Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Meridian during CMS and state inspections, most recent first.
A resident with transfer dependence and a care plan specifying a Hoyer total lift with a small red sling fell from a mechanical lift when staff used a black sling that was not the resident’s ordered sling. The resident shifted out of the sling, struck her head on the lift, sustained a head laceration with active bleeding, and was later diagnosed with a subarachnoid hemorrhage. Staff stated the sling was not the usual facility equipment and had been used because it was already under the resident in the wheelchair.
Incorrect Sling Used During Mechanical Lift Transfer: A resident who required a Hoyer total lift and a specific small red sling fell from a lift when staff used an inappropriate black sling that was already under the resident in the wheelchair. The resident, who had hemiplegia, a right above-knee amputation, and was on Eliquis for atrial fibrillation, struck her head on the lift and sustained a head laceration and a subarachnoid hemorrhage.
Staff misappropriated a deceased resident’s personal belongings while a hospice nurse was providing postmortem care. Multiple CNAs entered the room and removed items including drinks, toilet tissue, bed pads, a blanket, a cup, reading glasses, air fresheners, and bed bags while the resident’s body was still present. Several CNAs admitted they knew the items belonged to the resident, acknowledged that only the resident’s representative could authorize removal of belongings, and described taking items to personal locations such as a car or hiding them on the unit. The hospice nurse reported the behavior to an RN, who notified the DON, and the facility’s investigation concluded that staff actions demonstrated intent to misappropriate the resident’s property.
Surveyors observed that the facility did not properly store or monitor food items, resulting in overly ripe produce with visible spoilage, expired condiments, and failure to follow manufacturer storage instructions. The Dietary Manager and Administrator acknowledged that food safety procedures were not followed, leading to the presence of spoiled and improperly stored food in the kitchen.
The facility did not ensure that all direct care staffing hours, including those worked by salaried nursing leadership, were accurately recorded and submitted in the PBJ data to CMS. The DON and ADON worked on the floor during periods of low staffing but did not clock in or out, resulting in their hours not being included in the PBJ submission for the quarter. This led to the facility triggering for excessively low weekend staffing.
Residents repeatedly raised concerns about the lack of condiments during meals and delayed call light response times, with some reporting waits of up to 30 minutes and having to call 911 for assistance. Staff confirmed that condiments were unavailable due to delivery issues and that call light responsiveness was an ongoing problem, especially during meal service and overnight shifts. Despite these grievances being documented and reported through appropriate channels, the facility did not resolve them promptly as required by policy.
Surveyors identified inaccurate MDS coding for two residents, including one who was discharged home but coded as discharged to a hospital, and another whose MDS indicated anticoagulant use despite no such medication being ordered or administered. Staff interviews and record reviews confirmed these errors, reflecting a pattern of deficiency in MDS accuracy.
During a shift change, only one CNA was present on three resident halls while multiple call lights went unanswered for about 30 minutes, with nurses remaining at the nurse's station and unaware that CNAs had left the floor. A resident reported waiting for help for 30 to 40 minutes. Staff interviews confirmed that CNAs often leave without notifying nurses, walking rounds are not conducted, and staffing shortages are ongoing.
Three rooms were found with exposed sheetrock, chipped paint, and exposed metal, compromising the comfort and homelike environment for residents. The Maintenance Supervisor confirmed the need for repairs and noted that repair requests were often communicated verbally rather than documented in work orders.
A resident's care plan was not revised to reflect their improved transfer abilities after therapy discharge, resulting in continued documentation for a mechanical lift that was no longer needed. Staff confirmed the resident required only minimal assistance, but the care plan remained outdated and inconsistent with current assessments.
A resident with multiple cancer diagnoses did not receive timely pain management upon admission to the facility. Despite having physician orders for opioid analgesics, the facility did not have the prescribed medication available, resulting in unmanaged pain for approximately twelve hours. The resident's pain was not addressed until a nurse practitioner prescribed an alternative medication the following morning. Interviews revealed that the resident was in pain throughout the night, and the facility's Director of Nurses confirmed the delay in medication administration.
Improper Sling Used During Mechanical Lift Transfer
Penalty
Summary
The facility failed to implement care plan interventions for Resident #1 regarding the sling type and size used during a mechanical lift transfer. Resident #1 had a care plan focus for physical functioning deficits with transfers and required assistance with transferring using a Hoyer total lift with a small red sling, which had been initiated on 1/7/25. The resident was admitted with diagnoses including flaccid hemiplegia affecting the right dominant side, atrial fibrillation, and acquired absence of the right leg above the knee, and the quarterly MDS showed a BIMS score of 14, indicating the resident was cognitively intact. During the transfer from wheelchair to bed, staff used a black sling that was not consistent with the facility’s standard equipment and was not the sling identified in the resident’s care plan. The resident shifted in the sling and fell out of it, striking her head on the leg of the mechanical lift. Staff reported that the resident sustained a head laceration with active bleeding, and the resident was sent to the hospital. The acute hospital record documented a right occipital laceration repaired with staples and a clinical impression of subarachnoid hemorrhage. Interviews showed staff awareness that the sling used was not the usual facility sling and that it may have originated from another facility or outside provider. The DON stated the resident had been transferred using a black sling that was not consistent with standard equipment, and CNA #8 stated she had not previously used that sling for the resident or any other resident but used it because it was already positioned under the resident in the wheelchair. The report also states that the facility’s expectation was for nursing staff to ensure proper slings were used during transfers per the Kardex and care plan.
Incorrect Sling Used During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure the correct sling type and size were used during a mechanical lift transfer for a resident who required a full lift. The resident had diagnoses including flaccid hemiplegia affecting the right dominant side and acquired absence of the right leg above the knee, and the facility’s Kardex directed staff to use a Hoyer total lift with a small red sling and a sling for the resident’s right-side amputation. Facility lift guidelines stated that residents should be lifted or transferred by the lift and sling deemed appropriate after the lift evaluation and that there should be no interchanging of lifts and slings. During the transfer from a wheelchair to a bed, the resident fell from the lift when the sling was not the appropriate size. Staff interviews indicated the resident had a black sling underneath her while seated in the wheelchair, and one CNA believed it was acceptable to use because it was already positioned under the resident. Another staff member stated the resident shifted in the sling and fell out of it, and an LPN reported the resident struck her head on the leg of the mechanical lift. The resident sustained a head laceration with active bleeding and was transferred to the hospital, where records documented a subarachnoid hemorrhage. Record review and interviews also showed the resident was cognitively intact with a BIMS score of 14 and was receiving Eliquis for atrial fibrillation, a blood thinner. The DON later observed that the sling used was a black sling that was not consistent with the facility’s standard equipment, and the facility’s investigation concluded the sling was not the appropriate size for the resident. The incident involved one of four sampled residents and was identified by surveyors through interviews, record review, and review of the facility’s lift guidelines.
Staff Misappropriation of Deceased Resident’s Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s belongings from misappropriation by staff after the resident’s death. The facility’s Abuse, Neglect, Misappropriation, Exploitation Policy defined misappropriation of resident property as the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident’s belongings without the resident’s consent. Despite this policy, multiple CNAs entered the room of Resident #1 shortly after he was found unresponsive and removed various personal items while his body was still present in the room. Resident #1 had been admitted with diagnoses including heart failure and was documented as having died in the facility, with a progress note indicating he was found unresponsive with no respirations or pulse. According to the facility’s investigation records and staff interviews, a hospice nurse was providing postmortem care to Resident #1 when CNAs #1, 2, 3, 4, and 5 entered the room and began taking his belongings. Items removed included drinks, toilet tissue, bed pads, a cup, a blanket, reading glasses, air fresheners, and bed bags. CNA #1 reported seeing other CNAs in the room taking items and admitted to taking garbage bags and towels from the room and placing them at the nurse’s station to retrieve later. CNA #1 also noted that when the hospice nurse requested pads for the resident, there were none in the room, although there should have been pads available. CNA #2 stated that after being told the resident had passed away, she went into the room, found several workers there, took a pack of toilet paper, placed it in a bag, and took it to her car while the resident was still in the bed. She acknowledged that the tissue belonged to the resident and that taking it was stealing. CNA #3 reported that, after learning the resident had expired, she took two cases of citrus-flavored punch and two jugs of fruit punch from the room and placed them behind the nurse’s station, recognizing that the drinks belonged to the resident and admitting she did not have authorization from the resident’s representative to remove them. CNA #4 stated that another CNA said, “Hey, we might as well get this stuff,” and she then took a pack of sodas, a blanket, and a cup while the resident remained in the bed; she later returned the blanket and cup when questioned. CNA #5 reported that the day before the resident passed away, the resident had told her she could have some protective bed pads in his closet and that he often gave bed pads to other residents. However, she did not take the pads at that time and instead took them after he was deceased, acknowledging that it was wrong to wait until after his death to remove them. The hospice nurse reported to RN #1 that multiple CNAs had entered the room during postmortem care and taken personal belongings, and RN #1 relayed this information to the DNS. The Administrator learned of the incident through a report from the hospice company’s Executive Director and was informed that the DNS had interviewed staff and identified that staff had taken belongings from the deceased resident’s room. The facility’s own investigation summary concluded that there was intent for misappropriation of the resident’s property by the involved staff.
Failure to Store and Maintain Food in Accordance with Professional Standards
Penalty
Summary
During a kitchen observation, surveyors identified that the facility failed to store food and maintain food quality in accordance with professional standards for food safety. Specifically, refrigerator #3 contained a plastic storage container with 14 overly ripe cucumbers that had a white slimy rind, were soft and pliable, and had liquid accumulated at the bottom. In the pantry, there was an opened bottle of yellow mustard past its 'best if used by' date, an opened gallon-sized bottle of soy sauce that was not refrigerated as instructed by the manufacturer, 19 overly ripe oranges with green and white bio-growth on the rind, and an overly ripe apple with a brown soft spot and exposed interior. These findings were acknowledged by the Dietary Manager, who confirmed that she had not examined the produce that day as intended and recognized the risks associated with having overly ripe food in the kitchen. The Dietary Manager stated that it is her responsibility to ensure food is not expired and is stored properly, and the Administrator confirmed that monitoring food supplies for proper storage and spoilage is the DM's responsibility. The facility's policy requires all perishable foods to be maintained at a temperature of 41 degrees Fahrenheit or below, and the manufacturer's instructions for certain items were not followed. The observations and interviews confirmed that the facility did not adhere to its own food storage policies and professional standards, resulting in the presence of spoiled and improperly stored food items in the kitchen.
Failure to Accurately Report Direct Care Staffing in PBJ Submission
Penalty
Summary
The facility failed to ensure that its Payroll Based Journal (PBJ) submissions to CMS accurately reflected direct care staffing hours, as required. Review of CASPER reporting data showed the facility triggered for excessively low weekend staffing for one of four quarters. Examination of monthly schedules indicated that both the Director of Nursing (DON) and Assistant Director of Nursing (ADON), who are salaried employees, worked as supervisors and on the floor during weekends in the quarter in question. However, they did not clock in or out during this period, and their work hours were only documented on assignment sheets, not in the PBJ data submitted to CMS. Interviews with facility staff revealed that the DON and ADON only began clocking in and out within the last two weeks, and prior to that, there was no verifiable or auditable record of their hours worked on the floor. The staffing coordinator was responsible for correcting staff punches and updating codes when staff worked outside their usual roles, but the PBJ data sent to the corporate office did not include the DON and ADON's hours for the quarter in question. The Administrator and Director of Payroll were unaware that the facility had triggered for low weekend staffing, and the PBJ submission was accepted by CMS despite the incomplete data.
Failure to Resolve Resident Grievances on Condiments and Call Light Response
Penalty
Summary
The facility failed to promptly resolve grievances raised by residents regarding the lack of condiments during meals and delayed call light response times. Resident Council meeting minutes from October and November 2024 documented ongoing concerns about the absence of basic condiments such as salt, pepper, and butter. Observations confirmed that residents were served meals, including baked potatoes and roast beef, without condiments, and no salt or pepper shakers were present in the dining area. Staff interviews revealed that the dietary department had run out of condiments due to a delivery issue, and no alternative arrangements were made to provide these items to residents. Residents also reported significant delays in call light response times, with some stating that it could take up to 20 or 30 minutes for staff to respond, particularly during the overnight shift. Multiple residents described situations where staff would turn off call lights and promise to return but failed to do so, leading to unmet needs. One resident reported having to call 911 for assistance after her call light was ignored for an extended period. The Ombudsman corroborated these concerns, noting that CNAs were frequently not present or visible on the units during her visits. Interviews with facility staff, including the Social Services Director and Activities Director, confirmed that grievances about food service and call light response times were common and had been documented. However, these grievances were not resolved in a timely manner, as required by facility policy and resident rights regulations. The ongoing nature of these issues, as reported by residents and staff, demonstrated a failure to address and resolve resident concerns promptly.
Inaccurate MDS Coding for Discharge Status and Medication Administration
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to discharge status and medication administration. For one resident admitted with a fractured femur, the clinical record and discharge documentation indicated the resident was discharged home, but the Discharge MDS was incorrectly coded as a discharge to a short-term general hospital. The Social Services Director acknowledged making an incorrect entry, and both the Registered Nurse and Director of Nursing confirmed that it is the responsibility of the discipline completing each section of the MDS to ensure accuracy before submission. For another resident admitted with a seizure diagnosis, the Quarterly MDS indicated the resident was taking an anticoagulant, but a review of physician's orders and the Medication Administration Record for the relevant period showed no anticoagulant was ordered or administered. The error was confirmed by a Registered Nurse after reviewing the records, and the Administrator acknowledged the discrepancies in MDS coding for both discharge status and medication administration. These findings were based on record reviews, staff interviews, and facility policy review, and represent a pattern of deficiency as the same tag was cited on the previous annual recertification survey.
Insufficient Staffing During Shift Change Leads to Unanswered Call Lights
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs during a shift change on three of six resident halls. During the transition from day to evening shift, only one CNA was present on the floor while three nurses remained at the nurse's station, and five resident call lights were observed activated for approximately 30 minutes without response. Multiple staff interviews confirmed that CNAs left the floor without notifying nurses, and one CNA had been sent home on administrative leave, further reducing available staff. Nurses at the station were unaware that the CNAs had left and did not respond to the call lights, resulting in residents' needs going unmet for an extended period. A resident was heard calling for help, stating her call light had been on for 30 to 40 minutes and she needed assistance. Staff interviews revealed that it was common for CNAs to leave the floor before the next shift arrived and that walking rounds were not conducted to communicate care needs to the oncoming shift. The Assistant Director of Nursing and other nursing staff were unaware of the absence of CNAs during this period, and administrative staff confirmed ongoing staffing shortages and efforts to recruit additional staff. The facility's staffing policy requires adequate staffing based on resident acuity and needs, but this was not maintained during the observed shift change.
Failure to Maintain Safe and Homelike Resident Rooms
Penalty
Summary
The facility failed to provide a comfortable, homelike environment in three rooms on the North Unit, as required by its Resident Rights & Quality of Life Policy. Observations by a State Agent revealed exposed sheetrock surrounding the air conditioner in one room, and additional rooms were found to have exposed wall areas near doors and air conditioners, chipped paint, and exposed metal on the bottom corners of walls. The Maintenance Supervisor confirmed that these areas were in need of repair and attributed some of the damage to moving a bed. A review of maintenance work orders showed that no formal repair requests had been documented for these rooms, and the Maintenance Supervisor acknowledged that many repair needs are communicated verbally rather than being formally recorded.
Failure to Update Care Plan After Change in Transfer Needs
Penalty
Summary
The facility failed to revise the care plan for a resident who no longer required the use of a mechanical lift for transfers. Despite the resident's progress in therapy, which resulted in discharge at contact guard assist level and no longer needing a lift, the care plan continued to list interventions for a Hoyer Total Lift and related equipment. Multiple staff interviews confirmed that the resident was independent with transfers, requiring only assistance from one staff member, and that there were no current orders for a mechanical lift. However, the care plan had not been updated to reflect these changes, and the last lift evaluation on file was outdated. The deficiency was identified through observations, interviews, and record reviews, which revealed that the care plan did not accurately reflect the resident's current needs and abilities. The resident, who was cognitively intact and had a history of seizures, anxiety disorder, delusional disorders, and traumatic brain injury, was able to transfer with minimal assistance and did not require a lift. Facility staff, including nursing and therapy, confirmed the discrepancy between the resident's current status and the care plan documentation.
Failure to Provide Timely Pain Management for Resident with Cancer
Penalty
Summary
The facility failed to provide effective and timely pain management for a resident with multiple cancer diagnoses, including lung, pancreatic, rectal, and glottic cancer. Upon admission, the resident had physician orders for scheduled and as-needed opioid analgesics, including fentanyl and hydromorphone. However, the resident did not receive the prescribed PRN pain medication for approximately twelve hours following admission, resulting in unmanaged pain. The facility's policy on pain management, dated January 2021, requires pain evaluation upon admission and documentation in the electronic medical record, with physician notification as needed. Despite this policy, the resident was admitted with a hard copy prescription for hydromorphone, which was not available in the facility's emergency medications. The resident's pain level was documented as three in the early morning hours, and a nurse practitioner was contacted later that morning to prescribe an alternative pain medication, hydrocodone, which was administered around 10:46 AM. Interviews with staff and family members revealed that the resident was in pain throughout the night and that the facility did not have the prescribed medication available. The Director of Nurses confirmed the delay in medication administration due to the absence of the prescribed medication in the emergency supply. The resident's family reported that he was in significant pain and requested to be taken to the hospital, where he was later transferred for evaluation and treatment due to dropping pulse oximetry 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 Meridian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks Rehabilitation And Healthcare Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Trend Health & Rehab Of Meridian Llc | 1.1 mi | ★★★★★ | 2 | 0 |
| Poplar Springs Nursing Ctr, Llc | 2 mi | ★★★★★ | 0 | 0 |
| North Pointe Health & Rehabilitation | 2 mi | ★★★★★ | 0 | 0 |
| Bedford Care Center Of Marion | 2 mi | ★★★★★ | 9 | 0 |
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