Inspection Report
Life Safety
Deficiencies: 0
Aug 14, 2025
Visit Reason
The survey was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements at Bedford Alzheimer's Care Center.
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and all federal, state, and local emergency preparedness requirements. No deficiencies were cited during the survey.
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 0
Aug 14, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 08/12/25 through 08/14/25 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with all requirements and no deficiencies were cited during the survey.
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 0
Aug 14, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 8/12/25 to 8/14/25 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and Alzheimer's Disease/Dementia Care unit.
Findings
The facility was found to be in compliance with all applicable Minimum Standards and no deficiencies were cited during the survey.
Report Facts
Census: 59
Total Capacity: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2025
Visit Reason
The State Agency conducted complaint investigations related to elopement, neglect, quality of care, administration, resident rights, and abuse at the facility from 2025-02-19 through 2025-02-21.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigations MS #27921, MS #27978, and MS #27979 were conducted. MS #27921 involved elopement, neglect, and quality of care; MS #27978 involved neglect, administration, and quality of care; MS #27979 involved resident rights, abuse, and quality of care. The complaints were not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 60
Deficiencies: 0
Feb 21, 2025
Visit Reason
The State Agency conducted Complaint Investigations related to elopement, neglect, quality of care, administration, resident rights, and abuse at the facility from 2025-02-19 through 2025-02-21.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint Investigations MS #27921, MS #27978, and MS #27979 were conducted. MS #27921 investigated elopement, neglect, and quality of care; MS #27978 investigated neglect, administration, and quality of care; MS #27979 investigated resident rights, abuse, and quality of care. No deficiencies were found.
Report Facts
Licensed beds: 60
Census: 59
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 03/07/24 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 04/11/24.
Report Facts
Survey completion date: Mar 7, 2024
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 7, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the Bedford Alzheimer's Care Center from March 4, 2024 through March 7, 2024 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to unsafe food handling procedures, including leaving food opened and exposed, failure to date foods with use-by dates, storing foods without identifying labels, and not discarding food items after their use-by dates during kitchen observations.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Foods were stored unsafely by leaving food opened and exposed on the shelf, not dating foods with a use-by date, storing foods without an identifying label, and not discarding food items after their use-by date. | Level II |
Report Facts
Number of kitchen observations with deficiencies: 1
Number of pre-sliced apple packs observed: 42
Number of frozen pre-made omelets: 23
Frequency of dietary manager food storage checks: 5
Duration of dietary manager food storage checks: 8
Duration of Quality Assurance Committee review: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Acknowledged expired foods, undated foods, and exposed foods; responsible for food dating and storage. | |
| Administrator | Acknowledged improperly stored, dated, and exposed foods; stated facility should not have expired foods. |
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 1
Mar 7, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/04/2024 through 03/07/2024 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance due to failure to ensure food safety requirements were met, specifically improper storage of food including leaving food opened and exposed, lack of proper labeling and dating, and failure to discard food items after their use-by date.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Food items were not dated with a use-by date, lacked identifying labels, and were not discarded or used prior to the use-by date. | SS=F |
Report Facts
Census: 60
Total licensed capacity: 60
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Acknowledged expired foods, improper dating and storage of food items during interviews |
| Administrator | Administrator | Acknowledged improperly stored, dated, and exposed foods found in the kitchen and stated expectations for food safety |
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 0
Mar 7, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/04/2024 through 03/07/2024 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit during the annual recertification survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 7, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 03/07/24 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the State Agency recommended the facility be placed back in compliance effective 04/11/24.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 7, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 03/07/24 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 04/11/24.
Inspection Report
Life Safety
Deficiencies: 0
Mar 6, 2024
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during this survey.
Inspection Report
Deficiencies: 0
Mar 6, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 4, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/04/24 through 03/07/24 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit during the annual recertification survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 21, 2024
Visit Reason
The State Agency conducted a complaint investigation related to resident abuse and residents left soiled for extended periods.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited.
Complaint Details
Complaint MS #24220 was investigated and found to be unsubstantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 59
Capacity: 60
Deficiencies: 0
Feb 21, 2024
Visit Reason
The State Agency conducted a Complaint Investigation related to resident abuse and residents left soiled for extended periods.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #24220 regarding resident abuse and residents left soiled for extended periods; no deficiencies found.
Report Facts
Census: 59
Total Capacity: 60
Inspection Report
Annual Inspection
Census: 60
Capacity: 59
Deficiencies: 0
Jan 30, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and no deficiencies were cited.
Inspection Report
Follow-Up
Census: 59
Capacity: 60
Deficiencies: 0
Jan 30, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/30/24 related to a complaint survey conducted from 12/27/23 through 12/28/23.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 1/24/24.
Complaint Details
The visit was related to a complaint survey conducted from 12/27/23 through 12/28/23. The follow-up found the facility in compliance.
Report Facts
Licensed beds: 60
Census: 59
Inspection Report
Follow-Up
Deficiencies: 0
Jan 30, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 1/30/24 related to a complaint survey that was conducted from 12/27/23 through 12/28/23.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Minimum Standards of Operation for Alzheimer's Disease/Dementia Care Unit and recommends the facility be placed back in compliance effective 1/24/24.
Complaint Details
The visit was related to a complaint survey conducted from 12/27/23 through 12/28/23. The follow-up found the facility in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 28, 2023
Visit Reason
The State Agency conducted four complaint investigations at Bedford Alzheimer's Care Center from 12/27/23 through 12/28/23 related to resident to resident abuse and neglect incidents.
Findings
The facility failed to protect residents' rights to be free from resident to resident physical abuse involving four residents. Resident #1 initiated physical altercations resulting in injuries to Residents #1, #2, #3, and #4. The facility had multiple documented incidents of abuse, inadequate supervision, and ineffective interventions to manage Resident #1's aggressive behaviors.
Complaint Details
Four complaint investigations (CI MS #23651, CI MS #23698, CI MS #23700, and CI MS #23710) were conducted related to resident to resident abuse and neglect. Resident #1 was involved in multiple physical altercations causing injuries to other residents. The complaints were substantiated with documented injuries and incidents.
Severity Breakdown
Level III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect residents' rights to be free from resident to resident physical abuse for four of seven sampled residents. | Level III |
Report Facts
Complaint Investigations: 4
Sampled residents: 7
Residents affected by abuse: 4
BIMS scores: 15
BIMS scores: 10
BIMS scores: 6
BIMS scores: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director | Provided information about Resident #1's behaviors and staff interventions. |
| Director of Nursing | Director of Nursing | Provided information about Resident #1's medication management and supervision. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Described Resident #1's behaviors and transfer to Behavioral Unit. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Described physical altercation between Resident #1 and Resident #3. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Witnessed and described altercation between Resident #1 and Resident #4. |
| Administrator | Administrator | Provided information about staff training and supervision related to Resident #1. |
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 2
Dec 28, 2023
Visit Reason
The State Agency conducted four complaint investigations from 12/27/23 through 12/28/23 related to resident to resident abuse and neglect incidents reported both by the facility and anonymously.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to protect residents from resident to resident physical abuse involving four residents. Deficiencies were cited related to abuse prevention and baseline care planning, including failure to develop a baseline care plan addressing safety, supervision, and behavioral interventions for a resident with behavioral aggression.
Complaint Details
The complaint investigations involved four complaints (CI MS #23651, CI MS #23698, CI MS #23700, and CI MS #23710) related to resident to resident abuse and neglect. The facility reported two incidents and two were anonymously reported. The investigations found multiple physical altercations involving Resident #1 and Residents #2, #3, and #4, resulting in injuries and behavioral concerns.
Severity Breakdown
SS=H: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect residents from resident to resident physical abuse involving four residents with injuries including bruising, skin tears, hematoma, and redness. | SS=H |
| Failure to develop a baseline care plan within 48 hours that addressed safety concerns, identified the resident's need for supervision, or included behavioral interventions for a resident with behavioral aggression. | SS=H |
Report Facts
Complaint Investigations: 4
Facility licensed beds: 60
Census: 58
Residents sampled: 7
Residents involved in abuse incidents: 4
BIMS scores: 15
BIMS scores: 10
BIMS scores: 6
BIMS scores: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Described Resident #1's physical altercation with Resident #3 and aggressive behaviors. |
| Certified Nurse Aide #1 | CNA | Witnessed and described the altercation between Resident #1 and Resident #4. |
| Licensed Practical Nurse #1 | LPN | Provided care plan information and described Resident #1's admission and behaviors. |
| Social Services Director | SSD | Completed behavioral section of Resident #1's baseline care plan and provided information on staff training and interventions. |
| Director of Nursing | DON | Discussed Resident #1's medication management, supervision, and staff training. |
| Administrator | Provided information on staff education, supervision practices, and behavioral interventions for Resident #1. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 28, 2023
Visit Reason
The State Agency conducted four complaint investigations at Bedford Alzheimer's Care Center from 12/27/23 through 12/28/23 related to resident to resident abuse and neglect incidents reported both by the facility and anonymously.
Findings
The facility failed to develop a baseline care plan within 48 hours that addressed safety concerns, supervision needs, or behavioral interventions for a resident with behavioral aggression, resulting in multiple physical altercations causing injuries to several residents. The facility was found not in compliance with Minimum Standards of Operation for Alzheimer's Disease/Dementia Care Unit and state licensure requirements.
Complaint Details
Four complaint investigations (CI MS #23651, CI MS #23698, CI MS #23700, and CI MS #23710) were conducted related to resident to resident abuse and neglect. Two were facility reported incidents and two were anonymously reported complaints. The complaints were substantiated as the facility was found non-compliant.
Severity Breakdown
Level III: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a baseline care plan within 48 hours that addressed safety concerns, supervision needs, or behavioral interventions for a resident with behavioral aggression. | Level III |
Report Facts
Complaint Investigations: 4
Sampled residents: 7
Resident involved in incidents: 1
Dates of incidents: Physical altercations occurred on 12/9/23 and 12/19/23
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1/Care Plan nurse | Interviewed regarding baseline care plan completion | |
| Social Services Director | Completed Behavioral Section of care plan and interviewed about baseline care plan | |
| Administrator | Interviewed regarding baseline care plan content | |
| Director of Nursing (DON) | Interviewed regarding baseline care plan content and responsible for training and audits |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints, MS #21634 and MS #22080, from 7/18/23 through 7/20/23.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit. No deficiencies were cited related to quality of care, resident abuse, dietary services, accidents, physical environment, misappropriation of property, hydration, or resident rights.
Complaint Details
The investigation covered Quality of Care related to grooming, staffing, following physician orders, resident to resident abuse, dietary services, falls, physical environment, misappropriation of property, hydration, and resident rights. No deficiencies were found.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 20, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints (CI MS# 21634 and CI MS# 22080) from 7/18/23 through 7/20/23.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements. The investigation covered quality of care, resident abuse, dietary services, accidents, physical environment, misappropriation of property, hydration, and resident rights, with no deficiencies cited.
Complaint Details
The complaints investigated were MS# 21634 related to quality of care (grooming, staffing, following physician orders), resident to resident abuse, dietary services, accidents related to falls, physical environment, and misappropriation of property; and MS# 22080 related to quality of care (hydration) and resident rights. No deficiencies were cited.
Report Facts
Complaint Investigation Dates: Investigation conducted from 2023-07-18 through 2023-07-20
Inspection Report
Enforcement
Deficiencies: 1
Mar 20, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day period, specifically between 03/13/2023 and 03/19/2023, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Mar 13, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 03/06/2023 to 03/12/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during the required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Jan 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 3, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day period between 12/26/2022 and 01/01/2023, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Census: 53
Capacity: 60
Deficiencies: 0
Nov 23, 2021
Visit Reason
The State Agency conducted an annual survey from 11/21/2021 to 11/23/2021 to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found to be in compliance with no deficiencies cited during the annual survey.
Inspection Report
Annual Inspection
Census: 53
Capacity: 60
Deficiencies: 0
Nov 23, 2021
Visit Reason
The State Agency conducted an annual survey at the facility from 11/21/2021 to 11/23/2021 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with all requirements and no deficiencies were cited during the survey.
Inspection Report
Life Safety
Deficiencies: 0
Nov 22, 2021
Visit Reason
The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the 2012 Edition of the Life Safety Code (LSC).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No Life Safety Code deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Nov 22, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with applicable Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.
Inspection Report
Deficiencies: 0
Nov 22, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with applicable Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Jul 12, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period from 07/05/2021 to 07/11/2021, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Abbreviated Survey
Census: 43
Capacity: 60
Deficiencies: 0
Jan 12, 2021
Visit Reason
An abbreviated/partial COVID-19 Focused Infection Control Survey was conducted by the State Agency on 1/12/2021 to assess compliance with infection control regulations and COVID-19 preparedness.
Findings
The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 12, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/12/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Routine
Census: 48
Capacity: 60
Deficiencies: 0
Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 48
Capacity: 60
Deficiencies: 0
Dec 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Dec 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with Medicaid and Medicare requirements related to emergency preparedness.
Inspection Report
Routine
Census: 49
Capacity: 60
Deficiencies: 0
Aug 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 49
Capacity: 60
Deficiencies: 0
Aug 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/31/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 52
Capacity: 60
Deficiencies: 0
Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Routine
Census: 52
Capacity: 60
Deficiencies: 0
Aug 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/3/20 to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 52
Total Capacity: 60
Inspection Report
Routine
Census: 53
Capacity: 60
Deficiencies: 0
Jun 18, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 53
Capacity: 60
Deficiencies: 0
Jun 18, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Census: 53
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2019
Visit Reason
The State Agency conducted a complaint investigation survey (CI MS#16342) on 10/24/19 to investigate an allegation of abuse.
Findings
The State Agency was unable to substantiate the allegation of abuse and no deficiencies were cited.
Complaint Details
The complaint investigation was related to an allegation of abuse which was not substantiated.
Inspection Report
Plan of Correction
Deficiencies: 1
Oct 4, 2019
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related regulations, specifically regarding the protection of the facility's generator components.
Findings
The facility failed to properly protect all the generator's required components as per NFPA 110 and NFPA 99 standards, specifically lacking a remotely located annunciator panel for the temporary generator, which could potentially affect all residents.
Deficiencies (1)
| Description |
|---|
| Facility failed to properly protect all the generator's required components; no remotely located annunciator panel for the temporary generator operating in the facility. |
Report Facts
Date of survey completion: Oct 4, 2019
Plan of correction completion date: Dec 12, 2019
Order date for new generator: Oct 31, 2019
Inspection Report
Annual Inspection
Census: 60
Capacity: 60
Deficiencies: 4
Oct 3, 2019
Visit Reason
The State Agency conducted an annual survey from 09/30/2019 through 10/03/2019 to determine compliance with Medicare and Medicaid Requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with cited deficiencies related to notice requirements before transfer/discharge, accuracy of assessments, coordination of PASARR and assessments, and electrical system deficiencies.
Severity Breakdown
SS=E: 1
SS=D: 2
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to notify family in writing of reasons for resident hospital transfers for two residents. | SS=E |
| Failed to accurately reflect residents' status on Minimum Data Set (MDS) for two residents. | SS=D |
| Failed to refer residents to appropriate state authority for Level II PASARR for two residents. | SS=D |
| Failed to properly protect all generator's required components; no remotely located annunciator panel for temporary generator. | SS=F |
Report Facts
Licensed beds: 60
Census: 60
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding resident hospital transfers and reasons |
| Director of Nursing | DON | Confirmed family was not notified in writing of hospital transfers |
| Licensed Practical Nurse #1 | LPN / MDS Coordinator | Confirmed inaccuracies in MDS coding for residents |
| Social Worker #1 | Social Worker | Interviewed regarding PASARR referrals |
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