Diversicare Of Meridian
DIVERSICARE OF MERIDIAN in MERIDIAN, MS — inspection on May 21, 2025.
Found 3 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility's Monthly Schedule dated October, November, and December 2024 revealed the Director of Nursing (DON) worked as supervisor on October 26 and 27, November 3, and December 14 and 29, 2024.
She worked on the floor as a nurse on November 5 and December 29, 2024.
Review of the facility's Monthly Schedule dated October, November, and December 2025 revealed the Assistant Director of Nursing (ADON) worked as supervisor on October 6 and 19, November 3, 14, 16, and 17, and December 1 and 29, 2024.
The ADON worked on the floor on October 5, 12, 13, and 29, November 22, and December 29, 2024.
During an interview on 5/19/25 at 11:00 AM with the Director of Nursing (DON), she explained she did not know the facility triggered for low weekend staffing in the first quarter.
The DON said she and the Assistant Director of Nursing (ADON) work when the nursing staff is low.
The DON revealed that both are salaried employees and were not clocking in and out during the first quarter.
The DON said they just started clocking in and out within the last two (2) weeks.
The DON also said the only proof they have that they worked is the assignment sheets, where they wrote themselves in.
This is not included in the daily Payroll Based Journal.
During an interview on 5/19/25 at 11:15 AM with Certified Nursing Assistant (CNA) #2, she revealed she is responsible for the schedule for the nurses and CNAs. CNA #2 stated that if the staff members work a different shift or work beyond their routine shift, she goes into the system and corrects the information. If the staff works on the floor but normally performs other jobs, she changes the code to reflect the correct position the staff worked that day.
The corporate office is responsible for sending in the PBJ.
During an interview on 05/20/25 at 09:00 AM with the Administrator, she explained she was not aware the facility triggered in the first quarter of 2025 for excessively low weekend staff.
The staffing coordinator corrects the staff punches daily.
This goes directly to the corporate office.
The Administrator confirmed the facility just started two (2) weeks ago a new process requiring all salaried employees to clock in and out when they work on the floor.
During an interview with the Director of Payroll, he explained he has not received anything from CMS showing that the facility triggered for excessively low staff for the first quarter.
The Director said the PBJ was accepted.
255118
During an observation and interview on 05/18/25 at 11:41 AM, the State Agency (SA) observed Resident #14 sitting up in his wheelchair in the hallway. Resident #14 complained that the staff would not let him use the large bathroom in the hallway. He stated he could not get in and out of the bathroom in his room and had difficulty getting on the toilet. He reported he could transfer himself but did need assistance, although it took staff a long time to come and help.
On 05/19/25 at 12:10 PM, during an interview with Certified Nurse Aide (CNA) #3, she explained Resident #14 is very independent and will do everything for himself. He is to be assisted with transfers but will not wait or even ask for assistance.
She stated he requires assistance from one (1) staff member with transfers.
On 05/19/25 at 12:25 PM, the SA observed Resident #14 returning to his room with two (2) staff members.
During an interview with the Therapy Director, she explained the resident was recently discharged from therapy but was referred back due to his complaint about not being able to use his bathroom. Resident #14 was discharged from therapy with no problems using the bathroom in his room and was walking 10-15 feet with assistance. Resident #14 wheeled himself into the bathroom without concerns, stood, and used the assist bar on the wall. No concerns were noted with the transfer with therapy staff providing contact guard assist.
On 05/19/25 at 2:00 PM, during an interview with Registered Nurse (RN) #2, she explained Resident #14 requires assistance from one (1) staff member, but the resident will not call for assistance.
255118
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 255118 B.
Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Diversicare of Meridian 4728 Highway 39 North Meridian, MS 39301
Findings Include:
A review of the facility's Resident Rights and Protections Under State and Federal Law dated 2022 indicates, You have the right to voice grievances and recommend changes . to representatives . and The nursing home must try to resolve the issue promptly.
A review of the facility's Customer Concern (Grievance) Policy, effective date July 2018, indicates, Support residents' right to voice concerns . and ensure after receiving a concern, the center actively seeks a resolution ., and Customer concerns will have a prompt response .
A record review of the Resident Council meeting minutes dated October 16, 2024, and November 20, 2024, confirmed residents raised concerns about the lack of condiments.
On 05/18/25 at 12:30 PM, an observation of the dining room revealed baked potatoes served to residents with no salt or pepper packets on the trays to season the potatoes. No salt and pepper shakers were observed on the tables.
On 05/18/25 at 12:55 PM, the State Agent observed Resident #52 having lunch in Styrofoam to-go containers.
The resident's lunch consisted of slices of roast beef, carrots, baked potatoes, and a cookie. No condiments were noted on the tray.
On 05/18/25 at 01:00 PM, during an interview with a Certified Nursing Assistant (CNA), she confirmed that she assisted Resident #52 with lunch and noted the resident had no condiments on her tray, including butter, salt, or pepper.
She explained that she went to the kitchen and was informed there was no butter or salt and pepper.
She further explained that the dietary manager had announced over the intercom that all meals would be served in Styrofoam to-go containers due to only two kitchen staff working that day.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
255118
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 255118 B.
Wing 05/21/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Diversicare of Meridian 4728 Highway 39 North Meridian, MS 39301