Inspection Reports for
Care Center of Laurel
935 West Drive, Laurel, MS, 39440
Back to Facility Profile48 Reports
Inspection Report — May 19, 2026
Complaint Investigation
Date: May 19, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #3012226, at the facility on 5/19/26 related to quality of care and resident rights.
Complaint Details
Complaint number CI MS #3012226 was investigated related to quality of care and resident rights. The complaint was not substantiated as no deficiencies were cited.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — May 19, 2026
Complaint Investigation
Date: May 19, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #3012226, related to quality of care and resident rights.
Complaint Details
Complaint number CI MS #3012226 was investigated related to quality of care and resident rights. The complaint was not substantiated as no deficiencies were cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaints investigated: 1
Inspection Report — Sep 24, 2025
Life Safety
Date: Sep 24, 2025
Visit Reason
On 09/24/25 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 08/07/25. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The survey conducted on 08/07/25 revealed the facility met all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Sep 22, 2025
Annual Inspection
Date: Sep 22, 2025
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey completed on 08/07/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 09/18/25. No deficiencies were cited in this desk review.
Inspection Report — Aug 7, 2025
Routine
Date: Aug 7, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident trust fund refunds, resident environment, accurate resident assessments, comprehensive care plans, and food safety standards.
Findings
The facility was found deficient in refunding resident trust account funds timely after death, maintaining a homelike environment due to a persistent loud door noise, ensuring accurate Minimum Data Set (MDS) assessments, developing comprehensive care plans for residents, and properly storing and labeling food items with consistent temperature documentation.
Deficiencies (5)
F 0569: The facility failed to refund a resident's trust account funds to the family within 30 days after the resident's death, with the refund occurring more than 90 days later.
F 0584: The facility failed to maintain a homelike environment by not addressing a persistent loud squealing noise from a malfunctioning resident room door for multiple days during the survey.
F 0641: The facility failed to ensure the Minimum Data Set (MDS) accurately reflected a resident's active diagnosis of Atrial Fibrillation and failed to complete entry and discharge MDS assessments for another resident.
F 0656: The facility failed to develop comprehensive care plans for four residents, omitting interventions related to anticoagulant therapy, bowel and bladder care, and indwelling urinary catheter management.
F 0812: The facility failed to store, label, and date food items in a sanitary manner and failed to consistently document tray line temperatures during kitchen observations.
Report Facts
Resident trust account balance: 2
Missing temperature documentation days: 6
Number of residents sampled: 19
Number of residents with deficient care plans: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator (NHA) | Interviewed regarding trust fund refund process and awareness of refund requirements | |
| Director of Nursing (DON) | Interviewed regarding MDS accuracy, care plan development, and staff notification of maintenance issues | |
| Dietary Manager (DM) | Interviewed regarding food storage and temperature documentation | |
| Certified Nurse Aides (CNAs) #1 and #2 | Interviewed about awareness of door noise issue | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about door noise and maintenance reporting | |
| Maintenance Director | Interviewed about door noise and maintenance procedures | |
| Cook | Interviewed about tray line temperature checks and documentation |
Inspection Report — Aug 7, 2025
Annual Inspection
Date: Aug 7, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 8/4/25 to 8/7/25. 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 requirement and cited M500 and M815.
Findings
The facility was found not in compliance with state licensure requirements due to failure to maintain a homelike environment by not addressing a persistent unpleasant noise from a malfunctioning resident room door, and failure to refund a resident's trust account funds within 30 days after death. Additionally, the facility failed to store, label, and date food items properly and did not consistently document tray line temperatures.
Deficiencies (2)
M500 - Residents' Rights. The facility failed to ensure a homelike and comfortable environment by not addressing a persistent, unpleasant noise caused by a malfunctioning resident room door for three of four days and failed to refund a resident's trust account funds to their family within 30 days after death.
M815 - Safe Food Handling Procedures. The facility failed to store, label, and date food items in a sanitary manner and did not consistently document tray line temperatures during kitchen observations.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 7, 2025
Annual Inspection
Date: Aug 7, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 8/4/25 through 8/7/25. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F569, F584, F641, F656, and F812.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to deficiencies in personal funds conveyance, safe and homelike environment, accuracy of assessments, comprehensive care planning, and food safety practices.
Deficiencies (5)
F0569 - Notice and conveyance of personal funds. The facility failed to ensure that a resident's trust account funds were refunded to their family within 30 days after death for one of three closed records reviewed (Resident #91).
F0584 - Safe, clean, comfortable, and homelike environment. The facility failed to address a persistent, unpleasant noise caused by a malfunctioning resident room door for three of four days of the survey.
F0641 - Accuracy of assessments. The facility failed to ensure the Minimum Data Set (MDS) accurately reflected a resident's active diagnoses of Atrial Fibrillation (Resident #4) and failed to complete entry and discharge MDS assessments for another resident (Resident #90).
F0656 - Develop and implement comprehensive care plan. The facility failed to develop comprehensive care plans for four residents (Resident #3, #4, #17, and #31) including care plans for anticoagulant therapy, bowel and bladder care, and indwelling urinary catheter.
F0812 - Food procurement, storage, preparation, and service sanitary. The facility failed to store, label, and date food items in a sanitary manner and ensure tray line temperatures were consistently documented during kitchen observations.
Report Facts
Deficiencies cited: 5
Inspection Report — Aug 7, 2025
Life Safety
Date: Aug 7, 2025
Visit Reason
Emergency Preparedness Survey conducted on 08/07/2025 and Life Safety Code survey per 42 CFR 483.73.
Findings
The facility met all applicable emergency preparedness requirements. However, the facility failed to ensure the HVAC system complied with NFPA 101 and NFPA 90A standards, as the corridor was used as a return air plenum and documentation for HVAC upgrades was not provided.
Deficiencies (1)
K0521 - HVAC system did not comply with NFPA 101 and NFPA 90A standards; corridor was used as a return air plenum and plans for HVAC upgrade were not available.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 19, 2025
Complaint Investigation
Date: Feb 19, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #27711, MS #27712, and MS #27714, at the facility from 2/18/25 through 2/19/25. The investigations involved pressure sores, not following plan of care, quality of care, falls, resident not turned, and not groomed.
Complaint Details
Complaint Investigations MS #27711, MS #27712, and MS #27714 were conducted related to pressure sores, falls, resident care, and grooming. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations: 3
Inspection Report — Feb 19, 2025
Complaint Investigation
Date: Feb 19, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #27711, MS #27712, and MS #27714, related to pressure sores, not following plan of care, quality of care, falls, resident not turned, and not groomed.
Complaint Details
Complaint investigations MS #27711, MS #27712, and MS #27714 were conducted regarding pressure sores, falls, resident care, and grooming. The facility was determined to be in compliance 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: 3
Inspection Report — Oct 16, 2024
Complaint Investigation
Date: Oct 16, 2024
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #26058, CI MS #26272, CI MS #26499, and CI MS #26500) at the facility from 10/15/24 through 10/16/24. The investigations involved allegations of resident left wet and neglect, oversedation, falsification of records, death, and misappropriation of property.
Complaint Details
Four complaint investigations were conducted: CI MS #26058 for resident left wet and neglect; CI MS #26272 for neglect, resident left wet for periods, resident oversedated, and falsification of records; CI MS #26499 for death; and CI MS #26500 for death and misappropriation of property. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint investigations conducted: 4
Inspection Report — Oct 16, 2024
Complaint Investigation
Date: Oct 16, 2024
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #26058, CI MS #26272, CI MS #26499, and CI MS #26500) at the facility from 10/15/24 through 10/16/24. The investigations were for resident left wet and neglect, neglect, resident oversedated, falsification of records, death, and misappropriation of property.
Complaint Details
Four complaint investigations were conducted: CI MS #26058 for resident left wet and neglect, CI MS #26272 for neglect, resident left wet for periods, resident oversedated, and falsification of records, CI MS #26499 for death, and CI MS #26500 for death and misappropriation of property. The facility was found in compliance with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 4
Inspection Report — Jul 24, 2024
Complaint Investigation
Date: Jul 24, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #25351 and CI MS #25581) at the facility on 7/24/24. CI MS #25351 was investigated for physical environment. CI MS #25581 was investigated regarding resident left soiled and neglect.
Complaint Details
Complaint Investigations CI MS #25351 and CI MS #25581 were conducted; no deficiencies were cited and the facility was found in compliance.
Findings
The survey determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Jul 24, 2024
Complaint Investigation
Date: Jul 24, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #25351 and MS #25581, at the facility on 7/24/24. MS #25351 was investigated for physical environment. MS #25581 was investigated regarding resident left soiled and neglect.
Complaint Details
Complaint Investigations MS #25351 and MS #25581 were conducted; MS #25351 for physical environment and MS #25581 for resident left soiled and neglect. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Apr 30, 2024
Annual Inspection
Date: Apr 30, 2024
Visit Reason
On 04/30/24 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 03/21/24. 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 04/23/24. No deficiencies were cited in this desk review.
Inspection Report — Mar 21, 2024
Annual Inspection
Date: Mar 21, 2024
Visit Reason
The State Agency (SA) conducted an Annual Recertification Survey at the facility from 3/19/21 through 3/21/24. 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 requirement and cited M500, M610, M620, and M635.
Findings
The facility was found not in compliance with state licensure requirements, with deficiencies in residents' rights, activities of daily living, urinary incontinence care, and gastric feeding practices.
Deficiencies (4)
M500 - The facility failed to promote the dignity of residents by requiring two residents to use bedside commodes instead of functioning toilets in their rooms, causing discomfort and lack of privacy.
M610 - The facility failed to provide adequate assistance with activities of daily living, specifically failing to clean, cut, and file fingernails for one resident requiring such care.
M620 - The facility failed to provide incontinent care properly for one resident, neglecting to cleanse the penis after an incontinent episode, risking infection.
M635 - The facility failed to ensure the head of the bed was properly elevated for a resident receiving enteral feedings and at high risk for aspiration, as the resident was laid flat during care.
Report Facts
Deficiencies cited: 4
Inspection Report — Mar 21, 2024
Annual Inspection
Date: Mar 21, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 3/19/24 through 3/21/24. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F584, F656, F677, F690, F693, and F700.
Findings
The facility was found not in compliance with multiple requirements including resident dignity, safe environment, comprehensive care planning, ADL care, incontinent care, tube feeding management, and bedrail safety. Deficiencies were cited for failure to promote resident dignity, provide hot water, implement care plans, maintain hygiene, and ensure proper bedrail use.
Deficiencies (7)
F0550 - Resident Rights. The facility failed to promote the dignity of residents by requiring two residents to use bedside commodes instead of a functioning toilet in their rooms.
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to provide hot water in the shower room and for four residents on the Primary Care Unit.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plan interventions for a resident with a feeding tube and failed to develop a care plan for a resident with full length bedrails.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to clean, cut, and file fingernails for a resident who required assistance with personal hygiene.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide incontinent care in a manner to prevent complications for a resident with urinary incontinence.
F0693 - Tube Feeding Management/Restore Eating Skills. The facility failed to ensure the head of the bed was properly elevated for a resident who required enteral feedings and was at high risk for aspiration.
F0700 - Bedrails. The facility failed to adequately assess a resident for bedrail use, failed to attempt alternatives prior to placement of full bedrails, and failed to ensure bedrails were properly installed and assessed for entrapment risk.
Report Facts
Deficiencies cited: 7
Inspection Report — Mar 21, 2024
Routine
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, environment, care planning, personal hygiene, incontinent care, feeding tube care, and bedrail use at the Care Center of Laurel.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity by requiring bedside commodes due to broken toilets, failure to provide hot water to residents, incomplete care plans for residents with feeding tubes and bedrails, inadequate personal hygiene care, improper incontinent care, failure to maintain proper head-of-bed elevation for a feeding tube resident, and inadequate assessment and consent for bedrail use.
Deficiencies (7)
F 0550: The facility failed to promote residents' dignity by requiring two residents to use bedside commodes due to broken toilets, causing discomfort and lack of privacy.
F 0584: The facility failed to provide hot water in the shower room and bathrooms for four residents on the Primary Care Unit.
F 0656: The facility failed to implement comprehensive care plans for a resident with a feeding tube and for a resident with full length bedrails.
F 0677: The facility failed to clean, cut, and file fingernails for a resident requiring assistance with personal hygiene.
F 0690: The facility failed to provide incontinent care properly by not cleansing the penis of a resident after an incontinent episode.
F 0693: The facility failed to ensure the head of the bed was properly elevated for a resident with a feeding tube at high risk for aspiration.
F 0700: The facility failed to adequately assess, attempt alternatives, and properly maintain full length bedrails for a resident, including lack of updated consent and risk assessment.
Report Facts
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nursing Aide | Confirmed toilet issues and use of bedside commodes for residents #29 and #51 |
| Maintenance Director | Installed new toilet and hot water heater; unaware of ongoing issues | |
| Director of Nursing | DON | Acknowledged issues with toilet and care plan implementation; expected staff compliance |
| Administrator | Aware of toilet and hot water issues; committed to repairs | |
| CNA #9 | Certified Nursing Assistant | Lowered head of bed for Resident #26 against care plan; failed to cleanse penis during incontinent care |
| LPN #4 | Licensed Practical Nurse | Expected staff to follow care plan for Resident #26 and unaware of bedrails for Resident #66 |
| CNA #3 | Certified Nurse Aide | Confirmed Resident #55 had long, dirty nails and CNAs were not allowed to trim nails |
| LPN #2 | Licensed Practical Nurse | Explained nail care restrictions and confirmed Resident #55's nails were not recently clipped |
| RN #2 | Registered Nurse | Part-time weekend nurse who assessed nails but did not clip Resident #55's nails regularly |
| CNA #4 | Certified Nursing Assistant | Confirmed Resident #66 had full length bedrails due to falls and crawling out of bed |
Inspection Report — Mar 20, 2024
Life Safety
Date: Mar 20, 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 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 — Jan 30, 2024
Routine
Date: Jan 30, 2024
Visit Reason
Based on the content and tags, the survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 27, 2023
Complaint Investigation
Date: Nov 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #23118) at the facility on 11/27/23 related to grooming and staffing.
Complaint Details
Complaint CI MS #23118 related to grooming and staffing was investigated and found to be unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Sep 6, 2023
Complaint Investigation
Date: Sep 6, 2023
Visit Reason
On 09/06/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 07/26/23. 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 complaint investigation completed on 07/26/23; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 08/29/23.
Report Facts
Complaint survey date: Jul 26, 2023
Inspection Report — Jul 26, 2023
Complaint Investigation
Date: Jul 26, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility for three complaints, CI MS #21838, CI MS #22109, and CI MS #22131 from 7/24/23 through 7/26/23. The SA investigated CI MS #21838 for resident not groomed, therapeutic diets, and care not received and CI MS #22131 for services not performed per plan of care, cold food, and staff improperly qualified, but did not cite any deficiencies for those complaints. The SA investigated CI MS #22109 for quality of care and cited F580 and F656.
Complaint Details
Complaint investigation CI MS #22109 was for quality of care and deficiencies F580 and F656 were cited. The other two complaints, CI MS #21838 and CI MS #22131, were investigated but no deficiencies were cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to failure to notify the physician of feeding tube complications and failure to implement care plan interventions related to feeding tube complications for one resident with a feeding tube.
Deficiencies (2)
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to notify the physician of feeding tube complications for one of two residents reviewed with feeding tubes, specifically Resident #1 whose feeding tube residual greater than 100 ml was not reported to the physician as ordered.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plan approaches or interventions related to notifying the physician of feeding tube complications for one of four resident care plans reviewed, specifically Resident #1.
Report Facts
Deficiencies cited: 2
Complaints investigated: 3
Inspection Report — Jul 26, 2023
Complaint Investigation
Date: Jul 26, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify the physician of feeding tube complications for Resident #1.
Complaint Details
The complaint investigation found that the facility did not notify the physician of feeding tube complications for Resident #1. The issue was substantiated with interviews confirming nursing staff failed to notify the physician as ordered.
Findings
The facility failed to notify the physician of feeding tube residuals greater than 100 ml for Resident #1 as ordered. Interviews and record reviews confirmed that nursing staff did not follow physician orders or the care plan to notify the physician, although the resident was not in acute distress.
Deficiencies (2)
F 0580: The facility failed to notify the physician of feeding tube residuals greater than 100 ml for Resident #1 as required by physician orders. Nursing staff did not document notifying the physician despite the resident having a gastrostomy tube.
F 0656: The facility failed to implement the care plan related to notifying the physician of feeding tube complications for Resident #1. Nursing staff did not follow the care plan or physician orders to notify the physician of residuals greater than 100 ml.
Report Facts
Feeding tube residual volume: 100
Residents reviewed with feeding tubes: 2
Resident care plans reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Day Shift Supervisor | Confirmed not notifying physician of feeding tube residual on 7/2/23 |
| LPN #1 | Did not follow physician orders to notify MD of feeding tube residual on 7/2/23 | |
| Director of Nursing | Director of Nursing | Stated expectation that nurses follow physician orders and care plans |
| MD | Medical Doctor | Confirmed nurses did not notify him of feeding tube residual on 7/2/23 |
| RN #2 | Reported care plans are developed and individualized to ensure consistency |
Inspection Report — Jun 6, 2023
Complaint Investigation
Date: Jun 6, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #21013 and MS #21613, at the facility on 6/6/23. The SA investigated MS #21013, a facility reported incident, for verbal abuse and MS #21613 for dietary services and resident not groomed.
Complaint Details
Complaint Investigation MS #21013 and MS #21613 investigated verbal abuse, dietary services, and resident grooming; no deficiencies were cited and the facility was found in compliance.
Findings
The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Jun 6, 2023
Complaint Investigation
Date: Jun 6, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #21013 and CI MS #21613) at the facility on 6/6/23. CI MS #21013 was for verbal abuse and CI MS #21613 was for dietary services and resident not groomed.
Complaint Details
Complaint numbers CI MS #21013 and CI MS #21613 were investigated; no deficiencies were cited and the facility was found in compliance.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Nov 28, 2022
Complaint Investigation
Date: Nov 28, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19568, at the facility on 11/28/22.
Complaint Details
Complaint MS #19568 alleged residents were not groomed and residents denied visitation. The complaint was not substantiated and no deficiencies were cited.
Findings
The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Nov 28, 2022
Complaint Investigation
Date: Nov 28, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19568, at the facility on 11/28/22. The complaint alleged residents were not groomed and residents were denied visitation.
Complaint Details
CI MS#19568 alleged residents were not groomed and residents denied visitation. The complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no deficiencies were cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 22, 2022
Complaint Investigation
Date: Aug 22, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19093, at the facility on 08/22/22. The SA did not substantiate the complaint for neglect.
Complaint Details
Complaint number CI MS#19093 was investigated for neglect and was not substantiated; 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 and there were no deficiencies cited.
Inspection Report — Aug 22, 2022
Complaint Investigation
Date: Aug 22, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19093, at the facility on 08/22/22.
Complaint Details
Complaint number CI MS#19093 was investigated for neglect and was not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. The complaint for neglect was not substantiated and no deficiencies were cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 22, 2022
Routine
Date: Aug 22, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 08/22/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Feb 16, 2022
Annual Inspection
Date: Feb 16, 2022
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual survey conducted on 01/06/22. 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 02/07/22. No deficiencies were cited in this desk review.
Inspection Report — Feb 8, 2022
Complaint Investigation
Date: Feb 8, 2022
Visit Reason
The State Agency conducted a complaint investigation, CI MS #18119, concerning call light systems not being answered timely on 09/18/2021.
Complaint Details
CI MS #18119 concerned call light systems not being answered timely on 09/18/2021. The complaint was unsubstantiated and no deficiencies were cited.
Findings
The complaint investigation was unsubstantiated and no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid standards.
Report Facts
Complaint investigations: 1
Inspection Report — Jan 6, 2022
Annual Inspection
Date: Jan 6, 2022
Visit Reason
The State Agency conducted an annual survey and four complaint investigations from 1/3/22 to 1/6/22. The SA substantiated CI MS #17957 related to incontinent care and found the facility not in compliance with state licensure requirements citing M620 and M640.
Complaint Details
Four complaint investigations were conducted: CI MS #17957 related to incontinent care was substantiated; CI MS #18036 related to Activities of Daily Living care and abuse was substantiated; CI MS #17654 related to verbal abuse was substantiated; CI MS #18184 related to ADL care, medications not given, and personal property missing was not substantiated.
Findings
The facility failed to ensure residents' environment was free from accident hazards by not providing adequate supervision while residents were smoking, leaving them unattended on multiple occasions.
Deficiencies (2)
M640 - The facility failed to provide adequate supervision during residents' smoking breaks, leaving residents unattended which could result in accidents or injury.
M620 - The facility was not in compliance with Minimum Standards for Institutions for the Aged or Infirm as cited by the State Agency.
Report Facts
Deficiencies cited: 2
Complaint investigations: 4
Inspection Report — Jan 6, 2022
Annual Inspection
Date: Jan 6, 2022
Visit Reason
The State Agency (SA) conducted an Annual Survey and four (4) complaint investigations at the facility from 1/3/22 through 1/6/22. Complaint Investigations (CI) MS # 17654 related to verbal abuse, CI MS #18036 related to Activities of Daily Living (ADL) care and abuse, and CI MS #18184 related to ADL care, medications not being given, and personal property missing were unsubstantiated. CI MS # 17957 was substantiated related to incontinent care.
Complaint Details
Four complaint investigations were conducted: CI MS #17654 (verbal abuse), CI MS #18036 (ADL care and abuse), and CI MS #18184 (ADL care, medications not given, personal property missing) were unsubstantiated. CI MS #17957 was substantiated related to incontinent care.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited in coordination of PASARR assessments, care plan timing and revision, accident hazards and supervision, bowel/bladder incontinence care, and infection prevention and control.
Deficiencies (5)
F0644 - Coordination of PASARR and Assessments. The facility failed to complete a Level II PASARR for a resident with a new major mental illness diagnosis.
F0657 - Care Plan Timing and Revision. The facility failed to revise a resident's care plan to accurately reflect incontinent status and failed to ensure a comprehensive person-centered care plan.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision during resident smoking breaks, leaving residents unattended.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide incontinent care using correct technique, risking infection for a resident.
F0880 - Infection Prevention & Control. The facility failed to prevent possible spread of infection during incontinent care and failed to follow infection control procedures when handling contaminated items and during glove use.
Report Facts
Deficiencies cited: 5
Complaint investigations: 4
Inspection Report — Jan 6, 2022
Life Safety
Date: Jan 6, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider. The facility must meet the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to have deficiencies in portable fire extinguisher maintenance and HVAC system installation and compliance. Four fire extinguishers were overdue for 6-year inspection and the HVAC system was installed around 1969 with an expired continuing waiver.
Deficiencies (2)
K0355 - Portable fire extinguishers were not properly selected, installed, inspected, and maintained; four of eight extinguishers were overdue for 6-year inspection and had outdated or missing inspection collars.
K0521 - The facility failed to provide heating, ventilation, and air conditioning in accordance with NFPA standards; main egress corridors were used as supply, air, and exhaust plenum, limiting smoke passage, and the continuing waiver for the HVAC system expired in 2020.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 6, 2022
Life Safety
Date: Jan 6, 2022
Visit Reason
Survey conducted on 01/05/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Jan 6, 2022
Routine
Date: Jan 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, and safety in the nursing home.
Findings
The facility was found deficient in completing required Level II PASARR evaluations, revising care plans to reflect residents' continence status, providing adequate supervision during smoking, proper incontinent care techniques, and infection prevention practices. Several residents were affected by these deficiencies, with minimal harm or potential for harm noted.
Deficiencies (5)
F 0644: The facility failed to complete a Level II PASARR evaluation for a resident with a new major mental illness diagnosis, Resident #28.
F 0657: The facility failed to revise a comprehensive care plan to accurately reflect Resident #42's continence status, despite incontinent episodes.
F 0689: The facility failed to provide adequate supervision during smoking for residents, leaving them unattended and at risk of accidents.
F 0690: The facility failed to provide incontinent care using correct technique for Resident #42, including improper wiping and reuse of wipes.
F 0880: The facility failed to prevent possible infection spread during incontinent care for Residents #49 and #21 due to improper handling of contaminated items and failure to change gloves and wash hands.
Report Facts
Residents reviewed for PASARR completion: 3
Care plans reviewed: 23
Residents smoking observed: 5
Incontinent care observations: 5
Residents reviewed for infection prevention: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding PASARR evaluation and care plan revisions. | |
| Registered Nurse #1 | Confirmed failure to revise care plan for Resident #42. | |
| CNA #1 | Certified Nursing Assistant | Failed to provide proper incontinent care for Resident #42. |
| RN #2 | Registered Nurse | Improperly handled contaminated bag during care of Resident #49. |
| CNA #2 | Certified Nursing Assistant | Failed to change gloves and wash hands during care of Resident #21. |
| LPN #1 | Licensed Practical Nurse/Infection Control Nurse | Confirmed infection control breaches and proper procedures. |
Inspection Report — Jan 7, 2021
Routine
Date: Jan 7, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 1/7/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Jan 7, 2021
Complaint Investigation
Date: Jan 7, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #16759, CI MS 16851, CI MS #1723) at the facility on 1/7/2021.
Complaint Details
CI MS #16759: Unsubstantiated with no deficiencies cited for Verbal Abuse. CI MS #16851: Unsubstantiated with no deficiencies cited for Dietary Services, Resident Food Precautions, Misappropriation of Property, Quality of Care, Physical Environment, Infection Control, and Unqualified Personnel. CI MS #17239: Unsubstantiated with no deficiencies cited for Dietary Services, Quality of Care, and Physical Environment.
Findings
The facility was found in compliance with the Minimum Standards for State Licensure Requirements for nursing homes with no deficiencies cited.
Inspection Report — Jan 7, 2021
Routine
Date: Jan 7, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16759, CI MS #16851, CI MS #17239) was conducted by the State Agency (SA) on 1/7/2021.
Complaint Details
CI MS #16759: Unsubstantiated with no deficiencies cited for Verbal Abuse. CI MS #16851: Unsubstantiated with no deficiencies cited for Dietary Services, Resident Food Precautions, Misappropriation of Property, Quality of Care, Physical Environment, Infection Control, and Unqualified Personnel. CI MS #17239: Unsubstantiated with no deficiencies cited for Dietary Services, Quality of Care, and Physical Environment.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19. The complaint investigations were unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigations: 3
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 7, 2020
Routine
Date: Jul 7, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/7/20.
Findings
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.
Inspection Report — May 23, 2020
Routine
Date: May 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/23/20.
Findings
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.
Inspection Report — Mar 13, 2020
Complaint Investigation
Date: Mar 13, 2020
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #16664 and #16672, on 3/11/2020 through 3/13/2020. The SA unsubstantiated CI MS #16664, related to an allegation of Verbal Abuse, with no deficiencies cited. The SA substantiated CI MS #16672 related to Supervision, when the facility failed to properly secure Resident #1's wheelchair during van transport, which resulted in the resident receiving bilateral femur fractures. The facility also failed to report the incident to the appropriate State agencies in a timely manner.
Complaint Details
Complaint Investigation MS #16672 was substantiated related to supervision failures when the facility failed to properly secure Resident #1's wheelchair during van transport, resulting in bilateral femur fractures. The facility also failed to timely report the incident. Immediate Jeopardy was identified but removed prior to survey after corrective actions.
Findings
The facility was found not to be in compliance with Medicare and Medicaid requirements due to failure to timely report an incident and failure to properly secure a resident in a wheelchair during van transport, resulting in serious injury. Immediate Jeopardy was identified but removed prior to survey after corrective actions.
Deficiencies (2)
F0609 - Reporting of Alleged Violations. The facility failed to report an allegation of Quality of Care/Supervision related to an incident resulting in major injuries within the required two-hour timeframe for one of six residents reviewed. The incident was reported two days late.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and proper securing of a wheelchair during transport, resulting in Resident #1 falling from the wheelchair and sustaining bilateral femur fractures.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 13, 2019
Complaint Investigation
Date: Nov 13, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 11/13/19.
Complaint Details
CI MS #16355: The complaint investigation was substantiated for abuse with no deficiencies cited.
Findings
The investigation was substantiated for abuse with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Complaint investigations: 1
Inspection Report — Oct 31, 2019
Annual Inspection
Date: Oct 31, 2019
Visit Reason
The State Agency (SA) conducted an annual survey from 10/28/19 through 10/31/19. During the survey, the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements of participation.
Findings
The facility was found not in compliance with several requirements including care plan implementation, ADL care, pressure ulcer treatment, pain management, food safety, and infection control. Deficiencies were cited for failure to implement care plans, provide toenail care, manage wound pain, maintain food storage, and handle linens properly.
Deficiencies (6)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the care plan for two residents by not providing toenail care for Resident #6 and not providing pain medication during wound treatment for Resident #15.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide toenail care for Resident #6, whose toenails were long, thick, yellow, and had dried blood, despite reminders and body audits.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to ensure pressure ulcer treatment was provided in a manner to allow Resident #15 to be as pain free as possible during wound care, as the nurse did not stop treatment or offer pain medication when the resident cried.
F0697 - Pain Management. The facility failed to ensure Resident #15 was free from pain during wound care, as the resident cried and held onto the bed rail during treatment and was not offered additional pain medication.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to monitor medication storage room refrigerators for expired food items, incomplete temperature logs, and spills in three nurse station refrigerators.
F0880 - Infection Prevention & Control. The facility failed to handle linens properly to prevent the spread of infection, as soiled linens were found on the floor of a resident's room.
Report Facts
Deficiencies cited: 6
Inspection Report — Apr 23, 2019
Complaint Investigation
Date: Apr 23, 2019
Visit Reason
The State Agency (SA) conducted a complaint survey for CI MS #15810, #15851, and #15852 at the facility from 4/22/19 to 4/23/19. The SA was not able to substantiate CI MS #15810 related to Quality of Care or CI MS #15852 related to Injury of Unknown Origin, but substantiated CI MS #15851 related to Resident #4 exiting the building unsupervised on 4/13/19.
Complaint Details
Complaint investigation for CI MS #15810, #15851, and #15852. The SA was unable to substantiate CI MS #15810 and #15852, but substantiated CI MS #15851 related to Resident #4 exiting the building unsupervised. Deficiency F0689 was cited related to CI MS #15851.
Findings
The facility was found not in compliance with the requirements for Medicare and Medicaid participation due to failure to ensure adequate supervision and safety measures to prevent elopement of Resident #4. The facility failed to ensure the south lobby exit door functioned properly, allowing Resident #4 to exit unsupervised.
Deficiencies (2)
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure the south lobby exit door was functioning correctly, allowing Resident #4 to exit unsupervised and without alarm sounding, despite being assessed at risk for elopement and wearing a wanderguard bracelet.
M640 - Accidents. The facility failed to ensure the south lobby exit door was functioning correctly, allowing Resident #4 to exit unsupervised and without alarm sounding, despite being assessed at risk for elopement and wearing a wanderguard bracelet.
Report Facts
Deficiencies cited: 2
4 CMS Surveys
CMS Survey — Jul 26, 2023
Jul 26, 2023
CMS Survey — Jan 6, 2022
Jan 6, 2022
CMS Survey — Mar 21, 2024
Mar 21, 2024
CMS Survey — Aug 7, 2025
Aug 7, 2025
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