Inspection Reports for Diversicare of Safe Haven

The complaint investigation (CI MS# 28356) substantiated that the facility failed to implement Resident #1's care plan, resulting in improper transfer and a right femur fracture.

The facility was found non-compliant for neglecting to follow the resident's care plan during transfers, resulting in a resident sustaining a right femur fracture. The facility failed to ensure staff used the proper assistive device and number of staff members for transfers as required by the care plan and Kardex.

The complaint investigation (CI MS# 28356) found that staff neglected to refer to the kiosk Kardex to ensure proper transfer methods and assistive devices were used for Resident #1, leading to injury. The resident was transferred improperly by CNA #1, causing a fracture. CNA #1 admitted to not checking the Kardex and using an incorrect transfer method.

The facility was found non-compliant with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, specifically failing to ensure a resident's right to be free from neglect by not following proper transfer procedures, which resulted in a resident sustaining a right femur fracture.

The complaint investigation found that Resident #1 was transferred improperly on 3/14/25, resulting in a fracture. The investigation included staff interviews, record reviews, and policy reviews. CNA #1 admitted to not following the care plan and using the wrong transfer method. The Administrator confirmed expectations for staff to follow care plans and use the kiosk for guidance. Resident #1 was diagnosed with dementia and required maximal assistance for transfers.

The facility failed to follow the care plan for Resident #1, resulting in the resident being transferred using an incorrect method without the required number of staff or proper assistive devices. This led to the resident sustaining a right femoral shaft fracture. Interviews and record reviews confirmed staff did not adhere to the care plan instructions, and the facility's policies and procedures were not properly followed.

The facility was found not in compliance with multiple Medicare and Medicaid requirements including environmental issues, failure to implement care plans, failure to provide Activities of Daily Living (ADL) care, inaccessible call lights, hydration issues, privacy breaches, unsafe environment, medication administration errors, infection control failures, and inaccurate staffing data submission.

Seven complaint investigations were conducted (CI MS #27183, CI MS #27690, CI MS #27865, CI MS #28043, CI MS #28193, CI MS #28208, and CI MS #28282). Non-compliance was identified in several complaints related to activities of daily living, hydration, and environment. Three complaints were investigated with no deficiencies cited.

The facility was found not in compliance with multiple standards including residents' rights, activities of daily living, hydration, medication storage, housekeeping, infection control, and environmental safety. Deficiencies included call lights not within reach, inadequate ADL care, improper fluid intake monitoring, unsecured medication carts, pest control issues, maintenance deficiencies, and failure to follow infection control precautions.

Seven complaint investigations were conducted (CI MS #27183, CI MS #27690, CI MS #27865, CI MS #28043, CI MS #28193, CI MS #28208, and CI MS #28282). Deficiencies were cited in four of these complaints related to call light accessibility, care plan implementation, ADL care, and hydration. Three complaints were investigated with no deficiencies cited.

The facility was found not in compliance with multiple Medicare and Medicaid requirements, including issues with call light accessibility, environmental safety, care plan implementation, ADL care, and hydration monitoring. Several deficiencies were cited related to resident safety, hygiene, and facility maintenance.

Seven complaint investigations were conducted (CI MS #27183, #27690, #27865, #28043, #28193, #28208, #28282). Non-compliance was identified in several complaints including failure to provide ADLs, hydration, and environmental issues. Some complaints were investigated with no deficiencies cited.

The facility was found not in compliance with multiple standards including residents' rights, activities of daily living, hydration, environment, housekeeping, and maintenance. Deficiencies were identified related to call light accessibility, ADL care, fluid intake monitoring, environmental safety, and facility maintenance.

The facility failed to ensure call lights were within reach for residents, maintain a safe and clean environment, provide timely maintenance and repairs, implement complete care plans for activities of daily living, and accurately monitor and document fluid intake for residents on fluid restrictions.

The facility was found deficient in multiple areas including failure to ensure resident call lights were within reach, failure to secure electronic health records, unsafe and unclean resident environments, failure to implement care plans for activities of daily living and fluid restrictions, unsafe storage of hazardous chemicals, inaccurate staffing data submission, failure to follow infection prevention protocols including enhanced barrier precautions, and ineffective pest control.

The complaint investigation MS #24852 was substantiated with a deficiency cited for failure to provide services according to professional standards. Complaint investigation MS #25031 related to discharge had no deficiencies cited.

The facility was found non-compliant for failure to provide services in accordance with professional standards of practice, specifically failing to change a negative pressure wound therapy system dressing as ordered for one resident. No deficiencies were cited related to discharge for the second complaint. The wound vac dressing was not changed as ordered, leading to foam adherence to the wound and potential harm.

Complaint investigation confirmed failure to change wound vac dressing as ordered. Resident Representative notified staff about the need for dressing change. The deficiency was substantiated with actual harm to the resident.

The facility failed to ensure that Resident #1's wound vac dressing was changed as ordered, resulting in the foam dressing adhering to the wound bed and causing actual harm. Interviews and record reviews confirmed the dressing was not changed on scheduled dates and fragments remained in the wound after removal.

The complaint investigation was initiated due to Resident #1 eloping from the facility on 03/31/24, remaining missing for approximately 10-20 minutes. The State Agency identified Immediate Jeopardy and Substandard Quality of Care beginning on 03/31/24. The facility implemented corrective actions by 04/01/24, and the Immediate Jeopardy was removed on 04/02/24 prior to the State Agency's entrance on 04/05/24.

The facility failed to implement an effective elopement/wandering risk care plan for Resident #1, who had a documented history of wandering and elopement attempts. Resident #1 exited the facility through an unsecured kitchen door that lacked an alarm, resulting in a 10-20 minute unsupervised absence. The facility initiated corrective actions including staff in-services, installation of new door locks and alarms, 24/7 door monitoring, and updated care plans. The immediate jeopardy was removed after corrective actions were validated by the State Agency.

The visit was triggered by seven complaint investigations (CI MS #23878, #23901, #23910, #24000, #24186, #24221, #24352). Non-compliance was found in multiple complaint investigations with citations issued. The facility was in compliance related to CI MS #24000 and CI MS #23901.

The facility failed to provide sufficient nursing staff, failed to provide assistance with activities of daily living for several residents, failed to maintain a safe and clean environment including damaged floors and unclean areas, failed to provide adequate linens and blankets, and failed to ensure call lights were functioning properly for residents.

The complaint investigations were triggered by multiple complaints including failure to provide a safe clean environment, failure to provide timely showers and incontinent care, insufficient staffing, and issues with resident rights and call light systems.

The facility was found non-compliant with Medicare and Medicaid requirements, citing failures in providing a safe, clean environment, timely showers and incontinent care, sufficient staffing, and proper resident rights. Specific deficiencies included lack of linens, damaged floors, unclean environment, insufficient staff to meet resident needs, and malfunctioning call lights.

The facility was found deficient in multiple areas including failure to provide adequate linens and blankets to residents, unsafe and damaged flooring, unclean environment, insufficient assistance with activities of daily living (ADLs) for several residents, inadequate staffing levels impacting resident care, and malfunctioning call light systems in resident rooms.

The facility failed to report complete COVID-19 information to the NHSN during a required seven-day period, specifically between 10/30/2023 and 11/05/2023, which has the potential to cause more than minimal harm to residents.

The facility failed to develop and implement complete care plans for shaving for two residents, failed to keep a call light within reach for one resident, failed to consult a physician for medication changes for one resident, failed to apply a splint for one resident with assistive devices, and failed to maintain a safe and sanitary environment in one resident's room due to dirty air conditioner filters and residue on the wall.

The complaint investigation (CI MS #22673) was related to environment and Activities of Daily Living, with cited deficiencies including failure to apply hand splints and issues with resident nourishment refrigerators.

The facility was found not in compliance with several standards including failure to apply recommended hand splints to prevent contractures, inadequate cleaning and maintenance of kitchen equipment and resident nourishment refrigerators, and improper infection control related to oxygen tubing storage. Deficiencies were cited in range of motion treatment, kitchen sanitation, and infection control.

The complaint investigation (Cl MS #22673) found noncompliance related to environment and Activities of Daily Living, citing deficiencies F677 and F921.

The facility was found not in compliance with multiple regulatory requirements including reasonable accommodations, notification of changes, comprehensive care plans, range of motion/mobility, accident hazards, food safety, and infection prevention and control. Deficiencies were cited related to call light accessibility, failure to notify physician of elevated blood sugar, incomplete care plans, failure to apply splints, unsecured oxygen cylinders, unclean ice machine, improper dishwashing temperatures, and unsanitary resident nourishment refrigerators.

The complaint investigation MS #22673 found noncompliance related to environment and activities of daily living, specifically citing failure to provide shaving assistance to residents.

The facility was found not in compliance with standards related to activities of daily living, specifically failure to provide shaving assistance to two residents. Deficiencies were cited at M625, M935, M1570, and M610 related to environment and activities of daily living.

The complaint investigation (Cl MS #22673) found noncompliance related to environment and Activities of Daily Living, citing deficiencies F677 and F921.

The facility was found not in compliance with multiple Medicare and Medicaid requirements, including deficiencies in comprehensive care plans, activities of daily living care (shaving), safe and sanitary environment, and medication management. Specific issues included failure to develop/implement care plans for shaving, failure to keep call lights within reach, failure to consult physicians for medication changes, failure to apply assistive devices, and environmental concerns such as dirty air conditioner filters and residue on walls.

The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, failure to notify physicians of critical blood sugar levels, incomplete care plans for residents, failure to apply prescribed splints, unsecured oxygen cylinders, unclean ice machine and resident nourishment refrigerators, and improper infection control practices related to oxygen tubing.

The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, with a trouble signal observed on the fire alarm panel that could not be reset to normal. The issue affected all smoke compartments and all residents on the day of the survey.

The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, evidenced by a trouble signal on the fire alarm panel that could not be reset during the inspection. The deficiency affected all smoke compartments and all residents on the day of the survey.

The facility failed to report complete COVID-19 information to the NHSN during the required seven-day reporting period between 08/07/2023 and 08/13/2023, as determined by CMS based on CDC data.

The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/07/2023 to 08/13/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.

The complaint was substantiated for physical environment issues related to cleanliness and sanitation.

The facility failed to maintain a clean, comfortable environment as evidenced by thick, pink and black substances in and around toilets and bathtub drains in four of 75 bathrooms observed. Interviews with staff confirmed the unsanitary conditions and acknowledged the potential risk to residents.

The facility was found deficient in providing adequate nail care to a dependent resident, maintaining a clean and safe physical environment with multiple maintenance issues, and ensuring a properly functioning resident call system on the East Wing.

The complaint investigations included multiple complaint IDs related to call light system, activities of daily living, environment, elopement, quality of care, and infection control. The abuse allegation was not substantiated. The elopement incident was reported late beyond the required 24-hour timeframe.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated complaints related to call light system, activities of daily living, environment, and timely reporting of incidents. Deficiencies were cited in areas including safe environment, notification of incidents, care planning, pressure ulcer prevention, and medication storage.

Complaint investigations included allegations related to call light system, elopement, quality of care/treatment/staffing, infection control, and possible abuse. The abuse complaint was not substantiated. The call light system complaint was substantiated with citations.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. Deficiencies were cited related to activities of daily living, pressure ulcer treatment and assessment, housekeeping and maintenance issues, and a malfunctioning call light system on the East Wing.

The survey included complaint investigations CI MS #19370, CI MS #19362, CI MS #19225, CI MS #18823, and CI MS #19414. Abuse investigation was not substantiated. Complaints substantiated included call light system, ADLs, environment, and timely notification to State Agency.

The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated complaints related to call light system, ADLs, environment, and other care issues. Multiple deficiencies were cited including safe environment, notice of transfer/discharge, care planning, pressure ulcer treatment, medication storage, and resident call system.

The facility was found deficient in maintaining a safe and clean environment, timely notification of hospital transfers, comprehensive care planning, nail care provision, pressure ulcer assessment by qualified staff, secure storage of narcotics, and proper functioning of the call system in the East Wing.

The complaint investigation involved three complaint numbers (MS #17617, MS #17876, MS #18025). The agency was unable to substantiate most allegations except for MS #18025 related to Admission, Discharge, and Transfer concerning discharge medications.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to properly reconcile discharge medications for three residents. No deficiencies were substantiated for other complaint areas. The facility failed to ensure medication reconciliation was completed and reviewed with residents or their representatives at discharge.

The State Agency conducted complaint investigations MS #17256, #17501, #17196, #16871, and #17195. None were substantiated for quality of care, infection control notification, or pressure areas.

The facility was found not to be in substantial compliance with infection control practices, specifically improper mask use by two dietary employees, leading to repeated deficient practice citations at severity level F.

Complaint investigations MS #17256, #17501, #17196, #16871, and #17195 were conducted. CI #16871, #17195, #17196 were not substantiated for quality of care. CI #17501 was not substantiated for infection control notification. CI #17256 was not substantiated for pressure areas.

The facility was found not in substantial compliance with infection control practices, specifically improper mask use by two dietary employees, leading to repeated deficient practice citations at severity level 'F'. Multiple complaint investigations were not substantiated. The facility implemented re-education and daily monitoring to ensure compliance.

Complaint Investigation MS #16968 was not substantiated related to Quality of Care. Complaint Investigation MS #17013 was substantiated related to Infection Control.

The facility failed to follow CDC guidelines for mask use and timely communication of positive COVID-19 test results to employees, resulting in two COVID-positive employees working with symptoms and potentially exposing 135 staff and 105 residents. Immediate Jeopardy was identified and later removed after corrective actions including education, monitoring, and weekly testing were implemented.

The facility was found not in compliance with infection control regulations, with an Immediate Jeopardy identified due to two COVID-19 positive employees who were not informed of their results and continued working, potentially exposing staff and residents. The Immediate Jeopardy was removed after the facility submitted and implemented an acceptable Removal Plan.

The complaint investigation revealed that two employees tested positive for COVID-19 but were not informed of their results due to administrative delays, leading to potential exposure of 135 staff and 105 residents. Immediate Jeopardy was identified on 08/26/2020 and removed on 08/28/2020 after corrective actions.

The facility failed to follow CDC guidelines for PPE use, including improper mask wearing by staff and failure to timely communicate positive COVID-19 test results to employees, resulting in two COVID-positive employees working while symptomatic and exposing residents and staff. Immediate Jeopardy was identified and later removed after corrective actions including staff education, increased testing, and monitoring were implemented.

The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. Infection control guideline violations were also observed.

Complaint Investigation MS #16968 related to Quality of Care was not substantiated. Complaint Investigation MS #17013 related to Infection Control was substantiated with citation F880.

The facility was found non-compliant with infection control practices recommended by CMS and CDC, substantiating complaint MS #17013 related to infection control with citation F880. An Immediate Jeopardy was identified due to failure to notify two COVID-positive employees, resulting in potential exposure to 135 staff and 105 residents. The Immediate Jeopardy was removed after the facility submitted and implemented a removal plan.

The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. The Immediate Jeopardy was removed on 08/27/2020 after corrective actions.

The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and exposed others. Infection control guideline violations were also observed.

The complaint investigation was substantiated for resident abuse (MS #16676). The facility investigated an incident on 02/22/2020 where CNA #1 shoved Resident #1 into a chair after Resident #1 used racial slurs. The incident was reported to the State Agency and local police. CNA #1 was suspended and terminated. Resident #1 had no lasting physical injuries but received a psychosocial evaluation.

The survey substantiated the complaint MS #16676 for resident abuse involving a physical altercation between CNA #1 and Resident #1. The facility failed to ensure Resident #1 was protected from physical abuse. The facility took immediate action by suspending and terminating CNA #1. Psychosocial evaluation and staff education were implemented as corrective actions.

The complaint investigation substantiated resident abuse involving CNA #1 pushing Resident #1 into a chair after the resident used racial slurs. The facility suspended and terminated CNA #1 and reported the incident to the State Agency and local police. Psychosocial evaluation of the resident showed no lasting negative effects.

The facility was found not in compliance with Minimum Standards of Operation. The complaint of resident abuse (MS #16676) was substantiated involving an incident where a Certified Nursing Assistant (CNA #1) physically pushed Resident #1 into a chair. The complaint regarding quality of care (MS #16639) was not substantiated and no deficiencies were cited for that. The facility took corrective actions including suspension and termination of CNA #1, staff education, and ongoing monitoring.

The facility was found not in compliance with several regulatory requirements including safe environment, restraint evaluation, accuracy of assessments, comprehensive care planning, ADL care, respiratory care, fire alarm system maintenance, fire drills, and emergency electrical system maintenance.

The facility was found not in compliance with several standards including restraint evaluation, activities of daily living assistance, and proper care and storage of respiratory equipment. Deficiencies were noted in ongoing restraint evaluations, assistance with personal hygiene and nail care for multiple residents, timely response to call lights, and cleaning and storage of nebulizer equipment.