Average — CMS composite of the measures below.
The next survey window likely opens around April 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 Quitman during CMS and state inspections, most recent first.
Failure to Provide Written Hospital Transfer Notices: The facility did not ensure written notice of hospital transfers, including the reason for transfer, was provided to residents or their RRs in a language and manner they could understand. Three residents were affected, including two with BIMS scores of 15 and one with a BIMS score of 9; their RRs reported receiving phone calls about the transfers but no written explanations. The DON confirmed there was no documentation of written transfer notices, and the Administrator stated staff were expected to follow the transfer notification policy.
A resident returned from the hospital with a Foley catheter in place, but the facility did not document physician orders, catheter care, monitoring, or a related care plan until weeks later. The resident had obstructive uropathy and reflux uropathy, and the DON confirmed the catheter was placed during the hospital stay and that the care plan was not developed timely despite the resident’s current condition.
A resident with dementia and a BIMS score indicating cognitive intactness had a call light string out of reach during observation, and the resident stated she would not have been able to call for help if needed. Staff later found the string on the floor with the clip missing, preventing it from attaching to the resident’s clothing or bedding. Interviews showed staff were expected to keep call lights within reach and report equipment concerns, but no maintenance request had been made for the missing clip.
A resident with DM had a care plan for altered blood glucose that did not match current physician orders. The plan listed PRN and BID accuchecks, conflicting BG notification parameters, and glucagon instructions that were not reflected in the active orders, and the record lacked documentation that staff were monitoring for signs and symptoms of high or low BG and reporting advanced hypoglycemia. The RN/MDS nurse and DON confirmed the care plan was not accurate, and an LPN stated she did not review the care plan before, during, or after giving glucagon.
A resident with DM had repeated insulin holds, refusals, and low BG results without consistent documentation of actual BG values, symptoms, provider notification, or follow-up, and Gvoke was given for hypoglycemia without clear rationale or notification. Another resident returned from the hospital with a Foley catheter in place, but catheter care and monitoring orders were not entered or documented for weeks after return, despite staff confirming the catheter remained in place.
Improper Storage of Oxygen Tubing and Nasal Cannula: A resident with a PRN order for oxygen at 2L NC was observed with the oxygen concentrator in the room, but the tubing and nasal cannula were left exposed on top of the concentrator instead of being stored in a protective bag. The resident stated he had not worn the oxygen in a couple of weeks, and the DON confirmed the tubing should have been stored appropriately.
A resident with advanced sacral pressure injuries, a Foley catheter, and a documented wound infection with heavy growth of E. coli and Proteus mirabilis received wound care without proper Enhanced Barrier Precautions. During an observed dressing change, an LPN wore gloves but did not don a gown, there was no EBP signage on the door, and hand hygiene duration was below expected standards. The NP reported relying on nursing staff to initiate EBP, an RN stated EBP should be used for advanced pressure injuries, and the administrator acknowledged that EBP should have been consistently implemented, while the LPN admitted unawareness of the need for a gown or additional transmission-based precautions.
A resident with severe cognitive impairment wandered into another resident's room, leading to an altercation where the resident was injured and required an ED visit. The facility failed to provide adequate supervision to prevent this incident, as the wandering resident had a history of entering other rooms.
The facility failed to develop comprehensive care plans for two residents, one with obstructive sleep apnea and another with an indwelling catheter. The care plan for the resident with sleep apnea did not include necessary referrals or CPAP usage orders, while the resident with the catheter lacked a plan for catheter care. Interviews with staff confirmed communication breakdowns and omissions in care planning.
The facility failed to ensure residents' privacy and dignity, as wandering residents entered rooms without permission, and a urinary drainage bag was left uncovered. A resident reported frequent uninvited entries into her room, while another experienced similar issues, leading to a fall. The DON confirmed the need to cover a catheter bag to maintain dignity. Despite staff education on redirecting wandering residents, these incidents persisted, indicating a failure to uphold residents' rights.
The facility failed to implement physician orders for two residents, leading to deficiencies in care. A resident with COPD and obstructive sleep apnea did not have a CPAP order added to their medical record after hospital discharge. Another resident with a Stage 4 Pressure Ulcer and severe cognitive impairment had an indwelling catheter placed without a documented physician's order. These oversights were confirmed by facility staff, highlighting lapses in verifying and documenting orders.
The facility failed to maintain sufficient nursing staff, particularly on weekends, as indicated by low staffing alerts and staff interviews. The facility's policy requires adequate staffing to meet residents' needs, but the PBJ Staffing Data Report for Quarter 4, 2024, showed low weekend staffing. Interviews with CNAs and LPNs revealed staffing inconsistencies, leading to challenges in completing duties. The DON and Workforce Manager confirmed the staffing issues, with staffing grids showing low ratios. The Administrator acknowledged the challenges and outlined efforts to address them, but the issues remained unresolved.
Failure to Provide Written Hospital Transfer Notices
Penalty
Summary
The facility failed to ensure residents and their resident representatives received written notice of hospital transfers, including the reason for the transfer, in a language and manner they could understand for three residents reviewed for discharge and hospitalization. The facility policy titled Transfer and Discharge stated that before transferring or discharging a resident, the facility must notify the resident and the resident's representative of the basis for the transfer or discharge in a language and manner they understand. The record review showed that Resident #1, who had diabetes mellitus and a BIMS score of 15, was transferred to the hospital multiple times, but there was no documentation that written notification was provided to the resident or representative for those transfers. The resident's representative reported receiving phone calls about the transfers but not written explanations of the reasons. Resident #3, who also had diabetes mellitus and a BIMS score of 15, was transferred to the hospital several times, and the record contained no documentation that written notice of the transfers was given to the resident or representative. The resident's representative stated she was notified by phone each time but did not receive written notification explaining the reason for the transfers. Resident #98, who had hemiplegia and hemiparesis following cerebral infarction and a BIMS score of 9, was transferred to the hospital, and there was no documentation that written notification was provided to the resident or representative. The resident's representative stated she was told by phone on the day of transfer and did not receive any written notice. The BOM, SSD, DON, and Administrator each acknowledged that written transfer notifications were expected, and the DON confirmed there was no documentation that such notices were provided for these residents.
Delayed Care Planning for Foley Catheter
Penalty
Summary
The facility failed to timely develop a comprehensive care plan with interventions related to an indwelling Foley catheter for one resident. Resident #92 returned to the facility from an acute care hospital with the Foley catheter in place, and the hospital discharge summary instructed that the Foley remain in place at discharge. Although the resident had diagnoses including obstructive uropathy and reflux uropathy, there was no documentation of physician orders related to indwelling catheter care or monitoring from the resident’s return to the facility until approximately ten weeks later. The record showed the first documented physician orders for the Foley catheter and the first catheter care documentation were initiated on 5/4/26, and the care plan for the Foley catheter was also initiated on that date. The resident’s MDS indicated the resident did not have an indwelling catheter when discharged to the hospital, but the resident returned with the catheter in place on 2/26/26. During interview, the DON confirmed the catheter had been placed during the hospital stay and that the care plan was not developed until 5/4/26 despite the resident returning with the Foley in place, and the Administrator stated care plans were expected to be developed timely to reflect the resident’s current condition.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #77’s call light remained accessible and within reach. Resident #77 was admitted with a diagnosis including dementia, and the Quarterly MDS showed a BIMS score of 13, indicating the resident was cognitively intact. During observation, the resident’s call light string was seen out of reach, and the resident stated she would not have been able to call for assistance if needed. The call light system required the resident to pull the string to activate the call light outside the room and at the nurses’ station. During a later observation, a CNA picked the call light string up from the floor and noted the clip was missing, which meant the string could not attach to the resident’s clothing or bedding. The CNA stated the clip may have fallen off while the bed was being adjusted and could not recall how long it had been missing. Interviews with staff showed they were expected to keep call lights within reach and report equipment concerns through the facility’s maintenance process, but the Housekeeping/Maintenance Director stated no maintenance request had been received regarding the call light clip. The Administrator stated staff should have reported the concern and ensured the clip was replaced, and that Resident #77 should have been monitored more frequently until the clip was repaired.
Care plan not updated to match diabetic orders
Penalty
Summary
The facility failed to revise Resident #29’s comprehensive care plan to match current diabetic management orders and interventions. The care plan for alteration in blood glucose, initiated for hyperglycemic episodes and type 2 diabetes mellitus, included interventions for accuchecks PRN and BID, notification parameters for blood glucose values greater than 450 mg/dL and greater than 400, and glucagon administration instructions tied to blood sugar levels and unresponsiveness. However, the active physician orders did not include PRN accuchecks, BID accuchecks, or the same notification parameters, and the order for Gvoke did not include the blood sugar, symptom, or unresponsive criteria reflected in the care plan. The record also did not contain documentation that staff were observing the resident for signs and symptoms of high and low blood sugar and reporting signs and symptoms of advanced hypoglycemia to nursing and the physician. Resident #29 was admitted with diabetes mellitus and had a BIMS score of 15, indicating cognitive intactness. Current physician orders included NovoLOG with blood sugar checks three times daily, dapagliflozin daily, Lantus 70 units daily, and Gvoke PRN for hypoglycemia related to type 2 diabetes mellitus with diabetic neuropathy. During interview, the RN/MDS and care plan nurse confirmed the care plan had not been revised to reflect the current orders and stated the care plan contained conflicting instructions. The DON also confirmed the care plan was not accurate and had not been revised to reflect the resident’s current physician orders. An LPN stated she did not review the care plan before, during, or after administering glucagon because she was focused on the resident’s condition and satisfied with the resident’s response.
Failure to document and follow through on insulin, hypoglycemia, and Foley catheter orders
Penalty
Summary
The facility failed to provide treatment and services according to professional standards of practice for a resident with diabetes by not consistently monitoring, assessing, documenting, and following up on abnormal blood sugar results, insulin holds, insulin refusals, and glucagon administration. The resident had physician orders for NovoLOG insulin with blood sugar checks three times daily and a PRN Gvoke order for hypoglycemia, but the orders did not include parameters for when to hold insulin, when to notify the physician, or when to administer Gvoke. The MAR showed multiple instances where insulin was not given, including entries coded as sliding scale coverage not needed, refusal, hold, or other, but several of those entries lacked the actual blood sugar result or lacked documentation explaining why the insulin was not administered. The record also showed that when blood sugar values were documented as low, the nursing documentation did not include the resident’s signs or symptoms, interventions, physician or NP notification, or follow-up monitoring. One note documented a blood sugar of 54 with insulin held, and another documented a blood sugar of 65, but neither included the resident’s condition or notification to the provider. On another occasion, Gvoke was administered when the resident’s blood sugar was 66 and the resident was described as trembling and not himself, but the documentation did not include physician notification, the resident’s signs and symptoms, or the rationale for using glucagon instead of oral intervention. The DON acknowledged the documentation gaps, and the NP stated she wanted to be notified when blood sugar was less than 70 or greater than 400 and that staff should document actual blood sugar results, reasons insulin was not given, and refusals. The facility also failed to timely implement physician orders related to indwelling catheter management for another resident. The resident returned from the hospital with a Foley catheter in place, and the hospital discharge summary instructed that the Foley remain in place. Although the facility documented that the resident returned with the Foley catheter, there was no documentation of indwelling catheter care or monitoring for approximately ten weeks after the resident returned. The first catheter-related physician order and treatment documentation did not appear until much later, and the DON and Administrator confirmed that the orders should have been entered when the resident returned from the hospital and that the receiving nurse and unit manager were responsible for ensuring the orders were properly entered.
Improper Storage of Oxygen Tubing and Nasal Cannula
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained for Resident #29. The resident was admitted with diagnoses including Diabetes Mellitus and had a BIMS score of 15, indicating cognitive intactness. The resident had a physician order dated 5/8/26 for oxygen at 2L per nasal cannula PRN for decreased oxygen saturation. Facility policy, Oxygen Guideline dated 8/1/2024, stated medical oxygen is to be provided in accordance with a health care provider's order and acceptable standards of practice. During an observation on 5/18/26, Resident #29 was sleeping in bed with oxygen signage on the door, but was not wearing the nasal cannula. An oxygen concentrator was in the room, and the tubing and nasal cannula were lying on top of the concentrator with the nasal cannula exposed and not stored in a protective bag. A later observation and interview on 5/20/26 found the same condition, with the resident stating he had not worn his oxygen in a couple of weeks. The DON observed the exposed tubing and nasal cannula and confirmed they should have been stored in a bag, stating she expected staff to ensure the tubing was stored appropriately.
Failure to Implement Enhanced Barrier Precautions During Wound Care for Infected Pressure Injury
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) and proper infection prevention and control practices for a resident with advanced pressure injuries and a documented wound infection. The resident, who was rarely/never understood per the MDS and had a history of cerebral infarction due to embolism of the left carotid artery, was readmitted from home with a worsening sacral pressure ulcer that progressed from stage 3 to stage 4. A wound culture collected on 03/10/2026 and reported on 03/13/2026 showed heavy growth of Escherichia coli and Proteus mirabilis, and the resident was started on Ciprofloxacin. Active orders included a Foley catheter for urinary incontinence and wound healing and treatment orders for a stage 4 sacral pressure injury. Despite these conditions, during an observation of wound care on 03/17/2026, there was no EBP signage on the resident’s door, and the LPN performing the dressing change wore gloves but did not don a gown. During the observed wound care, the LPN performed hand hygiene, but the handwashing duration was approximately 10 seconds during care and 7 seconds after completion, which did not meet expected standards. The Nurse Practitioner acknowledged awareness of the draining wound and Foley catheter but stated she did not order EBP, indicating that nursing staff typically initiate those precautions. An RN confirmed that EBP should be implemented for all wound care, especially for advanced pressure injuries, and that the nurse providing wound care is responsible for following physician orders and evidence-based standards. The Licensed Nursing Home Administrator acknowledged that, based on the resident’s sacral pressure injuries and documented infection requiring antibiotics, the LPN should have ensured EBP practices were consistently implemented. The LPN later stated she typically used gloves and standard precautions, did not recognize the need for additional transmission-based precautions, was unaware that a gown was required for this resident during wound care, and confirmed there was no EBP signage posted at the time of treatment.
Resident-on-Resident Altercation Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, resulting in one resident sustaining a hematoma and requiring an emergency department visit. The incident occurred when a resident with a diagnosis of unspecified dementia, who was assessed as having severely impaired cognitive status, wandered into another resident's room. The resident in the room perceived the intruder as a threat and reacted by hitting the wandering resident, causing the injury. The incident was discovered when a floor tech heard a commotion and found the injured resident in the room. The staff responded by removing the injured resident and cleaning up the spilled water. The facility's investigation revealed that the wandering resident had a history of entering other residents' rooms, and interventions such as stop signs on doors were implemented after the incident. However, at the time of the altercation, these measures were not in place, leading to the deficiency in supervision and safety.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident #2, who was diagnosed with obstructive sleep apnea, did not have a care plan that included the necessary referral for a sleep study or the physician's orders for CPAP usage at night following their return from the hospital. Interviews with the facility's Nurse Practitioner, Director of Nursing, and an LPN confirmed that the care plan was not updated appropriately, and there was a breakdown in communication regarding the hospital discharge orders. Resident #74, who had an indwelling catheter, also lacked a care plan with interventions for catheter care. Observations and interviews revealed that the catheter was not covered, and the facility's Director of Nursing and Administrator acknowledged the failure to develop a comprehensive care plan. The RN responsible for developing the care plan admitted to not seeing any orders for the catheter and did not inquire further, resulting in a lack of guidance for staff on proper catheter care.
Failure to Ensure Residents' Privacy and Dignity
Penalty
Summary
The facility failed to uphold residents' rights to privacy and dignity, as evidenced by several incidents involving wandering residents entering rooms without permission and the improper handling of a urinary drainage bag. Resident #5 reported that a female resident in a wheelchair frequently entered her room uninvited, both during the day and at night, despite keeping her door closed to prevent such intrusions. This issue persisted even after she reported it to the staff. Resident #57 also experienced similar issues, with residents entering his room uninvited and rummaging through his belongings, which led to a fall when he attempted to intervene. Both residents expressed concerns about the safety and privacy of their personal belongings. Additionally, Resident #74's urinary drainage bag was observed to be uncovered and visible from the hallway, compromising her dignity. The Director of Nursing confirmed the need to cover the catheter bag to maintain the resident's dignity. The facility acknowledged the presence of several wandering residents and confirmed that staff had been educated on redirecting them to respect others' privacy. However, these measures were insufficient to prevent the reported incidents, indicating a failure to ensure residents' rights to privacy and dignity.
Failure to Implement Physician Orders for CPAP and Catheter
Penalty
Summary
The facility failed to implement physician orders for two residents, leading to deficiencies in care. For Resident #2, who was admitted with Chronic Obstructive Pulmonary Disease (COPD) and later diagnosed with obstructive sleep apnea, the facility did not add the new diagnosis or the physician's orders for a CPAP machine to the resident's medical record after returning from the hospital. This oversight was confirmed by the Nurse Practitioner and the Director of Nursing, who acknowledged the importance of verifying hospital discharge orders to ensure continuity of care. For Resident #74, who was admitted with a Stage 4 Pressure Ulcer and had severe cognitive impairment, the facility failed to document a physician's order for an indwelling catheter that was placed by RN #1. The nurse assumed another nurse had obtained the order, but this was not the case. The absence of a documented physician's order was confirmed by the Administrator and the Director of Nursing, who emphasized the necessity of entering verbal orders into the electronic medical record.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of residents, particularly during weekends, as evidenced by low staffing alerts and interviews with staff. The facility's policy requires sufficient nursing staff to be present at all times to meet residents' individual care needs and maintain a safe environment. However, the Payroll-Based Journal (PBJ) Staffing Data Report for Quarter 4, 2024, indicated excessively low weekend staffing compared to weekdays. Interviews with staff, including CNAs and LPNs, revealed that staffing was inconsistent and often insufficient, leading to challenges in completing duties and requiring staff to work extra hours. The Director of Nursing and the Workforce Manager confirmed awareness of the staffing issues, with staffing grids showing multiple weekends with low staffing ratios. The facility aimed to staff an average of 10 CNAs on day shifts, seven on evening shifts, and five on night shifts, but actual staffing fell short, with as few as five CNAs on day shifts, four on evening shifts, and three on night shifts. The Administrator acknowledged the ongoing staffing challenges and outlined efforts to address the shortages, such as offering bonuses and recruiting from local vocational schools, but these efforts had not resolved the issues.
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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 Quitman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arabella Health & Wellness Of Meridian | 22.9 mi | ★★★★★ | 1 | 0 |
| Reginald P White Nursing Facility | 23.3 mi | ★★★★★ | 2 | 0 |
| James T Champion | 23.3 mi | ★★★★★ | 5 | 0 |
| Pine View Health And Rehabilitation Center | 24.4 mi | ★★★★★ | 8 | 0 |
| Trend Health & Rehab Of Meridian Llc | 24.5 mi | ★★★★★ | 2 | 0 |
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