Diversicare of Shelby

In the surveyor’s words

From the most serious findings on record at Diversicare of Shelby, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jul 1, 2025

  Based on staff interview, record review, Payroll-Based Journal (PBJ) staffing data review and facility policy review, the facility failed to submit PBJ data accurately to the Centers for Medicare and Medicaid Services (CMS) for one (1) of four (4) quarters reviewed. 2nd Quarter 2025 (January 1, 2025, through March 31, 2025) Findings include: Record review of the facility policy titled, Payroll Based Journal Entry Submission, dated 2022, revealed, Procedure .7. Hours that each team member works each day must be submitted. […]

• No harm, potential for more than minimal, widespreadF851May 22, 2024

  Based on staff interviews, record review and facility document review, the facility failed to submit accurate staffing information into the Payroll-Based Journal (PBJ) system for one (1) of four quarters reviewed. First quarter 2024 Findings Include: Record review of a typed document on facility letterhead, dated 5/21/24 and signed by the Licensed Nursing Home Administrator (LNHA) revealed Staffing: It is the practice of (Proper name of the facility) to assure that adequate staffing is maintained to provide the necessary care and services for each resident. Staffing expectations are based on resident acuity and needs and may fluctuate based on the center population as identified in the facility assessment. […]

• No harm, potential for more than minimal, isolatedF584Jul 1, 2025

  Based on observation, interview, record review and facility policy review, the facility failed to maintain a clean, safe, and homelike environment in one (1) of fifty-five (55) resident rooms observed. This deficient practice resulted in a room environment with visible water damage and possible mold growth, which may pose a health risk to the resident occupying the room. room [ROOM NUMBER] B. Findings include: A review of the facility ' s policy, Types of Maintenance, with no date, revealed, Routine Maintenance. […]

• No harm, potential for more than minimal, isolatedF656Jul 1, 2025

  Based on observation, resident/staff interview, and record review, the facility failed to implement a comprehensive care plan for nail care for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead with an effective date of October 2024 that revealed, Policy: Care plans will be developed for all patients and residents based upon the RAI (Resident Assessment Instrument) manual guidelines. Care plans are developed by the interdisciplinary team and revised as needed according to resident and patient status or change. Record review of Resident #10's Care Plan Report revealed under, Focus: Self-care deficit due to: Recent surgery for trans metatarsal amputation of left foot. […]

• No harm, potential for more than minimal, isolatedF677Jul 1, 2025

  Based on observation, interviews and record review, the facility failed to perform nail care for a resident requiring assistance with activities of daily living (ADLs) for one (1) of 28 sampled residents. Resident #10 Findings Include: The facility provided a statement on letterhead that read, Policy: Proper name of the facility uses Clinical Nursing Skills and Techniques, [NAME]. [NAME], as a supplementary policy and procedure care guide. An observation and interview with Resident #10 on 6/29/25 at 11:55 AM revealed she was lying in bed with long fingernails bilaterally that measured approximately three-eighths (3/8) of an inch long and were jagged. She admitted that staff had told her they would trim them, but no one ever came. […]