a misunderstanding of facility policy, with staff believing they were not allowed to assist residents with toileting during mealtimes due to concerns about cross-contamination. The DON acknowledged the resident's right to use the bathroom when needed but indicated a need to review the policy. The resident involved was cognitively intact, with medical diagnoses including overactive bladder, Type 2 Diabetes Mellitus, and heart failure.
Failure to Implement and Develop Care Plans for Residents
Penalty
Summary
The facility failed to implement and develop care plans for three residents, leading to deficiencies in their care. Resident #41's care plan included daily nail care, but observations revealed that the resident's fingernails were long and untrimmed, indicating that the care plan was not followed. Interviews with staff confirmed the oversight. Resident #51 required leg braces to aid mobility, but no care plan was developed for their use. The resident reported not wearing the braces since therapy ended, and staff interviews revealed a communication failure in entering therapy orders into the system, resulting in the absence of a care plan. Resident #113, who was diagnosed with Binge Eating Disorder, did not have a care plan addressing this condition. The oversight was confirmed during interviews with the RN Director of Clinical Services and the DON, who acknowledged that the diagnosis was not incorporated into the care plan upon the resident's readmission. This lack of a care plan for behavior monitoring was attributed to a failure in updating the resident's care needs after hospital discharge.
Failure to Provide Diabetic Nail Care
Penalty
Summary
The facility failed to provide adequate personal hygiene care for a resident, specifically in the area of nail care. The resident, who is diabetic and moderately cognitively impaired, expressed the need for her nails to be cut as they were long and causing her to scratch herself. During an observation and interview, it was noted that the resident's nails were approximately one-half inch in length, indicating they had not been trimmed in a significant amount of time. Interviews with facility staff, including an LPN and the DON, revealed that diabetic nail care was not scheduled or documented in the Treatment Administration Record (TAR) but was expected to be performed as needed. The LPN confirmed that nail care for diabetic residents should be conducted by a nurse due to the potential for skin injury. Despite this understanding, the facility did not have a formal process in place to ensure regular nail care for diabetic residents, leading to the oversight in the resident's personal hygiene.
Failure to Monitor Binge Eating Disorder in Resident
Penalty
Summary
The facility failed to provide appropriate behavioral monitoring and interventions for a resident with a new diagnosis of Binge Eating Disorder. The resident, who was admitted with Type 2 Diabetes and Schizophrenia, was readmitted with the additional diagnosis of Binge Eating Disorder. Despite this, the facility did not implement monitoring for this behavior. Interviews with staff, including CNAs and an RN, revealed that they were unaware of the resident's Binge Eating Disorder diagnosis, although they noted the resident's frequent requests for snacks and instances of taking food from carts. The Medication Administration Record did not include monitoring for Binge Eating Disorder, focusing instead on other behaviors such as hallucinations and delusions. The Director of Clinical Services and the DON confirmed the absence of monitoring for the disorder, acknowledging that the diagnosis was not picked up upon the resident's return from the hospital. The DON noted that behavior monitoring is crucial for timely management, especially given the resident's severe cognitive impairment and the potential impact on blood sugar levels due to binge eating.
Failure to Implement Dietary Recommendations for Enteral Nutrition
Penalty
Summary
The facility failed to address dietary recommendations for a resident receiving enteral nutrition through a PEG tube. The Registered Dietician (RD) assessed the resident and recommended changes to the tube feeding and water flushes to meet the resident's nutritional needs. The RD sent these recommendations to the interdisciplinary team via email. However, the Director of Nursing (DON) did not notice the recommendations in the email, and the Licensed Practical Nurse (LPN) did not act on them as she was not instructed to do so by the DON. Consequently, the necessary changes to the resident's nutritional plan were not implemented. The resident, who was admitted with diagnoses including cerebral infarction and gastrostomy care, continued to receive inadequate nutrition as per the existing orders. The RD's recommendations, which included increasing the caloric intake and adjusting the water flushes, were not communicated to the supervising physician for approval and activation in the electronic medical record. This oversight resulted in the resident's nutritional needs not being met during their stay at the facility.
Inaccurate MDS Medication Coding for Two Residents
Penalty
Summary
The facility failed to accurately complete Section N of the Minimum Data Set (MDS) assessment for two residents, leading to discrepancies in medication documentation. For Resident #46, the MDS indicated that the resident received anticoagulant medication for seven days during the observation look-back period. However, a review of the Electronic Medication Administration Record (eMAR) revealed that the resident did not receive any anticoagulant medication during this period. Instead, the resident was on antiplatelet medication, which was incorrectly coded by a remote MDS worker. The resident was admitted with diagnoses including Peripheral Vascular Disease, Tachycardia, and Atherosclerotic heart disease. Similarly, for Resident #96, the MDS inaccurately documented that the resident received anticoagulant medication for seven days, while the eMAR showed no such medication was administered. Instead, the resident was on an antibiotic, Macrobid, which was not coded in the MDS. The resident's admission diagnoses included Cerebral infarction and Hyperlipidemia. The MDS Coordinator confirmed these coding errors during an interview, attributing them to a remote MDS worker's mistake.
Failure to Apply Leg Braces for Resident with Limited Mobility
Penalty
Summary
The facility failed to ensure a resident with limited mobility received appropriate services and assistance to maintain or improve mobility. The resident, who was supposed to wear leg braces twice a day to improve mobility, reported that staff had not applied the braces since his therapy was discontinued. The braces were observed to be unused in the resident's room, and interviews confirmed that the staff had not followed through with the plan of care established by the therapy team. The Physical Therapist confirmed that the resident's therapy was discontinued, and a plan was in place for the resident to continue using the braces. However, the Director of Nursing (DON) was unaware of the issue and noted that there was no active order for the braces in the system. The failure to enter the order into the system resulted in no tasks being assigned to staff, leading to the resident not receiving the necessary range of motion services. Interviews with staff revealed a lack of communication and understanding of the agreed-upon schedule for brace application. A Certified Nursing Assistant (CNA) reported that the resident refused to wear the braces when offered at an incorrect time, which was not aligned with the resident's preferences. The Physical Therapy Assistant confirmed that the facility staff did not apply the braces as required, and the resident expressed gratitude for the resolution of the issue, hoping the new system would prevent future occurrences.
Improper Storage of Inhalant Medication
Penalty
Summary
The facility failed to store an inhalant medication in a locked storage compartment, as observed during a medication administration for a resident. The incident involved a respiratory inhaler, which was left on the resident's overbed table by an LPN after administration. The resident confirmed that the nurse had brought the inhaler for use earlier and left it at the bedside. The LPN admitted to forgetting to return the inhaler to the locked medication cart, despite being aware of the facility's policy on medication storage. The resident involved had a history of Chronic Obstructive Pulmonary Disease and Asthma and was cognitively intact, as indicated by a BIMS score of 15. The resident was assessed for medication administration with supervision, not independent administration. The Director of Nursing confirmed that the improper storage of medication posed a risk for unauthorized access. The facility's records showed an active order for the inhaler, which was administered by the LPN on the day of the observation.
Failure to Provide Bedtime Snacks to Residents
Penalty
Summary
The facility failed to provide residents with a bedtime snack, as revealed during a resident council meeting. Six residents, including those with diabetes, reported not receiving snacks at night. The facility's snack program indicated that snacks were delivered to the nurse's desk between 7:30 pm and 8:00 pm, but they were not distributed to residents. Instead, residents who were mobile could retrieve snacks from the desk, leaving those who were not mobile without access. This practice resulted in a 'first come, first served' situation, disadvantaging residents who could not reach the desk. Interviews with staff, including the Administrator and Dietary Manager, confirmed the issue. The Administrator was unaware of the problem and noted that the kitchen had stopped sending individual snacks with residents' names. The Dietary Manager stated that bulk snacks were sent to the nurse's desk, and aides were responsible for distribution. A Registered Nurse working the night shift confirmed that residents often had to ask for snacks at the desk. The report highlights the facility's failure to ensure that all residents, particularly those with diabetes, received necessary bedtime snacks to prevent low blood sugar levels.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Eupora
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster Health Services Nursing Facilty | 0.2 mi | ★★★★★ | 3 | 0 |
| Choctaw Nursing And Rehabilitation Center | 16.1 mi | ★★★★★ | 0 | 0 |
| Carrington, Llc D/b/a The Carrington | 20.3 mi | ★★★★★ | 5 | 0 |
| Baptist Nursing Home-calhoun, Inc | 23.7 mi | ★★★★★ | 1 | 0 |
| Starkville Manor Health Care And Rehabilitation Ce | 25.9 mi | — | 10 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.