Diversicare Of Southaven
DIVERSICARE OF SOUTHAVEN in SOUTHAVEN, MS — inspection on February 20, 2026.
Found 2 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
continued as needed.
The DNS reviewed Resident #1's plan of care to ensure reflection of elopement
jeopardy to resident health or and operation immediately on 2/14/26, at 3:05 PM by Maintenance.
All doors were functioning safety properly.
The facility determined that Resident #1 followed a visitor and exited at the front entrance on 2/14/2026, at 1:08 PM.
The door alarm system functioned appropriately.
The Medical Director was
was notified by LPN #1 on 2/14/26, at approximately 2:00 PM. On 2/14/2026, a 100% audit of all residents identified for elopement risk was completed by the DNS to ensure placement and functioning of the wander guard system. An audit of elopement books located on all units and reception was completed by the DNS on 2/14/2026, to ensure pictures and care plans were present for all at-risk residents.
Elopement drills were completed on all shifts on 2/14/26, by Maintenance.
The Receptionist was educated on elopement guidance with emphasis on prompt response and investigation of alarm activation on 2/14/2026, by the DNS.
The Receptionist was placed on administrative leave on 2/14/2026.
The DNS and Assistant Director of Nursing Services immediately initiated an in-service on 2/14/2026, with nursing staff regarding elopement guidelines, including completion of risk assessments, care plan updates, and elopement book updates.
The DNS and Assistant Director of Nursing Services initiated additional staff education on elopement guidelines and abuse and neglect on 2/14/2026.
Education was provided to Social Services on 2/16/2026, by the Director of Clinical Operations on elopement guideline oversight. On 2/15/26, the DNS returned to the facility to educate staff and monitor effectiveness. On 2/16/2026, the DNS returned to educate staff and monitor effectiveness. On 2/18/2026, the DNS educated House Supervisors and Managers on Duty regarding elopement book accuracy. No staff member will be permitted to work without completing education. On 2/14/2026, facility leadership conducted a QAPI (Quality Assurance and Performance Improvement) meeting to address root cause and corrective action.
All corrective actions were completed on 2/18/26, and the facility alleged the IJ was removed on 2/19/26.
Validation: The State Agency validated the Removal Plan on-site during Complaint Investigation (CI) #2744403 and CI #2744399 through record review and interviews on 2/20/26.
The SA determined all corrective actions were completed on 2/18/26, and the IJ was removed on 2/19/26.
255109 02/20/2026
Diversicare of Southaven 1730 Dorchester Dr Southaven, MS 38671
administered as ordered for one (1) of three (3) resident reviewed for significant medication errors.
the Nurse Consultant as the facility protocol for missing medications, revealed, If medication is not available at administration time: Check E Kit (Emergency Medication Kit), call the pharmacy, obtain estimated time of delivery, notify supervisor. If greater than four (4) hours, call Medical Doctor (MD) to inform and obtain plan to address.
Record review of the January 2026 Electronic Medication Administration Record (eMAR) for Resident #4 revealed that on the night of admission, 1/9/26, Resident #4 had physician orders for Terazosin Hydrochloride (HCL) oral capsule 1 milligram (MG), give one (1) capsule by mouth one (1) time a day related to Essential Hypertension, scheduled at hour of sleep (HS); Dabigatran Etexilate Mesylate oral capsule 150 mg, give one (1) capsule by mouth two (2) times a day related to Paroxysmal Atrial Fibrillation, scheduled at HS; and Morphine Sulfate oral tablet 30 mg, give one (1) tablet by mouth two (2) times a day for pain related to Rheumatoid Arthritis.
Administration of all three (3) medications was documented as code seven (7), which indicates Other/See Progress Notes, indicating the medications were not administered as ordered.
Record review of Progress Notes, dated 1/9/26, and timed 11:48 PM, for Resident #4 revealed documentation stating, awaiting medications, with no further documentation to indicate the medications were obtained or administered in accordance with facility protocol.
Interview with Licensed Practical Nurse (LPN) #2 on 2/19/26 at 11:40 AM revealed that when a new resident is admitted , medication orders are transmitted to the pharmacy for dispensing and delivery.
She stated that if a medication is not available, staff may obtain medications from the Emergency Medication Kit (E Kit).
She further stated that if the medication is not available in the E Kit, staff may contact the pharmacy, including the backup or emergency pharmacy for after-hours needs, to obtain the medication. LPN #2 stated that failure to administer Resident #4's prescribed medications could result in adverse outcomes including elevated blood pressure, cardiac complications, or unmanaged pain.
Record review of the January 2026 eMAR for Resident #4 and interview with the Director of Nursing (DON) on 2/19/26 at 11:53 AM confirmed that the three (3) prescribed medications had not been administered as ordered.
The DON further stated that facility staff did not follow the facility protocol for obtaining unavailable medications and that it was her expectation that the medications would have been obtained and administered in accordance with physician orders and facility protocol.
Record review of the facility admission Record revealed that Resident #4 was admitted to the facility on [DATE] with diagnoses that included Essential Hypertension, Paroxysmal Atrial Fibrillation, and Rheumatoid Arthritis, which required ongoing physician-ordered medication management.
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.