Inspection Reports for
Care Center of Aberdeen
505 Jackson Street, Aberdeen, MS, 39730
Back to Facility Profile6 Reports
Inspection Report — Dec 3, 2025
Complaint Investigation CMS
Date: Dec 3, 2025
Visit Reason
The inspection was conducted in response to a complaint regarding the use of psychotropic medications without proper consent for Resident #5.
Complaint Details
The complaint was substantiated based on findings that the resident's representative was unaware of psychotropic medications prescribed and had not signed consent forms. The facility confirmed the lack of consent documentation.
Findings
The facility failed to ensure that Resident #5 was free from chemical restraints by administering psychotropic medications without obtaining required consent from the resident or representative. The Director of Nursing was unable to locate any consent forms for the medications Haldol and Sertraline prescribed to Resident #5.
Deficiencies (1)
F 0605: The facility administered psychotropic medications to Resident #5 without obtaining required consent to inform the resident or representative of risks, benefits, and alternatives. This failure constitutes the use of chemical restraints without proper authorization.
Report Facts
Residents reviewed for chemical restraints: 3
Medication orders for Haldol: 0.5
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lack of consent for psychotropic medications |
Inspection Report — Jul 29, 2025
CMS
Date: Jul 29, 2025
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights regarding notification of room changes in the facility.
Findings
The facility failed to honor the resident's right to receive written notification, including the reason for the change, before moving Resident #1 to a different room in September 2024.
Deficiencies (1)
F 0559: The facility failed to provide written notice to Resident #1 or their representative before changing the resident's room in September 2024, violating the resident's right to be informed of room changes and the reasons for them.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Named in relation to failure to notify resident representative about room change. | |
| Administrator | Confirmed facility failed to notify resident representative of room change. |
Inspection Report — May 15, 2025
Routine CMS
Date: May 15, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulatory requirements related to resident rights, grievance resolution, care planning, PASRR referrals, accident prevention, and food safety.
Findings
The facility failed to honor residents' rights to determine end-of-life care for several residents, failed to resolve a resident grievance related to timely ADL care, failed to submit a required PASRR change in status referral, failed to implement comprehensive care plans for ADL nail care, failed to provide adequate supervision and safety during resident transport resulting in a fall, and failed to maintain proper food labeling and kitchen cleanliness.
Deficiencies (7)
F578: The facility failed to verify and document cognitive residents' end-of-life care preferences for three residents, resulting in failure to honor their wishes.
F585: The facility failed to address and resolve a resident grievance regarding timely Activities of Daily Living care for one resident, despite multiple complaints.
F644: The facility failed to submit a required Level II PASRR change in status referral for a resident with a new mental health diagnosis.
F656: The facility failed to implement care plans related to nail care for two residents, resulting in long, unclean fingernails despite resident preferences.
F677: The facility failed to provide ADL care to maintain personal hygiene for two residents, including failure to keep nails clean and trimmed as preferred.
F689: The facility failed to ensure resident safety during transport when a wheelchair lift safety belt was not used, resulting in a resident falling from the lift and sustaining a head injury.
F812: The facility failed to properly label and store food and maintain kitchen equipment cleanliness, including undated opened food items and dirty food service windows.
Report Facts
Residents reviewed for end-of-life care rights: 24
Residents affected by end-of-life care deficiency: 3
Residents sampled for grievance: 20
Residents affected by grievance deficiency: 1
PASRRs reviewed: 4
Residents affected by PASRR deficiency: 1
Residents sampled for care plan review: 20
Residents affected by care plan deficiency: 2
Residents affected by ADL care deficiency: 2
Residents affected by accident: 1
Length of laceration: 3
Number of kitchen tours: 3
Number of kitchen tours with deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in fall incident involving failure to use wheelchair lift safety belt |
| Director of Nursing | Director of Nursing | Named in multiple interviews confirming deficiencies and fall investigation |
| Licensed Social Worker | Licensed Social Worker | Named in interviews regarding PASRR referral and grievance process |
| Mental Health Nurse Practitioner | Mental Health Nurse Practitioner | Named in diagnosis of resident with new psychosis diagnosis |
| Administrator | Administrator | Named in interviews regarding grievance process and fall incident |
| Dietary Manager | Dietary Manager | Named in interviews regarding food storage and kitchen cleanliness |
| Production Supervisor | Production Supervisor | Named in interview regarding kitchen cleanliness |
| Registered Nurse #1 | Registered Nurse | Named in observation and interview regarding resident nail care |
| CNA #2 | Certified Nurse Aide | Named in interview regarding training of CNA #1 on van safety |
| CNA #3 | Certified Nurse Aide | Named in interview regarding training of CNA #1 on van safety |
| MDS Coordinator | MDS Coordinator | Named in interviews regarding care plan development and implementation |
Inspection Report — Oct 24, 2024
Complaint Investigation CMS
Date: Oct 24, 2024
Visit Reason
The inspection was conducted in response to complaints regarding unsanitary conditions, specifically dirty wheelchairs and offensive odors in resident rooms.
Complaint Details
The complaint was substantiated. The complainant reported persistent urine odors and filthy wheelchairs, which were confirmed by observations and staff interviews. The complainant expressed concern for residents unable to speak for themselves.
Findings
The facility failed to maintain a clean environment as evidenced by dirty wheelchairs and strong, offensive odors in the rooms of three sampled residents. Observations and interviews confirmed the presence of foul odors, unclean wheelchairs, and inadequate cleaning protocols.
Deficiencies (1)
F 0584: The facility failed to ensure a clean environment, including dirty wheelchairs and strong offensive odors in the rooms of Residents #6, #7, and #8. The facility lacked an effective plan to ensure wheelchairs were cleaned regularly and did not maintain an odor-free environment.
Report Facts
Residents sampled: 7
Residents affected: 3
Admission date: May 24, 2021
Admission date: Jul 30, 2021
Admission date: Jan 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding wheelchair cleaning responsibilities and lack of effective cleaning plan |
| Administrator | Administrator | Confirmed odor and cleanliness issues and acknowledged need for correction |
| CNA #1 | Certified Nursing Assistant | Interviewed about wheelchair cleaning duties on night shift |
Inspection Report — Nov 16, 2023
Complaint Investigation CMS
Date: Nov 16, 2023
Visit Reason
The inspection was conducted due to complaints regarding the facility's failure to honor a resident's right to smoke, failure to submit required PASRR change in status referrals, inadequate supervision during smoke breaks, and inaccurate staffing data submission.
Complaint Details
The complaint investigation substantiated that the facility failed to honor a resident's right to smoke, failed to submit required PASRR referrals, failed to provide adequate supervision during smoking times, and failed to submit accurate staffing data.
Findings
The facility failed to honor a resident's right to smoke cigarettes, failed to submit a required Level 2 PASRR change in status referral for a resident with new mental health diagnoses and medications, failed to provide adequate supervision during smoke breaks to prevent residents from obtaining smoking paraphernalia, and failed to submit accurate staffing data into the Payroll-Based Journal system.
Deficiencies (4)
F 0561: The facility failed to honor Resident #45's right to smoke cigarettes by revoking his smoking privileges and only allowing use of a vape pen despite his desire to smoke.
F 0644: The facility failed to submit a change in status referral for a Level 2 PASRR for Resident #24 after new mental health diagnoses, new antipsychotic medication orders, and an inpatient psychiatric stay.
F 0689: The facility failed to provide adequate supervision during smoke breaks to prevent Resident #45 from obtaining cigarette butts and a lighter, despite having two staff supervising.
F 0851: The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for one quarter by not including agency staff hours.
Report Facts
Number of smokers in facility: 17
Number of residents requiring smoking supervision: 15
Brief Interview for Mental Status (BIMS) score: 15
Fiscal Year Quarter: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Discussed revocation of Resident #45's smoking privileges and supervision issues. | |
| Administrator | Confirmed facility is a smoking facility and discussed staffing and smoking privilege issues. | |
| Registered Nurse #1 | Reported usual supervision of smokers and noted Resident #45 had been caught smoking in his room. | |
| Social Services | Responsible for submitting Level II Change in Status Request forms; admitted failure to submit for Resident #24. | |
| Human Resource/Payroll Director | Explained agency staff hours submission process for PBJ reporting. |
Inspection Report — Sep 1, 2022
Routine CMS
Date: Sep 1, 2022
Visit Reason
Routine inspection to assess compliance with care standards including oral care, feeding tube management, and food safety in the nursing home.
Findings
The facility failed to provide adequate oral care to a resident dependent on staff, resulting in dry, cracked, and peeling lips with bleeding. The resident's head of bed was improperly positioned below 30 degrees during continuous tube feeding, increasing aspiration risk. Additionally, the ice machine used for all residents was found with black spots indicating poor sanitation, risking foodborne illness.
Deficiencies (3)
F 0677: The facility failed to provide oral care for a resident dependent on staff, evidenced by dry, cracked, and peeling lips with a bleeding slit. Oral care was inconsistently provided, missing 5 days out of 13 and only once daily on 5 days.
F 0693: The facility failed to maintain the head of bed elevation above 30 degrees for a resident receiving continuous PEG tube feeding, increasing aspiration risk. Observations confirmed the head of bed was below 30 degrees multiple times.
F 0812: The facility failed to prevent the likelihood of foodborne illness due to black spots inside the ice machine used for all residents. Cleaning procedures were not properly documented or fully followed.
Report Facts
Residents reviewed: 91
PEG tube feeding residents reviewed: 6
Black spots on ice machine: 25
Days without oral care: 5
Days with oral care only once: 5
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