Diversicare Of Brookhaven
519 Brookman Drive, Brookhaven, MS 39601 · For profit - Corporation · 58 certified beds · (601) 833-2881 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2025
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $8,788 in federal fines (most recent 2025-06-04)
- its independent health-inspection rating is low (2/5)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 2 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 3 to 2 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 15.0% | 20.5% | 15.4% | typical |
| Long-stay residents who lose too much weight | 6.7% | 6.2% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.6% | 1.4% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.8% | 2.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.0% | 1.6% | 6.5% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.2% | 0.1% | better |
| Long-stay residents with falls causing major injury | 0.7% | 3.1% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 17.6% | 19.6% | 16.1% | typical |
| Long-stay residents on antianxiety or hypnotic medication | 27.0% | 23.8% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 97.0% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.7% | 6.3% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 24.2% | 20.7% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 7.8% | 21.7% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.8% | 2.5% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 95.7% | 84.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 31.2% | 27.7% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 23.9% | 15.5% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 2.39 | 2.43 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 5.23 | 2.86 | 1.80 | worse |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
67.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 103 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 55.8% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 43 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 6% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 67.3%CMS range 58.4–75.2 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 9.1–15.6 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 55.8% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 39.5% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 53.5% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 98.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | 100.0% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 1.5% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 3.1% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.9%CMS range 4.2–14.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 58 beds and averages 51.0 residents a day — about 88% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.49 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.05 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 2.89 hrs/resident/day on weekends vs 3.73 on weekdays — 22% thinner on weekends — a notable drop. RN hours go from 0.71 to 0.21 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 52% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Actual harm · G2025-06-04 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to protect residents right to be free from verbal, mental, and physical abuse for two (2) of four (4) sampled residents (Resident #2 and Resident #3). Specifically, Certified Nurse Aide (CNA) #1 verbally and physically abused Resident #2 during incontinence care on 5/21/25 by striking the resident's legs, scolding him, and failing to provide care in a safe, supportive, and respectful manner, resulting in the resident experiencing fear, shame, emotional distress, and feelings of helplessness. Additionally, CNA #1 verbally and mentally abused Resident #3 on 5/21/25 by scolding and berating the resident for incontinence, causing the resident to feel humiliated, ashamed, and fearful that the behavior would recur. Findings Included: Record review of the facility's Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed, .Purpose: To prohibit and prevent abuse, neglect .Definitions: Abuse: The willful infliction of .intimidation .with resulting physical harm, pain or…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-08 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews and facility policy the facility failed to obtain a physician order for oxygen (02) before administrating for one (1) of two (2) residents reviewed for oxygen. Resident #27Findings include:A record review of the facility's Oxygen Guideline policy with an update of 8/1/24, revealed medical oxygen is classified by the Food and Drug Administration as a drug and therefore it is provided in accordance with a healthcare provider's order and in accordance with acceptable standards of practice .On 01/05/2026 at11:32 AM, in an observation of Resident #27 in bed eating lunch. Resident #27 has O2 flowing at 2 milliliters (ml).On 01/07/2026 at 8:20 AM, an observation of Resident #27 in bed oxygen flowing at 2ml.On 01/08/26 at 12:18 PM, in an interview, the Director of Nursing (DON) stated they do not have standing orders. She stated we call the Nurse Practitioner (NP) for all orders. She confirmed oxygen is a medication and should not be given without physician order.Record…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2026-01-08 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to foods not dated, staff touching the garbage can lid and then touching clean dishes, touching food that is ready to eat with hands, staff touching their face then touching the food thermometer, placing used water pitchers back on the shelf with clean dishes during two (2) of (2) kitchen observations.Findings include:A review of the facility's policy, Handwashing Procedure for Dining Services, undated, revealed .situations that require hand hygiene.After handling soiled equipment or utensils.After.touching your.face.A review of the facility's policy, Food Storage: Cold Foods, revised 2/2023 revealed, .Procedures.5. All foods will be stored.labeled and dated.On 01/05/2026 at 10:08 AM, observation during an initial tour of the kitchen revealed Refrigerator #2 contained one (1) cup of what the Dietary Manager (DM) revealed to be thickened milk with no label or date. The DM acknowledged the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews and facility policy review the facility failed to develop a comprehensive care plan regarding Post Traumatic Stress Disorder (PTSD) and for the use of oxygen (O2) therapy for two (2) of 20 care plans reviewed. Resident #2 and Resident #27.Findings include:A record review of the facility policy Care Plan with an effective date of October 2021 revealed Care plans will be developed for all patients and residents based upon the Resident Assessment Instrument (RAI) manual guidelines .On 1/6/25 at 1:30 PM, in an interview Resident #2 stated she was in the Army for 34 years. She stated she fought in a war and that triggered her PTSD. She was very vague and would not talk much about it. She was talkative about other things. No behavior noted during interview.On 01/07/2026 at 2:40 PM, in an interview with Licensed Practical Nurse (LPN) # 1 stated residents have schizophrenia and get confused at times. She stated she is aware of PTSD and that should be on the care plan. On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-01-08 · tag F0679 — failed to provide activities — isolatedProvide activities to meet all resident's needs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review and facility policy review the facility failed to provide activities and invitations to activities to meet the residents' psychosocial needs for one (1) of 17 residents sampled. Resident # 19 Findings include:A review of the facility's policy, Resident Rights and Quality of Life Policy, with an effective date of March 13, 2020, revealed, .A patient or resident has a right.To receive services in a center environment that is.comfortable with adequate space for activities.A review of the facility's Recreation Services Assessment dated 12/29/25 revealed the resident listed several activities that he would enjoy including Bingo.During an interview on 1/05/2026 at 11:15 AM, Resident #19 revealed he was new to the facility. The resident stated he was not interested in group activities but would like to participate in one-on-one activities. The Resident stated he has not been offered any opportunities for activities since moving into the facility.On 01/06/2026 at 9:40 AM, during an observation the Activities Supervisor (AS) walked from room to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2026-01-08 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure infection control practices were followed during medication administration for one (1) of three (3) residents observed for medication pass (Resident #52).Findings include:Record review of the facility policy Handwashing/Hand Hygiene with an effective date of 11/1/2017 revealed .2. All team members shall follow the handwashing/hand hygiene procedures.8. Single use disposable gloves should be used.b. When anticipating contact with blood or body fluids; and C. When in contact with a resident, or the equipment or environment of a resident, who is on contact precautions .On 01/07/2026 at 8:10 AM, an observation of medication administration for Resident #52 was conducted with Licensed Practical Nurse (LPN) #1. During this time, the nurse was observed administering a nasal spray, an inhaler, and a lidocaine patch. LPN #1 entered the resident's room and placed the medications on the bedside table without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-24 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, facility policy review, and record review, the facility failed to revise the comprehensive care plan to reflect ongoing behavioral concerns and physical aggression for one (1) of three (3) sampled residents (Resident #1). Findings Include:A policy review of the facility's Care Plan policy dated 10/21 revealed culturally component goals and interventions for mood, behaviors, history of trauma, cognitive concerns. should be added to the comprehensive care plan .On 11/24/25 at 11:29 AM, in a phone interview, Certified Nursing Assistant (CNA) #1 stated Resident #1 had been physically abusive toward her on multiple occasions, including hitting, kicking, and grabbing her. She reported the behavior to the Nursing Home Administrator and was moved off the resident's hall.On 11/24/25 at 12:18 PM, Resident #1 was observed calm in bed, oriented to two domains, intermittently providing appropriate responses.On 11/24/25 at 12:30 PM, CNA #2 stated she had witnessed Resident #1 become aggressive with CNAs.On 11/24/25 at 12:53 PM, Resident #3, the roommate of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-11-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — patternProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, policy review and interviews, the facility failed to provide incontinent supplies and services for one (1) resident with indwelling urinary catheter (Resident #4) and for three (3) incontinent residents out of six (6) sampled incontinent residents, Residents #1, #2 and #3. Findings include:Policy review of the facility policy titled Proper Techniques for Urinary Catheter Maintenance, undated, revealed the policy revealed, .Do not rest the bag on the floor .Empty the collecting bag regularly, as a standard of practice at least every shift The policy did not address necessity of physician's order for indwelling catheters. Record review of the Incontinence Care Statement dated 10/27/25 signed by the facility Administrator revealed the facility provides incontinence care and follows the audit tool; the document did not address incontinence supplies. Record review of the Peri Care Audit Tool, undated revealed, If Foley catheter present .maintains drainage. Resident #1, #2 and #3 Incontinence suppliesOn 10/20/25 at 9:10 AM the facility Ombudsman…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-11-18 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility staff failed to handle and transport linens in accordance with accepted standards in order to provide hygienically clean linens and prevent the spread of infection for one (1) of five (5) observations and failed to follow appropriate infection control practice for management of drainage system associated with indwelling catheter within accepted standards of practice for one (1) of six (6) sampled residents, Resident #4.Record review of Facility History revealed the facility was cited 6/04/25 at level D for F880 for infection control due to improper handling of clean linen, therefore the scope and severity was increased to E.Findings include:Policy review of the facility policy titled, DESCRIPTION OF STEPS IN THE LAUNDRY PROCESS, Revision Date 10/25/16, revealed the policy stated, Soiled Linen containers or barrels should be on each Nursing unit stored in a soiled area so that nursing can deposit soled linen.it is very important to properly transport and store soiled linens to prevent the spread of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-11-18 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, policy review, and interviews the facility failed to ensure the right of the residents to reside and receive services in the facility with reasonable accommodation of resident needs to achieve independent functioning, dignity and well-being that reflect the resident's needs, specifically to call system within reach for two (2) of six (6) sampled residents, Resident #1 and Resident #4. Findings included: Policy review of the facility policy titled, Nurse Call System Effective Date 9/01/14, revealed the policy revealed, 2. Each cord needs to be visible and reachable by the resident to which it operates for . Resident #1On 10/20/25 at 1:25 PM during observation and interview with Resident #1 in his room revealed the call light for Resident #1 was attached to the transfer bar on the right side of the resident's bed by a clamp and not within the reach of the resident seated in his wheelchair on the left side of the bed. Resident #1 stated that he was not able to reach the call light.Record review of Resident #1's Minimum Data Set (MDS) with an Assessment Reference…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-04 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure care was provided in a manner that protected the dignity and privacy of residents for three (3) of four (4) sampled residents (Resident #1, Resident #2, and Resident #4). Specifically, the facility failed to maintain privacy during incontinence care for Resident #1 when staff provided care with the window curtain open, exposing the resident's perineal area; failed to provide a catheter bag cover for Resident #2 to maintain dignity; and failed to assist Resident #4 with meals in a respectful manner by standing over the resident while providing feeding assistance, rather than sitting at the resident's side. Findings Include: A review of the facility's policy, Resident Rights and Quality of Life, dated 3/13/20 revealed, .It is the policy of .that all residents and patients have the right to a dignified existence . A record review of the facility's Peri (Perineal) Care Audit Tool, undated, revealed Action including Staff must .provide privacy (door, window, room divider curtain .…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 15 citations
- Potential for harm · D2025-06-04 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on policy review, record review and interviews the facility failed to conduct a thorough investigation of an allegation of verbal and mental abuse for one (1) of two (2) sampled residents that reported an allegation of abuse, Resident #3. Findings included: Policy review of the facility titled Abuse, Neglect, Misappropriation, Exploitation Policy with Effective Date January 2019 revealed .Investigation If actual violation or alleged violation occurs the resident will immediately be assessed and removed from any potential harm (as applicable). The Administrator, or designee will oversee the center in conducting an internal investigation against any violation/alleged violation of abuse .Investigations will be prompt, comprehensive and responsive to the situation .The investigation will include .Notification of the physician and resident or resident representative .Interviews of all involved persons .Follow-up resolution .All material and documentation of the pertinent data to the investigation is collected, maintained and safeguarded by the center . A record review of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-04 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to implement comprehensive care plan interventions for one (1) of four (4) sampled residents reviewed for care plan implementation, Resident #1. Findings included: A review of the facility's policy titled Care Plans, 09/2020, revealed, .Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines . A record review of the Care Plan Report revealed Resident #1 had a Focus of At risk for falls . with Interventions including Resident to be taken to the dining room for meals, initiated on 4/28/25. On 6/2/25 at 12:00 PM, during an observation, Resident #1 was observed seated in her wheelchair in the hallway next to the door of her room, across from the nurses station, assisted by staff while eating lunch. On 6/3/25 at 12:00 PM, during an observation, Resident #1 was observed seated in her wheelchair in the hallway next to the door of her room, across from the nurses station, assisted by Certified Nurse Aide (CNA) #3 while…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-06-04 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to follow hand hygiene practices consistent with accepted standards of practice during incontinence care for one (1) of four (4) sampled residents reviewed for incontinence care, Resident #1. Findings included: A review of the facility's Peri (Perineal) Care Audit Tool, undated, revealed Action including, .7. STOP! Removes gloves, washes/sanitizes hands and re-gloves. 8. Applies clean brief, dresses resident . On 6/4/25 at 10:45 AM, during an observation, Certified Nurse Aide (CNA) #3 and CNA #5 provided incontinence care for Resident #1. After completing the care, the CNAs did not perform hand hygiene or change gloves before applying a clean brief and adjusting the resident's clothing. On 6/4/25 at 11:11 AM, during an interview with the Director of Nursing Services (DNS), she stated that during incontinence care, staff were supposed to stop after cleaning a resident with a wet and/or soiled brief, change gloves, and perform hand hygiene by washing hands or using hand sanitizer prior to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-20 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff and resident interviews, record review, facility policy review, and manufacturer's guidelines review, the facility failed to ensure a resident rinsed her mouth after the administration of a steroid Metered-Dose Inhaler to prevent possible mouth and throat irritation for one (1) of one (1) resident observed for administration of a Metered-Dose Inhaler. (Resident #32) Findings include: Review of the facility's policy for Medication Administration, titled, Administration of Metered dose Inhalers, reviewed/updated 04/22, revealed, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Procedure: . 10. Rinse mouth when required per manufacturer's recommendations or according to standards of practice . A review of manufacturer's guidelines on Important Safety Information for Symbicort revealed, . Symbicort may cause serious side effects, including…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff and resident interviews and record review the facility failed to ensure that a resident's CPAP (Continuous Positive Airway Pressure) mask was properly stored when not in use, for one (1) of fourteen (14) sampled residents. (Resident # 48) Findings Include: During an observation and interview with Resident #48 on 06/17/24 at 11:10 AM, he stated that he had been told by staff that they were not responsible for assisting with his CPAP mask. The resident's CPAP mask was observed uncovered and lying on the dresser near the foot of the resident's bed. On 06/17/24 at 4:28 PM, during an observation and interview, License Practical Nurse (LPN) #3 stated that the CPAP mask should be in a bag. She explained that this is to prevent the resident from contracting respiratory infections. She emphasized that nurses must ensure that the mask is sealed in a zip-lock bag when not in use, to prevent contamination of the mask. In an interview with the Director of Nursing (DON) on 6/20/24 at 3:12 PM, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-20 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, resident and staff interviews and record reviews, the facility failed to ensure a medication error rate of less than 5%, as evidenced by two (2) medication errors observed out of 27 opportunities for errors, resulting in a medication error rate of 7.4%. Residents #25 and #32 Findings Include: Review of the facility's policy for Medication Administration, titled, , Administration of Nasal Spray Preparations, dated 04/22 revealed, Medications are administered as prescribed . Personnel authorized to administer medication do so only after they have familiarized themselves with the medications . Review of the facility's policy for Medication Administration, titled, Administration of Metered dose Inhalers, reviewed/updated 04/22, revealed, Medications are administered as prescribed . Personnel authorized to administer medications do so only after they have familiarized themselves with the medications. Procedure: . 10. Rinse mouth when required per manufacturer's recommendations or according to standards of practice . A review of manufacturer's guidelines on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-03-21 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, record review, and facility policy review, the facility failed to ensure the Physician and Resident Representative (RR) were notified when a resident refused to take medications for one (1) of seven (7) sampled residents. (Resident #3) Findings include: Review of the facility's policy, Notifications of Patient/Resident Change, dated 11/1/16, revealed, The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient/resident's legal representative or an interested family member when there is: . (C) A need to alter treatment significantly . Record review of the Order Summary Report with active orders as of 12/1/23 revealed an order dated 12/30/22 for Albuterol Sulfate HFA (Hydrofluoroalkane) Aerosol Solution 108 mcg (micrograms) 2 puffs inhale orally two times a day related to Chronic Obstructive Pulmonary Disease (COPD). Record review of Resident #3's Electronic Medication Administration Record (EMAR) revealed Resident #3 refused Albuterol Sulfate HFA Aerosol Solution 108 mcg (micrograms) 2 puffs inhale…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2023-08-31 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure that each resident was treated with respect as evidenced by staff using foul language in the presence of residents for one (1) of four (4) residents reviewed. Resident #1. Findings include: Record review of the facility policy Resident Rights and Quality of Life, dated May 1, 2012, revealed, Policy Statement: It is the policy of Advocat that all residents have the right to a dignified existence . On 8/29/23 at 9:00 AM, during a telephone interview with the facility ombudsman, he confirmed he had received notification of inappropriate speech with foul language by Certified Nursing Assistant (CNA) #1, during care of Resident #1. On 8/29/23 at 9:40 AM, during an interview with the Administrator, she revealed CNA #1 was using poor customer service and was cursing and used foul language in the presence of residents. She stated that CNA #1 had received disciplinary action prior to 7/20/23 and that CNA #1's employment at the facility had been terminated on 7/24/23. The Administrator…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2023-08-31 · tag F0584 — failed to keep a safe, clean, comfortable home — isolatedHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and policy review, the facility failed to provide a safe, clean, comfortable, and homelike environment for two (2) of four (4) residents reviewed Residents #3 and #4 Findings include: Record review of the (Formal Name of Environmental Services) 5-Step Daily Room Cleaning, undated, revealed, PURPOSE: To teach Environmental Services employees the proper cleaning method to sanitize a patient room or any area in a healthcare facility .2. Horizontal Surfaces - disinfected *Using a solution of properly diluted germicide, sanitize all horizontal surfaces .*Tabletops, headboards, windowsills, chairs, over bed lights, wall ledges, over bed tables, and the bases of over bed tables should all be done . 4. Dust Mop . *Remember to dust mop and damp mop under beds . *When finished dust mopping, use a dustpan and brush to sweep up the debris. 5. Damp Mop . *The most important area of a patient's room to disinfect is the floor. This is where most airborne bacteria will settle and so it needs to be sanitized daily . *Mop all flooring surfaces . making…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2022-12-01 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, staff interviews, and facility policy review, the facility failed to ensure cookware was properly sanitized for one (1) of two (2) kitchen tours. All 55 residents residing in the facility had the potential to be affected. Findings Include: A review of the Facility's policy, Manual Warewashing Policy, revised 09/2017, revealed, . All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized. Procedures 1. The Dining Service staff will be knowledgeable in proper technique including .chemical sanitizer testing and concentrations. 2. Appropriate test strips will be utilized to measure the concentration of the sanitizer solution. Results will be recorded on the Three-Compartment Sink Log . An observation on 11/30/22 at 10:52 AM, revealed the chemical sanitizer in the three-compartment sink was checked with the assistance of the Dietary Manager (DM). The DM placed a sanitizer test strip into the compartment that should have held the sanitizer, removed it, and compared it to the color chart on the test…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-12-01 · tag F0919 — failed to provide a working call system — patternMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and facility policy review the facility failed to maintain a properly functioning call system for one (1) of four (4) halls observed. B Hall Findings Include: Review of facility's policy titled, Nurse Call System, dated September 1, 2014, revealed Purpose: To maintain center call systems in an ideal mechanical condition to ensure optimum performance when residents request assistance from staff.Monthly the Nurse call system should be checked for the following: 4. Any component that does not function should be repaired as soon as practically feasible. 5. Systems with audio functions should be tested monthly. Any non-operating components should be repaired as soon as practically feasible. An observation on 11/28/22 at 03:45 PM, revealed the call light above the door of room [ROOM NUMBER] on B Hall was on, but there was no audible sound in the hall or at the nurse's desk. In an interview on 11/28/22 at 03:45 PM, with Licensed Practical Nurse (LPN) #3, she stated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interviews, and facility policy review, the facility failed to honor a resident's right to choose health care by not administering the requested influenza vaccination to a resident upon admission for one (1) out of 6 (six) vaccination records reviewed. Resident #307 Findings include: Review of the facility's policy, Influenza Vaccination Policy (Patients and Residents), dated 11/1/16, revealed, . For the health and safety of all patients and residents, influenza immunization is required on an annual basis, based on the risk presented to patients and residents through routine and direct exposure. Vaccination has been shown to reduce the transmission of influenza while reducing influenza related illness and death in health care centers . On 11/28/22 at 4:37 PM, in an interview with the son of Resident #307, he stated the resident wants a flu shot and no one has given it to her. On 11/29/22 at 2:00 PM, in an interview with Resident #307, she confirmed she has not gotten her flu shot yet. She…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · tag F0644 — isolatedCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and facility policy review, the facility failed to ensure a PASRR (Pre-admission Screening and Resident Review) Level II was obtained for a resident after a diagnosis of a serious mental disorder was received for one (1) of five (5) resident records reviewed. Resident #20. Findings include: Review of the facility's policy, PASRR, (undated), revealed . 2. A subsequent PASRR Level II is defined as any PASRR Level II completed after an initial PASRR Level II when there is a significant change in the physical, mental, or emotional condition of and NF (nursing facility) resident. a) The significant change is for persons with previously identified MI (Mental Illness), ID/DD (Intellectual Disability/Developmental Disability) and/or RC (Related Condition) whose needs have changed as well as for persons with newly discovered or suspected MI, ID/DD and/or RC. b) The purpose of a subsequent PASRR Level II is to assess whether the resident is still appropriate for the NF level of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-12-01 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, interviews, and facility policy review, the facility failed to store the Flonase belonging to Resident #109 in a locked compartment to prevent possible overdose of a medication for one (1) of five (5) medication observations. Resident #109 Findings Include: Record review of the facility's, Medication Administration Competency Checklist, reveals the facility uses [NAME] and [NAME], Clinical Nursing Skills & Techniques, 8th Edition, as their medication administration policy and procedure. Review of the checklist revealed . 2. Administered medications: p. Stayed with the resident until the resident completely took all medication by the prescribed route, . Review of the facility's, Licensed Nurse Core Clinical Competency, revealed RN #1 was checked off on Medication Administration on 10/29/22. An observation on 11/29/22 at 1:17 PM, revealed a bottle of Flonase on the bedside table of Resident #109. In an interview on 11/29/22 at 1:17 PM, Registered Nurse (RN) #2 confirmed there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- No harm found · B2024-06-20 · tag F0641 — patternEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, staff interviews, and facility policy review, the facility failed to correctly code a discharge from the facility on the Discharge Minimum Data Set Assessment (MDS) for one (1) of 14 sampled residents reviewed for assessment accuracy. Resident #49 Findings Include: Record review of the facility's policy titled, MDS and Care Plans, with the latest effective date, August 2019, revealed, Care plans and MDS will be developed and maintained per RAI (Resident Assessment Instrument) Guidelines. Record review of the facility's, Progress Notes, revealed Resident #49 was discharged to home, with a local Home Health Agency on 4/2/2024. Record Review of the Discharge MDS, with an Assessment Reference Date (ARD) of 04/02/24, revealed in Section A that Resident #49 was discharged to an acute hospital. Review of the facility's, admission Record for Resident #49 revealed an admission date of 03/07/24, which included diagnoses of Fracture of Left Patella, Unspecified Dementia, and Major Depression.…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$8,788 in federal fines across 1 penalty.
- $8,788 — penalty dated 2025-06-04
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to DIVERSICARE HEALTHCARE — 44 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 2 of 5 | 2.6 | -0.6 vs chain |
| Health inspection | 2 of 5 | 2.5 | -0.5 vs chain |
| Staffing | 3 of 5 | 3.0 | ≈ chain avg |
| Quality measures | 3 of 5 | 3.5 | -0.5 vs chain |
The other 43 homes this chain runs (chain average 2.6★, per CMS)
Showing 40 of 43; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| DIVERSICARE LEASING COMPANY III LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | since 07/01/2016 |
| ADVOCAT FINANCE, LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 07/01/2016 |
| DAC NEWCORP INC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/04/2022 |
| DIVERSICARE HEALTHCARE SERVICES LLC | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 04/04/2022 |
| DIVERSICARE MANAGEMENT SERVICES LP. | Organization | 5% OR GREATER INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 07/01/2016 |
| KELLMAN, FRANKLIN | Individual | CORPORATE DIRECTOR | — | since 09/13/2024 |
| KOHN, BRIAN | Individual | CORPORATE DIRECTOR | — | since 11/19/2021 |
| RATNER, ERAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | — | since 09/13/2024 |
| BODIE, REBECCA | Individual | CORPORATE OFFICER | — | since 03/02/2020 |
| NEE, STEPHEN | Individual | CORPORATE OFFICER | — | since 02/20/2023 |
| WEISHAAR, MATTHEW | Individual | CORPORATE OFFICER | — | since 12/01/2003 |
| DIVERSICARE OF BROOKHAVEN LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | since 10/01/2016 |
| CANOVA, CHAROLETT | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 10/04/2017 |
| HODGES, COLE | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 11/15/2024 |
CMS files one row per role, so the 18 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.
6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $364K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MS
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Mississippi Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 255175. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.