Diversicare Of Shelby

Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data review and facility policy review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 2nd Quarter 2025 (January 1, 2025, through March 31, 2025) Findings include: Record review of the facility policy titled, Payroll Based Journal Entry Submission, dated 2022, revealed, Procedure .7. Hours that each team member works each day must be submitted. Per CMS training hours and corporate team member hours may be included if the team member is providing direct care or performing direct care duties . Review of the PBJ Staffing Data Report revealed the facility triggered for excessively low weekend staffing for the 2nd quarter, 2025 (January 1, 2025, through March 31, 2025). During an interview on 6/30/25 at 12:40 PM, the Human Resource Coordinator revealed the facility used a phone application (APP) for their payroll time clock system. At times, the APP did not work properly and during those times, the employee's…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and facility policy review, the facility failed to maintain a clean, safe, and homelike environment in one (1) of fifty-five (55) resident rooms observed. This deficient practice resulted in a room environment with visible water damage and possible mold growth, which may pose a health risk to the resident occupying the room. room [ROOM NUMBER] B. Findings include: A review of the facility ' s policy, Types of Maintenance, with no date, revealed, Routine Maintenance. This is the most frequently done activity of all and is done by performing routine and scheduled maintenance of the property . On 6/29/2025 at 11:30 AM, during an observation, room [ROOM NUMBER] on the B-side was noted to have a large, irregular-shaped light brown and black discoloration on the far wall, extending approximately two (2) feet across the ceiling and approximately two (2) feet down the wall. On 6/30/2025 at 8:38 AM, during an observation with the Infection Control Nurse, she verified 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.

Based on observation, resident/staff interview, and record review, the facility failed to implement a comprehensive care plan for nail care for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead with an effective date of October 2024 that revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Record review of Resident #10's Care Plan Report revealed under, Focus: Self-care deficit due to: Recent surgery for trans metatarsal amputation of left foot. Additionally revealed under, Interventions/Tasks: Nail, hair, and oral care daily as needed. On 6/29/25 at 11:55 AM an observation and interview with Resident #10 revealed fingernails on both hands were long, jagged, and measured approximately three-eighths (3/8) inches in length from the fingertip. She stated she would like them trimmed and explained that her…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record review, the facility failed to perform nail care for a resident requiring assistance with activities of daily living (ADLs) for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead that read, Policy: Proper name of the facility uses Clinical Nursing Skills and Techniques, [NAME]. [NAME], as a supplementary policy and procedure care guide. An observation and interview with Resident #10 on 6/29/25 at 11:55 AM revealed she was lying in bed with long fingernails bilaterally that measured approximately three-eighths (3/8) of an inch long and were jagged. She admitted that staff had told her they would trim them, but no one ever came. She stated that her nails had never been as long as they are now and she wanted them trimmed. An observation and interview with Certified Nurse Aide (CNA) #1 on 6/30/25 at 8:35 AM confirmed Resident #10's long nails. She stated the treatment nurse was responsible for trimming 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.

Based on observation, staff interview, record review, and facility policy review, the facility failed to use Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC) for one (1) of 16 residents on EBP reviewed.(Resident #206). Findings include: Review of the policy titled, Proper Name Infection Control Guide, dated 2025, revealed Enhanced Barrier Precautions (EBP) refer to the expanded use of PPE (personal protective equipment) and involve the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs (multidrug-resistant organisms). Nursing home residents with indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. Indwelling devices, e.g., (for example) central lines. Review of the Order Summary Report for Resident #206 revealed an order for Cefepime Intravenous (IV) solution 2 (two) GM/100 ML (grams/milliliter): administer two grams intravenously twice daily, with a start date of 6/26/25 and an end date of 7/06/25. IV-PICC:…

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.

Based on staff interviews, record review and facility document review, the facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for one (1) of four quarters reviewed. First quarter 2024 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator (LNHA) revealed Staffing: It is the practice of (Proper name of the facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staffing expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment. The center conducts work force management meetings daily to discuss open positions, open shifts and call ins as related to patient needs. We continue to actively recruit staff offering various incentives. Record review of the PBJ (Payroll-Based Journal) Staffing Data Report revealed the facility submitted excessively low weekend staffing data for the 1st quarter 2024 (October…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and facility policy review the facility failed to provide blinds or window coverings in good repair for one (1) of 60 resident rooms observed for a clean, comfortable, and homelike environment. room [ROOM NUMBER]. Findings Include: Review of the facility policy Work Orders and Paging, effective September 1, 2014, revealed, Purpose, To establish a productive procedure for communicating and coordinating the needs of the residents and employees from the Maintenance Department . Work Orders, TELS . is a Computerized Maintenance Management System (CMMS). Employees shall complete Work Orders through TELS. When a verbal request for maintenance is received from center personnel, maintenance staff should request that a work order be submitted . An observation of room [ROOM NUMBER] on 5/19/24 at 1:00 PM, revealed the window blind had broken slats creating a 12 by six (6) inch opening on the right side through which the parking lot was visible. In an interview on 5/20/24 at 9:35 AM,…

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.

Based on observation, staff interview, record review, and facility policy review, the facility failed to implement a comprehensive care plan for a resident receiving an enteral feeding (Resident #1), and failed to develop a comprehensive care plan for a resident receiving antipsychotic medication (Resident #54) for two (2) of nineteen care plans reviewed. Findings Include: Review of the facility policy titled Care Plans with a revision date of October 2021 revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. This document was dated 5/21/24 and signed by the Licensed Nursing Home Administrator. Resident #1 Record review of Resident #1's care plan revealed, Focus: (Proper name of Resident #1) has PEG (Percutaneous Endoscopic Gastrostomy) tube placed and is at risk for complications R/T (related to) feeding tube .Interventions . every shift Jevity 1.5 @ (at) 65…

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.

Based on observation, staff interview, and record review and facility document review, the facility failed to ensure a resident who received enteral nutrition received appropriate treatment and services, as evidenced by, the facility's failure to administer an enteral feeding according to the physician's order for one (1) of 11 residents with a feeding tube. Resident #1 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator revealed, Standards of Practice: The expectation set forth by (Proper Name of the facility) is that nurses comply with current standards of practice in terms of following physician's orders. This includes following orders for medication and enteral feedings. An observation on 5/19/2024 at 12:25 PM, revealed Resident #1 with his eyes closed lying in bed A bottle of Jevity 1.5 was hanging via pump, which was turned off. An observation on 5/19/2024 at 3:15 PM, revealed Resident #1 lying in bed with his eyes closed. A bottle of Jevity 1.5 was hanging via pump, which was turned…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, the facility failed to refer a resident to the appropriate agency for a Level II Preadmission Screening and Resident Review (PASARR) following an inpatient Geri-psych admission with a new psychiatric diagnosis and new psychiatric medications for one (1) of four (4) sampled residents reviewed for PASARR. Resident #16. Findings include: Record review of a typed document on facility letterhead dated 1/4/22 provided and signed by the Administrator revealed (Formal Name of Facility) go by the State Guidelines on performing PASSARS. We do not have a Passar Policy. Record review of the Medical Diagnosis List for Resident #16 revealed a diagnosis of Schizophrenia, Unspecified, with a date of 11/19/19. Record review revealed there was no Change in Status Form completed for Resident #16, related to the inpatient admission to Geri-psych on 11/8/19 during which the resident received a new psychiatric diagnosis of Schizophrenia, dated 11/19/19, and a new physician's order for new…

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.