Inspection Report Summary
The most recent inspections on November 25, 2025, found no deficiencies during complaint investigations related to facility construction and a resident fall. Earlier inspections showed a mixed record, with the facility addressing prior deficiencies related to resident assessments, care planning, culturally relevant activities, infection control, and Life Safety Code compliance. Main themes of past deficiencies included incomplete resident assessments, failure to implement individualized care plans and activities, infection prevention issues, and Life Safety Code violations such as unsealed hazardous areas and missing emergency generator controls. Complaint investigations were mostly unsubstantiated, with one substantiated complaint in 2022 for failure to provide scheduled baths, but no fines, immediate jeopardy, or license actions were noted in recent reports. The facility appears to have made improvements since 2024, resolving earlier cited deficiencies and maintaining compliance in the most recent reviews.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
58% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
73% occupied
Based on a November 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 88
Capacity: 120
Deficiencies: 0
Date: 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.
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.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.
Report Facts
Licensed beds: 120
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
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.
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.
Inspection Report
Complaint Investigation
Census: 95
Capacity: 120
Deficiencies: 0
Date: May 8, 2025
Visit Reason
The State Agency conducted a complaint investigation related to disrespectful treatment and poor nursing care at the facility.
Complaint Details
Complaint Investigation (CI), MS #28551, related to disrespectful treatment and poor nursing care; no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Report Facts
Licensed beds: 120
Census: 95
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Routine
Deficiencies: 5
Date: Oct 24, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, activities, medical record documentation, and infection control at Bedford Care Center of Hattiesburg.
Findings
The facility was found deficient in accurately completing resident assessments, implementing care plans and culturally relevant activities, documenting resident weights accurately, and properly storing reusable medical equipment to prevent infection spread.
Deficiencies (5)
Failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one of nineteen assessments reviewed (Resident #93).
Failed to implement care plan interventions for one of nineteen sampled residents (Resident #6).
Failed to implement individualized and culturally relevant activities to meet the interests and preferences of one Spanish-speaking resident (Resident #6).
Failed to accurately document a resident's weight in the medical record for one of nineteen sampled residents (Resident #49).
Failed to store reusable medical equipment in a manner to prevent possible spread of infection; mechanical lift batteries were stored in a biohazard room without cleaning supplies.
Report Facts
Assessments reviewed: 19
Residents sampled: 19
Spanish-speaking residents reviewed: 2
Residents sampled for weight documentation: 19
Resident #6 BIMS score: 4
Resident #49 weight recorded: 211.4
Resident #49 weight recorded: 186.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding inaccurate discharge assessment and infection control deficiencies |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Confirmed coding error in discharge assessment for Resident #93 |
| Activities Assistant | Activities Assistant | Interviewed about in-room activities and cultural preferences for Resident #6 |
| Activities Director | Activities Director | Confirmed lack of culturally specific activities for Resident #6 |
| Administrator | Administrator | Interviewed about care plan adherence and cultural activity provision |
| Minimum Data Set Coordinator | MDS Coordinator | Explained purpose of care plans and need for adherence |
| Dietary Manager | Dietary Manager | Responsible for entering resident weights into MDS and discussed importance of accuracy |
| Registered Nurse #1 | Registered Nurse (RN) | Reviewed resident weights and expressed concerns about accuracy |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Described storage of mechanical lift batteries in biohazard room |
| Registered Nurse #2 | Registered Nurse (RN) | Part of Infection Control Team confirming improper storage of equipment |
| Registered Nurse #3 | Registered Nurse (RN) | Part of Infection Control Team confirming improper storage of equipment |
Inspection Report
Annual Inspection
Census: 95
Capacity: 120
Deficiencies: 5
Date: 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.
Deficiencies (5)
Failed to accurately complete a Minimum Data Set (MDS) Discharge assessment for one resident.
Failed to implement care plan interventions for one resident, including providing culturally appropriate materials and activities.
Failed to provide individualized and culturally relevant activities to meet interests and preferences of a Spanish-speaking resident.
Failed to accurately document a resident's weight in the medical record.
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.
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
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding inaccurate MDS discharge assessment and weight documentation |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed MDS discharge coding error for Resident #93 |
| Activities Assistant | Activities Assistant | Interviewed about lack of culturally relevant activities for Resident #6 |
| Activities Director | Activities Director | Confirmed absence of culturally specific activities for Resident #6 |
| Administrator | Administrator | Interviewed about care plan and activities deficiencies |
| Minimum Data Set Coordinator | MDS Coordinator | Explained purpose of care plans and issues with adherence |
| Dietary Manager | Dietary Manager | Responsible for entering weights and acknowledged importance of accurate weight documentation |
| Registered Nurse #1 | Registered Nurse | Discussed weight changes and accuracy concerns for Resident #49 |
| Certified Nurse Aide #1 | Certified Nurse Aide | Explained storage of mechanical lift batteries in biohazard room |
| Registered Nurse #2 | Registered Nurse | Infection Control Team member confirming improper storage of lift batteries |
| Registered Nurse #3 | Registered Nurse | Infection Control Team member confirming improper storage of lift batteries |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: 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.
Deficiencies (2)
Failed to implement individualized and culturally relevant activities to meet the interests and preferences of one Spanish-speaking resident.
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.
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
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding storage and sanitization of mechanical lift batteries |
| Registered Nurse #2 | Director of Nursing | Confirmed storage practices of mechanical lift batteries and infection control concerns |
| Registered Nurse #3 | Infection Control Team | Confirmed storage practices of mechanical lift batteries and infection control concerns |
Inspection Report
Deficiencies: 0
Date: 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
Date: 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.
Deficiencies (2)
Facility failed to protect hazardous areas in accordance with NFPA 101; specifically, the Water Heater Room had unsealed openings allowing smoke passage.
Facility failed to provide a remote manual stop station for the emergency generator as required by NFPA 110 section 5.6.5.6.
Report Facts
Roof penetrations to be fabricated and installed: 14
Generator exercise frequency: 12
Generator exercise duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged findings during exit interview. | |
| Maintenance Supervisor | Verified observations during exit interview. | |
| Maintenance Director | Contacted vendor and responsible for corrective actions and monitoring. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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)
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
| Name | Title | Context |
|---|---|---|
| Administrator | Acknowledged the finding during the exit interview | |
| Maintenance Supervisor | Verified the observation during the exit interview | |
| Maintenance Director | Responsible for contacting vendor, monitoring installation and function of remote manual stop station |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
Complaint Details
Complaint Investigation MS #24619 was substantiated with no citations written after investigation of 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.
Inspection Report
Complaint Investigation
Census: 88
Capacity: 120
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Investigation MS #24619 was investigated related to rehabilitation services, neglect, pressure sores, and not being turned. No deficiencies were found.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Licensed beds: 120
Census: 88
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Investigation MS #21496 and MS #22189 were investigated with no deficiencies cited.
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.
Inspection Report
Complaint Investigation
Census: 87
Capacity: 120
Deficiencies: 0
Date: 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.
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.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Licensed beds: 120
Census: 87
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Life Safety
Deficiencies: 0
Date: 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
Date: 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
Date: 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
Date: 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.
Deficiencies (2)
Failed to post daily nurse staffing information in a location visible to residents and visitors on three of four days reviewed.
Failed to prevent possible spread of infection during medication preparation when a nurse handled medication with bare hands contaminating other medications.
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
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for handling medication with bare hands during medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding nurse staffing posting and infection control issues |
| Registered Nurse #1 | Infection Prevention Nurse/Staff Development Nurse | Interviewed regarding infection control practices and medication handling |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: 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
Date: 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
Routine
Deficiencies: 2
Date: Feb 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to nurse staffing postings and infection prevention and control during medication administration.
Findings
The facility failed to post daily nurse staffing information in a location visible to the public on three of four days reviewed, and failed to prevent possible infection spread during medication preparation when a nurse handled medication with bare hands.
Deficiencies (2)
Failed to post daily nurse staffing information for public viewing on three of four days reviewed.
Failed to prevent possible spread of infection during medication preparation when a nurse dispensed medication with bare hands contaminating other medications.
Report Facts
Days staffing not posted for public viewing: 3
Medication administration observations: 3
Medication order date: Feb 3, 2023
Skills checkoff date: Aug 5, 2022
Policy revision date: Jul 21, 2022
Policy revision date: Aug 2, 2022
Training document date: Aug 5, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for handling medication with bare hands |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing posting and infection control issues |
| Registered Nurse #1 | Infection Prevention Nurse/Staff Development Nurse | Interviewed regarding infection control during medication administration |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19588 at the facility on 11/02/22.
Complaint Details
Complaint MS #19588 was investigated and not substantiated for pests in the facility and rehabilitation services.
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.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Date: 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.
Complaint Details
Complaint Investigation (CI MS #19588) was not substantiated for 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.
Report Facts
Licensed beds: 120
Census: 85
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19588 at the facility on 11/02/22.
Complaint Details
Complaint MS #19588 was investigated and not substantiated for pests in the facility and rehabilitation services.
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2022-03-25.
Complaint Details
The complaint survey conducted on 2022-03-25 was reviewed and found the facility in compliance.
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.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: 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.
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.
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.
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
Date: 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.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Facility failed to ensure one resident received showers at least three times a week as scheduled.
Report Facts
Showers received: 4
Showers scheduled per week: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nursing | Interviewed on 3/23/22 and 3/24/22 regarding shower schedule and compliance. |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Interviewed on 3/24/22 about documentation and notification procedures for resident bath refusals. |
| Social Worker | Interviewed on 3/23/22 regarding resident complaints about showers. |
Inspection Report
Complaint Investigation
Census: 89
Capacity: 120
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Facility failed to ensure one resident received showers at least three times a week as scheduled, resulting in missed baths and resident discomfort.
Report Facts
Beds licensed: 120
Resident census: 89
Showers received: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nursing | Verified shower schedule and confirmed missed baths could cause skin issues |
| Certified Nurse Assistant #1 | Certified Nurse Assistant | Described procedure for documenting resident bath refusals |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 100
Deficiencies: 0
Date: 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.
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.
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.
Report Facts
Census: 65
Total Capacity: 100
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: 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
Date: 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
Date: 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.
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.
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.
Report Facts
Complaint Investigations: 4
Inspection Report
Abbreviated Survey
Census: 77
Capacity: 100
Deficiencies: 0
Date: 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
Date: 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
Date: Mar 16, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 3/16/2020 regarding verbal abuse allegations.
Complaint Details
Complaint investigation was unsubstantiated for verbal abuse.
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.
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 0
Date: Jan 13, 2020
Visit Reason
The State Agency conducted a complaint investigation related to Residents' Rights concerning resident code status.
Complaint Details
Complaint investigation was unsubstantiated for Residents Right related to resident code status with no deficiencies cited.
Findings
The complaint was unsubstantiated with no deficiencies cited, and the facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Inspection Report
Complaint Investigation
Census: 146
Capacity: 152
Deficiencies: 0
Date: 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.
Complaint Details
Complaint investigation was unsubstantiated for Quality of Care related to Facility Staffing and Neglect related to Medication with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was determined to be in substantial compliance with Medicare and Medicaid requirements.
Inspection Report
Annual Inspection
Census: 143
Capacity: 152
Deficiencies: 2
Date: 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.
Deficiencies (2)
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.
Facility failed to prevent possible spread of infection during medication administration when nurses touched medications with bare hands.
Report Facts
Census: 143
Total Capacity: 152
Medication count: 7
Medication count: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed touching medications with bare hands during administration |
| LPN #2 | Licensed Practical Nurse | Observed placing medications into bare hand before administration |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control practices and medication administration |
| Social Worker #1 | Social Worker | Interviewed about resident education on survey results posting |
| Activity Director #1 | Activity Director | Interviewed about resident education on survey results posting |
Inspection Report
Annual Inspection
Census: 143
Capacity: 152
Deficiencies: 1
Date: 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.
Deficiencies (1)
Failed to ensure residents were aware of the location and availability of the most recent survey results.
Report Facts
Residents unaware of survey results: 4
Survey posting duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Did not know where last year's survey results were posted and did not know how residents were educated about the posting. | |
| Activity Director #1 | Stated Social Services conducts Resident Council meetings and had not educated residents on where survey results were posted. | |
| Licensed Nursing Home Administrator | Informed staff of the location of survey results and regulations on September 26, 2019. | |
| Maintenance Director | Posted survey results at nurses stations on September 26, 2019. | |
| Licensed Master's Social Worker | Informed Resident Council members of survey results locations during meetings. |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 26, 2019
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations, including resident rights to access survey results and infection prevention and control practices during medication administration.
Findings
The 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 results were posted. Additionally, the facility failed to prevent possible infection spread during medication preparation, as two nurses were observed handling oral medications with bare hands, contrary to infection control policies.
Deficiencies (2)
Failed to ensure residents were aware of the location and availability of the most recent survey results.
Failed to prevent possible spread of infection during medication preparation by nurses touching oral medications with bare hands.
Report Facts
Residents unaware of survey results: 4
Nurses observed mishandling medications: 2
Medications handled by LPN #1: 8
Medications handled by LPN #2: 9
Training dates: Oct 17, 2018
Training dates: Sep 6, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed touching oral medications with bare hands during medication preparation. |
| LPN #2 | Licensed Practical Nurse | Observed touching oral medications with bare hands during medication preparation. |
| Director of Nursing | Director of Nursing (DON) | Confirmed that nurses should not touch oral medications with bare hands and identified this as an infection control concern. |
| Social Worker #1 | Social Worker | Did not know where last year's survey results were posted and was unaware of resident education on this. |
| Activity Director #1 | Activity Director | Stated Social Services conducts Resident Council meetings and had not educated residents on where survey results were posted. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2019
Visit Reason
A complaint investigation was conducted at the facility.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 140
Capacity: 152
Deficiencies: 4
Date: 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.
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.
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.
Deficiencies (4)
Failure to report elopement and lack of supervision of Resident #4 to the State Agency.
Failure to provide adequate assessment and supervision for a confused, demented resident with exit-seeking behavior.
Failure to develop and implement a comprehensive care plan to prevent elopement for residents at risk.
Failure to ensure the resident environment remains free of accident hazards and provide adequate supervision to prevent accidents.
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
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Evaluated Resident #4 after elopement with no injuries noted |
| Receptionist #1 | Receptionist | Responsible for monitoring front door, observed on cell phone during elopement incident |
| LPN #1 | Licensed Practical Nurse | Assessed Resident #4 after elopement and returned resident to facility |
| Administrator | Facility Administrator | Notified of Immediate Jeopardy and elopement incident; involved in investigation and corrective actions |
| DON | Director of Nursing | Involved in training and quality assurance related to elopement |
| Staff Development Nurse | Staff Development Nurse | Conducted training on elopement and related policies |
| ADON #1 | Assistant Director of Nursing | Interviewed regarding elopement incident and care planning |
Inspection Report
Annual Inspection
Census: 133
Capacity: 152
Deficiencies: 4
Date: 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.
Deficiencies (4)
Failure to ensure Resident #25's dignity by not providing coverage for the indwelling urinary catheter drainage bag.
Failure to follow Resident #22's comprehensive care plan related to pressure ulcers.
Failure to prevent pressure ulcer development for Resident #22.
Failure to establish and maintain an infection prevention and control program, specifically improper sanitary handling of ice on the South Wing.
Report Facts
Deficiencies cited: 4
Census: 133
Total capacity: 152
BIMS score: 12
BIMS score: 5
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Supervisor #2 | Registered Nurse Supervisor | Changed Resident #25's urinary catheter drainage bag to a fig leaf privacy drainage bag. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Noted dignity issue regarding Resident #25's catheter bag not covered. |
| Director of Nurses | Director of Nurses | Acknowledged dignity issue and described auditing and training plans. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Confirmed dignity issue for Resident #25's catheter bag. |
| Registered Nurse #2 | Registered Nurse | Provided wound care to Resident #22's right heel. |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Assisted RN #2 with wound care for Resident #22. |
| Registered Nurse #1 | Registered Nurse | Confirmed expectation that staff follow Resident #22's care plan. |
| Director of Nurses | Director of Nurses | Discussed Resident #22's pressure ulcer development and staff standards. |
| Registered Nurse Supervisor #1 | Registered Nurse Supervisor | In-serviced CNAs #2 and #3 on proper handling of ice. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Observed leaving ice scoop inside ice chest, causing infection control issue. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Observed ice scoop left in ice and moved it to holder; aware of infection control issue. |
| Staff Development Nurse | Staff Development Nurse | Acknowledged infection control issue with ice scoop and described agency staff training efforts. |
Inspection Report
Annual Inspection
Census: 133
Capacity: 152
Deficiencies: 2
Date: 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.
Deficiencies (2)
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.
Failure to prevent pressure ulcer development for Resident #22, including inadequate treatment and monitoring of a stage three pressure ulcer.
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
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed and stated expectation that staff follow resident's care plan |
| Registered Nurse #2 | Registered Nurse | Observed providing wound care to Resident #22 |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Assisted RN #2 in providing wound care to Resident #22 |
| Director of Nurses | Director of Nurses | Interviewed regarding Resident #22's pressure ulcer and care standards |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 152
Deficiencies: 1
Date: 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).
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.
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.
Deficiencies (1)
Failed to ensure supervision to prevent accidents for Resident #1 who eloped from the facility without staff knowledge.
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
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported resident missing, found resident, and managed resident care post-elopement |
| LPN #2 | Licensed Practical Nurse | Found Resident #1 after elopement and returned him to the facility |
| LPN #3 | Licensed Practical Nurse | Observed resident holding door open for ambulance crew and reported incident |
| Director of Nursing | Director of Nursing | Placed wanderguard on Resident #1 and provided information about resident supervision |
| Administrator | Facility Administrator | Provided information on resident elopement, reviewed video footage, and described corrective actions |
| Maintenance Supervisor | Maintenance Supervisor | Conducted door inspections and described changes to door locking systems post-elopement |
| Licensed Social Worker | Licensed Social Worker | Communicated with resident's sister and provided social support information |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 152
Deficiencies: 1
Date: 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.
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.
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.
Deficiencies (1)
Failed to ensure supervision to prevent accidents for a resident at risk for elopement; resident left facility unsupervised and wanderguard did not activate.
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
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Reported resident missing, involved in resident assessment and monitoring |
| LPN #2 | Licensed Practical Nurse | Found resident and returned him to the facility |
| LPN #3 | Licensed Practical Nurse | Observed resident holding door open and reported incident |
| Director of Nursing | Director of Nursing | Interviewed regarding wanderguard placement and resident monitoring |
| Administrator | Facility Administrator | Provided information on resident elopement, video review, and corrective actions |
| Maintenance Supervisor | Maintenance Supervisor | Provided information on door locking mechanisms and security measures |
| Licensed Social Worker | Licensed Social Worker | Interviewed regarding resident's family notification and social history |
| RN #2 | Registered Nurse | Provided proof of staff training and orientation procedures |
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