Diversicare of Tupelo: Resident Falls from Bed - MS
The resident, identified in inspection records only as Resident #1, has been a patient at Diversicare of Tupelo since November 2015. He was admitted following a cerebral infarction that left him with hemiplegia and hemiparesis affecting the right dominant side of his body. He cannot reposition himself in bed without help. He cannot toilet himself without help. Both facts were written into his care record.
The fall happened on July 25.
A nursing assistant, identified in the inspection report as CNA #1, was providing incontinent care that morning. She was working alone. As she turned the resident, he reached toward his bedside table and fell off the bed. In an interview with inspectors on August 11, she said she had been turning him alone or with one other person "depending on his mood." She confirmed she knew she was supposed to check his Kardex, the individual care instruction sheet that staff use to know what each resident requires, and that she believed it called for one-to-two-person assistance.
It did not. The Kardex for the period covering July 22 through July 25 specified two-person physical assist for both bed mobility and toileting. The facility's own administrator confirmed this to inspectors at 2:00 PM on August 11, stating directly that staff failing to follow those instructions caused the accident.
Two other aides described the situation plainly. CNA #2, who had been at the facility for about a month and had cared for Resident #1, told inspectors she was trained to follow the Kardex and that he had required two-person assistance the entire time she worked with him. CNA #3, who was also regularly assigned to the resident, confirmed the same thing. She explained he needed two people for bed mobility and incontinent care because he is contracted, meaning his muscles pull and stiffen in ways that make repositioning unpredictable.
The facility's own clinical assessment told the same story. A Minimum Data Set assessment completed July 15, ten days before the fall, coded Resident #1 as requiring two-person physical assist for bed mobility and two-person physical assist for toileting. The requirement was not ambiguous. It was not new. It was not buried in a file nobody read.
Federal inspectors classified the violation as causing actual harm, the agency's designation for deficiencies that result in real injury or decline rather than a theoretical risk.
What the inspection does not say is whether Resident #1 was hurt in the fall, what treatment he received, or whether he was alone on the floor while staff sought help. The report does not say how long the requirement had been in place before July 25 or how many times he may have been moved by a single aide before that morning. It does not say whether anyone was disciplined.
What it does say is that three different nursing assistants understood the requirement, that it was documented in the records they were trained to consult, and that on July 25, a man who cannot control the right side of his body was turned by one person anyway. He reached for something on his nightstand, the way anyone might when they feel themselves going, and he fell.
He has lived at Diversicare of Tupelo for nearly ten years.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Diversicare of Tupelo from 2025-08-11 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
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Last verified: November 4, 2026 · Our methodology
DIVERSICARE OF TUPELO in TUPELO, MS was cited for violations during a health inspection on August 11, 2025.
The resident, identified in inspection records only as Resident #1, has been a patient at Diversicare of Tupelo since November 2015.
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.