Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Tupelo during CMS and state inspections, most recent first.
A cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident while both were seated together in the dining room without staff present. A dietary staff member observed the male resident stroking the female resident’s face and hair, and a CNA then witnessed the breast touching and reported it. The male resident later admitted to the touching and stated he did it because he loved her or to see her reaction, while the female resident, who had dementia and a BIMS score indicating moderate cognitive impairment, was unable to recall the incident. These events occurred despite the facility’s abuse policy stating it would take steps to prevent abuse and neglect.
Failure to notify the State LTC Ombudsman of a resident’s hospital transfer. Facility policy required notice to the resident, representative, and Ombudsman when a resident was transferred or discharged, but the resident’s hospital transfer for AMS was not listed on the Ombudsman’s Emergency Transfer Log. The DON/Administrator acknowledged the omission. The resident had GERD and COPD, and his BIMS score indicated intact cognition.
The facility failed to implement care plans for two residents. One resident was receiving Eliquis, but there was no monitoring for signs or symptoms of bleeding despite the care plan directing staff to observe for bleeding. Another resident’s ADL care plan included hair washing with bath or shower days, but the resident reported not having her hair washed for about two weeks, and an RN observed the hair appeared unwashed. The DON and MDS Coordinator confirmed the expected monitoring and ADL care were part of the residents’ plans.
Failure to revise a resident’s fall care plan after a fall. A post-fall review documented that the resident fell in her room and listed bed in low position as an intervention, but the care plan and Kardex were not updated. During observation, the resident had old facial bruising, stated she had fallen in her room, and her bed was not in the low position. The DON confirmed the intervention was not added; the resident had PVD and severely impaired cognition (BIMS 02).
A resident who required ADL assistance did not receive grooming and personal hygiene care as assessed, including hair washing. The resident said her hair had not been washed for about two weeks and that she wanted it washed, and an RN observed that her hair appeared unwashed. A CNA said she had not washed the resident’s hair because she did not want to cause pain, while the DON stated CNAs were expected to wash the resident’s hair on scheduled shower days. The resident had Cognitive Communication Deficit and a BIMS score indicating severely impaired cognition.
Failure to provide adequate behavioral health supervision after suicidal ideation. A resident with bipolar disorder, depression, and anxiety told staff she wanted to see a psychiatrist after an ER visit for mood instability, insomnia, crying spells, and fleeting thoughts of self-harm without plan or intent. The ER recommended urgent psych follow-up, close monitoring of mood, anxiety, and sleep, and environmental modifications, but the DON stated the facility treated the resident’s return as an “all clear” and did not add monitoring or other interventions.
Improper Catheter Care During Peri Care: A CNA provided catheter care in the wrong sequence for a resident with an indwelling urinary catheter, washing the groin area before the penis, meatus, and catheter, and did not rinse soap between areas. The CNA acknowledged the error and said she was in a hurry; the DON confirmed the improper sequence could cause infection and that soap left on the skin could cause irritation. The resident had diagnoses including obstructive and reflux uropathy and UTI, and was moderately cognitively impaired with an indwelling catheter.
The facility failed to ensure ongoing monitoring for adverse effects of Eliquis for a resident prescribed anticoagulation therapy. The resident’s record lacked evidence of bleeding monitoring and no q shift order for signs and symptoms of bleeding was on the MAR. The DON confirmed there was no such order and stated residents receiving anticoagulants should have MAR monitoring for bleeding.
Infection control practices were not consistently followed for oxygen equipment and EBP. Two residents receiving oxygen had tubing and humidifier water bottles that were not dated, and an LPN confirmed the items were undated while the DON stated the facility no longer tracks when they are changed. In a separate observation, a CNA performed catheter care for a resident requiring EBP without wearing a gown, despite the gown being available.
A resident with hemiplegia and hemiparesis, requiring extensive two-person assistance for bed mobility and toileting, was injured after a CNA provided care alone, contrary to the Kardex instructions. The resident fell from the bed while being turned, resulting in a skin tear, facial swelling, bruising, and a maxillary hematoma, necessitating increased pain management with tramadol.
Two residents admitted from the hospital did not receive their prescribed medications on time due to delays in obtaining them from the facility's pharmacy, which was not local and did not have the required drugs in the on-site dispensing system. Staff interviews revealed that medication orders entered late in the day sometimes resulted in delayed start times, and both the DON and administrator acknowledged that the facility failed to provide timely pharmaceutical services, resulting in missed doses for antibiotics and other critical medications.
The facility failed to honor the voting rights of residents during the 2024 presidential election. Several residents expressed their desire to vote but were not provided with the necessary assistance. A resident who was unable to walk requested a mail-in ballot but did not receive one, while another was promised a ballot by staff but did not receive it. The facility's Social Services staff member acknowledged the oversight, resulting in several residents being unable to exercise their right to vote.
The facility was found deficient in several areas, including administration, resident care, medication management, and infection control. Residents reported ongoing dissatisfaction with food quality, and issues were noted with incontinent care and unauthorized medications. Unattended medication carts and inadequate implementation of Enhanced Barrier Precautions further highlighted the facility's failure to use resources effectively.
The facility's QAA committee failed to maintain and monitor interventions after a recertification survey, leading to repeated deficiencies in areas such as ADL care. Despite implementing EMBRACE rounds to identify issues, the facility struggled with follow-up and addressing root causes, resulting in a pattern of ineffective quality assurance efforts.
Two residents in a LTC facility were observed with uncovered urinary catheter bags, violating their dignity. One resident expressed embarrassment about being transported to therapy with the uncovered bag. Staff, including the ADON, RN Unit Manager, and DON, acknowledged the issue, confirming that catheter bags should be covered as per facility policy.
The facility failed to inform all residents about Resident Council meetings, limiting their participation and ability to voice grievances. Residents expressed dissatisfaction with food quality, citing issues like undercooked meals. Despite repeated complaints, grievances were not resolved, and the facility lacked a structured process to address these issues.
Two residents experienced deficiencies in their care environment. A resident had a frayed electric bed control cord with exposed wires, posing a safety hazard that had been unaddressed for over a year. Another resident's wheelchair was found dirty, with staff acknowledging the night shift's responsibility for cleaning it. Both residents were cognitively intact and had specific medical conditions requiring assistance.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. A resident with a history of nicotine dependence was found with smoking materials in his room, contrary to his care plan. Two residents with self-care deficits were observed with long, untrimmed fingernails, despite their care plans specifying regular nail care. Interviews confirmed that the care plans were not followed, resulting in inadequate care for these residents.
A facility failed to provide necessary ADL care for three residents, including nail and incontinent care. A resident was found with saturated briefs and a strong urine odor, indicating missed rounds. Two residents had long, jagged fingernails, risking infection. Staff confirmed these deficiencies, acknowledging the failure to adhere to care protocols.
The facility failed to prevent accident hazards by allowing a resident to have smoking materials in their room and another resident to self-administer medications without an order. The presence of a cigarette box in a resident's room violated the facility's smoking policy, while another resident had medications on their bedside dresser, posing a risk of double dosing. The facility relied on an honor system to manage smoking materials and was unaware of the self-administration of medications.
The facility failed to securely store medications, as observed with two medication carts. An LPN left a cart unattended with a medicine cup and bottles of magnesium, Colace, and calcium on top. The ADON confirmed this was against policy. In another instance, an RN left medication cards unsecured on a cart. Both staff members acknowledged the potential hazard of leaving medications accessible to residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) and infection control measures, affecting 11 residents. Observations showed inadequate EBP signage and staff unfamiliarity with EBP, despite prior in-service training. A CNA placed a soiled bed pad on the floor, and an LPN did not wear a gown while administering PEG tube medication, both actions posing infection risks. The number of residents on EBP increased during the survey, indicating initial under-implementation.
A resident, admitted with COPD and cognitively intact, repeatedly did not receive her preferred sweet tea with meals, despite it being listed on her meal ticket. The Dietary Manager confirmed the oversight, acknowledging the resident's right to have her preferences honored, as per facility policy.
The facility failed to ensure advance directives were properly addressed for three residents. One resident was unaware of their DNR status and wished to be a full code, another had a mismatch between their written directive and electronic records, and a third had an incomplete directive form. These issues were due to oversight and errors in handling advance directives.
A facility failed to protect resident information when a medication cart was left unattended with a visible list of resident names, room numbers, code status, and hospice or dialysis status. The ADON and DON confirmed this as a privacy violation, and the LPN responsible acknowledged the oversight. The list included details of 26 residents.
The facility failed to conduct a timely background check for a newly hired RN Unit Manager, as required by their policy. The background check was outdated, having been completed over two years before the hire date. Interviews with the Administrator, ADON, and Human Resources confirmed the oversight, acknowledging the need for an updated check to ensure no disqualifying events.
A facility failed to update a resident's care plan to include a raised perimeter air mattress used for fall prevention. Despite observations and staff interviews confirming the mattress's purpose, the care plan was not revised to reflect this intervention. The resident, diagnosed with Huntington's Disease, was admitted with specific needs that required the care plan to be updated according to facility policy.
A facility failed to administer IV antibiotics as ordered for a resident with a UTI. The MAR showed missing documentation for three days of a five-day course of Meropenem, confirmed by interviews with nursing staff. The resident, cognitively intact and dependent on renal dialysis, did not receive the full course of treatment, as confirmed by the DON.
The facility failed to assess and obtain consent for bed rails for two residents, leading to deficiencies in care. One resident with Huntington's Disease was observed with unauthorized bed rails, and the DON was unaware of their presence. Another resident with multiple health issues was found with improperly positioned bed rails, contrary to their assessment. Both cases lacked necessary consent, indicating a lapse in the facility's processes.
The facility failed to provide meals that met residents' preferences and were served in an appealing manner, affecting four residents. Complaints included repetitive, unappetizing meals, overcooked or frozen food, and lack of alternative options. Despite being aware of these issues, the Dietary Manager and Registered Dietician did not intervene, and food committee meetings ceased during the Dietary Manager's maternity leave, leaving complaints unresolved.
A resident with reduced mobility and no cognitive deficits was denied assistance with toileting by a CNA, who suggested using a brief instead. This refusal was observed by a state agency representative. Interviews with facility staff confirmed the CNA's actions were inappropriate and against the facility's policy on resident dignity.
Two residents experienced deficiencies in personal hygiene care due to the facility's failure to implement ADL care plans. One resident, with a self-care deficit, was not shaved as per her care plan, despite her request. Another resident had not received oral care since admission and lacked necessary supplies, resulting in poor oral hygiene. The DON confirmed that care plans were not followed, leading to these deficiencies.
Two residents in the facility did not receive adequate personal care, specifically in shaving and oral hygiene. One resident, with no cognitive deficits, was not shaved as per her preference, despite it being part of her care plan. Another resident, with moderate cognitive deficits, had not been provided with a toothbrush or toothpaste since admission and was not shaved regularly. The facility's policy requires care to be provided according to standards and resident preferences, but these were not met for the residents involved.
Failure to Prevent Sexual Abuse Between Residents in Dining Area
Penalty
Summary
The facility failed to protect a resident from sexual abuse when one cognitively intact male resident inappropriately touched the breast of a moderately cognitively impaired female resident. The incident occurred while both residents were seated together at a dining table without staff present in the dining room. A dietary staff member first observed the male resident stroking the female resident’s face and rubbing her hair, and then a CNA entered and directly observed him touching the female resident’s breast over her shirt. When confronted, the male resident stated he did not care if the incident was reported. Subsequent interviews and documentation showed that the male resident admitted to touching the female resident’s breast, variously explaining that he did it because he loved her, that it was what men do when they are in love, and that he wanted to see her reaction. The female resident had been admitted with unspecified dementia with mood disturbance and had a BIMS score of 11, indicating moderate cognitive impairment. During surveyor interviews, she was ambulatory but displayed a flat affect, responded only to simple questions, and was unable to consistently understand or recall the incident, stating she did not remember what had occurred. The male resident, admitted with epilepsy, anxiety disorder, and unspecified mood disorder, had a BIMS score of 15, indicating he was cognitively intact. He acknowledged being attracted to the female resident and having talked with her for a day or two before the incident, and also acknowledged being attracted to other female residents in the past, though he denied touching them. These events and conditions occurred despite the facility’s written abuse policy stating it would take appropriate steps to prevent abuse, neglect, injuries of unknown origin, and misappropriation of resident property.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to notify the State Long-Term Care Ombudsman of a resident’s transfer to the hospital, as required by facility policy for transfers and discharges. Facility policy titled, "Transfer and discharge" stated that before the facility transfers or discharges a resident, it shall notify the resident and the resident’s representative of the basis for the transfer or discharge in a language and manner they understand, and will also notify the State Long-Term Care Ombudsman. Record review showed Resident #46 had an order to send him to the hospital emergency room for altered mental status, and the Emergency Transfer Log for the Office of the State Long-Term Care Ombudsman for November 2025 did not list him for that transfer. During interview, the Administrator stated she was responsible for completing and submitting the Emergency Transfer Log to the Ombudsman and acknowledged that the log provided information on residents transferred to the hospital. She confirmed that Resident #46’s name was not placed on the November log for the hospital admission. Resident #46 was admitted to the facility with diagnoses of gastro-esophageal reflux disease and chronic obstructive pulmonary disease, and his MDS assessment showed a BIMS score of 15, indicating he was cognitively intact.
Failure to Implement Care Plans for Anticoagulant Monitoring and ADL Care
Penalty
Summary
The facility failed to implement the comprehensive care plan for two residents. For one resident, the MAR showed the resident was receiving Eliquis 5 mg PO twice daily as of 10/15/25, but there was no monitoring for signs or symptoms of bleeding. The care plan for risk for complications related to anticoagulant use, reviewed on 10/23/25, directed staff to observe for signs and symptoms of bleeding such as tarry stools, blood in urine, bruising, and petechiae. During interview, the DON confirmed there was no order to monitor for bleeding every shift and stated her expectation was that any resident on an anticoagulant should have an order on the MAR to monitor for signs and symptoms of bleeding. The resident’s record also showed diagnoses of COPD, systolic CHF, and paroxysmal atrial fibrillation, and the quarterly MDS dated 10/27/25 showed a BIMS score of 15. For another resident, the care plan identified an ADL self-care performance deficit related to failure to thrive and directed staff to provide full assistance with oral hygiene, toileting hygiene, and showering/bathing. During rounds, the resident stated she had received baths but had not had her hair washed in approximately two weeks and wanted her hair washed. An RN later observed that the resident’s hair appeared unwashed. The MDS Coordinator confirmed that hair washing was included in the ADL care plan and stated it was to occur on the resident’s bath or shower days. The resident’s record showed diagnoses including cognitive communication deficit, and the quarterly MDS dated 10/20/25 showed a BIMS score of 07.
Failure to Revise Fall Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise Resident #83’s comprehensive care plan after a fall. Facility policy stated that care plans are developed by the interdisciplinary team and revised as needed according to resident status or change. A post-fall review documented that the resident fell in her room on 12/31/2025 at 9:06 PM and listed “bed in low position” among the recommendations/interventions, but the record showed the care plan/Kardex was not updated with new interventions. During observation on 1/11/2026, Resident #83 was lying in bed with old facial bruising and stated she had fallen in her room and that it was “almost healed now.” Her bed was observed not to be in the low position. The resident’s risk for falls care plan, last revised on 10/3/2025, did not include an intervention for the bed to be kept in low position. The DON later confirmed that the intervention was not added to the care plan or Kardex and stated that all beds were supposed to be left in low position. Resident #83 had diagnoses including Peripheral Vascular Disease and a quarterly MDS with a BIMS score of 02, indicating severely impaired cognition.
Failure to Provide Scheduled Hair Washing and Grooming Care
Penalty
Summary
The facility failed to ensure a resident who required assistance received ADL care, including grooming and personal hygiene services such as hair washing, in accordance with the resident’s assessed needs. Resident #58 stated that she had received baths but had not had her hair washed in approximately two weeks and said she wanted her hair washed. During an interview and observation, RN #1 confirmed at the resident’s bedside that the resident’s hair appeared unwashed. CNA #5 stated she was not familiar with the resident and had not washed her hair over the past couple of weeks because she did not want to cause her pain. She further stated that, now that she knew the resident, she would wash the resident’s hair on Mondays, Wednesdays, and Fridays, which were the resident’s scheduled shower days. The DON stated that the expectation was for the resident’s hair to be washed by CNAs on scheduled shower days. The resident’s record showed diagnoses including Cognitive Communication Deficit, and the quarterly MDS documented a BIMS score of 07, indicating severely impaired cognition.
Failure to Provide Adequate Behavioral Health Monitoring After Suicidal Ideation
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring for one resident after the resident expressed suicidal ideation and returned from the emergency room with recommendations for psychiatric follow-up. Resident #8, who had diagnoses including bipolar disorder, depression, anxiety, type 2 diabetes mellitus with diabetic polyneuropathy, and a urinary tract infection, told staff she had recently been to the ER and wanted to see a psychiatrist. The resident’s BIMS score was 15, indicating she was cognitively intact. The facility policy stated that each resident must receive necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. ER records showed the resident presented with mood instability, insomnia, crying spells, moodiness, and fleeting thoughts of self-harm without plan, intent, or access to means. She declined psychiatric admission and requested outpatient psychiatric follow-up with the psychiatrist who visits the facility. The telepsychiatry consult recommended urgent psychiatric follow-up at the assisted living facility, close monitoring of mood, anxiety, and sleep patterns, and environmental modifications. However, the DON stated the facility viewed the resident’s return from the hospital as an “all clear” and did not place additional interventions or monitoring into effect. Social Services stated a referral was made later, but no documentation supported a prior interaction with the resident, and the ER did not provide follow-up orders.
Improper Catheter Care During Peri Care
Penalty
Summary
Improper catheter care was observed for one resident with an indwelling urinary catheter. During an observation of catheter care provided by CNA #4, the CNA prepared one pan of clean water, wet a washcloth, applied Dynacare shampoo and body wash directly to the cloth, and then washed the resident’s groin area first, followed by the shaft of the penis, the urinary meatus, and lastly the catheter. The CNA did not rinse the washcloth between cleaning the different areas of the groin, and the sequence used did not match the facility’s Peri Care Audit Tool, which directed staff to wash the catheter tube first and then wash from the meatus up the tube about 6 inches twice with changing position of the cloth. The resident involved had been admitted with diagnoses including obstructive and reflux uropathy and urinary tract infection, and the MDS identified an indwelling catheter and moderate cognitive impairment with a BIMS score of 10. During interview, CNA #4 acknowledged she did not use the correct catheter-cleaning sequence and did not rinse the soap, stating she was in a hurry and messed up. The DON confirmed that the improper sequence could cause infection and that not rinsing soap could cause skin irritation.
Failure to Monitor for Bleeding With Anticoagulant Use
Penalty
Summary
The facility failed to ensure ongoing monitoring for adverse effects of Eliquis for Resident #39, who was prescribed Eliquis 5 mg PO twice daily on 10/15/2025. Review of the resident’s medical record found no evidence that nursing staff monitored for signs and symptoms of bleeding, and the record lacked an order for q shift bleeding monitoring on the MAR. During interview on 1/12/2026, the DON confirmed there was no order to monitor every shift for bleeding and stated her expectation was that any resident receiving an anticoagulant should have an order on the MAR to monitor for signs and symptoms of bleeding. Resident #39’s record showed diagnoses of COPD, unspecified systolic CHF, and paroxysmal atrial fibrillation, and the quarterly MDS dated 10/27/2025 documented a BIMS score of 15, indicating the resident was cognitively intact.
Infection Control Deficiencies With Oxygen Equipment and EBP
Penalty
Summary
The facility failed to consistently implement infection prevention and control practices for oxygen equipment and Enhanced Barrier Precautions (EBP). For Resident #37, who was admitted with chronic obstructive pulmonary disease and had a BIMS score of 15, an observation on 1/11/26 and again on 1/12/26 showed that the oxygen tubing and humidifier water bottle were not dated. Resident #93, who was also admitted with chronic obstructive pulmonary disease and had a BIMS score of 15, was observed receiving oxygen via concentrator on 1/11/26 and again on 1/12/26, and the oxygen tubing and humidifier water bottle were also undated. During interview, an LPN stated the tubing and water bottles are to be dated when changed so staff know how long the resident has been using the same equipment, and she confirmed the items for Residents #37 and #93 were not dated. The DON stated the facility no longer dates oxygen tubing or water bottles and has no method to determine when the equipment was last changed. For Resident #70, who had diagnoses including obstructive and reflux uropathy and urinary tract infection, was moderately cognitively impaired with a BIMS score of 10, and had an indwelling catheter, CNA #4 performed catheter care without wearing a gown during an observed EBP-required high-contact care activity. The CNA stated she had the gown ready but forgot to apply it, and the DON stated staff were expected to follow EBP to reduce infection risk.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Injury
Penalty
Summary
Staff failed to follow the resident's Kardex instructions requiring two-person assistance for bed mobility and toileting, resulting in a fall. On the day of the incident, a CNA was providing incontinent care to a resident with hemiplegia and hemiparesis following a cerebral infarction, who was documented as needing extensive two-person assistance for both bed mobility and toileting. The CNA attempted to turn the resident alone, during which the resident reached for the over-bed table and fell from the bed. This incident was confirmed by interviews with the CNA, other staff, the DON, and the Administrator, as well as a review of the Kardex and MDS documentation, all of which indicated the requirement for two-person assistance. As a result of the fall, the resident sustained a skin tear to the buttocks, facial swelling, bruising, and a maxillary hematoma, which led to increased pain and a new order for tramadol, an opioid analgesic. Prior to the fall, the resident had only required minimal pain management. The facility's policy required a safe environment and adherence to care plans, but staff did not follow the documented care instructions, directly resulting in the resident's injuries.
Failure to Provide Timely Pharmacy Services for Newly Admitted Residents
Penalty
Summary
The facility failed to provide timely pharmacy services to meet the medication needs of two residents following their admission from the hospital. Both residents were admitted with specific medication orders for serious conditions, including a foot infection with osteomyelitis and COPD for one resident, and seizures with pneumonia for the other. Upon review, it was found that the required medications, such as Vancomycin and Augmentin, were not administered as ordered due to delays in obtaining them from the pharmacy. The facility's medication dispensing system did not have these medications available, and the pharmacy used by the facility was not local, resulting in further delays. Interviews with staff, including an LPN and the DON, revealed that the process for entering medication orders into the facility's system sometimes resulted in start times being set for the following day if entered after a certain hour. This contributed to the missed doses, as the medications were not available in the facility and were not delivered in time for administration. The DON acknowledged that it was the nurses' responsibility to obtain information about the last dose given at the hospital and to ensure medications were administered as ordered, but this did not occur for the two residents in question. The administrator confirmed that the facility admitted residents without ensuring the immediate availability of their required medications and that pharmacy services were not able to provide the ordered medications in a timely manner. Both residents missed critical doses of their prescribed medications, and this failure was acknowledged by facility leadership as a deficiency in providing necessary pharmaceutical services.
Failure to Honor Residents' Voting Rights
Penalty
Summary
The facility failed to honor the voting rights of residents during the 2024 presidential election. Three residents, identified as #4, #5, and #6, expressed their desire to vote but were not provided with the necessary assistance to do so. Resident #6, who was unable to walk, requested a mail-in ballot but did not receive one. Resident #7 was promised a ballot by the staff but did not receive it, and Resident #8, who was registered to vote, was not taken to the polling station. The facility's Social Services staff member acknowledged the oversight, stating that she mistakenly believed that registration would automatically result in absentee ballots being mailed to the residents. This misunderstanding, coupled with a lack of timely action, resulted in several residents being unable to exercise their right to vote. The facility's policy on Resident's Rights and Quality of Life emphasizes the right of residents to a dignified existence and the ability to exercise their rights as citizens. However, the facility did not ensure that these rights were upheld, as evidenced by the failure to assist residents in voting. The administrator confirmed the facility's failure to properly assist residents in exercising their voting rights. The record review showed that out of 47 residents who desired to vote, only a small number were able to do so, with several residents not receiving the necessary support to vote either by absentee ballot or in person.
Deficiencies in Administration and Care Practices
Penalty
Summary
The facility was found to be deficient in several areas during a survey, indicating a failure to administer the facility in a manner that effectively uses its resources to ensure resident well-being. One significant issue was the lack of an Administration Policy, as confirmed by the Administrator. This deficiency was cross-referenced with multiple tags, including F 565, F 677, F 689, F 761, and F 880, highlighting various areas of concern. For instance, residents expressed dissatisfaction with the food quality during resident council meetings, and it was noted that these complaints were not consistently documented or addressed, as confirmed by the Administrator. In another instance, Resident #7 was found in a room with a strong odor of urine, indicating a lack of timely incontinent care. The resident was wearing two heavily saturated briefs, which was not in accordance with care protocols. The CNA responsible admitted to not making rounds as required, and the DON acknowledged that such neglect could increase the risk of skin breakdown. Additionally, Resident #22 was found with smoking materials in his room, contrary to facility policy, and Resident #34 had unauthorized medications, raising concerns about potential overmedication. Further deficiencies were observed in medication management and infection control practices. Unattended medication carts were found with unsecured medications, posing a risk to residents. The facility also failed to implement Enhanced Barrier Precautions (EBP) effectively, as staff were either unaware or inadequately trained on the procedures. This was evident when a nurse administered medication without donning appropriate protective gear, despite EBP signage. The Administrator admitted to a lack of follow-up on staff training and implementation of EBP, which could lead to infection control issues.
Ineffective QAA Program Leads to Repeated Deficiencies
Penalty
Summary
The facility's Quality Assurance and Assessment (QAA) committee failed to maintain and monitor the interventions they implemented following a recertification survey conducted on June 22, 2023. This failure was evident during a subsequent recertification survey on September 16, 2024, where the facility was cited for multiple deficiencies, including F 550, F 565, F 584, F 656, F 677, F 689, F 761, and F 880. The repeated deficiencies across two state surveys indicate a pattern of ineffective QAA program implementation. The facility's policy on Quality Assurance and Performance Improvement (QAPI) emphasizes a proactive approach to improving quality of life and care, involving team members at all levels to identify improvement opportunities and monitor the effectiveness of interventions. However, the facility's inability to sustain these efforts was highlighted by the recurrence of deficiencies. Interviews with the Administrator (ADM) revealed that the facility's EMBRACE rounds, intended to identify and correct issues, were not effectively addressing the root causes of deficiencies. The ADM acknowledged that while staff identified deficient practices during rounds, the follow-up was lacking. The ADM also noted that the facility's focus on daily operations and staffing led to oversight of critical details, resulting in a disconnect in monitoring and follow-up. The ADM admitted that both the floor staff and leadership, including herself and the Director of Nurses (DON), failed to consistently identify and address issues, leading to complacency when monitoring ceased.
Failure to Maintain Resident Dignity with Uncovered Catheter Bags
Penalty
Summary
The facility failed to uphold the dignity of residents by not covering urinary catheter bags, as observed in two residents. Resident #52 was seen with an uncovered urinary catheter bag containing approximately 100 cc of urine during multiple observations. The Assistant Director of Nurses confirmed that the lack of a privacy cover was a dignity issue, as per the facility's policy. Resident #52 had been admitted with diagnoses including seizures, urinary tract infection, and cognitive communication deficit, and the Minimum Data Set indicated the presence of an indwelling catheter. Similarly, Resident #190 was observed with an uncovered catheter bag containing 350 ml of urine, facing the door. The resident expressed concern about being wheeled to physical therapy with the uncovered bag, feeling embarrassed. The RN Unit Manager and the Director of Nursing acknowledged the dignity issue, agreeing that catheter bags should be covered. Resident #190, who was cognitively intact, had diagnoses including obstructive and reflux uropathy, rhabdomyolysis, and paraplegia. The Physical Therapy Assistant admitted to not paying attention to the catheter bag during transport and agreed it should be covered.
Failure to Inform Residents of Council Meetings and Address Grievances
Penalty
Summary
The facility failed to ensure that all residents were informed about the monthly Resident Council meetings, which impeded their ability to participate and voice grievances. Interviews with residents revealed that some were unaware of the meetings, with one resident stating they had never heard of them, and another attending only one meeting in three years. The Activities Director admitted that the meetings were not consistently included on the activities calendar and were sometimes only advertised via flyers in the hallway, which residents might not see. Additionally, the facility did not adequately address grievances raised during the Resident Council meetings, particularly concerning food quality. Multiple residents expressed dissatisfaction with the meals, describing issues such as undercooked or hard-to-chew food. Despite these complaints being raised repeatedly in meetings, there was no evidence of resolutions being implemented. The Social Services staff and the Administrator acknowledged that food complaints were ongoing and unresolved, with the dietary department not consistently documenting or addressing these grievances. The report highlights specific instances where residents voiced their dissatisfaction with the food, including complaints about the menu and the quality of meals served. The Dietary Manager confirmed that complaints were often related to personal preferences, but the issues persisted even after attempts to address them. The lack of a structured grievance process and the absence of a food committee during the Dietary Manager's maternity leave contributed to the ongoing dissatisfaction among residents.
Facility Fails to Maintain Clean and Safe Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by two specific incidents involving residents. Resident #12 had an electric bed control with a frayed cord and exposed wires, which posed a potential safety hazard. Despite the resident's concerns about the risk of burns or fire, the issue had persisted for over a year. Staff interviews confirmed the hazard, and a maintenance supervisor acknowledged the potential for a minor electrical shock if the wires touched. Resident #12 was cognitively intact, with a BIMS score of 15, and had been admitted with diagnoses including Type 2 Diabetes Mellitus and Chronic Kidney Disease. Resident #71's wheelchair was observed to be dirty, with a thick, grayish-dried substance and food crumbs on the base and wheel spokes. The resident expressed dissatisfaction with the cleanliness of the wheelchair. Staff interviews revealed that the night shift was responsible for cleaning wheelchairs, but the task had not been completed for Resident #71. The Assistant Director of Nurses confirmed the wheelchair's unclean state. Resident #71 was also cognitively intact, with a BIMS score of 14, and had been admitted with diagnoses including Cerebral infarction.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in their care. Resident #22, who had a personal history of nicotine dependence, was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite his care plan stating that he should not have smoking materials on his person. This indicates that the care plan was not followed, as confirmed by the Assistant Director of Nursing. Resident #58, who had an ADL self-care performance deficit due to contractures and decreased mobility, was observed with long, jagged fingernails, despite his care plan specifying that nail care should be performed on bath days and as needed. Interviews with the resident, a CNA, and the Administrator confirmed that the care plan for nail care was not followed, as the resident's nails were not checked and trimmed as required. Similarly, Resident #59, who had a self-care deficit related to a history of CVA and decreased functional abilities, was found with long, jagged fingernails and a brown substance under some nails. His care plan included daily nail care, but interviews with the resident and the Administrator revealed that this aspect of the care plan was not adhered to, as the resident had not received the necessary assistance to maintain his nail hygiene.
Deficiencies in ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADL) care for three residents, specifically in the areas of nail care and incontinent care. Resident #7 was observed to be lying in bed with a strong odor of urine in the room, indicating a lack of timely incontinent care. Certified Nurse Aide (CNA) #7 confirmed that the resident was incontinent and had not been checked since the start of her shift, revealing that the resident was wearing two heavily saturated incontinent briefs, which was against protocol. The Director of Nursing (DON) and the Administrator acknowledged that not providing timely incontinent care and the use of two briefs could increase the risk of skin breakdown. Resident #58 was observed to have long, jagged fingernails, which he stated were not being checked as they should be during his scheduled showers. CNA #2 confirmed the condition of the resident's nails and acknowledged that they could cause scratches and potential infections. The Assistant Director of Nursing (ADON) and the Administrator confirmed that nail care should be performed during resident baths and showers, and that the CNAs were responsible for checking nails daily. Despite the resident's cognitive intactness, he required substantial assistance with personal hygiene, which was not adequately provided. Resident #59 also had long, jagged fingernails with a brown substance underneath, and he expressed that his fingernails had not been checked in a while. CNA #2 and Registered Nurse (RN) #1 confirmed the condition of the resident's nails and the potential for infection. The resident, who had impaired vision and required assistance with personal hygiene, did not receive the necessary nail care during his scheduled baths. The facility's failure to adhere to its policy on ADL care resulted in these deficiencies, as confirmed by staff interviews and observations.
Deficiency in Preventing Accident Hazards
Penalty
Summary
The facility failed to ensure a safe environment for residents by allowing smoking paraphernalia and medications to be accessible in resident rooms. Resident #22 was found with a cigarette box containing a cigarette and a used cigarette butt in his room, despite the facility's policy prohibiting residents from keeping smoking materials. The Director of Nursing and the Administrator acknowledged that the resident could have obtained cigarettes from outside the facility and emphasized the use of an honor system to manage smoking materials. The Administrator confirmed the risk of fire due to the presence of smoking materials in the resident's room. Resident #34 was observed with bottles of Rolaids, Magnesium, and Multivitamins on his bedside dresser, which he brought from home and self-administered without an order. The Registered Nurse confirmed that the resident should not have had medication in his room, as it could lead to double dosing and medication errors. The Administrator was unaware of the resident's possession and self-administration of these medications, acknowledging the potential risk of overmedication if the resident was also receiving the same medications from the nursing staff.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored securely in a locked medication cart or storage room, as observed in two of the four medication carts used in the facility. During an observation, an unattended medication cart was found outside the dining room with a medicine cup full of a red liquid, a bottle of magnesium, Colace, and calcium sitting on top. The Assistant Director of Nurses confirmed that these medications should not have been left unattended, as it could lead to residents ingesting them accidentally. The Licensed Practical Nurse responsible for the cart admitted to leaving the medications unsecured while retrieving additional medication. In another instance, a Registered Nurse was observed leaving medication cards unsecured on a medication cart. The nurse placed medication cards, including Baclofen, Buspar, Augmentin, and Cyproheptadine, inside a narcotic binder but left the cart unattended with the card edges visible and accessible. Upon returning, the nurse acknowledged that leaving the medications unsecured was a hazard, as residents could have accessed them. The Director of Nurses confirmed that medications should never be left unattended on a cart.
Failure to Implement Enhanced Barrier Precautions and Infection Control Measures
Penalty
Summary
The facility failed to fully implement Enhanced Barrier Precautions (EBP) and follow infection control measures, affecting 11 residents on EBP and two specific residents. Observations revealed inadequate signage for EBP across different halls, with only a few rooms displaying the necessary signs. Interviews with staff, including CNAs, LPNs, and the RN/Infection Preventionist, indicated a lack of awareness and understanding of EBP, with some staff members having never heard of it or being unsure of its purpose. This lack of knowledge persisted despite an in-service conducted two months prior, as confirmed by the Director of Nurses and the Administrator. During the survey, it was observed that a CNA placed a soiled disposable bed pad on the floor while assisting a resident with a colostomy bag, which was acknowledged as an infection control concern by both the CNA and the Administrator. Additionally, an LPN failed to don a gown while administering medication via a PEG tube to a resident, despite the presence of an EBP sign on the door. The LPN admitted to missing the part of the in-service that covered the need for precautions with PEG medications, although the DON confirmed that staff had been in-serviced on this requirement. The facility's failure to implement EBP effectively was further highlighted by the discrepancy in the number of residents listed on EBP, which increased from four to eleven after the survey began. The Administrator acknowledged the need for auditing staff post-in-service to ensure proper implementation of EBP, which was not done, leading to the observed deficiencies.
Failure to Honor Resident's Beverage Preference
Penalty
Summary
The facility failed to honor a resident's choice for sweet tea with meals, as observed and confirmed through interviews and meal ticket reviews. Resident #44 expressed her preference for sweet tea, which had not been provided for over a month despite her requests. On two separate occasions, the resident received unsweetened tea with her meals, contrary to the meal ticket instructions that specified sweetened iced tea. The Dietary Manager confirmed that the meal ticket listed sweet tea, and acknowledged that the resident's preferences should be honored. Resident #44, who was cognitively intact with a BIMS score of 15, was admitted to the facility with a diagnosis of Chronic Obstructive Pulmonary Disease. The facility's policy on Resident's Rights and Quality of Life emphasizes the importance of self-determination and honoring resident choices. However, the facility's failure to provide the resident with her preferred sweet tea demonstrates a lapse in adhering to this policy, as confirmed by the Dietary Manager's acknowledgment of the oversight.
Failure to Address and Update Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly addressed or updated for three residents, leading to discrepancies in their code status. Resident #43's advance directive indicated a Do Not Resuscitate (DNR) order, but the resident was unaware of its meaning and expressed a desire to be a full code. Interviews revealed that the resident's cognitive status had improved since admission, and he was capable of making his own medical decisions. However, the facility did not reassess or update his advance directive to reflect his current wishes until it was brought to their attention. Resident #63 initially signed a DNR order upon admission when he was very ill, but later expressed a desire to change to full code as his condition improved. Despite this, there was a mismatch between the written advance directive and the electronic system, which incorrectly listed him as a full code. This discrepancy was acknowledged by the facility staff, who admitted it was an oversight that the advance directives did not match. Resident #84's advance directive was incomplete, with only the resident's name and date of birth filled out, and lacked any indication of the resident's code status. The form was erroneously signed by a physician without being properly completed. The facility admitted that this was a careless error, as the resident's code status had not been addressed upon admission, despite the resident being cognitively intact and capable of making such decisions.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the confidentiality of resident information, as observed during a survey. On one of the survey days, a medication cart was found outside the dining room door with a visible list containing resident names, room numbers, code status, and information on whether they were on hospice or dialysis. This list was accessible to anyone passing by, violating the residents' right to privacy and confidentiality as outlined in the facility's policy. The Assistant Director of Nurses (ADON) confirmed the visibility of the resident list and acknowledged it as a privacy violation. The Licensed Practical Nurse (LPN) responsible for the cart admitted to leaving the list exposed while retrieving medications, recognizing it as a privacy issue. The Director of Nurses (DON) also confirmed that the exposure of resident information was a breach of privacy. The list included details of 22 residents from the B Hall and four from the A Hall.
Failure to Conduct Timely Background Check for New Hire
Penalty
Summary
The facility failed to ensure that a new employee, specifically a Registered Nurse (RN) Unit Manager, had a current background check completed prior to employment. The facility's policy mandates that background checks must be conducted on all applicants offered employment to ensure workplace productivity, safety, and security. However, the RN Unit Manager was hired with a background check that was outdated, having been completed over two years prior to her hiring date. Interviews with the Administrator, Assistant Director of Nurses (ADON), and Human Resources confirmed the oversight, acknowledging that the background check should have been updated within two years of the hire date to ensure there were no disqualifying events or allegations against the staff member.
Failure to Update Resident Care Plan with Fall Prevention Measures
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised and updated, as required, for one of the sampled residents. The resident, who was admitted with a medical diagnosis including Huntington's Disease, was observed on two separate occasions lying in bed with a raised perimeter air mattress. This mattress was intended to prevent the resident from rolling out of bed. However, a review of the resident's Fall Care Plan revealed that it had not been revised to include the use of the secured perimeter air mattress. Interviews with the Director of Nursing and the Administrator confirmed that the care plan should have been updated to reflect the use of the mattress as part of the resident's fall prevention strategy. The facility's policy mandates that care plans be developed by the interdisciplinary team and revised as needed according to the resident's status or changes, which was not adhered to in this case.
Failure to Administer IV Antibiotics as Ordered
Penalty
Summary
The facility failed to adhere to nursing standards of practice for a resident who had a physician order for intravenous (IV) antibiotics. The Medication Administration Record (MAR) for the resident indicated an order for Meropenem to be administered intravenously for five days. However, the MAR was only initialed for two days, with no documentation for the remaining three days, suggesting the medication was not administered as prescribed. Interviews with the resident and nursing staff, including the Registered Nurse (RN) Unit Manager and a Licensed Practical Nurse (LPN), confirmed the lack of documentation and administration for those days. The resident, who was admitted with a urinary tract infection and dependence on renal dialysis, was cognitively intact as per the Minimum Data Set (MDS) assessment. The Director of Nursing (DON) confirmed that without documentation, the medication was considered not given. The absence of a facility policy on Standards of Practice was noted, and the failure to administer the antibiotic as ordered could potentially worsen the resident's infection, although this was not explicitly stated in the report.
Failure to Assess and Obtain Consent for Bed Rails
Penalty
Summary
The facility failed to properly assess and obtain consent for the use of bed rails for two residents, leading to deficiencies in their care. Resident #33, who was admitted with Huntington's Disease, was observed with half side rails up on both sides of her bed, despite a clinical evaluation indicating that side rails should not be utilized. The Director of Nursing (DON) was unaware of the bed rails' presence, and the Assistant Director of Nursing (ADON) confirmed that no consent was signed for their use. The resident was on hospice care, and the bed rails were mistakenly left in place when a new bed was delivered. Resident #60, who has Type 2 Diabetes Mellitus, gait and mobility abnormalities, and a mixed receptive-expressive language disorder, was also observed with half side rails up on both sides of the bed. The Registered Nurse (RN) and DON confirmed that the bed rails were not supposed to be in that position, as the resident's assessment indicated that side rails should not be used. The Administrator acknowledged that the staff should have identified the incorrect positioning of the bed rails. Both residents' records lacked the necessary consent for the use of bed rails, highlighting a failure in the facility's assessment and consent processes.
Deficiency in Food Quality and Resident Satisfaction
Penalty
Summary
The facility failed to provide food that met the residents' preferences and served meals in an unappealing and unpalatable manner for four residents. Resident #20, who was on a renal diet, expressed dissatisfaction with the repetitive and unappetizing meals, such as a thick, gray chicken breast on a dry bun and mushy pasta salad. Despite being aware of the resident's dislikes, the Dietary Manager and Registered Dietician did not intervene to offer alternative meal options. Resident #20 was cognitively intact and had been admitted with a urinary tract infection and dependence on renal dialysis. Resident #27 reported that the food was terrible, with chicken too hard to chew and hash-browns that were still frozen inside. When requesting an alternate meal, the resident received the same meal again. The resident, who was cognitively intact and had Type 2 Diabetes Mellitus, had complained to aides but was unsure of whom else to inform. Similarly, Resident #43, who had Alzheimer's Disease, complained about the chicken being overcooked and difficult to chew, and despite multiple complaints to the cooks, no improvements were made. Resident #50 also experienced issues with food quality, receiving meals that were cold and difficult to chew, such as frozen hash-browns and overcooked chicken. The resident, who was cognitively intact and had Chronic Obstructive Pulmonary Disease, reported these issues to aides but received no resolution. The facility's Administrator and Dietary Manager acknowledged ongoing food complaints, which had not been addressed since the Dietary Manager's maternity leave, leading to a lapse in food committee meetings and unresolved resident concerns.
Failure to Assist Resident with Toileting
Penalty
Summary
The facility failed to uphold a resident's right to dignity and respect when a staff member refused to assist with toileting. During an observation and interview, a resident who was unable to walk and required assistance with toileting expressed frustration about being told by Certified Nursing Assistants (CNAs) to use her brief instead of being helped to the bathroom. The resident, who had no cognitive deficits and used a sit-to-stand lift for toileting, reported that CNAs often told her they didn't have time to assist her and suggested she use her brief instead. This incident was directly observed when a CNA refused to help the resident to the bathroom, despite the resident's request and the presence of a state agency representative. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the CNA's actions were inappropriate and did not align with the facility's policy on resident dignity. The DON and the facility Administrator both acknowledged that refusing to assist a resident with toileting and suggesting they use their brief was unacceptable behavior. The resident's admission records indicated she had reduced mobility and required assistance with personal care, further emphasizing the need for staff to provide the necessary support when requested.
Failure to Implement ADL Care Plans for Residents
Penalty
Summary
The facility failed to implement Activities of Daily Living (ADL) care plans for two residents, leading to deficiencies in personal hygiene care. Resident #1, who had a self-care deficit related to decreased functional abilities, was observed with facial hair that had not been removed as per her care plan. Despite her expressed desire to have the facial hair removed, it was confirmed by an LPN that this task was not completed on her last bath day. The resident's care plan required extensive assistance with personal hygiene, including cueing, supervision, and assistance with ADLs, which was not adhered to. Similarly, Resident #8, who also had a self-care deficit, was found with unshaven facial hair and had not received oral care since admission. The resident expressed a need for a toothbrush and toothpaste, which had not been provided, resulting in visible white substance between his teeth and gums. The CNA assigned to him confirmed the lack of assistance with mouth care, and the LPN acknowledged the oversight in providing daily mouth care and shaving. The Director of Nursing confirmed that the care plans for both residents were not followed, as they should have been shaved on their scheduled bath days and provided with necessary oral care supplies.
Deficiencies in Personal Care for Residents
Penalty
Summary
The facility failed to provide adequate personal care for two residents, specifically in the areas of oral hygiene and shaving. Resident #1, who has no cognitive deficits and requires assistance with personal care due to reduced mobility, was observed with unwanted facial hair that had not been removed as per her preference. Despite having a care plan that included shaving during her bath on 06/10/24, the CNAs did not perform this task, as confirmed by the CNA Bath & Shower Report. Resident #8, who has moderate cognitive deficits and requires supervision for personal hygiene, was found with significant facial hair and had not been provided with a toothbrush or toothpaste since his admission over a week prior. He expressed a desire to be shaved more frequently, as he used to do at home, and had not brushed his teeth since arriving at the facility. The CNAs were responsible for providing daily mouth care and shaving during scheduled bath times, but these tasks were not completed for Resident #8, as confirmed by the CNA Bath & Shower Report and interviews with staff. The facility's policy on Activities of Daily Living (ADLs) requires that care be provided according to accepted standards and resident preferences. However, the observations and interviews revealed that the facility did not adhere to these standards for Residents #1 and #8, resulting in unmet personal care needs. The Director of Nursing confirmed that the deficiencies in shaving and oral care should have been addressed during the residents' regular bath times.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Tupelo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tupelo Community Care Center | 0.5 mi | ★★★★★ | 9 | 0 |
| Cedars Health Center | 5 mi | ★★★★★ | 5 | 1 |
| The Meadows | 15.5 mi | ★★★★★ | 8 | 0 |
| Courtyards Comm Living Center | 15.5 mi | ★★★★★ | 0 | 0 |
| Shearer-richardson Memorial Nursing Home | 16.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.