Inspection Reports for
Care Center of Aberdeen
505 Jackson Street, Aberdeen, MS, 39730
Back to Facility Profile51 Reports
Inspection Report — Aug 25, 2026
Complaint Investigation
Date: Aug 25, 2026
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed 07/20/26-07/21/26. The facility confirmed corrective measures were implemented and sustained compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation was reviewed and found to be substantiated with no deficiencies cited; the facility was placed back in compliance.
Findings
The facility was found to be in compliance as of 08/21/26 with no deficiencies cited during this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 21, 2026
Complaint Investigation
Date: Jul 21, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #3023726) at the facility from 7/20/2026 through 7/21/2026. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Complaint Details
CI MS #3023726 was investigated and deficiency F0580 was cited for failure to timely notify the Resident Representative of a significant change in condition. The facility was found not in compliance.
Findings
F0580 - The facility failed to timely notify the Resident Representative of a significant change in condition requiring treatment for Resident #1, who developed three new Stage II pressure injuries and had treatment initiated without notification to the representative.
Deficiencies (1)
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to ensure the Resident Representative was notified timely of a significant change in condition requiring treatment for Resident #1 who developed three new Stage II pressure injuries and treatment was initiated without notification.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 10, 2026
Life Safety
Date: Jun 10, 2026
Visit Reason
On 06/10/26 the State Agency conducted a desk review of the information related to the annual survey conducted on 05/05/26. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The survey conducted on 05/05/26 revealed the facility meets all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Jun 9, 2026
Annual Inspection
Date: Jun 9, 2026
Visit Reason
On 06/09/26 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 05/06/26. 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 06/08/26. No deficiencies were cited in this desk review.
Inspection Report — May 7, 2026
Annual Inspection
Date: May 7, 2026
Visit Reason
The State Agency conducted an Annual Recertification survey along with two Complaint Investigations (CI MS #2994835 and CI MS #2965477) at the facility from 5/4/26 through 5/7/26. CI MS #2994835 was investigated for Quality of Care/Treatment and Resident Rights and CI MS #2965477 was investigated for resident not groomed, weight loss, and neglect. There were no citations related to the Complaint Investigations.
Complaint Details
Two complaint investigations (CI MS #2994835 and CI MS #2965477) were conducted for Quality of Care/Treatment, Resident Rights, resident not groomed, weight loss, and neglect. No citations were issued related to these complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for two deficiencies related to food safety and payroll based journal staffing data accuracy.
Deficiencies (2)
F0812 - Food procurement, storage, preparation, and serving were not sanitary. The facility failed to ensure accurate food thermometer calibration and proper food labeling, dating, and storage during kitchen observations.
F0851 - The facility failed to ensure the accuracy of Payroll Based Journal data submitted to CMS when nurses with administrative duties were not recorded in the correct job titles for three months reviewed.
Report Facts
Deficiencies cited: 2
Inspection Report — May 7, 2026
Annual Inspection
Date: May 7, 2026
Visit Reason
The State Agency conducted an Annual Re-licensure survey along with two Complaint Investigations (CI MS #2994835 and CI MS #2965477) at the facility from 5/4/26 through 5/7/26. CI MS #2994835 was investigated for Quality of Care/Treatment and Resident Rights and CI MS #2965477 was investigated for resident not groomed, weight loss, and neglect. There were no citations related to the Complaint Investigations. 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.
Complaint Details
Two complaint investigations were conducted (CI MS #2994835 for Quality of Care/Treatment and Resident Rights, and CI MS #2965477 for resident not groomed, weight loss, and neglect). There were no citations related to these complaints and the facility was found in compliance regarding these investigations.
Findings
Two deficiencies were cited related to food safety and garbage disposal. The facility failed to ensure accurate food temperatures due to improper calibration of the food thermometer and failed to store food properly with unlabeled and undated items. Additionally, garbage was not contained in a sanitary manner, with an exterior trash bin overflowing with debris including filled garbage bags and plastic gloves on the ground.
Deficiencies (2)
M0815 - Safe Food Handling Procedures. The facility failed to ensure accurate food temperatures due to improper calibration of the food thermometer and failed to store food properly with unlabeled and undated food items during kitchen observations.
M0980 - Garbage Disposal. The facility failed to ensure garbage was contained in a sanitary manner and was removed, as an exterior trash bin was observed overflowing with debris including filled garbage bags and plastic gloves on the ground for one of four days of survey.
Report Facts
Deficiencies cited: 2
Inspection Report — May 6, 2026
Annual Inspection
Date: May 6, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility on 05/04/26 through 05/06/26. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F641, F656, F658, F677, F692 and F812.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were identified in food safety and sanitation, accuracy of resident assessments, development and implementation of comprehensive care plans, provision of professional standard services, activities of daily living care, and nutrition/hydration status maintenance.
Deficiencies (6)
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to ensure food items in the kitchen were properly labeled and dated after opening and failed to maintain a clean refrigerator to prevent cross-contamination of stored foods during one of two kitchen tours.
F0641 - Accuracy of Assessments. The facility failed to accurately complete the Minimum Data Set (MDS) assessment, incorrectly coding three of nineteen sampled residents during the 7-day observation look-back period.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to ensure the feeding tube care plan was implemented for Resident #5 and an Activities of Daily Living care plan was implemented for Resident #17 for two of nineteen care plans reviewed.
F0658 - Services Provided Meet Professional Standards. The facility failed to ensure blood sugar monitoring was provided in accordance with professional standards of practice for one of five residents reviewed for medication monitoring.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide activities of daily living care necessary to maintain personal hygiene for one resident, as evidenced by long, jagged fingernails with dark brown/black substance underneath.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to ensure physician-ordered continuous enteral feedings were consistently administered for one of two residents reviewed for tube feeding management.
Report Facts
Deficiencies cited: 6
Inspection Report — May 5, 2026
Life Safety
Date: May 5, 2026
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
One deficiency was cited related to electrical systems. The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B.
Deficiencies (1)
K0911 - Electrical Systems - Other. The facility failed to have a properly installed bypass isolation switch for the generator as required by NFPA 110 chapter 6.4.4 and annex B, affecting all 89 residents at the time of survey.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 8, 2026
Complaint Investigation
Date: Jan 8, 2026
Visit Reason
On 01/08/26 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 12/03/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was reviewed and the facility was found to have corrected the deficient practice; no deficiencies were cited.
Findings
The facility was found to be back in compliance effective 01/07/26 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Dec 29, 2025
Complaint Investigation
Date: Dec 29, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2697562) at the facility on 12/29/25. The SA investigated the complaint for admission, transfer, and discharge rights and quality of care.
Complaint Details
CI MS #2697562: The complaint involved admission, transfer, and discharge rights and quality of care. The complaint was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The SA determined the facility was in compliance with the requirements of participation in Medicare and Medicaid. There were no citations related to this complaint, but the facility remains out of compliance due to deficiencies cited on the 12/03/25 survey.
Inspection Report — Dec 3, 2025
Complaint Investigation
Date: Dec 3, 2025
Visit Reason
The State Agency conducted five onsite complaint surveys (MS CI# 2585925, MS CI# 2595399, MS CI# 2631965, MS CI# 2628229, and MS CI# 2605660) at the facility on 12/3/25. The SA determined the facility was not in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm for MS CI# 2605660 and cited F0605 related to chemical restraints. The SA also found the facility was not in compliance with CI MS #2671788 and F0689 related to Accidents. The SA investigated Quality of Care, activities of daily living and staffing.
Complaint Details
Five complaint surveys were conducted (MS CI# 2585925, MS CI# 2595399, MS CI# 2631965, MS CI# 2628229, and MS CI# 2605660). Deficiencies were cited for MS CI# 2605660 (F0605) and CI MS #2671788 (F0689). The SA investigated Quality of Care, activities of daily living and staffing.
Findings
The facility was found not in compliance due to failure to ensure residents were free from chemical restraints for one resident, Resident #5, by administering psychotropic medications without obtaining required consent. The facility failed to inform the resident or representative of the risks, benefits, and alternatives of the medication prior to use.
Deficiencies (2)
F0605 - Chemical restraints. The facility failed to obtain required consent for psychotropic medications administered to Resident #5 and did not inform the resident or representative of the risks, benefits, and alternatives prior to use.
F0689 - Accidents. The facility was cited related to accidents as part of the complaint investigation CI MS #2671788.
Report Facts
Deficiencies cited: 2
Complaint surveys conducted: 5
Inspection Report — Dec 3, 2025
Complaint Investigation
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 — Oct 20, 2025
Complaint Investigation
Date: Oct 20, 2025
Visit Reason
The State Agency conducted an onsite complaint investigation for (CI MS # 2642868) at the facility on 10/20/25. The SA investigated Quality of Care, Nursing Services, Neglect, weight loss, notification of change, and activities of daily living.
Complaint Details
Complaint number CI MS # 2642868 investigated Quality of Care, Nursing Services, Neglect, weight loss, notification of change, and activities of daily living. The complaint was determined to be unsubstantiated as the facility was found in compliance.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 19, 2025
Complaint Investigation
Date: Aug 19, 2025
Visit Reason
On 08/19/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 7/29/25. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey completed on 7/29/25 was reviewed and the facility was found to have corrected the deficient practice and sustained compliance.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 8/18/25. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 29, 2025
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 — Jul 29, 2025
Complaint Investigation
Date: Jul 29, 2025
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2570650, CI MS #2570913, and CI MS #2573259) at the facility from 7/28/25 through 7/29/25. The SA investigated CI MS #2570650 related to abuse/neglect, quality of care related to psychotropic medication, and physical environment, and CI MS #2573257 related to staffing with no citations. The SA investigated CI MS #2570913 related to resident rights and cited F559.
Complaint Details
Three complaint investigations were conducted: CI MS #2570650 (abuse/neglect, psychotropic medication, physical environment), CI MS #2573257 (staffing), and CI MS #2570913 (resident rights). Only CI MS #2570913 was substantiated with a deficiency cited.
Findings
The facility was found not in compliance due to failure to provide written notification including the reason for a room change to one resident. The Social Service Director failed to notify Resident #1's representative of a room change in September 2024, violating the resident's rights.
Deficiencies (1)
F0559 - The facility failed to honor the resident's right to receive written notification, including the reason for the change, before the resident's room was changed for one resident.
Report Facts
Deficiencies cited: 1
Complaint investigations: 3
Inspection Report — Jun 9, 2025
Follow-Up
Date: Jun 9, 2025
Visit Reason
On 06/09/25 the State Agency conducted an onsite revisit for the annual survey that was completed on 05/15/2025. The information reviewed 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 06/02/25. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — May 15, 2025
Annual Inspection
Date: May 15, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey and complaint investigation (CI MS# 28988) at the facility from 05/12/25 through 05/15/25. During the survey the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited regulatory deficiencies at F578, F585, F644, F656, F677, F689 and F812. The SA investigated complaint MS#28988 related to an allegation of verbal abuse with no deficiency cited.
Complaint Details
Complaint investigation CI MS# 28988 related to an allegation of verbal abuse was investigated and no deficiency was cited.
Findings
The facility was found not in compliance with several requirements including residents' rights to determine end-of-life care, grievance resolution, PASARR coordination, comprehensive care planning, ADL care, accident prevention, and food safety. Deficiencies were cited for failure to honor cognitive residents' advance directives, unresolved grievances, failure to submit PASARR change of status, incomplete care plans for nail care, inadequate ADL care, failure to use wheelchair lift safety belts resulting in a resident fall, and improper food labeling and sanitation.
Deficiencies (7)
F0578 - The facility failed to ensure cognitive residents' right to determine their end-of-life care for three residents (#37, #73, and #75) as evidenced by failure to verify and document their wishes and to allow them to sign their own advance directive forms.
F0585 - The facility failed to address and resolve a resident grievance related to timely Activities of Daily Living care for one resident (#247) despite multiple complaints about delayed care.
F0644 - The facility failed to submit a change in status referral for a Level II PASARR for one resident (#5) with a new mental health diagnosis of psychosis.
F0656 - The facility failed to implement a comprehensive care plan for Activities of Daily Living related to nail care for two residents (#63 and #75), as their nails were long, jagged, and dirty despite care plan interventions.
F0677 - The facility failed to provide necessary Activities of Daily Living care to maintain personal hygiene for two residents (#63 and #75), as evidenced by long, dirty fingernails and failure to maintain nails at the preferred length.
F0689 - The facility failed to protect a resident's safety when staff did not use a wheelchair lift safety belt during transport, resulting in the resident (#37) rolling backwards off the lift and sustaining a head laceration.
F0812 - The facility failed to label and store food properly and maintain the kitchen and equipment in a clean and sanitary condition, including unlabeled opened food items and a heavily soiled roll-up food service window and steam table.
Report Facts
Deficiencies cited: 7
Inspection Report — May 15, 2025
Routine
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 — May 14, 2025
Life Safety
Date: May 14, 2025
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 21, 2025
Complaint Investigation
Date: Apr 21, 2025
Visit Reason
On 04/21/25 the State Agency conducted two onsite complaint investigations (CI MS #28225 and CI MS #28314) for allegations of neglect.
Complaint Details
Two complaint investigations (CI MS #28225 and CI MS #28314) for allegations of neglect were conducted and found to be unsubstantiated with no deficiencies cited.
Findings
The State Agency determined that the facility was in compliance with the Rules and Regulations for the Aged and Infirmed and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 2
Inspection Report — Feb 13, 2025
Complaint Investigation
Date: Feb 13, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS#26976) at the facility on 02/13/25 related to misappropriation of resident funds.
Complaint Details
Complaint number CI MS#26976 related to misappropriation of resident funds was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 26, 2024
Complaint Investigation
Date: Nov 26, 2024
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 10/24/24. The review confirmed the facility had implemented measures to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation completed on 10/24/24; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance as of 11/25/24 following the corrective measures implemented after the complaint survey.
Report Facts
Deficiencies cited: 0
Inspection Report — Oct 24, 2024
Complaint Investigation
Date: Oct 24, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI) MS #25801 and CI MS #26372 at the facility on 10/23/24 through 10/24/24. The SA investigated CI MS #26372 related to offensive odors and unclean environment and cited F584. The SA also investigated resident rights and there was no deficient practice identified with CI MS#25801.
Complaint Details
Complaint investigation CI MS #26372 was related to offensive odors and unclean environment and deficiencies were cited. CI MS #25801 related to resident rights was investigated and no deficient practice was identified.
Findings
F0584 - The facility failed to ensure a clean environment as evidenced by dirty wheelchairs and strong, offensive odors in the rooms and bathrooms of three sampled residents. Observations and interviews confirmed urine odors, liquid on bathroom floors, and unclean wheelchairs that had not been properly cleaned or documented.
Deficiencies (1)
F0584 - The facility failed to ensure a clean environment as evidenced by dirty wheelchairs and strong, offensive odors for three of seven sampled residents. Resident rooms and bathrooms had foul odors and liquid on floors, and wheelchairs were found with grime, dust, and dried substances. The facility lacked an effective plan to ensure wheelchairs were cleaned regularly and documented.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 24, 2024
Complaint Investigation
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 — Jan 8, 2024
Annual Inspection
Date: Jan 8, 2024
Visit Reason
On 01/08/24 the State Agency conducted a desk review of the information that was provided related to the annual survey completed on 11/16/23. The information 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 01/01/24. No deficiencies were cited in this desk review.
Inspection Report — Jan 8, 2024
Date: Jan 8, 2024
Visit Reason
On 01/08/24 the State Agency conducted a desk review of the information provided related to the annual survey completed on 11/16/23. The information 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 01/01/24. No deficiencies were cited in this desk review.
Inspection Report — Dec 4, 2023
Complaint Investigation
Date: Dec 4, 2023
Visit Reason
On 12/04/23 the State Agency conducted a complaint investigation for CI MS #23429. The SA determined that the facility was in compliance with the State regulations and requirements for The Aged and Infirmed and no deficiencies were cited.
Complaint Details
CI MS #23429 complaint investigation found the facility in compliance with no deficiencies cited.
Findings
The facility was found in compliance with no deficiencies cited during this complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 11/16/2023 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 16, 2023
Annual Inspection
Date: Nov 16, 2023
Visit Reason
The State Agency conducted an annual recertification survey with a complaint investigation (CI) MS #23250 at the facility from 11/13/23 through 11/16/23.
Complaint Details
Complaint investigation CI MS #23250 involved allegations of resident neglect. The facility was found in compliance with no citations related to the complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in resident rights, PASARR coordination, accident hazards supervision, and Payroll Based Journal submission. The facility was in compliance related to the complaint investigation for resident neglect.
Deficiencies (4)
F0561 - The facility failed to honor a resident's choice to smoke cigarettes for one of 17 smokers, restricting Resident #45 to vape use despite his desire to smoke tobacco cigarettes.
F0644 - The facility failed to submit a change in status referral for a level 2 PASRR for Resident #24 who had a new mental diagnosis, new antipsychotic medication, and an inpatient psychiatric stay.
F0689 - The facility failed to provide adequate supervision during smoke breaks to prevent Resident #45 from obtaining smoking paraphernalia and maintain safety, as he was caught smoking in his room and stealing cigarette butts and a lighter.
F0851 - The facility failed to submit accurate staffing data into the Payroll Based Journal system for one quarter, not accurately reporting agency staff hours despite sufficient staffing.
Report Facts
Deficiencies cited: 4
Inspection Report — Nov 16, 2023
Complaint Investigation
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 — Nov 15, 2023
Life Safety
Date: Nov 15, 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 — Oct 12, 2023
Complaint Investigation
Date: Oct 12, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22882) at the facility on 10/12/23 related to unnecessary transfer of residents to emergency department on the weekends and not answering phone calls when calling with updates.
Complaint Details
CI MS #22882 related to unnecessary transfer of residents to emergency department on the weekends and not answering phone calls when calling with updates. The SA determined the facility was in compliance and no deficiencies were cited.
Findings
The survey determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 31, 2023
Complaint Investigation
Date: Aug 31, 2023
Visit Reason
The State Agency conducted a complaint investigation on 8/31/23 at the facility for MS00021958 related to falls.
Complaint Details
Complaint MS00021958 related to falls was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements for participation and no deficiencies were cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 21, 2023
Complaint Investigation
Date: Jun 21, 2023
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS# 21165, CI MS# 21416, CI MS# 21814) at the facility from 06/20/23 through 06/21/23.
Complaint Details
Three complaint investigations (CI MS# 21165, CI MS# 21416, CI MS# 21814) were conducted and no deficiencies were cited; the complaints were not substantiated.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services. No deficiencies were cited related to abuse, pressure ulcers, or misappropriation of property.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Oct 11, 2022
Annual Inspection
Date: Oct 11, 2022
Visit Reason
On 10/11/22 the State Agency conducted a desk review of the information that was provided related to the annual survey completed on 09/01/22. The information 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 10/04/22. No deficiencies were cited in this desk review.
Inspection Report — Sep 1, 2022
Routine
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
Inspection Report — Sep 1, 2022
Annual Inspection
Date: Sep 1, 2022
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 08/29/22 to 09/01/22. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation at F677 related to not performing oral care on a resident dependent for oral care and F693 related to not elevating the head of the bed for a resident receiving continuous Percutaneous Endoscopic Gastrostomy as ordered and F812 related to dietary services.
Findings
The facility was found not in compliance with deficiencies related to oral care for a dependent resident, improper head of bed elevation for a resident with a gastrostomy tube, and unsanitary conditions in the dietary ice machine. The facility failed to provide oral care to a resident ordered NPO, failed to maintain the head of the bed elevated for a PEG tube feeding resident, and failed to keep the ice machine clean, posing risks to residents.
Deficiencies (3)
F0677 - The facility failed to provide oral care for a resident dependent for activities of daily living as evidenced by dry, peeling, and cracked lips for one resident. Oral care was not provided consistently, with gaps of up to five days without care.
F0693 - The facility failed to prevent the likelihood of aspiration by not maintaining the head of the bed elevated at 30 degrees or more for a resident receiving continuous gastrostomy tube feeding, as the head of the bed was observed below 30 degrees multiple times.
F0812 - The facility failed to prevent the likelihood of a foodborne illness as evidenced by a black substance resembling mold on the inside door of the ice machine used for all residents, indicating inadequate cleaning and sanitation.
Report Facts
Deficiencies cited: 3
Inspection Report — Sep 1, 2022
Life Safety
Date: Sep 1, 2022
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 was found to be in compliance with the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report — Jun 23, 2022
Follow-Up
Date: Jun 23, 2022
Visit Reason
On 06/23/2022 the State Agency (SA) conducted an on site follow-up visit for MS00018478 involving a resident fall with injuries from a wheelchair inside the facility van/bus.
Complaint Details
CI MS #18478 involved a resident fall with injuries from a wheelchair inside the facility van/bus. The SA determined the facility was in substantial compliance and no deficiencies were cited.
Findings
The SA determined that the facility had made all the corrections for the cited deficiencies of F0689 Scope and Severity "G." The SA determined that the facility was in substantial compliance with the Standards for Participation in Medicare and Medicaid.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 23, 2022
Life Safety
Date: Jun 23, 2022
Visit Reason
Life Safety Code survey conducted by the State Agency.
Findings
The facility was found in compliance with Life Safety Code requirements; no deficiencies were cited.
Inspection Report — May 19, 2022
Complaint Investigation
Date: May 19, 2022
Visit Reason
The State Agency conducted onsite complaint investigations and a Covid 19 survey from 05/17/2022 to 05/19/2022 for three complaints: CI MS #18224 alleged abuse by two staff members in the bathroom/shower area; CI MS #18478 alleged abuse and/or neglect while riding in a wheelchair on the facility van/bus; and CI MS #18521 alleged abuse and/or neglect by staff refusing to deliver quality care to a cognitively impaired resident.
Complaint Details
Three complaints were investigated: CI MS #18224 alleging abuse by two staff members in the bathroom/shower area; CI MS #18478 alleging abuse and/or neglect while riding in a wheelchair on the facility van/bus; and CI MS #18521 alleging abuse and/or neglect by staff refusing to deliver quality care to a cognitively impaired resident. The SA unsubstantiated abuse and neglect for complaints #18224 and #18521, but substantiated CI MS #18478 and cited M640.
Findings
The facility was found not in compliance with the Minimum Standard for Institutions for the Aged or Infirm. The SA substantiated complaint CI MS #18478 and cited M640 for failure to supervise and secure seat belts on a bilateral amputee resident during transport in the facility van/bus, resulting in the resident falling and sustaining fractures and a head injury.
Deficiencies (1)
M640 - Accidents. The facility failed to supervise and secure seat belts to a bilateral amputee resident while riding in the facility van/bus, resulting in the resident falling from an unsecured wheelchair and sustaining fractures to his hand and fingers, a head injury requiring stitches, and transport to the Emergency Room.
Report Facts
Complaints investigated: 3
Deficiencies cited: 1
Inspection Report — May 19, 2022
Routine
Date: May 19, 2022
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 5/17/2022 to 05/19/2022.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Apr 29, 2021
Complaint Investigation
Date: Apr 29, 2021
Visit Reason
The State Agency conducted a complaint survey, MS #17207, MS#17577, and MS#17646 at the facility from 04-28-2021 to 04-29-2021.
Complaint Details
Complaint survey MS #17207, MS#17577, and MS#17646 regarding neglect, quality of care, pressure ulcer development, oversedation, and admission/transfer/discharge rights were not substantiated.
Findings
The facility was found in compliance with the requirements of The Aged and Infirmed. No deficiencies were cited and the complaints were not substantiated.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 16, 2020
Routine
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on September 16, 2020. The facility was in substantial compliance with Infection Control guidelines.
Findings
The facility was found to be in substantial compliance with infection control safety practices and guidance recommended by CMS and CDC during the COVID-19 pandemic.
Inspection Report — Sep 16, 2020
Routine
Date: Sep 16, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on September 16, 2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report — Jul 17, 2020
Routine
Date: Jul 17, 2020
Visit Reason
A COVID-19 Focused Survey for Nursing Homes was initiated by the State Agency (SA) on 07/14/2020 and concluded on 07/17/2020. The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to follow Infection Control safety practices during the COVID-19 pandemic.
Findings
The facility failed to follow COVID-19 Infection Control Guidelines, including hand hygiene, social distancing, and proper use of PPE, which likely caused the death of four residents who had not left the facility. Observations and interviews confirmed staff did not practice social distancing, failed to change gloves or wash hands between rooms, and exited the COVID unit without removing contaminated PPE.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to follow COVID-19 infection control guidelines including hand hygiene, social distancing, and proper use of PPE, resulting in an Immediate Jeopardy that contributed to the deaths of four residents who had not left the facility.
Report Facts
Deficiencies cited: 1
COVID-19 related deaths: 9
COVID-19 deaths of residents who had not left the facility: 4
Residents tested positive for COVID-19: 32
Residents on COVID unit: 21
Facility licensed beds: 120
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency along with a complaint investigation (CI MS #16823).
Complaint Details
CI MS #16823: The complaint investigation was unsubstantiated with no deficiencies cited for infection control.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid requirements. The complaint investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — May 12, 2020
Routine
Date: May 12, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/12/20. 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 — Dec 17, 2019
Complaint Investigation
Date: Dec 17, 2019
Visit Reason
The State Agency conducted a complaint survey, MS#16417 at the facility on 12/17/19 related to distribution of alcohol by a resident in the facility.
Complaint Details
Complaint MS#16417 related to distribution of alcohol by a resident was investigated and found not substantiated with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no deficiencies were cited.
Inspection Report — Jul 11, 2019
Annual Inspection
Date: Jul 11, 2019
Visit Reason
The State Agency conducted an annual recertification, along with a complaint, MS #15972, from 7/9/19 to 7/11/19. During the survey, the SA determined the facility was not in compliance with the requirements of participation for Medicare and Medicaid. The SA cited F693 during the survey. The SA did not substantiate MS #15972 for neglect and cited no deficiencies.
Complaint Details
Complaint MS #15972 was investigated during the survey but was not substantiated for neglect and no deficiencies were cited related to the complaint.
Findings
The facility was found not in compliance due to failure to ensure proper placement of the Percutaneous Endoscopic Gastrostomy (PEG) tube prior to medication administration for one resident. Additionally, smoke barrier doors failed to properly close upon fire alarm activation, affecting two smoke compartments and 14 residents. No deficiencies were cited for emergency preparedness.
Deficiencies (2)
F0693 - The facility failed to ensure proper placement of the Percutaneous Endoscopic Gastrostomy (PEG) tube prior to administration of medications via PEG tube for one resident out of eight residents with PEG tubes.
K0374 - The facility failed to properly maintain door openings in smoke barrier walls; smoke barrier doors near room 101 did not fully close upon activation of the fire alarm system, affecting two of six smoke compartments and 14 residents.
Report Facts
Deficiencies cited: 2
6 CMS Surveys
CMS Survey — Oct 24, 2024
Oct 24, 2024
CMS Survey — Jul 29, 2025
Jul 29, 2025
CMS Survey — Dec 3, 2025
Dec 3, 2025
CMS Survey — Sep 1, 2022
Sep 1, 2022
CMS Survey — Nov 16, 2023
Nov 16, 2023
CMS Survey — May 15, 2025
May 15, 2025
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