Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 23, 2025
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2025-08-28 to determine compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2025-09-22.
Complaint Details
The visit was complaint-related, reviewing information from a complaint survey completed on 2025-08-28. The facility was found to be in compliance and the complaint was effectively resolved.
Inspection Report
Life Safety
Deficiencies: 0
Aug 28, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA) for Bedford Care Center-Monroe Hall.
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Census: 71
Capacity: 80
Deficiencies: 2
Aug 28, 2025
Visit Reason
The State Agency conducted an annual recertification survey and multiple complaint investigations at the facility from 08/25/2025 through 08/28/2025.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident dignity during feeding assistance and food safety violations involving expired food items being stored and served.
Complaint Details
Multiple complaint investigations were conducted for allegations including rude and delayed care by Certified Nurse Aides, sexual harassment by housekeeping staff, residents left unchanged for hours, verbal and physical abuse by CNAs, and unsanitary resident rooms. No citations were related to these complaints.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff were observed standing over a resident while assisting with feeding, violating the resident's dignity. | SS = D |
| The facility failed to remove expired grape juice and expired yogurt from storage and failed to prevent the service of expired food items to residents. | SS = D |
Report Facts
Expired yogurt containers: 34
Facility licensed beds: 80
Resident census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Affirmed violation of resident dignity and stated staff will be in-serviced on proper feeding assistance. |
| Infection Preventionist | Infection Preventionist | Observed standing over resident while assisting with feeding and acknowledged violation of resident dignity. |
| Dietary Manager | Dietary Manager | Confirmed expired grape juice and yogurt findings and acknowledged food safety violations. |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Stated expectation for dietary staff to check expiration dates and discard food prior to use-by date. |
| Administrator | Administrator | Confirmed awareness of findings and expectation for dietary staff to check food dates consistently. |
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 28, 2025
Visit Reason
The State Agency conducted an annual recertification survey combined with multiple complaint investigations at Bedford Care Center-Monroe Hall from August 25 through August 28, 2025. The complaints involved allegations of staff rudeness, delayed care, sexual harassment, abuse, and unsanitary conditions.
Findings
The facility was found not in compliance with state licensure requirements, citing violations related to residents' rights and safe food handling procedures. Specific deficiencies included staff standing over a resident while feeding, violating dignity standards, and failure to remove expired food items such as grape juice and yogurt from service.
Complaint Details
Multiple complaints were investigated including allegations that CNAs were rude, delayed incontinence care, and abusive; shower aides were disrespectful; a housekeeping staff member sexually harassed a resident; a resident was left unchanged for hours; and a resident's room was unsanitary. No citations were related to these complaints.
Deficiencies (2)
| Description |
|---|
| Staff were standing while assisting a resident with feeding, violating the resident's dignity. |
| Failure to remove out-of-date grape juice from the reach-in cooler and expired yogurt from the refrigerator, risking service of expired food to residents. |
Report Facts
Complaint investigations: 6
Residents sampled: 20
Expired yogurt containers: 34
Expired grape juice containers: 1
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Infection Preventionist (IP) | Observed standing while feeding Resident #6 and acknowledged the violation. | |
| Director of Nursing (DON) | Affirmed the feeding assistance violation and stated staff will be in-serviced on proper feeding assistance. | |
| Dietary Manager | Confirmed expired grape juice and yogurt findings and acknowledged the issues. | |
| Registered Dietitian Consultant | Stated expectation for dietary staff to check expiration dates and discard expired food. | |
| Administrator | Confirmed awareness of food safety findings and expectation for dietary staff to check food dates consistently. |
Inspection Report
Annual Inspection
Census: 71
Capacity: 80
Deficiencies: 2
Aug 28, 2025
Visit Reason
The State Agency conducted an annual recertification survey and multiple complaint investigations at the facility from 08/25/2025 through 08/28/2025.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident dignity during feeding assistance and food safety violations involving expired food items. No citations were related to the complaint investigations.
Complaint Details
Multiple complaint investigations were conducted for allegations including rude and disrespectful staff behavior, sexual harassment by housekeeping staff, residents left unchanged for hours, verbal and physical abuse by CNAs, and unsanitary resident rooms. No citations were issued related to these complaints.
Severity Breakdown
SS = D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff were observed standing while assisting a resident with feeding, violating the resident's dignity. | SS = D |
| Facility failed to remove expired grape juice and expired yogurt from refrigerators, risking service of expired food to residents. | SS = D |
Report Facts
Expired yogurt containers: 34
Facility licensed beds: 80
Resident census: 71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Affirmed violation of resident dignity and stated staff will be in-serviced on proper feeding assistance. |
| Infection Preventionist | Infection Preventionist | Observed standing while feeding Resident #6 and acknowledged the violation. |
| Dietary Manager | Dietary Manager | Confirmed expired grape juice and yogurt findings and acknowledged they had been served. |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Stated expectation for dietary staff to check expiration dates and discard expired food. |
| Administrator | Administrator | Confirmed awareness of findings and expectation for dietary staff to check food dates consistently. |
Inspection Report
Annual Inspection
Deficiencies: 2
Aug 28, 2025
Visit Reason
The State Agency conducted an annual recertification survey combined with multiple complaint investigations at Bedford Care Center-Monroe Hall from August 25 through August 28, 2025. The complaints involved allegations of staff rudeness, delayed care, sexual harassment, abuse, and unsanitary conditions.
Findings
The facility was found not in compliance with state licensure requirements, citing violations related to residents' rights and safe food handling procedures. Specific deficiencies included staff standing over a resident while feeding, violating dignity standards, and failure to remove expired food items such as grape juice and yogurt from service.
Complaint Details
Multiple complaint investigations were conducted for allegations including rude and disrespectful behavior by Certified Nurse Aides and shower aides, sexual harassment by housekeeping staff, residents left unchanged for hours, verbal and physical abuse by CNAs, and unsanitary resident rooms. No citations were issued related to these complaints.
Deficiencies (2)
| Description |
|---|
| Staff were standing while assisting a resident with feeding, violating the resident's dignity as per facility policy. |
| Failure to remove out-of-date grape juice from the reach-in cooler, expired yogurt from the refrigerator, and prevention of serving expired food items to residents. |
Report Facts
Expired yogurt containers: 34
Expired grape juice containers: 1
Residents sampled: 20
BIMS score: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Affirmed violation of resident dignity and stated staff will be in-serviced on proper feeding assistance. |
| Infection Preventionist | Infection Preventionist | Observed standing while feeding Resident #6 and acknowledged the violation. |
| Dietary Manager | Dietary Manager | Confirmed expired grape juice and yogurt findings and acknowledged they had been served. |
| Registered Dietitian Consultant | Registered Dietitian Consultant | Stated expectation for dietary staff to check expiration dates and discard expired food. |
| Administrator | Administrator | Confirmed awareness of findings and expectation for dietary staff to check food dates consistently. |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 28, 2025
Visit Reason
The visit was related to the annual survey of the facility conducted on 08/28/25, with a desk review completed on 09/23/25 to confirm corrective measures.
Findings
The facility had implemented measures to correct previously identified deficient practices and sustain compliance with Medicare and Medicaid participation requirements. The State Agency recommended the facility be placed back in compliance effective 09/22/25.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 25, 2024
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2024-10-29 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance based on the information provided, and the State Agency recommended the facility be placed back in compliance effective 2024-11-19.
Complaint Details
The visit was related to a complaint survey completed on 2024-10-29. The facility was found compliant and the complaint was effectively resolved.
Inspection Report
Complaint Investigation
Census: 75
Capacity: 80
Deficiencies: 3
Oct 29, 2024
Visit Reason
The State Agency conducted a complaint investigation from 10/28/24 through 10/29/24 regarding resident safety and neglect after a resident was left unattended in the facility's transportation van.
Findings
The facility failed to ensure a resident was free from neglect when Resident #1 was left alone in the facility van for an undetermined amount of time on 10/21/24. The investigation was incomplete, and the facility failed to report the incident within 24 hours as required. No injuries were identified, but the resident's cognition was severely impaired.
Complaint Details
The complaint investigation was triggered by allegations of resident safety and neglect after Resident #1 was left unattended in the facility van for an undetermined amount of time on 10/21/24. The facility failed to report the incident timely and did not conduct a thorough investigation.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was free from neglect when left unattended in the facility van for an undetermined amount of time. | SS=D |
| Facility failed to report a violation of neglect within 24 hours when notified that a resident had been left in a facility van. | SS=D |
| Facility failed to conduct a thorough investigation related to a resident left on the facility's transportation van upon return from an outing. | SS=D |
Report Facts
Licensed capacity: 80
Census: 75
BIMS score: 6
Number of residents in van: 5
Time resident left unattended: 20
Audit frequency: 5
Audit duration: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse/Supervisor | Reported Resident #1 missing and participated in search and notification |
| LPN #1 | Licensed Practical Nurse | Found Resident #1 locked in the van and retrieved keys to open the van |
| Administrator | Led investigation, received notifications, and made decisions regarding reporting and investigation | |
| DON | Director of Nursing | Notified Administrator of incident and participated in investigation |
| Nurse Practitioner | Nurse Practitioner | Assessed Resident #1 after incident and documented clinical notes |
| Van Driver | Transported residents and left Resident #1 unattended in the van | |
| Front Desk #1 | Reported watching Resident #1 in the van and gave van keys to nurse | |
| CNA #1 | Certified Nurse Assistant | Found Resident #1 in the locked van and assisted in removal |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 29, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at Bedford Care Center-Monroe Hall from 10/28/24 through 10/29/24 related to resident safety and neglect.
Findings
The facility failed to ensure a resident was free from neglect when Resident #1 was left alone and locked in the facility transportation van for an undetermined amount of time on 10/21/24. The resident was found without injuries but was left unattended for up to approximately 2.5 hours and then again until about 5:00 PM. The facility's surveillance system was not operational at the time, and staff statements about the timeline were inconsistent. The facility implemented a Transportation Vehicle Inspection and Log process to prevent recurrence.
Complaint Details
The complaint was investigated related to resident safety and neglect. Resident #1 was left in the facility van alone after returning from an outing on 10/21/24. The resident was found locked in the van at approximately 5:00 PM with no injuries. The facility staff had inconsistent accounts of the timeline and supervision. The Nurse Practitioner ordered blood work due to environmental exposure concerns. The facility conducted in-services on abuse, neglect, and documentation.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident was free from neglect when Resident #1 was left alone and locked in the facility van for an undetermined amount of time. | Level II |
Report Facts
Residents in van at time of incident: 5
Resident left in van: 1
Time resident left in van: 1
BIMS score: 6
Date of incident: Oct 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Provided statements about the incident and facility response. | |
| Director of Nursing (DON) | Reported the incident to the Administrator and confirmed notification of Nurse Practitioner. | |
| RN #1 | Registered Nurse/Supervisor | Reported Resident #1 missing and assisted in locating him in the van. |
| LPN #1 | Licensed Practical Nurse | Retrieved van keys and opened the van to remove Resident #1. |
| CNA #1 | Certified Nurse Assistant | Found Resident #1 in the van and assisted with the incident. |
| Van driver | Left Resident #1 in the van while retrieving supplies and assisted in removing him from the van. | |
| Nurse Practitioner (NP) | Assessed Resident #1 after the incident and ordered blood work. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Oct 29, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at Bedford Care Center-Monroe Hall from 10/28/24 through 10/29/24 related to resident safety and neglect.
Findings
The facility failed to ensure a resident was free from neglect when Resident #1 was left alone and locked inside the facility transportation van for an undetermined amount of time on 10/21/24. The resident was found without injuries but was left unattended for several hours. The facility implemented a Transportation Vehicle Inspection and Log process following the incident.
Complaint Details
The complaint was investigated related to resident safety and neglect. Resident #1 was left in the facility van from approximately 2:45 PM until about 5:00 PM on 10/21/24. The resident was found secured in a seatbelt, the van door was locked, and no injuries were documented. The facility staff had conflicting statements about supervision and timeline. The Nurse Practitioner ordered blood work due to environmental exposure concerns. The facility held an emergency Quality Assurance meeting and conducted in-services on abuse, neglect, and documentation.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure a resident was free from neglect when Resident #1 was left alone and locked inside the facility van for several hours on 10/21/24. | Level II |
Report Facts
Residents transported in van: 5
Resident left in van: 1
BIMS score: 6
Quality Assurance Committee meeting date: Oct 22, 2024
Audit frequency: 5
Audit frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Found Resident #1 in the van, admitted to documenting resident as present without seeing him |
| RN #1 | Registered Nurse/Supervisor | Informed NP about Resident #1 left in van, participated in search and reporting |
| Administrator | Interviewed regarding incident, coordinated Quality Assurance meeting | |
| Nurse Practitioner | Nurse Practitioner | Assessed Resident #1 after incident, ordered blood work, provided progress notes and addendum |
| Van driver | Left Resident #1 in van while retrieving supplies, assisted in removing resident from van | |
| Front Desk #1 | Reported watching Resident #1 in van, gave van keys to nurse | |
| CNA #1 | Certified Nurse Assistant | Found Resident #1 in van during search |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2024
Visit Reason
The inspection was conducted as a complaint survey triggered by a complaint received by the State Agency.
Findings
The facility provided information confirming corrective measures were implemented to address the deficient practice, sustaining compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 11/19/2024.
Complaint Details
The complaint survey was completed on 10/29/2024. The State Agency conducted a desk review on 11/25/2024 and found the facility had corrected the deficiencies and sustained compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 1, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25364 at the facility related to quality of care regarding resident safety.
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 Investigation MS #25364 related to quality of care regarding resident safety; no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 80
Deficiencies: 0
Jul 1, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25364, related to quality of care regarding resident safety at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #25364 related to quality of care regarding resident safety was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Licensed beds: 80
Census: 71
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 22, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-03-28 to verify 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 2024-04-19.
Inspection Report
Annual Inspection
Deficiencies: 1
Mar 28, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/25/2024 through 03/28/2024 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 failure to ensure proper storage of a nebulizer mask for one resident requiring respiratory care, which posed a risk of infection or complications. Staff were retrained and corrective actions were implemented to ensure compliance.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure a nebulizer mask was stored in a designated storage bag for one resident requiring respiratory care. | Level II |
Report Facts
Deficiencies cited: 1
BIMS score: 2
Physician's Order frequency: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding improper storage of nebulizer mask |
| Director of Nursing | Director of Nursing | Interviewed regarding policy and expectations for nebulizer mask storage |
| Staff Development Nurse | Staff Development Nurse | Provided training on proper storage of respiratory tubing |
Inspection Report
Annual Inspection
Census: 75
Capacity: 80
Deficiencies: 2
Mar 28, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/25/2024 through 03/28/2024 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements related to timely transmission of resident assessments (MDS) and proper respiratory care, specifically the storage of a nebulizer mask. Deficiencies were cited under F640 and F695.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to transmit a Discharge Minimum Data Set (MDS) Assessment in a timely manner for one resident (Resident #58). | SS=D |
| Failed to ensure a nebulizer mask was stored in a designated storage bag for one resident (Resident #179). | SS=D |
Report Facts
Residents reviewed for MDS assessments: 19
Licensed capacity: 80
Current census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Confirmed failure to transmit hospital discharge MDS for Resident #58 |
| Director of Nursing | Director of Nursing | Responsible for training MDS nurses and auditing MDS schedule; stated expectation for timely transmission of hospital discharge MDS |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed nebulizer mask was not stored properly for Resident #179 |
| Staff Development Nurse | Staff Development Nurse | Trained nursing staff on proper storage of respiratory tubing |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Will use RN Round Checklist to ensure proper storage of respiratory tubing |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 28, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 03/28/24 to confirm corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance. The State Agency recommended the facility be placed back in compliance effective 04/19/24.
Inspection Report
Life Safety
Deficiencies: 0
Mar 26, 2024
Visit Reason
The inspection 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, and no LSC deficiencies were cited during this survey.
Inspection Report
Life Safety
Deficiencies: 0
Mar 26, 2024
Visit Reason
The inspection was conducted to assess the facility's 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, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Mar 26, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 6, 2023
Visit Reason
The State Agency conducted a complaint investigation related to neglect at the facility on 9/6/23.
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 investigation MS #22511 related to neglect was conducted and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 74
Capacity: 80
Deficiencies: 0
Sep 6, 2023
Visit Reason
The State Agency conducted a complaint investigation related to neglect at the facility on 2023-09-06.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #22511 was related to neglect and was found to be unsubstantiated as no deficiencies were cited.
Report Facts
Licensed beds: 80
Resident census: 74
Inspection Report
Complaint Investigation
Deficiencies: 0
May 15, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #20898, related to Quality of Care concerning incontinent care and grooming, and Resident Rights related to providing privacy.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, with no deficiencies cited.
Complaint Details
Complaint Investigation MS #20898 was substantiated as no deficiencies were found related to Quality of Care and Resident Rights.
Inspection Report
Complaint Investigation
Census: 76
Capacity: 80
Deficiencies: 0
May 15, 2023
Visit Reason
The State Agency conducted a complaint investigation related to Quality of Care concerning incontinent care and grooming, and Resident Rights related to providing privacy.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, with no deficiencies cited during the investigation.
Complaint Details
Complaint Investigation (CI MS #20898) for Quality of Care related to incontinent care and grooming and Resident Rights related to providing privacy; no deficiencies cited.
Report Facts
Licensed capacity: 80
Census: 76
Inspection Report
Complaint Investigation
Deficiencies: 2
Jan 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at Bedford Care Center - Monroe Hall from 1/26/23 through 1/27/23 related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, specifically failing to ensure reasonable accommodation for a resident's call light accessibility and failing to provide necessary assistance with activities of daily living, including grooming and personal hygiene for four of seven sampled residents.
Complaint Details
Complaint investigation MS #20570 related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care. The complaint was substantiated with findings of noncompliance.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure reasonable accommodation was provided when a resident's call light device was not within reach. | Level II |
| Failed to ensure residents unable to carry out activities of daily living received necessary assistance to maintain grooming and personal hygiene. | Level II |
Report Facts
Sampled residents with call light issue: 1
Sampled residents with grooming deficiencies: 4
BIMS score: 10
BIMS score: 0
BIMS score: 12
BIMS score: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Development Nurse | Confirmed call lights are supposed to be within residents' reach and responsible for staff education on call light accessibility. | |
| Director of Nursing | Confirmed staff are supposed to leave call lights within reach and responsible for assessment and provision of fingernail and toenail care. | |
| Facility Administrator | Confirmed staff should place call lights within reach and that nursing staff are responsible for fingernail and toenail care. | |
| Wound Care Nurse | Provided observations and care related to residents' nail conditions. | |
| Registered Nurse #1 | Registered Nurse | Responsible for supervision of Licensed Practical Nurses and care of residents; confirmed staff training and expectations for ADL care. |
| Certified Nurse Aide #4 | Reported facility provided in-service training for ADLs. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 80
Deficiencies: 2
Jan 27, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI) were conducted due to allegations related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care.
Findings
The facility was found non-compliant with Medicare and Medicaid participation requirements, citing deficiencies in ADL care for dependent residents and bowel/bladder incontinence care. Specific failures included inadequate grooming and personal hygiene for residents unable to perform ADLs and improper incontinence care that could lead to urinary tract infections.
Complaint Details
The complaint was related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care. The investigation found non-compliance with cited deficiencies F677 and F690.
Severity Breakdown
SS=E: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents unable to carry out ADLs received necessary grooming and personal hygiene services, including nail care for four of seven sampled residents. | SS=E |
| Failed to ensure a resident incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. | SS=D |
Report Facts
Licensed beds: 80
Resident census: 75
Sampled residents with ADL deficiencies: 4
Residents receiving nail care correction: 4
BIMS scores: Resident #1 had a BIMS score of 00; Resident #3 had 12; Resident #5 had 00; Resident #7 had cognitive impairment
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed responsibility for nail care and incontinence care; involved in assessments and interviews |
| Staff Development Nurse | Staff Development Nurse | Provided in-service training on ADL and incontinence care; responsible for CNA orientation and competencies |
| Registered Nurse #1 | Registered Nurse | Supervised LPNs and care of residents; confirmed staff training and care procedures |
| Certified Nurse Aide #1 | Certified Nurse Aide | Performed incontinence care incorrectly by wiping back to front and acknowledged the mistake |
| Certified Nurse Aide #4 | Certified Nurse Aide | Reported facility provided in-service training for ADLs |
| Facility Administrator | Administrator | Confirmed nursing staff responsibility for nail and personal hygiene care |
Inspection Report
Routine
Deficiencies: 0
Jan 27, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from January 26, 2023 through January 27, 2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 1/26/23 through 1/27/23 related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, specifically failing to ensure residents unable to carry out Activities of Daily Living (ADLs) received necessary grooming and personal hygiene services for four of seven sampled residents.
Complaint Details
Complaint investigation MS #20570 was substantiated with findings related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care. The facility was cited for noncompliance with standards M500 and M610.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to ensure residents unable to carry out ADLs received necessary grooming and personal hygiene services, including nail care, for four of seven sampled residents. | Level II |
Report Facts
Sampled residents with deficient ADL care: 4
Sample size: 7
BIMS score: 0
BIMS score: 12
BIMS score: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Responsible for supervision of Licensed Practical Nurses and care of residents; confirmed staff training and ADL care procedures. |
| Staff Development Nurse | Staff Development Nurse | Responsible for general facility orientation and checkoff competencies for CNAs including ADL care. |
| Director of Nursing | Director of Nursing | Confirmed nursing staff responsibility for assessment and provision of fingernail and toenail care. |
| Administrator | Facility Administrator | Confirmed nursing staff responsibility for fingernail and toenail care as part of personal hygiene/grooming. |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 80
Deficiencies: 3
Jan 27, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI) were conducted due to complaints related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care.
Findings
The facility was found non-compliant with Medicare and Medicaid participation requirements, citing deficiencies related to reasonable accommodations, ADL care for dependent residents, and bowel/bladder incontinence care. Specific issues included call lights not being within reach, inadequate nail care for dependent residents, and improper incontinence care that could lead to urinary tract infections.
Complaint Details
The complaint was related to verbal abuse, resident grooming, neglect, infection control, administration, and resident incontinence care. The complaint investigation found the facility non-compliant in areas related to resident care and accommodations.
Severity Breakdown
SS=D: 2
SS=E: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure reasonable accommodation was provided when a resident's call light device was not within reach. | SS=D |
| Failure to ensure residents unable to carry out ADLs received necessary services to maintain grooming and personal hygiene for four sampled residents. | SS=E |
| Failure to ensure a resident incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. | SS=D |
Report Facts
Licensed beds: 80
Resident census: 75
Sampled residents with call light issue: 1
Sampled residents with ADL care deficiencies: 4
Sampled residents with incontinence care deficiencies: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff Development Nurse | Staff Development Nurse | Confirmed call lights should be within reach and conducted in-service training on call light accessibility and incontinence care |
| Director of Nursing | Director of Nursing | Confirmed staff responsibilities for call light placement and nail care; confirmed incontinence care policy and training |
| Administrator | Facility Administrator | Confirmed staff should place call lights within reach upon completion of care and confirmed nursing staff responsibilities for nail care |
| Certified Nurse Aide #1 | Certified Nurse Aide | Performed incontinence care wiping from back to front, acknowledged mistake |
| Certified Nurse Aide #2 | Certified Nurse Aide | Observed performing incontinence care with CNA #1 |
| Wound Care Nurse | Wound Care Nurse | Observed and reported on resident nail conditions |
| Registered Nurse #1 | Registered Nurse | Responsible for supervision of LPNs and care of residents; confirmed staff training and expectations for ADL care |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 27, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from January 26, 2023 through January 27, 2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 27, 2023
Visit Reason
The visit was conducted as a complaint survey triggered by a complaint received by the State Agency.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm based on the desk review of information provided related to the complaint survey.
Complaint Details
The complaint survey was completed on 01/27/23. The facility was found compliant and the State Agency recommended placing the facility back in compliance effective 02/17/23.
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 27, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2023-01-27 to assess the facility's corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were implemented to address the deficient practice, and the State Agency recommended the facility be placed back in compliance effective 2023-02-17.
Complaint Details
The visit was complaint-related, involving a complaint survey completed on 2023-01-27. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation of compliance restoration.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 26, 2023
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from January 26, 2023 through January 27, 2023.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 72
Capacity: 80
Deficiencies: 0
May 13, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 5/12/22 through 5/13/22 regarding allegations of resident death and neglect.
Findings
The complaint was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited in a prior survey dated 04/28/2022.
Complaint Details
Complaint investigation MS #18791 regarding resident death and neglect was not substantiated.
Report Facts
Licensed beds: 80
Census: 72
Inspection Report
Follow-Up
Deficiencies: 0
May 13, 2022
Visit Reason
The State Agency conducted a follow-up revisit survey at the facility on 5/13/22 to verify compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
During the follow-up survey, the facility was found to be in compliance with the applicable Mississippi state regulations and licensure requirements effective 5/5/22.
Inspection Report
Follow-Up
Census: 72
Capacity: 80
Deficiencies: 0
May 13, 2022
Visit Reason
The State Agency conducted a follow-up revisit related to a complaint survey that was conducted on 2022-04-28.
Findings
The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid and was recommended to be placed back in compliance effective 2022-05-05.
Complaint Details
Follow-up revisit related to a complaint survey conducted on 2022-04-28; facility found in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 0
May 13, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 2022-05-12 through 2022-05-13 regarding a complaint for resident death and neglect.
Findings
The complaint was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on a prior survey dated 2022-04-28.
Complaint Details
Complaint investigation MS #18791 was conducted and the complaint for resident death and neglect was not substantiated.
Inspection Report
Complaint Investigation
Census: 73
Capacity: 80
Deficiencies: 2
Apr 28, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 4/13/22 through 4/14/22, with additional visits through 4/28/22, to investigate allegations related to a resident fall resulting in multiple fractures.
Findings
The facility was found not in compliance with state licensure requirements due to failure to ensure an assistive device was used during a transfer, resulting in a resident fall with multiple fractures. Contract staff did not follow the resident's plan of care or facility policy, and the incident was not reported timely. Immediate corrective actions and staff training were implemented.
Complaint Details
Complaint Investigation MS #18689 was substantiated for a resident fall resulting in multiple fractures. Complaint Investigation MS #18729 was not substantiated.
Severity Breakdown
Level III: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor by staff resulting in multiple fractures. | Level III |
| Failure to report the incident up the chain of command as per facility policy. | Level III |
Report Facts
Licensed beds: 80
Resident census: 73
Date of fall incident: Mar 10, 2022
Date of bruising noted: Mar 11, 2022
Training completion date: Mar 24, 2022
Observation frequency: 10
Observation frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Assistant | Named in resident fall and failure to follow transfer plan |
| NA #3 | Nursing Assistant | Named in resident fall and failure to follow transfer plan |
| CNA #4 | Certified Nurse Assistant | Observed resident on floor but failed to notify nursing staff or administration |
| LPN #1 | Licensed Practical Nurse | Evaluated resident after bruising was noted |
| DON | Director of Nursing | Assessed resident, initiated investigation, and participated in QAC |
| Administrator | Participated in investigation and QAC, confirmed staff suspensions and training | |
| Nurse Practitioner | Gave verbal orders to send resident to Emergency Room | |
| LPN #2 | Licensed Practical Nurse | Observed transfer with mechanical lift and confirmed staff training |
| RN #1 | Registered Nurse | Noted bruising and deformity, notified Nurse Practitioner |
| Contract Agency Representative #1 | Provided information on agency staff orientation and background checks |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 80
Deficiencies: 2
Apr 28, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 4/13/22 through 4/14/22, with additional visits to obtain information. The investigation was triggered by complaints MS #18689 and MS #18729, with MS #18689 substantiated for a resident fall resulting in multiple fractures.
Findings
The facility failed to ensure an assistive device was used during a transfer, causing Resident #1 to be lowered to the floor by staff, resulting in multiple fractures. Contract agency staff did not follow the resident's plan of care or facility policy, and the incident was not reported timely. Immediate corrective actions included suspension of involved staff, staff training, and enhanced orientation and monitoring procedures for agency staff.
Complaint Details
Complaint Investigation MS #18689 was substantiated for a resident fall resulting in multiple fractures. Complaint MS #18729 was not substantiated.
Severity Breakdown
Level III: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor resulting in multiple fractures. | Level III |
| Failure to investigate and report an unexplained accident resulting in injury. | Level III |
Report Facts
Licensed beds: 80
Resident census: 73
Date of fall incident: Mar 10, 2022
Date of bruising noted: Mar 11, 2022
Training completion date: Mar 24, 2022
Observation frequency: 10
Observation frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Assistant | Named in resident fall incident for failure to use assistive device and failure to report incident |
| NA #3 | Nursing Assistant | Named in resident fall incident for failure to use assistive device and failure to report incident |
| CNA #4 | Certified Nurse Assistant | Observed resident on floor and advised reporting of incident but did not notify nursing staff or administration |
| LPN #1 | Licensed Practical Nurse | Evaluated resident after bruising was noted and notified Director of Nursing |
| LPN #2 | Licensed Practical Nurse | Observed transfer with mechanical lift and confirmed staff training on Kardex use |
| DON | Director of Nursing | Assessed resident, initiated investigation, confirmed fall incident, and implemented corrective actions |
| Administrator | Facility Administrator | Confirmed incident details, staff suspensions, and staff training completion |
| Contract Agency Representative #1 | Agency Representative | Provided information on agency staff background checks, skills evaluation, and orientation obligations |
Inspection Report
Complaint Investigation
Census: 73
Capacity: 80
Deficiencies: 4
Apr 28, 2022
Visit Reason
The State Agency conducted a complaint investigation triggered by two complaint investigations (CI MS #18689 and CI MS #18729) at the facility from 4/13/22 through 4/14/22, with additional visits through 4/28/22 to obtain more information.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to use an assistive device during a resident transfer, resulting in a resident fall with multiple fractures. The facility also failed to report the incident timely and did not follow the resident's care plan for transfers. Contract agency staff involved were suspended and corrective actions including staff training and enhanced orientation were implemented.
Complaint Details
The complaint investigation MS #18689 was substantiated for a resident fall resulting in multiple fractures. The complaint investigation MS #18729 was not substantiated.
Severity Breakdown
SS=G: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure an assistive device was used during a transfer, causing a resident to be lowered to the floor resulting in multiple fractures. | SS=G |
| Failure to report a fall with major injury immediately as required by policy and regulations. | SS=G |
| Failure to develop and implement a comprehensive care plan consistent with resident needs, specifically related to transfer assistance. | SS=G |
| Failure to ensure the resident environment was free of accident hazards and to provide adequate supervision and assistance devices to prevent accidents. | SS=G |
Report Facts
Licensed bed capacity: 80
Resident census: 73
Date of fall incident: Mar 10, 2022
Date bruising noted: Mar 11, 2022
Training completion date: Mar 24, 2022
Observation frequency: 10
Observation frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nursing Assistant | Named in transfer incident causing resident fall and failure to report |
| NA #3 | Nursing Assistant | Named in transfer incident causing resident fall and failure to report |
| CNA #4 | Certified Nursing Assistant | Observed resident on floor but failed to notify nursing staff or administration |
| LPN #1 | Licensed Practical Nurse | Evaluated resident after bruising was noted and notified Director of Nursing |
| LPN #2 | Licensed Practical Nurse / MDS Nurse | Interviewed regarding transfer procedures and staff training |
| Director of Nursing | Director of Nursing | Assessed resident, initiated investigation, confirmed findings, and described corrective actions |
| Administrator | Facility Administrator | Confirmed incident details, staff suspensions, and training implementation |
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 11, 2022
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 seven-day period from 04/04/2022 to 04/10/2022 as required by regulation, potentially causing 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. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Census: 66
Capacity: 80
Deficiencies: 0
Feb 18, 2022
Visit Reason
The State Agency conducted an annual survey from 2/15/22 through 2/18/22 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements during the annual survey.
Inspection Report
Annual Inspection
Census: 66
Capacity: 80
Deficiencies: 5
Feb 18, 2022
Visit Reason
The State Agency conducted an annual survey from 2/15/22 through 2/18/22 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with cited deficiencies related to transfer/discharge notice, PASARR screening accuracy, catheter care, bowel/bladder incontinence, infection prevention and control, and medication administration practices.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide written notice of transfer to the Responsible Representative for four residents. | SS=D |
| Failed to ensure accurate Pre-Admission Screening (PASARR) Application completion for one resident. | SS=D |
| Failed to ensure catheter tubing was anchored to minimize movement or prevent trauma and failed to provide catheter care to prevent infection for one resident. | SS=D |
| Failed to ensure residents with urinary and fecal incontinence received appropriate treatment and services to maintain or restore continence. | SS=D |
| Failed to prevent possible spread of infection during medication administration and PEG site care for multiple observations. | SS=D |
Report Facts
Licensed beds: 80
Resident census: 66
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in infection control and medication administration deficiencies |
| LPN #1 | Licensed Practical Nurse | Named in infection control and PEG site care deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding transfer notice and infection control deficiencies |
| Social Services Director | Social Services Director | Named in transfer notice and PASARR screening deficiencies |
| Registered Nurse #1 | Infection Preventionist | Interviewed regarding infection control deficiencies |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in catheter care deficiency |
Inspection Report
Life Safety
Deficiencies: 0
Feb 16, 2022
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
Life Safety
Deficiencies: 0
Feb 16, 2022
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 LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Feb 16, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with 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: 0
Oct 26, 2021
Visit Reason
The State Agency conducted a desk review related to a complaint investigation that was conducted on 2021-09-22 to verify corrective measures taken by the facility.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2021-10-21.
Complaint Details
The visit was related to a complaint investigation conducted on 2021-09-22. The facility was found to have corrected the deficiencies and sustained compliance.
Inspection Report
Complaint Investigation
Census: 71
Capacity: 80
Deficiencies: 2
Sep 22, 2021
Visit Reason
The State Agency conducted a complaint survey based on MS Complaint #18085 from 09/21/21 through 09/22/21 to investigate allegations of verbal and physical abuse at Bedford Care Center-Monroe Hall.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to report and thoroughly investigate allegations of abuse involving two residents. The complaint for verbal and physical abuse was not substantiated, but deficiencies were cited for failure to report alleged violations and failure to investigate and prevent abuse properly.
Complaint Details
The complaint investigation was triggered by MS Complaint #18085 alleging verbal and physical abuse. The complaint was not substantiated, but related deficiencies were cited. The facility failed to report allegations within required timeframes and failed to conduct thorough investigations, including notifying families, physicians, and the State Survey Agency.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report an allegation of physical and/or verbal abuse for two of four sampled residents investigated for abuse. | SS=E |
| Failure to thoroughly investigate allegations of physical abuse for two of four sampled residents, including lack of documentation, failure to notify responsible parties, and failure to protect residents during investigation. | SS=E |
Report Facts
Census: 71
Total Capacity: 80
Residents Screened for Abuse: 20
Residents Sampled for Abuse Investigation: 4
Residents with Alleged Abuse Not Reported: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Assistant | Named in allegations of verbal and physical abuse against Resident #1 and Resident #2. |
| CNA #2 | Certified Nurse Assistant | Reported allegations of abuse against CNA #1 and wrote statements regarding incidents involving Resident #1 and Resident #2. |
| Director of Nursing | Director of Nursing (DON) | Responsible for investigation and reporting of abuse allegations; failed to report allegations and conduct thorough investigations. |
| Administrator | Facility Administrator | Notified of allegations; failed to ensure reporting to State Survey Agency and proper investigation. |
| RN #1 | Registered Nurse Supervisor | Assessed Resident #2 after abuse complaint and reported to DON. |
| MDS Nurse | Minimum Data Set Nurse | Received abuse report from CNA #2 and forwarded it to DON. |
| RN #3 | Infection Preventionist | Provided opinion on proper investigation procedures and resident protection during investigations. |
Inspection Report
Abbreviated Survey
Census: 71
Capacity: 80
Deficiencies: 0
Aug 18, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 8/18/21 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.
Report Facts
Licensed beds: 80
Census: 71
Inspection Report
Abbreviated Survey
Deficiencies: 0
Aug 18, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 8/18/21 to assess compliance with emergency preparedness regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
May 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 05/24/21 to assess compliance with emergency preparedness regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Census: 68
Capacity: 80
Deficiencies: 0
May 24, 2021
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
Routine
Census: 73
Capacity: 80
Deficiencies: 0
Sep 29, 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: 73
Capacity: 80
Deficiencies: 0
Sep 29, 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.
Report Facts
Census: 73
Total licensed capacity: 80
Inspection Report
Routine
Census: 76
Capacity: 80
Deficiencies: 0
Jun 19, 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
Routine
Census: 76
Capacity: 80
Deficiencies: 0
Jun 19, 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
Complaint Investigation
Deficiencies: 0
Aug 26, 2019
Visit Reason
A complaint investigation was conducted at the facility.
Findings
The investigation was substantiated with no deficiencies cited.
Complaint Details
The complaint investigation was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 76
Capacity: 80
Deficiencies: 1
Aug 21, 2019
Visit Reason
The State Agency conducted complaint investigations on 08/20/2019-08/21/2019 related to allegations of abuse at Bedford Care Center-Monroe Hall.
Findings
The facility was found not in compliance with requirements for Medicare and Medicaid participation due to substantiated abuse involving verbal and physical abuse of one resident by a Certified Nursing Assistant (CNA). The resident was cognitively impaired and had no physical injuries, but the CNA was terminated following investigation. The facility implemented staff training and abuse prevention measures.
Complaint Details
Two complaint investigations were conducted (CI-MS #15921 and CI-MS #16169). The first was unsubstantiated with no deficiencies cited. The second was substantiated for abuse with regulatory deficiencies cited. The abusive CNA was removed from duty and terminated. The resident was assessed with no psychosocial or physical harm. Other residents assigned to the CNA were interviewed with no problems noted.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a resident from verbal and physical abuse by a CNA, including cursing and slapping the resident. | Level II |
Report Facts
Census: 76
Total Capacity: 80
Complaint Investigations: 2
Residents reviewed for abuse: 5
Date of incident: Aug 16, 2019
Date of survey: Aug 21, 2019
Date CNA terminated: Aug 21, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Witnessed abuse and reported incident |
| CNA #2 | Certified Nursing Assistant | Alleged perpetrator of verbal and physical abuse, terminated from employment |
| RN #1 | Registered Nurse / Shift Supervisor | Responded to abuse report, notified administration and authorities |
| RN #2 | Registered Nurse | Assessed resident for injuries and interviewed residents |
| Administrator | Facility Administrator | Managed investigation, communicated with CNA #2, and initiated termination |
| Unit Manager | Registered Nurse, Unit Manager | Assessed resident for harm and removed CNA #2 from assignment |
Inspection Report
Annual Inspection
Census: 79
Capacity: 80
Deficiencies: 4
May 16, 2019
Visit Reason
A standard recertification survey was conducted by Healthcare Management Solutions on behalf of the MS State Department of Health from May 13, 2019 to May 16, 2019 to assess compliance with Medicare/Medicaid participation requirements.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid requirements with deficiencies cited related to care planning, accident hazards, psychotropic medication use, medication labeling and storage. Specific issues included failure to implement a care plan for mental health needs, improper assessment of side rail use as accident hazards, unnecessary psychotropic drug use without behavior documentation, and expired medical supplies in medication rooms.
Deficiencies (4)
| Description |
|---|
| Failure to implement a comprehensive care plan to meet a resident's mental health needs as identified in the assessment for Resident #64. |
| Failure to properly assess the use of bilateral side rails as a potential accident hazard for Resident #37. |
| Failure to ensure residents' drug regimens are free from unnecessary psychotropic drugs, including lack of gradual dose reductions and inadequate documentation for Resident #64. |
| Failure to label and store drugs and biologicals properly, including expired culture swabs found in medication storage rooms. |
Report Facts
Deficiencies cited: 4
Resident census: 79
Total licensed beds: 80
Expired culture swabs: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #33 | Licensed Practical Nurse | Interviewed regarding Resident #64's behavior and medication use. |
| CNA #119 | Certified Nursing Assistant | Interviewed regarding Resident #64's behavior. |
| MDS/LPN #58 | Minimum Data Set Nurse / Licensed Practical Nurse | Interviewed regarding care plan implementation for Resident #64. |
| CNA #42 | Certified Nursing Assistant | Interviewed regarding Resident #37's attempts to get out of bed. |
| CNA #62 | Certified Nursing Assistant | Interviewed regarding Resident #37's attempts to climb out of bed. |
| RN #66 | Registered Nurse | Interviewed regarding Resident #37's attempts to climb out of bed. |
| PT #102 | Physical Therapist | Interviewed regarding nursing assessment of side rail use. |
| MDS Coordinator | Interviewed regarding side rail use and accident hazard assessment for Resident #37. | |
| DON | Director of Nursing | Interviewed regarding side rail consent, medication storage, and expired supplies. |
| Pharmacist Consultant #114 | Consultant Pharmacist | Interviewed regarding psychotropic medication use and dose reductions for Resident #64. |
| Physician #120 | Facility Physician | Interviewed regarding Resident #64's medication regimen. |
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