Diversicare Meridian: Call Lights Ignored 40 Minutes - MS
The May 20 incident unfolded during shift change when three nurses sat at the nursing station conducting report while call lights rang throughout the North Wing. Five call lights sounded across three halls. Nobody answered them.
Resident #11's call light had been on for 30 or 40 minutes when inspectors entered her room at 2:45 PM. She told them she needed help.
The nursing assistants had simply walked away. CNA #4 went outside to dump her barrel before shift change without informing nurses she was leaving the hall. CNA #1 also left to dump her barrel and "did not think to notify the nurse." A third assistant, CNA #9, had been sent home on administrative leave at 2:45 PM.
None of the nurses knew where their nursing assistants had gone.
"I did not know where the CNAs were," the Assistant Director of Nursing told inspectors the next day. She was unaware that the Administrator had sent CNA #9 home on administrative leave until inspectors asked about the unanswered call lights.
Licensed Practical Nurse #3 confirmed no nursing assistants were on the floor at 2:30 PM. She didn't know they had left until inspectors asked to speak with them. She didn't know how long they had been gone.
"CNAs are supposed to report off to the nurses before leaving or going home but often fail to do so," LPN #3 told inspectors. She said administrative staff knew that nursing assistants often left without notification.
The evening shift nursing assistant, CNA #8, clocked in at 2:25 PM and found call lights sounding with no nursing assistants on the hall. She observed three nurses at the nursing station. CNA #8 normally worked as the transportation aide on day shift but had been working evenings due to staffing shortages.
"We try to do the best we can with what we have," CNA #1 told inspectors, explaining that the hall was often short-staffed.
The facility's own staffing policy requires adequate staffing to provide necessary care and services for each resident. It states that staff conduct workforce management meetings daily to discuss open positions and call-ins related to patient needs.
But the breakdown in basic communication left an entire wing without direct care staff during the vulnerable shift change period.
LPN #2, who was receiving report at the nursing station at 2:30 PM, confirmed that nursing assistants do not conduct walking rounds and that day shift assistants were not on the hall when she arrived. She didn't know this until inspectors asked.
"She would have helped with call lights if she had known and acknowledged that nurses struggle to assist due to CNA shortages," inspectors documented.
The Administrator confirmed around 2:50 PM that she had informed CNA #2 that CNA #9 had been placed on administrative leave, leaving the North Hall down one nursing assistant. She was unaware the other assistants were not on the hall.
CNA #6 told inspectors that day shift nursing assistants "are often gone before the evening shift arrives." She confirmed only one evening shift nursing assistant was on the floor when she arrived for her shift.
The staffing crisis extended beyond that single incident. Federal data revealed the facility triggered for excessively low weekend staffing during the fourth quarter of 2024. The Director of Nursing and Assistant Director of Nursing worked shifts to cover shortages but failed to clock in and out, meaning their hours weren't captured in federal staffing reports.
"Both are salaried employees and were not clocking in and out during the first quarter," the Director of Nursing told inspectors. "The only proof they have that they worked is the assignment sheets, where they wrote themselves in."
The facility only began requiring salaried employees to clock in and out when working direct care shifts two weeks before the inspection.
Kitchen conditions added another layer of concern. Inspectors found 14 overly ripe cucumbers with white slimy rind, soft and pliable to the touch, with liquid pooled at the bottom of the container in refrigerator #3. The pantry contained 19 overly ripe oranges with green and white growth on the rind and an apple with a brown soft spot and exposed interior.
An opened bottle of yellow mustard was past its "best if used by" date. A gallon-sized bottle of soy sauce sat unrefrigerated despite manufacturer instructions to "refrigerate after opening for quality."
The Dietary Manager acknowledged the spoiled produce and improperly stored items. She told inspectors it was her responsibility to ensure food wasn't expired and was stored properly. She hadn't examined the produce that day as she had intended.
"The DM confirmed the risks of having overly ripe food in the kitchen," inspectors documented.
The Administrator acknowledged both the spoiled food and the staffing breakdown. She stated her expectation that the Dietary Manager would develop a system to stay on top of monitoring food safety.
The facility actively recruits staff and offers various incentives to address ongoing shortages. Available shifts are posted for staff to pick up as needed. But the May 20 incident demonstrated how quickly gaps in coverage can leave vulnerable residents without help.
CNA #8 spent her first 20 minutes on shift answering the call lights that had been ringing unanswered. By then, Resident #11 had been calling for help for nearly an hour.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Meridian from 2025-05-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
DIVERSICARE OF MERIDIAN in MERIDIAN, MS was cited for violations during a health inspection on May 21, 2025.
Five call lights sounded across three halls.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at DIVERSICARE OF MERIDIAN?
- Five call lights sounded across three halls.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in MERIDIAN, MS, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from DIVERSICARE OF MERIDIAN or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 255118.
- Has this facility had violations before?
- To check DIVERSICARE OF MERIDIAN's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.