25 Reports
Inspection Report — Mar 23, 2026
Annual Inspection
Date: Mar 23, 2026
Visit Reason
On 03/23/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 02/19/26. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that your facility be placed back in compliance effective 03/17/26. No deficiencies were cited in this desk review.
Inspection Report — Mar 23, 2026
Date: Mar 23, 2026
Visit Reason
On 03/23/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 02/19/26.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending your facility be placed back in compliance effective 03/17/26.
Inspection Report — Feb 23, 2026
Life Safety
Date: Feb 23, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility met all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Feb 19, 2026
Annual Inspection
Date: Feb 19, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 02/17/26 through 2/19/26. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F656, F677, F689, F761, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies in care plan implementation, ADL care, chemical and medication storage, and infection prevention and control practices.
Deficiencies (5)
F0656 - The facility failed to implement the resident's care plan relating to personal hygiene for one resident, Resident #7, who had visible facial hair she wished to have removed but staff did not follow her preference.
F0677 - The facility failed to ensure a resident unable to carry out activities of daily living received necessary services to maintain good grooming, as evidenced by Resident #7's unremoved facial hair.
F0689 - The facility failed to ensure the resident environment was free of accident hazards and that chemicals were stored properly and secured, as an unattended spray bottle of disinfectant was accessible to residents.
F0761 - The facility failed to ensure medications were stored securely and expired medications were removed, as a wound care cart was found unlocked and unattended and expired influenza vaccines were not disposed of.
F0880 - The facility failed to implement infection prevention and control practices for three residents on droplet isolation precautions, including improper handling of contaminated items, failure to perform hand hygiene, and failure to wear appropriate personal protective equipment.
Report Facts
Deficiencies cited: 5
Inspection Report — Feb 19, 2026
Annual Inspection
Date: Feb 19, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 02/17/26 through 02/19/26. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M610, M640, M715, M1570.
Findings
The facility was found not in compliance with state licensure requirements, with deficiencies cited in activities of daily living, accident prevention, medication labeling and storage, and infection control practices affecting multiple residents.
Deficiencies (4)
M0610 - Activities of daily living. The facility failed to ensure a resident unable to carry out ADLs received necessary grooming services, as Resident #7 had visible long facial hair despite wanting it removed.
M0640 - Accidents. The facility failed to ensure chemicals were properly stored and secured, as a disinfectant spray bottle was left unattended and accessible to residents.
M0715 - Labeling of drugs. The facility failed to ensure medications were stored securely and expired medications were removed, evidenced by an unlocked wound care cart with medications and expired influenza vaccines not disposed.
M1570 - Infection Control. The facility failed to implement infection prevention and control practices for three residents, including improper handling of contaminated items, failure to perform hand hygiene, and not following droplet precautions.
Report Facts
Deficiencies cited: 4
Inspection Report — Dec 20, 2024
Annual Inspection
Date: Dec 20, 2024
Visit Reason
On 12/20/24 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/14/24. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/20/24. No deficiencies were cited in this desk review.
Inspection Report — Dec 18, 2024
Life Safety
Date: Dec 18, 2024
Visit Reason
On 12/18/24 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey conducted on 11/12/24. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 12/18/24. No deficiencies were cited in this desk review.
Inspection Report — Nov 14, 2024
Annual Inspection
Date: Nov 14, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 11/12/24 to 11/14/24. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M815, M855 and M1570.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in safe food handling, food preparation respecting resident preferences, and infection control practices.
Deficiencies (3)
M815 - Safe Food Handling Procedures. The facility failed to ensure food items were stored according to professional standards, as several items in the kitchen were not labeled or dated.
M855 - Food Preparation. The facility failed to ensure dietary staff supported the nutritional well-being of residents by not honoring the food preferences of one resident who required a high-protein, low-carbohydrate diet.
M1570 - Infection Control. The facility failed to implement Enhanced Barrier Precautions for a resident at high risk for multidrug-resistant organisms and failed to practice proper hand hygiene during care for five sampled residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 14, 2024
Annual Inspection
Date: Nov 14, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 11/12/24 through 11/14/24. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F800, F812, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to dietary services not meeting residents' nutritional needs, improper food storage labeling, and failures in infection prevention and control practices.
Deficiencies (3)
F0800 - Provided diet meets needs of each resident. The facility failed to ensure dietary staff supported the nutritional well-being of residents by not consistently honoring Resident #169's high-protein, low-carbohydrate diet preferences.
F0812 - Food procurement, store, prepare, serve sanitary. The facility failed to ensure food items were labeled and dated properly in the kitchen, with several open food containers lacking dates.
F0880 - Infection prevention and control. The facility failed to implement Enhanced Barrier Precautions for a resident at high risk for multidrug-resistant organisms and failed to practice proper hand hygiene during care for five sampled residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Nov 12, 2024
Life Safety
Date: Nov 12, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility failed to provide half hour fire rating in the smoke barrier doors in two of six smoke compartments, affecting 23 residents. The smoke barrier doors did not close properly, allowing smoke to pass through the facility.
Deficiencies (1)
K0374 - The facility failed to provide half hour rating in the smoke barrier doors in accordance with NFPA 101 sections 19.3.7.6. Two smoke compartments' doors did not close properly, allowing smoke to pass through the facility.
Report Facts
Deficiencies cited: 1
Inspection Report — May 1, 2023
Annual Inspection
Date: May 1, 2023
Visit Reason
On 05/01/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 04/06/23.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 04/27/23.
Inspection Report — Apr 6, 2023
Annual Inspection
Date: Apr 6, 2023
Visit Reason
The State Agency (SA) conducted an annual survey at the facility from 4/04/23 through 4/06/23. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F888.
Findings
F0888 - The facility failed to follow its policies and procedures to ensure implementation of additional precautions to mitigate COVID-19 transmission among staff who were not fully vaccinated. Several employees with vaccination exemptions were not wearing masks as required, and the facility was not following CDC guidelines or its own policy.
Deficiencies (1)
F0888 - The facility failed to follow policies and procedures to ensure additional precautions for unvaccinated staff, including mask-wearing, which could affect all residents. Interviews revealed staff with exemptions were not wearing masks and were not tested more frequently, contrary to policy and CDC guidelines.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 6, 2023
Life Safety
Date: Apr 6, 2023
Visit Reason
The facility was surveyed for 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. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Apr 6, 2023
Annual Inspection
Date: Apr 6, 2023
Visit Reason
The State Agency (SA) conducted an Annual Recertification Survey at the facility from 4/4/23 through 4/6/23.
Findings
During the survey, the SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and there were no deficiencies cited.
Inspection Report — Mar 3, 2023
Complaint Investigation
Date: Mar 3, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for (1) complaint, MS #19880 on 3/03/23.
Complaint Details
Complaint MS #19880 involved Dietary Services, Quality of Care, Resident Assessment, and Safety/Falls. The complaint was investigated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited related to Dietary Services, Quality of Care, Resident Assessment, and Safety/Falls.
Report Facts
Complaints investigated: 1
Inspection Report — Mar 3, 2023
Complaint Investigation
Date: Mar 3, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for (1) complaint, MS #19880 on 3/03/23. The SA investigated MS #19880 for Dietary Services and Quality of Care, Resident Assessment and Quality of Care related to Safety/Falls.
Complaint Details
Complaint MS #19880 investigated for Dietary Services, Quality of Care, Resident Assessment, and Safety/Falls; no deficiencies cited.
Findings
The SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaints investigated: 1
Inspection Report — Jun 8, 2022
Routine
Date: Jun 8, 2022
Visit Reason
The State Agency conducted a desk review of information related to the Focused Infection Control Survey conducted on 05/06/22. The facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 05/31/22.
Inspection Report — Jun 8, 2022
Life Safety
Date: Jun 8, 2022
Visit Reason
The State Agency conducted a desk review of information related to the Emergency Preparedness survey conducted on 05/06/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to Emergency Preparedness.
Inspection Report — May 6, 2022
Routine
Date: May 6, 2022
Visit Reason
A COVID-19 Focused Infection Control survey was conducted by the State Agency (SA) on 5/6/22. The facility was found not to be in compliance with infection control regulations and the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19. During the survey, the SA cited F880 and F883.
Findings
The facility failed to ensure proper storage of an ice scoop during ice distribution, posing an infection control risk. Additionally, the facility failed to administer an influenza vaccine to one resident after signed consent was obtained.
Deficiencies (2)
F0880 - Infection Prevention & Control. The facility failed to ensure an ice scoop was properly stored during ice distribution for one of six ice chests observed, with cups left inside the ice chest posing contamination risks.
F0883 - Influenza and Pneumococcal Immunizations. The facility failed to administer an influenza vaccine after signed consent was obtained for one of five residents reviewed for immunizations.
Report Facts
Deficiencies cited: 2
Inspection Report — May 6, 2022
Routine
Date: May 6, 2022
Visit Reason
The State Agency (SA) conducted a COVID-19 Focused Emergency Preparedness Survey at the facility on 5/6/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 1, 2021
Complaint Investigation
Date: Jul 1, 2021
Visit Reason
The State Agency conducted a complaint investigation for complaints MS #16726, MS #16993, MS #16942 and MS #117364 at the facility from 6/28/2021 to 7/1/2021.
Complaint Details
Complaint investigation for complaints MS #16726, MS #16993, MS #16942 and MS #117364; the complaints for quality of care, neglect, and infection control were not substantiated.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 4
Inspection Report — May 22, 2020
Routine
Date: May 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/22/20. The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Jan 30, 2020
Annual Inspection
Date: Jan 30, 2020
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 01/28/2020 to 01/30/2020. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation and cited deficiencies at F657, F761 and F812.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to deficiencies in care plan timing and revision, medication storage, and food procurement and sanitation.
Deficiencies (3)
F0657 - The facility failed to revise a care plan related to hospice for one resident after hospice services were discontinued.
F0761 - The facility failed to ensure an expired medication was removed from the medication stock in one of three medication storage areas observed.
F0812 - The facility failed to ensure the milk and ice cream cooler were kept in a clean and sanitary condition during two kitchen observations.
Report Facts
Deficiencies cited: 3
Inspection Report — Feb 26, 2019
Complaint Investigation
Date: Feb 26, 2019
Visit Reason
A complaint investigation was conducted on February 26, 2019 in the facility.
Complaint Details
CI MS #15688: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Nov 2, 2018
Annual Inspection
Date: Nov 2, 2018
Visit Reason
The State Agency (SA) conducted an annual recertification survey from 10/31/18 to 11/02/18. The SA determined the facility was not in compliance with State Licensure Regulations for the Aged and Infirm and cited State Statute M950.
Findings
The facility was found not in compliance with state licensure regulations, citing two deficiencies related to residents' rights and sanitation. The facility failed to develop a comprehensive care plan for a resident with depression and failed to keep the outside waste container lid closed on multiple days.
Deficiencies (2)
M500 - Residents' Rights. The facility failed to ensure Resident #122's right to receive care and services for the treatment and management of depression by not developing a comprehensive care plan addressing this diagnosis.
M950 - Sanitation and Medical Waste. The facility failed to ensure the outside dumpster lid was closed for two of three days during environmental tours.
Report Facts
Deficiencies cited: 2
Employees mentioned
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