Diversicare Of Eupora

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

leg up to her chest then she kicked LPN #1 and LPN #1 called her a b**** and shoved her leg/knee back in her chest.During a phone interview with CNA #2 on 8/27/25 at 2:40 PM, she stated Resident #1 was confused, fighting, hitting, kicking, and biting at staff. She stated staff were blocking the resident from hitting and kicking while trying to calm her down. She stated the resident managed to kick LPN #1 in the stomach, and LPN #1 called the resident a stupid b**** and pushed the resident's leg back toward her head. She confirmed she was present in the hallway during the incident and denied telling the Administrator or Director of Nursing (DON) that she had been at the nurse's station. She confirmed that she had sent the Administrator a text to let her know about the incident.Record review of a written statement provided by the Administrator and attributed to CNA #2 revealed: I love LPN #1 to death, but she went entirely too far when Resident #1 kicked her. Then she called her a stupid b****.During a phone interview with LPN #2 on 8/27/25 at 3:30 PM, she stated she worked on 7/28/25 and recalled Resident #1 being confused, resisting care, and fighting, kicking, and biting staff. She stated that staff attempted to block the resident's arms and legs to prevent injury. She denied seeing the incident but confirmed she heard LPN #1 use profanity in an attempt to calm the resident. She stated that while she did not view it as cursing at the resident, she acknowledged that profanity and blocking movements could have made the resident feel threatened.Record

review of a written statement provided by the Administrator and attributed to LPN #2 revealed: On 7/28/25 approximately 1900, LPN #1 did use profanity to get patient to stop kicking.Record review of an interview summary conducted by the Administrator and the DON revealed LPN #1 stated she heard a commotion, Resident #1 was on the floor in the hallway, kicking and biting. She stated she did not recall using any profanity during the situation. She stated she did push the resident's leg while trying to block the kick as the resident was trying to kick her and the CNAs.Record review of a Progressive Discipline Form for LPN #1 dated 8/5/25 revealed: On 7/28/25 it was reported that profane language was used with a resident. It was also alleged that physical force was used with the resident. Upon completion of the investigation, it was determined that profane language was used; however, no improper force was substantiated.Record review of an in-service titled Abuse and Neglect, dated 7/1/25, revealed LPN #1, LPN #2, CNA #1, and CNA #2 attended the training and signed the attendance sheet.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Diversicare of Eupora

156 E Walnut Ave Eupora, MS 39744

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on staff interviews, record review, and facility policy review, the facility failed to ensure that all allegations of abuse were immediately reported to the State Agency, failed to report allegations involving a licensed nurse to the appropriate licensing board, and failed to ensure staff recognized and reported abuse.

This deficient practice was identified for one (1) of three (3) residents reviewed for abuse allegations. (Resident #1)Findings include: Cross-reference F 600Review of the facility policy titled, Abuse, Neglect, Misappropriation, Exploitation Policy, dated January 2019, revealed: All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property, will be reported immediately to the Administrator, State Agency, and other officials in accordance with State law. Allegations involving licensed staff will be reported to the appropriate licensing authority.Record review of a facility-reported incident dated 7/29/25 revealed allegations of abuse were made against Licensed Practical Nurse (LPN) #1 involving Resident #1. The incident was reported to the State Agency; however, the facility did not notify to the Board of Nursing as required for allegations involving licensed staff.During an interview with Certified Nursing Assistant (CNA) #1 on 8/27/25 at 2:30 PM, she stated she witnessed the incident on 7/28/25 when LPN #1 used profanity and applied force to Resident #1.

She stated she did not report the allegation until the next day because she assumed another nurse would have reported it.During a phone interview with CNA #2 on 8/27/25 at 2:40 PM, she confirmed she also witnessed the incident but delayed reporting until the following day because she assumed another nurse had already reported it.During a phone interview with LPN #2 on 8/27/25 at 3:30 PM, she stated she heard LPN #1 use profanity toward Resident #1 but did not consider it abuse and therefore did not report the allegation either. LPN #2 confirmed that it is never okay to use profanity towards a resident and that she was the supervisor over the CNAs and she should have reported the incident right away.During an

interview with the Administrator and the Director of Nursing (DON) on 8/28/25 at 9:31 AM, they confirmed that staff failed to immediately report allegations of abuse that occurred on 7/28/25 related to LPN #1 and Resident #1. They also confirmed the allegation was not reported to the Board of Nursing because the facility did not substantiate the abuse, although they had statements of abuse from both CNAs.Record

review of an in-service titled Abuse and Neglect, dated 7/1/25, revealed LPNs #1 and #2 and CNAs #1 and #2 attended the training and signed the attendance sheet. In-service material: If any allegations of abuse that is reported to any team member, it is to be reported immediately.Remember to always report any suspicion of abuse and neglect immediately. Different types of abuse.when in doubt report it.

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