Inspection Reports for Bedford Care Center of Hattiesburg

MS, 39401

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Deficiencies per Year

8 6 4 2 0
2018
2019
2020
2022
2023
2024
2025
Severe High Moderate Low Unclassified

Census Over Time

60 90 120 150 180 Feb '18 Dec '18 Jan '20 Oct '20 Aug '23 Nov '25
Census Capacity
Inspection Report Complaint Investigation Census: 88 Capacity: 120 Deficiencies: 0 Nov 25, 2025
Visit Reason
The State Agency conducted complaint investigations related to facility construction environment and a resident fall during the period from 11/24/2025 through 11/25/2025.
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 investigations MS #2587291 and MS #2613605 were conducted; MS #2587291 related to environment during facility construction and MS #2613605 related to a fall. No deficiencies were cited.
Report Facts
Licensed beds: 120 Census: 88
Inspection Report Complaint Investigation Deficiencies: 0 Nov 25, 2025
Visit Reason
The State Agency conducted complaint investigations related to facility construction environment and a resident fall at Bedford Care Center of Hattiesburg from 11/24/2025 through 11/25/2025.
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 #2587291 and MS #2613605 were conducted; MS #2587291 related to environment during facility construction and MS #2613605 related to a fall. Both complaints were investigated with no deficiencies found.
Inspection Report Complaint Investigation Census: 95 Capacity: 120 Deficiencies: 0 May 8, 2025
Visit Reason
The State Agency conducted a complaint investigation related to disrespectful treatment and poor nursing care at the facility.
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 (CI), MS #28551, related to disrespectful treatment and poor nursing care; no deficiencies cited.
Report Facts
Licensed beds: 120 Census: 95
Inspection Report Plan of Correction Deficiencies: 0 Nov 25, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-10-24 to confirm 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, and the State Agency recommended the facility be placed back in compliance effective 2024-11-21.
Inspection Report Annual Inspection Deficiencies: 0 Nov 25, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2024-10-24 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were taken to address deficiencies, and the State Agency recommended the facility be placed back in compliance effective 2024-11-21.
Report Facts
Survey completion date: Oct 24, 2024
Inspection Report Annual Inspection Deficiencies: 0 Nov 21, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey conducted on 2024-10-23 to verify corrective measures and compliance with the Life Safety Code.
Findings
The facility provided information confirming corrective actions were taken to address deficient practices, sustaining compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 2024-11-21.
Inspection Report Annual Inspection Census: 95 Capacity: 120 Deficiencies: 5 Oct 24, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/21/2024 through 10/24/2024 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with several requirements including accuracy of assessments, comprehensive care plan implementation, activities meeting resident interests and needs, resident records accuracy, and infection prevention and control. Deficiencies were cited related to inaccurate MDS discharge assessment, failure to implement care plan interventions, lack of culturally relevant activities, inaccurate resident weight documentation, and improper storage of reusable medical equipment.
Severity Breakdown
SS=D: 4 SS=E: 1
Deficiencies (5)
DescriptionSeverity
Failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one resident.SS=D
Failed to implement care plan interventions for one resident, including providing culturally appropriate materials and activities.SS=D
Failed to provide individualized and culturally relevant activities to meet interests and preferences of a Spanish-speaking resident.SS=D
Failed to accurately document a resident's weight in the medical record.SS=D
Failed to store reusable medical equipment in a manner to prevent possible spread of infection; mechanical lift batteries stored in biohazard room without cleaning supplies.SS=E
Report Facts
Census: 95 Total Capacity: 120 Deficiencies cited: 5 Resident assessments reviewed: 19 Residents sampled for activities: 2 Resident cognition score: 4 Resident weight: 211.4 Resident weight: 186.5
Employees Mentioned
NameTitleContext
Director of NursingDirector of NursingInterviewed regarding inaccurate MDS discharge assessment and weight documentation
Licensed Practical Nurse #1Licensed Practical NurseConfirmed MDS discharge coding error for Resident #93
Activities AssistantActivities AssistantInterviewed about lack of culturally relevant activities for Resident #6
Activities DirectorActivities DirectorConfirmed absence of culturally specific activities for Resident #6
AdministratorAdministratorInterviewed about care plan and activities deficiencies
Minimum Data Set CoordinatorMDS CoordinatorExplained purpose of care plans and issues with adherence
Dietary ManagerDietary ManagerResponsible for entering weights and acknowledged importance of accurate weight documentation
Registered Nurse #1Registered NurseDiscussed weight changes and accuracy concerns for Resident #49
Certified Nurse Aide #1Certified Nurse AideExplained storage of mechanical lift batteries in biohazard room
Registered Nurse #2Registered NurseInfection Control Team member confirming improper storage of lift batteries
Registered Nurse #3Registered NurseInfection Control Team member confirming improper storage of lift batteries
Inspection Report Annual Inspection Deficiencies: 2 Oct 24, 2024
Visit Reason
The State Agency conducted an annual recertification survey at Bedford Care Center of Hattiesburg from 10/21/2024 through 10/24/2024 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 with standards related to individualized and culturally relevant activity programs for residents, specifically failing to meet the needs of a Spanish-speaking resident. Additionally, the facility failed to properly store reusable medical equipment, specifically mechanical lift batteries, in a manner that prevents infection transmission.
Severity Breakdown
Level II: 2
Deficiencies (2)
DescriptionSeverity
Failed to implement individualized and culturally relevant activities to meet the interests and preferences of one Spanish-speaking resident.Level II
Failed to store reusable medical equipment (mechanical lift batteries) in a manner to prevent possible spread of infection, with batteries stored in a biohazard room without cleaning supplies available.Level II
Report Facts
Survey duration days: 4 Brief Interview for Mental Status score: 4 Number of mechanical lift batteries observed: 4 Monitoring period: 3
Employees Mentioned
NameTitleContext
Certified Nurse Aide #1Certified Nurse AideInterviewed regarding storage and sanitization of mechanical lift batteries
Registered Nurse #2Director of NursingConfirmed storage practices of mechanical lift batteries and infection control concerns
Registered Nurse #3Infection Control TeamConfirmed storage practices of mechanical lift batteries and infection control concerns
Inspection Report Deficiencies: 0 Oct 23, 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 and no deficiencies were cited during the survey.
Inspection Report Life Safety Deficiencies: 2 Oct 23, 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), focusing on hazardous areas enclosure and essential electrical systems.
Findings
The facility failed to properly protect hazardous areas from smoke passage due to unsealed openings in the Water Heater Room, and failed to provide a remote manual stop station for the emergency generator as required by NFPA 110. Both deficiencies were acknowledged by the Administrator and Maintenance Supervisor.
Severity Breakdown
SS=D: 1 SS=F: 1
Deficiencies (2)
DescriptionSeverity
Facility failed to protect hazardous areas in accordance with NFPA 101; specifically, the Water Heater Room had unsealed openings allowing smoke passage.SS=D
Facility failed to provide a remote manual stop station for the emergency generator as required by NFPA 110 section 5.6.5.6.SS=F
Report Facts
Roof penetrations to be fabricated and installed: 14 Generator exercise frequency: 12 Generator exercise duration: 4
Employees Mentioned
NameTitleContext
AdministratorAcknowledged findings during exit interview.
Maintenance SupervisorVerified observations during exit interview.
Maintenance DirectorContacted vendor and responsible for corrective actions and monitoring.
Inspection Report Plan of Correction Deficiencies: 1 Oct 23, 2024
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding the presence of a remote manual stop station for the facility's generator.
Findings
The facility failed to provide a remote manual stop station for the generator as required by NFPA 110 section 5.6.5.6, affecting all residents on the day of the survey. The deficiency was acknowledged by the Administrator and Maintenance Supervisor.
Deficiencies (1)
Description
Facility failed to provide a remote manual stop station for the generator in accordance with NFPA 110 section 5.6.5.6.
Report Facts
Deficiency completion date: Nov 15, 2024 Monitoring duration: 3
Employees Mentioned
NameTitleContext
AdministratorAcknowledged the finding during the exit interview
Maintenance SupervisorVerified the observation during the exit interview
Maintenance DirectorResponsible for contacting vendor, monitoring installation and function of remote manual stop station
Inspection Report Plan of Correction Deficiencies: 0 Oct 23, 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 Oct 23, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey conducted on 10/23/24 to verify the facility's compliance with the Life Safety Code.
Findings
The facility provided information confirming corrective measures were implemented to address deficient practices and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 11/21/24.
Inspection Report Complaint Investigation Deficiencies: 0 Apr 16, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24619, related to rehabilitation services, neglect, pressure sores, and not being turned.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no citations were written.
Complaint Details
Complaint Investigation MS #24619 was substantiated with no citations written after investigation of rehabilitation services, neglect, pressure sores, and not being turned.
Inspection Report Complaint Investigation Census: 88 Capacity: 120 Deficiencies: 0 Apr 16, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24619, related to rehabilitation services, neglect, pressure sores, and not being turned.
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 Investigation MS #24619 was investigated related to rehabilitation services, neglect, pressure sores, and not being turned. No deficiencies were found.
Report Facts
Licensed beds: 120 Census: 88
Inspection Report Complaint Investigation Deficiencies: 0 Aug 2, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 7/31/23 through 8/2/23 related to pharmaceutical services, resident neglect, misappropriation of property, residents left wet for extended periods, call light not answered, resident assessment, and facility cleanliness.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #21496 and MS #22189 were investigated with no deficiencies cited.
Inspection Report Complaint Investigation Census: 87 Capacity: 120 Deficiencies: 0 Aug 2, 2023
Visit Reason
The State Agency conducted a Complaint Investigation from 7/31/23 through 8/2/23 related to pharmaceutical services, neglect, misappropriation of property, resident left wet for extended periods, call light not answered, resident assessment, and facility cleanliness.
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
The complaint investigation involved two cases: MS #21496 concerning pharmaceutical services, neglect, and misappropriation of property; and MS #22189 regarding resident care issues and facility cleanliness. Both complaints were investigated with no deficiencies found.
Report Facts
Licensed beds: 120 Census: 87
Inspection Report Plan of Correction Deficiencies: 1 Jun 5, 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 05/29/2023 to 06/04/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.F
Report Facts
Reporting period: 7
Inspection Report Plan of Correction Deficiencies: 1 May 2, 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 04/24/2023 to 04/30/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Life Safety Deficiencies: 0 Feb 17, 2023
Visit Reason
The survey 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 Feb 17, 2023
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 Annual Inspection Deficiencies: 0 Feb 16, 2023
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 02/13/2023 to 02/16/2023 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 all applicable standards and no deficiencies were cited during the survey.
Inspection Report Annual Inspection Census: 86 Capacity: 120 Deficiencies: 2 Feb 16, 2023
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 02/13/2023 to 02/16/2023 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements related to nurse staffing information posting and infection prevention and control practices, specifically during medication preparation.
Severity Breakdown
SS=C: 1 SS=E: 1
Deficiencies (2)
DescriptionSeverity
Failed to post daily nurse staffing information in a location visible to residents and visitors on three of four days reviewed.SS=C
Failed to prevent possible spread of infection during medication preparation when a nurse handled medication with bare hands contaminating other medications.SS=E
Report Facts
Census: 86 Total licensed capacity: 120 Days staffing not posted properly: 3 Date range of survey: Survey conducted from 2023-02-13 to 2023-02-16
Employees Mentioned
NameTitleContext
LPN #1Licensed Practical NurseNamed in infection control deficiency for handling medication with bare hands during medication administration
Director of NursingDirector of NursingInterviewed regarding nurse staffing posting and infection control issues
Registered Nurse #1Infection Prevention Nurse/Staff Development NurseInterviewed regarding infection control practices and medication handling
Inspection Report Annual Inspection Deficiencies: 0 Feb 16, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 02/16/23 to confirm 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 based on the desk review.
Inspection Report Annual Inspection Deficiencies: 0 Feb 16, 2023
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 02/16/23 to verify 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 03/16/23.
Inspection Report Plan of Correction Deficiencies: 1 Dec 19, 2022
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period from 12/12/2022 to 12/18/2022 as required by regulation, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
F 884: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete COVID-19 information to the CDC's NHSN during a seven-day period as required by regulation.F 884
Report Facts
Reporting period: 7
Inspection Report Complaint Investigation Deficiencies: 0 Nov 2, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19588 at the facility on 11/02/22.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. The complaint regarding pests and rehabilitation services was not substantiated and no deficiencies were cited.
Complaint Details
Complaint MS #19588 was investigated and not substantiated for pests in the facility and rehabilitation services.
Inspection Report Complaint Investigation Census: 85 Capacity: 120 Deficiencies: 0 Nov 2, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #19588) at the facility on 11/02/2022 related to pests in the facility and rehabilitation services.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint regarding pests and rehabilitation services was not substantiated, and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #19588) was not substantiated for pests in the facility and rehabilitation services.
Report Facts
Licensed beds: 120 Census: 85
Inspection Report Complaint Investigation Deficiencies: 0 Nov 2, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19588 at the facility on 11/02/22.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. The complaint regarding pests and rehabilitation services was not substantiated and no deficiencies were cited.
Complaint Details
Complaint MS #19588 was investigated and not substantiated for pests in the facility and rehabilitation services.
Inspection Report Complaint Investigation Deficiencies: 0 Apr 28, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2022-03-25.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The facility was recommended to be placed back in compliance effective 2022-04-20.
Complaint Details
The complaint survey conducted on 2022-03-25 was reviewed and found the facility in compliance.
Inspection Report Plan of Correction Deficiencies: 0 Apr 28, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey conducted on 2022-03-25 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that corrective measures were implemented to address the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-04-20.
Complaint Details
The visit was related to a complaint survey conducted on 2022-03-25. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation of compliance.
Report Facts
Survey date: Mar 25, 2022 Desk review date: Apr 28, 2022 Compliance effective date: Apr 20, 2022
Inspection Report Plan of Correction Deficiencies: 1 Mar 28, 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 information about COVID-19 to the CDC's NHSN during a seven-day period from 03/21/2022 to 03/27/2022, as required by regulation. This failure to report has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
DescriptionSeverity
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period.SS=F
Report Facts
Reporting period: 7
Inspection Report Complaint Investigation Deficiencies: 1 Mar 25, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at Bedford Care Center of Hattiesburg from March 22, 2022 through March 25, 2022, triggered by multiple complaints regarding baths not given, medications not given, inappropriate discharge, and food preferences and availability.
Findings
The facility was found not in compliance with Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm. One complaint was substantiated for failure to provide baths as scheduled, specifically one resident did not receive showers at least three times a week as required. Other complaints regarding medications, discharge, and food were not substantiated.
Complaint Details
Complaint Investigation MS #18462, MS #18498, MS #18597, and MS #18603. MS #18597 was substantiated for baths not given. MS #18603 was not substantiated for medications not given. MS #18462 was not substantiated for inappropriate discharge. MS #18498 was not substantiated for food preferences, insufficient food, and snacks not offered at night.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure one resident received showers at least three times a week as scheduled.Level II
Report Facts
Showers received: 4 Showers scheduled per week: 3
Employees Mentioned
NameTitleContext
Director of NursesDirector of NursingInterviewed on 3/23/22 and 3/24/22 regarding shower schedule and compliance.
Certified Nurse Assistant #1Certified Nurse AssistantInterviewed on 3/24/22 about documentation and notification procedures for resident bath refusals.
Social WorkerInterviewed on 3/23/22 regarding resident complaints about showers.
Inspection Report Complaint Investigation Census: 89 Capacity: 120 Deficiencies: 1 Mar 25, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from March 22 through March 25, 2022, triggered by multiple complaint survey numbers related to bathing, medication administration, discharge, and food service.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. One complaint (MS #18597) was substantiated for failure to provide baths as scheduled, resulting in a cited deficiency (F677). Other complaints regarding medications, discharge, and food preferences were not substantiated.
Complaint Details
Complaint Investigation included MS #18462, MS #18498, MS #18597, and MS #18603. MS #18597 was substantiated for baths not given. MS #18603, MS #18462, and MS #18498 were not substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Facility failed to ensure one resident received showers at least three times a week as scheduled, resulting in missed baths and resident discomfort.SS=D
Report Facts
Beds licensed: 120 Resident census: 89 Showers received: 4
Employees Mentioned
NameTitleContext
Director of NursesDirector of NursingVerified shower schedule and confirmed missed baths could cause skin issues
Certified Nurse Assistant #1Certified Nurse AssistantDescribed procedure for documenting resident bath refusals
Inspection Report Complaint Investigation Census: 65 Capacity: 100 Deficiencies: 0 Oct 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI #17130, CI #16846, CI #16868, CI #16799) was conducted by the State Agency.
Findings
The facility was found to be in compliance with infection control regulations and implemented CMS and CDC recommended practices for COVID-19. All complaint investigations were unsubstantiated with no deficiencies cited related to quality of care, resident neglect, or safety.
Complaint Details
Four complaint investigations (CI #16799, CI #16846, CI #16868, CI #17130) were unsubstantiated with no deficiencies cited for issues including pressure sore precautions, resident neglect, assessment/monitoring, grooming, staffing, and resident safety/falls.
Report Facts
Census: 65 Total Capacity: 100
Inspection Report Abbreviated Survey Deficiencies: 0 Oct 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 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report Abbreviated Survey Deficiencies: 0 Oct 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 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report Complaint Investigation Census: 65 Capacity: 100 Deficiencies: 0 Oct 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI #17130, CI #16846, CI #16868, CI #16799) was conducted by the State Agency.
Findings
The facility was found to be in compliance with infection control regulations and implemented CMS and CDC recommended practices for COVID-19. All complaint investigations were unsubstantiated with no deficiencies cited.
Complaint Details
Four complaint investigations (CI #17130, CI #16846, CI #16868, CI #16799) were conducted and all were unsubstantiated with no deficiencies cited related to quality of care, resident neglect, facility staffing, or resident safety.
Report Facts
Complaint Investigations: 4
Inspection Report Abbreviated Survey Census: 77 Capacity: 100 Deficiencies: 0 Jun 23, 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 Deficiencies: 0 Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/23/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report Complaint Investigation Census: 134 Capacity: 160 Deficiencies: 0 Mar 16, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 3/16/2020 regarding verbal abuse allegations.
Findings
The investigation was unsubstantiated for verbal abuse with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint investigation was unsubstantiated for verbal abuse.
Inspection Report Complaint Investigation Census: 149 Deficiencies: 0 Jan 13, 2020
Visit Reason
The State Agency conducted a complaint investigation related to Residents' Rights concerning resident code status.
Findings
The complaint was unsubstantiated with no deficiencies cited, and the facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint investigation was unsubstantiated for Residents Right related to resident code status with no deficiencies cited.
Inspection Report Complaint Investigation Census: 146 Capacity: 152 Deficiencies: 0 Jan 9, 2020
Visit Reason
The State Agency conducted a complaint investigation related to Quality of Care concerning Facility Staffing and Neglect related to Medication.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was determined to be in substantial compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint investigation was unsubstantiated for Quality of Care related to Facility Staffing and Neglect related to Medication with no deficiencies cited.
Inspection Report Annual Inspection Census: 143 Capacity: 152 Deficiencies: 2 Sep 26, 2019
Visit Reason
The State Agency conducted an annual recertification survey from 9/23/19 through 9/26/19 to determine compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to residents' awareness of survey results posting and infection prevention and control practices during medication administration.
Severity Breakdown
SS=E: 1 SS=D: 1
Deficiencies (2)
DescriptionSeverity
Facility failed to ensure residents were aware of the location and availability of the most recent survey results, as four of five residents did not know where the survey results were located.SS=E
Facility failed to prevent possible spread of infection during medication administration when nurses touched medications with bare hands.SS=D
Report Facts
Census: 143 Total Capacity: 152 Medication count: 7 Medication count: 9
Employees Mentioned
NameTitleContext
LPN #1Licensed Practical NurseObserved touching medications with bare hands during administration
LPN #2Licensed Practical NurseObserved placing medications into bare hand before administration
Director of NursingDirector of NursingInterviewed regarding infection control practices and medication administration
Social Worker #1Social WorkerInterviewed about resident education on survey results posting
Activity Director #1Activity DirectorInterviewed about resident education on survey results posting
Inspection Report Annual Inspection Census: 143 Capacity: 152 Deficiencies: 1 Sep 26, 2019
Visit Reason
The annual recertification survey was conducted from 9/23/19 through 9/26/19 to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found not in compliance with residents' rights regulations, specifically failing to ensure residents were aware of the location and availability of the most recent survey results. Survey results were posted but not adequately communicated to residents, as four of five residents interviewed did not know where the results were located.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure residents were aware of the location and availability of the most recent survey results.Level II
Report Facts
Residents unaware of survey results: 4 Survey posting duration: 3
Employees Mentioned
NameTitleContext
Social Worker #1Did not know where last year's survey results were posted and did not know how residents were educated about the posting.
Activity Director #1Stated Social Services conducts Resident Council meetings and had not educated residents on where survey results were posted.
Licensed Nursing Home AdministratorInformed staff of the location of survey results and regulations on September 26, 2019.
Maintenance DirectorPosted survey results at nurses stations on September 26, 2019.
Licensed Master's Social WorkerInformed Resident Council members of survey results locations during meetings.
Inspection Report Complaint Investigation Deficiencies: 0 Mar 19, 2019
Visit Reason
A complaint investigation was conducted at the facility.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report Complaint Investigation Census: 140 Capacity: 152 Deficiencies: 4 Dec 4, 2018
Visit Reason
The State Agency conducted a partial extended survey for Complaint Investigation (CI) MS #15548 from 11/26/18 to 12/4/18, substantiating the complaint for elopement but not other quality of care concerns.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing regulatory deficiencies including an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) related to failure to provide adequate supervision and follow the care plan for a confused, demented resident with a history of exit-seeking behavior, resulting in elopement.
Complaint Details
The complaint investigation substantiated the elopement of Resident #4, a confused and demented resident with a history of exit-seeking behavior. The facility failed to provide adequate supervision and failed to report the elopement to the State Agency. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Severity Breakdown
Level J: 3 Level IV: 1
Deficiencies (4)
DescriptionSeverity
Failure to report elopement and lack of supervision of Resident #4 to the State Agency.Level J
Failure to provide adequate assessment and supervision for a confused, demented resident with exit-seeking behavior.Level J
Failure to develop and implement a comprehensive care plan to prevent elopement for residents at risk.Level J
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision to prevent accidents.Level IV
Report Facts
Licensed beds: 152 Census: 140 Resident elopement risk score: 14 Visual checks frequency: 15 Visual checks duration: 24 Visual checks frequency after 72 hours: 60 Training attendance: 26
Employees Mentioned
NameTitleContext
RN #1Registered NurseEvaluated Resident #4 after elopement with no injuries noted
Receptionist #1ReceptionistResponsible for monitoring front door, observed on cell phone during elopement incident
LPN #1Licensed Practical NurseAssessed Resident #4 after elopement and returned resident to facility
AdministratorFacility AdministratorNotified of Immediate Jeopardy and elopement incident; involved in investigation and corrective actions
DONDirector of NursingInvolved in training and quality assurance related to elopement
Staff Development NurseStaff Development NurseConducted training on elopement and related policies
ADON #1Assistant Director of NursingInterviewed regarding elopement incident and care planning
Inspection Report Annual Inspection Census: 133 Capacity: 152 Deficiencies: 4 Aug 16, 2018
Visit Reason
The State Agency conducted a recertification survey from 08/13/18 through 08/16/18 to determine compliance with Medicare and Medicaid Requirements for Participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident rights and dignity, comprehensive care planning, pressure ulcer prevention and treatment, and infection control practices.
Severity Breakdown
SS=D: 4
Deficiencies (4)
DescriptionSeverity
Failure to ensure Resident #25's dignity by not providing coverage for the indwelling urinary catheter drainage bag.SS=D
Failure to follow Resident #22's comprehensive care plan related to pressure ulcers.SS=D
Failure to prevent pressure ulcer development for Resident #22.SS=D
Failure to establish and maintain an infection prevention and control program, specifically improper sanitary handling of ice on the South Wing.SS=D
Report Facts
Deficiencies cited: 4 Census: 133 Total capacity: 152 BIMS score: 12 BIMS score: 5 BIMS score: 8
Employees Mentioned
NameTitleContext
Registered Nurse Supervisor #2Registered Nurse SupervisorChanged Resident #25's urinary catheter drainage bag to a fig leaf privacy drainage bag.
Certified Nursing Assistant #1Certified Nursing AssistantNoted dignity issue regarding Resident #25's catheter bag not covered.
Director of NursesDirector of NursesAcknowledged dignity issue and described auditing and training plans.
Certified Nursing Assistant #4Certified Nursing AssistantConfirmed dignity issue for Resident #25's catheter bag.
Registered Nurse #2Registered NurseProvided wound care to Resident #22's right heel.
Certified Nursing Assistant #5Certified Nursing AssistantAssisted RN #2 with wound care for Resident #22.
Registered Nurse #1Registered NurseConfirmed expectation that staff follow Resident #22's care plan.
Director of NursesDirector of NursesDiscussed Resident #22's pressure ulcer development and staff standards.
Registered Nurse Supervisor #1Registered Nurse SupervisorIn-serviced CNAs #2 and #3 on proper handling of ice.
Certified Nursing Assistant #2Certified Nursing AssistantObserved leaving ice scoop inside ice chest, causing infection control issue.
Certified Nursing Assistant #3Certified Nursing AssistantObserved ice scoop left in ice and moved it to holder; aware of infection control issue.
Staff Development NurseStaff Development NurseAcknowledged infection control issue with ice scoop and described agency staff training efforts.
Inspection Report Annual Inspection Census: 133 Capacity: 152 Deficiencies: 2 Aug 16, 2018
Visit Reason
The State Agency conducted a recertification survey from 08/13/18 to 08/16/18 to determine compliance with the Minimum Standards for The Institutions For The Aged And Infirm.
Findings
The facility was found not in compliance with state statute M615 related to pressure sores. Specifically, the facility failed to ensure Resident #22's right to receive care to prevent a pressure ulcer, as evidenced by failure to follow the comprehensive care plan related to pressure ulcers.
Severity Breakdown
Level II: 2
Deficiencies (2)
DescriptionSeverity
Failure to ensure Resident #22's right to receive care to prevent a pressure ulcer, including failure to follow the comprehensive care plan related to pressure ulcers.Level II
Failure to prevent pressure ulcer development for Resident #22, including inadequate treatment and monitoring of a stage three pressure ulcer.Level II
Report Facts
Census: 133 Total Capacity: 152 Deficiencies cited: 2 Assessment Reference Date: Jun 4, 2018 Assessment Reference Date: Jul 24, 2018 Admission Date: May 28, 2018
Employees Mentioned
NameTitleContext
Registered Nurse #1Registered NurseInterviewed and stated expectation that staff follow resident's care plan
Registered Nurse #2Registered NurseObserved providing wound care to Resident #22
Certified Nursing Assistant #5Certified Nursing AssistantAssisted RN #2 in providing wound care to Resident #22
Director of NursesDirector of NursesInterviewed regarding Resident #22's pressure ulcer and care standards
Inspection Report Complaint Investigation Census: 148 Capacity: 152 Deficiencies: 1 Feb 6, 2018
Visit Reason
The State Agency conducted a complaint survey initiated on 2018-01-14 but was aborted due to an influenza outbreak. The survey continued on 2018-02-05 and concluded on 2018-02-06 to investigate compliance with State Licensure Regulations following a complaint (MS#14952).
Findings
The facility failed to ensure adequate supervision to prevent accidents, specifically for Resident #1 who eloped from the facility on 2017-12-31. The resident left the facility unnoticed despite wearing a wanderguard that did not activate. The facility identified issues with door locking mechanisms and staff supervision, and implemented corrective actions including disabling remote door unlocking and increased staff training and monitoring.
Complaint Details
Complaint survey MS#14952 was initiated due to an elopement incident involving Resident #1 on 2017-12-31. The resident left the facility unnoticed, wearing a wanderguard that failed to activate. The resident was found within 30 minutes and sent to the emergency room for evaluation. The complaint was substantiated with findings of inadequate supervision and door security.
Severity Breakdown
Level II: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure supervision to prevent accidents for Resident #1 who eloped from the facility without staff knowledge.Level II
Report Facts
Census: 148 Total licensed capacity: 152 Deficiency severity level II: 1 Distance resident eloped: 0.4 BIMS score: 3 BIMS score: 7
Employees Mentioned
NameTitleContext
LPN #1Licensed Practical NurseReported resident missing, found resident, and managed resident care post-elopement
LPN #2Licensed Practical NurseFound Resident #1 after elopement and returned him to the facility
LPN #3Licensed Practical NurseObserved resident holding door open for ambulance crew and reported incident
Director of NursingDirector of NursingPlaced wanderguard on Resident #1 and provided information about resident supervision
AdministratorFacility AdministratorProvided information on resident elopement, reviewed video footage, and described corrective actions
Maintenance SupervisorMaintenance SupervisorConducted door inspections and described changes to door locking systems post-elopement
Licensed Social WorkerLicensed Social WorkerCommunicated with resident's sister and provided social support information
Inspection Report Complaint Investigation Census: 148 Capacity: 152 Deficiencies: 1 Feb 6, 2018
Visit Reason
A complaint survey was initiated due to a complaint regarding elopement. The survey was conducted to investigate the complaint and assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility failed to ensure adequate supervision to prevent accidents for a resident at risk for elopement, resulting in the resident leaving the facility unsupervised. The wanderguard alarm did not activate, and the exit door locking mechanism failed. The resident was found and returned with no new injuries. The facility implemented corrective actions including disabling remote door unlocking, staff training, door inspections, and replacement of entrance and exit doors.
Complaint Details
The complaint survey was substantiated for elopement. Resident #1 left the facility without staff knowledge on 12/31/17, wearing a wanderguard that did not alarm. The resident was found within 30 minutes and sent to the emergency room for evaluation of a head injury, which was determined to be an old injury. The facility's investigation revealed door locking failures and inadequate supervision.
Severity Breakdown
SS=D: 1
Deficiencies (1)
DescriptionSeverity
Failed to ensure supervision to prevent accidents for a resident at risk for elopement; resident left facility unsupervised and wanderguard did not activate.SS=D
Report Facts
Census: 148 Total Capacity: 152 BIMS Score: 3 BIMS Score: 7 Time resident missing: 30 Date of elopement: Dec 31, 2017
Employees Mentioned
NameTitleContext
LPN #1Licensed Practical NurseReported resident missing, involved in resident assessment and monitoring
LPN #2Licensed Practical NurseFound resident and returned him to the facility
LPN #3Licensed Practical NurseObserved resident holding door open and reported incident
Director of NursingDirector of NursingInterviewed regarding wanderguard placement and resident monitoring
AdministratorFacility AdministratorProvided information on resident elopement, video review, and corrective actions
Maintenance SupervisorMaintenance SupervisorProvided information on door locking mechanisms and security measures
Licensed Social WorkerLicensed Social WorkerInterviewed regarding resident's family notification and social history
RN #2Registered NurseProvided proof of staff training and orientation procedures

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