Inspection Reports for
Carrington Nursing Center
307 Reed Road, Starkville, MS 39759, MS, 39759
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
34% better than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
90% occupied
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 20, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-12-03 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address prior deficiencies, and the State Agency recommended placing the facility back in compliance effective 2026-01-16.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jan 20, 2026
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-12-03 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation. The State Agency recommended the facility be placed back in compliance effective 2026-01-16.
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 4
Date: Dec 3, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 12/01/2025 through 12/03/2025 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to comprehensive care plans, ADL care, accident hazards, and food safety. Specific issues included failure to develop and implement care plans for hair and facial hair hygiene, inadequate personal grooming assistance, unsafe environment hazards such as wet floors without caution signs, unsupervised shaving by a resident on blood thinners, and improper labeling and storage of opened food items in the kitchen.
Deficiencies (4)
Failed to develop and implement a comprehensive care plan for routine hair hygiene and facial hair removal for three residents.
Failed to provide personal grooming, including removal of facial hair and routine hair care for two residents.
Failed to ensure the environment was free of accident hazards when a resident room was mopped and left wet without a caution sign and failed to provide adequate supervision for a resident on blood thinners shaving with a disposable razor.
Failed to properly store and label opened food items in the refrigerator.
Report Facts
Census: 54
Total Capacity: 60
Deficiencies cited: 4
BIMS Score: 15
BIMS Score: 10
BIMS Score: 99
Medication Dosage: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Confirmed Resident #1's hair was greasy and oily and facial hair was long |
| Minimum Data Set Nurse #1 | MDS Nurse | Confirmed care plan was not developed for personal hygiene related to hair care and facial hair for Resident #1 |
| Licensed Practical Nurse #1 | LPN | Confirmed Resident #25's facial hair should be removed during shower and Resident #29 should not have regular razors due to bleeding risk |
| Minimum Data Set Nurse #2 | MDS Nurse | Responsible for updating care plans and confirmed care plans were not followed for Residents #25 and #29 |
| Director of Nursing | DON | Confirmed expectations for aides to shampoo hair and remove female facial hair during bathing |
| Registered Nurse Supervisor | RN Supervisor | Confirmed residents should not shave themselves with regular razors and that Resident #29's unsupervised shaving was hazardous |
| Housekeeping #1 | Housekeeping Staff | Observed mopping without placing caution signs |
| Housekeeping Supervisor | Housekeeping Supervisor | Confirmed training on use of caution signs when mopping |
| Dietary Cook | Dietary Cook | Confirmed opened lunch meat packages were not labeled or dated |
| Dietary Manager | Dietary Manager | Confirmed failure to label and date opened food items and importance of food safety |
| Administrator | Administrator | Confirmed hazard of Resident #29 having access to regular razors and need for supervision |
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 3
Date: Dec 3, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 12/01/2025 through 12/03/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with licensure requirements, citing deficiencies in activities of daily living assistance, accident hazard prevention, and safe food handling procedures. Specific issues included failure to provide personal grooming and facial hair removal for residents, inadequate supervision and environmental hazards, and improper labeling and dating of opened food items in the dietary department.
Deficiencies (3)
Failed to provide personal grooming services and removal of facial hair for two of four residents reviewed for activities of daily living (Residents #1 and #25).
Failed to ensure environment was free of accident hazards when a resident room was mopped without use of a caution sign and failed to provide adequate supervision for a resident on blood thinners shaving with a razor (Resident #29).
Failed to open and store food items properly in the dietary department; three packages of lunch meats were opened and not labeled or dated.
Report Facts
Residents reviewed for ADLs: 4
Residents with grooming deficiencies: 2
Occupied rooms observed: 31
Residents sampled for supervision: 19
Packages of lunch meat: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Interviewed regarding Resident #1's grooming and bathing | |
| Director of Nursing (DON) | Confirmed expectations for aides to shampoo hair and remove facial hair | |
| Licensed Practical Nurse (LPN) #1 | Confirmed Resident #25's facial hair condition and care requirements | |
| CNA Supervisor | Stated facial hair should be removed during shower time | |
| Registered Nurse (RN) Supervisor | Confirmed personal hygiene includes facial hair removal | |
| Housekeeping #1 | Observed mopping without caution sign and stated lack of training | |
| Housekeeping Supervisor | Confirmed training on use of caution signs during mopping | |
| Licensed Practical Nurse (LPN) #1 | Confirmed presence of razors in Resident #29's room and supervision requirements | |
| Registered Nurse (RN) Supervisor | Confirmed hazards of razors in Resident #29's room and need for electric razor | |
| Administrator | Confirmed hazard of razors and supervision needs for Resident #29 | |
| Dietary Cook | Confirmed unlabeled and undated lunch meat packages | |
| Dietary Manager | Confirmed policy and training on labeling and dating food items |
Inspection Report
Life Safety
Deficiencies: 0
Date: Dec 3, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements.
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and all Federal, State, and local emergency preparedness requirements. No deficiencies were cited during this survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
The State Agency conducted a desk review on 04/02/24 of information related to the annual survey completed on 02/08/24 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were implemented to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 04/01/24.
Inspection Report
Annual Inspection
Census: 54
Deficiencies: 1
Date: Feb 8, 2024
Visit Reason
The State Agency conducted an annual survey at the facility from February 6, 2024 through February 8, 2024 to assess compliance with Minimum Standards for Institutions for Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to infection control deficiencies, specifically failing to prevent possible spread of infection by improper handling of a pulse oximeter during medication administration to Resident #31.
Deficiencies (1)
Failure to prevent possible spread of infection by placing a pulse oximeter in a nurse's uniform pocket during medication pass without cleaning it between residents.
Report Facts
Census: 54
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency related to pulse oximeter handling |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding pulse oximeter cleaning practices |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control policies and pulse oximeter cleaning |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted inservice training on infection control and cleaning of equipment |
| Nursing Supervisor | Nursing Supervisor | Assessed Resident #31 after alleged deficient practice |
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 2
Date: Feb 8, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 2/6/24 through 2/8/24 to determine compliance with Medicare and Medicaid requirements for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited related to providing a safe, clean, and homelike environment due to poor furniture condition, and infection prevention and control practices including improper handling of a pulse oximeter during medication administration.
Deficiencies (2)
Failed to provide a safe homelike environment in resident rooms as evidenced by furniture being in poor condition, including scuffed and worn bedside tables, dresser, and closet doors in Room 105.
Failed to establish and maintain an infection prevention and control program as evidenced by placing a pulse oximeter in a nurse's uniform pocket during medication pass without cleaning it before or after use on Resident #31.
Report Facts
Deficiencies cited: 2
Census: 54
Total Capacity: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control deficiency for improper handling of pulse oximeter. |
| Administrator | Facility Administrator | Confirmed condition of furniture and lack of policy on environmental cleanliness. |
| Director of Nursing | Director of Nursing | Provided interview on proper pulse oximeter cleaning and storage procedures. |
| Assistant Director of Nursing | Assistant Director of Nursing | Conducted inservice training on infection control and cleaning of equipment. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Confirmed rough edges on bedside table that could cause injury. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 02/08/24 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the State Agency recommended the facility be placed back in compliance effective 04/01/24.
Inspection Report
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report
Routine
Deficiencies: 0
Date: Feb 7, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The State Agency conducted four complaint investigations at the facility from 6/19/23 through 6/20/23.
Complaint Details
Four complaint investigations (CI MS# 21290, CI MS# 21462, CI MS# 21479, and CI MS# 21480) were conducted and none were substantiated.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaints related to Rehabilitation Services or Accidents were not substantiated and no deficiencies were cited.
Report Facts
Licensed beds: 60
Census: 58
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Date: Jun 20, 2023
Visit Reason
The State Agency conducted four complaint investigations at the facility from 6/19/23 through 6/20/23.
Complaint Details
Four complaint investigations (CI MS# 21290, CI MS# 21462, CI MS# 21479, and CI MS# 21480) were conducted. Complaints related to Rehabilitation Services and Accidents were not substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding Rehabilitation Services and Accidents were not substantiated and no deficiencies were cited.
Report Facts
Licensed beds: 60
Census: 58
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility on 04/06/2023.
Complaint Details
Complaint survey (CI MS #20621) was conducted and no deficiencies were cited, indicating compliance.
Findings
The facility was found to be in compliance with the Minimal Standards of Operation for Institutions for the Aged or Infirm with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Date: Apr 6, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS #20621) at the facility on 04/06/23.
Complaint Details
Complaint investigation CI MS #20621 was conducted and found no deficiencies; the facility was in compliance.
Findings
The facility was found to be in compliance with Medicare and Medicaid Services requirements with no deficiencies cited.
Report Facts
Census: 53
Total Capacity: 60
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 15, 2023
Visit Reason
The State Agency conducted a Life Safety Code (LSC) revisit survey to verify information provided related to the annual survey conducted on 2023-01-17.
Findings
The facility had implemented measures to correct the previously identified deficient practice and sustained compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 2023-02-10.
Report Facts
Survey dates: Jan 17, 2023
Survey dates: Feb 15, 2023
Compliance effective date: Feb 10, 2023
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 01/17/23 to 01/19/23.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 54
Capacity: 60
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 01/17/23 to 01/19/23 to determine compliance with Medicare and Medicaid regulations.
Findings
The facility was found to be in compliance with Medicare and Medicaid regulations with no deficiencies cited during the survey.
Inspection Report
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Deficiencies: 0
Date: Jan 17, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Life Safety
Census: 54
Deficiencies: 2
Date: Jan 17, 2023
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), focusing on interior wall and ceiling finishes and fire alarm system maintenance.
Findings
The facility failed to maintain proper fire-rated interior ceiling finishes and failed to properly maintain the fire alarm system, both deficiencies affecting all 54 residents. The ceiling was replaced with non-fire rated OSB board with gaps allowing smoke passage, and the fire alarm panel was in trouble mode due to water-damaged smoke detectors.
Deficiencies (2)
Facility failed to maintain proper interior finish of ceilings with fire-rated materials, replaced gypsum ceiling with non-fire rated OSB board causing smoke passage.
Facility failed to properly maintain fire alarm system; fire alarm panel was in trouble mode due to two water-damaged smoke detectors not replaced.
Report Facts
Residents affected: 54
Completion date for ceiling repair: Jan 30, 2023
Completion date for fire alarm repair: Jan 26, 2023
Inspection Report
Life Safety
Census: 54
Deficiencies: 1
Date: Jan 17, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (NFPA 101) regarding the proper interior finish of ceilings in the facility.
Findings
The facility failed to maintain fire-rated interior ceiling finishes, having replaced gypsum ceilings with non-fire rated oriented strand board (OSB) in multiple areas, which compromised smoke resistance. Repairs were contracted and completed to replace the non-fire rated board with fire-rated sheetrock.
Deficiencies (1)
Failure to maintain proper interior finish of ceilings with fire-rated materials as required by NFPA 101 sections 19.3.3.1 and 19.3.3.2, affecting smoke resistance.
Report Facts
Residents affected: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Provided statement regarding ceiling damage caused by frozen sprinkler pipes | |
| Administrator | Responsible for ongoing rounds to ensure proper ceiling maintenance |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 60
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility from 12/5/22 through 12/7/22 to investigate complaints related to Resident Rights, Resident Abuse, Resident Assessment, Neglect, Quality of Care, and other concerns.
Complaint Details
Complaints related to Resident Rights, Resident Not Treated with Dignity/Respect, Resident Abuse related to Verbal Abuse, Resident Assessment, Neglect, Quality of Care related to Services not Provided per Physician's Order, Improper Incontinent Care, No Pressure Sore Precautions Taken By Facility, Responsible Party Not Notified, Call Lights Not Answered Timely, Resident Safety were investigated and not substantiated.
Findings
The survey determined that the facility was in compliance with Mississippi Regulations for Minimum Standards for Institution for Aged or Infirm and did not substantiate the complaints. No deficiencies were cited.
Report Facts
Census: 54
Total Capacity: 60
Inspection Report
Complaint Investigation
Census: 54
Capacity: 60
Deficiencies: 0
Date: Dec 7, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility from 12/5/22 through 12/7/22 to investigate multiple complaints including Resident Rights, Resident Abuse, Resident Assessment, Neglect, Quality of Care, and Resident Safety.
Complaint Details
Complaints related to Resident Rights, Resident Not Treated with Dignity/Respect, Resident Abuse (Verbal), Resident Assessment, Neglect, Quality of Care (Services not Provided per Physician's Order), Improper Incontinent Care, No Pressure Sore Precautions, Responsible Party Not Notified, Call Lights Not Answered Timely, and Resident Safety were investigated and found unsubstantiated.
Findings
The survey determined that the facility was in compliance with Medicare and Medicaid requirements and did not substantiate the complaints. No deficiencies were cited.
Report Facts
Census: 54
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
The State Agency conducted a Complaint Investigation for MS00019350 and MS00019372 related to Quality of Care and Staffing from 07/11/22 through 07/12/22.
Complaint Details
Complaint investigation for MS00019350 and MS00019372 related to Quality of Care and Staffing; complaints were not substantiated.
Findings
The facility was found to be in compliance with the requirements of The Aged and Infirm and the complaint allegations were not substantiated.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Date: Jul 12, 2022
Visit Reason
The State Agency conducted complaint investigations related to Quality of Care and Staffing on 07/11/22 through 07/12/22.
Complaint Details
Complaint investigations for CI MS #19350 and CI MS #19372 related to Quality of Care and Staffing were conducted and not substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements and the complaint allegations were not substantiated.
Report Facts
Census: 58
Total Capacity: 60
Inspection Report
Complaint Investigation
Census: 56
Capacity: 60
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
The State Agency conducted two onsite complaint investigations regarding alleged verbal and mental abuse and alleged sexual inappropriate comments by staff to residents.
Complaint Details
Two complaint investigations were conducted: CI MS #18912 for alleged verbal and mental abuse, and CI MS #19003 for alleged sexual inappropriate comments. Both were unsubstantiated.
Findings
Both complaint investigations were unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with the standards for participation in The Aged and Infirmed.
Report Facts
Resident census: 56
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Census: 56
Capacity: 60
Deficiencies: 0
Date: Jun 14, 2022
Visit Reason
The State Agency conducted two onsite complaint investigations on 06/14/2022 regarding alleged verbal and mental abuse and alleged sexual inappropriate comments by staff to residents.
Complaint Details
Two complaint investigations (CI MS #18912 and CI MS #19003) were conducted for alleged verbal and mental abuse and alleged sexual inappropriate comments by staff. Both complaints were unsubstantiated.
Findings
Both complaint investigations were unsubstantiated, no deficiencies were cited, and the facility was determined to be in substantial compliance with Medicare and Medicaid participation standards.
Report Facts
Resident census: 56
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 27, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey that was conducted on 2022-04-08.
Complaint Details
The visit was complaint-related, and the facility was found to be in compliance based on the desk review.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The facility was recommended to be placed back in compliance effective 2022-05-18.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 27, 2022
Visit Reason
The State Agency conducted a desk review related to a complaint survey conducted on 2022-04-08 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey conducted on 2022-04-08. The facility's corrective actions were reviewed and found sufficient to address the deficiencies.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2022-05-18.
Report Facts
Survey date: Apr 8, 2022
Inspection Report
Complaint Investigation
Census: 55
Capacity: 60
Deficiencies: 1
Date: Apr 8, 2022
Visit Reason
On April 7, 2022, the State Agency conducted an onsite complaint investigation for alleged abuse of a resident.
Complaint Details
The complaint investigation (CI MS# 18697) was substantiated. The staff member (Housekeeping Supervisor) sent a sexually explicit picture of his penis to Resident #1's cell phone. The staff member was terminated on March 29, 2022. The Attorney General's office was involved and classified the incident as a cyber-crime. Resident #1 was visibly upset and refused therapy following the incident. The facility took corrective actions including staff in-service training and increased monitoring.
Findings
The facility was found not in substantial compliance due to failure to prevent abuse and neglect when a staff member sent an inappropriate picture to a resident's cell phone. The complaint was substantiated and deficiencies were cited at a Level II severity.
Deficiencies (1)
Failed to protect resident rights by failing to prevent abuse and neglect when a staff member sent an inappropriate picture to Resident #1's cell phone.
Report Facts
Licensed beds: 60
Resident census: 55
Deficiency severity level: 2
Date of incident: Mar 29, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Housekeeping Supervisor | Staff member who sent inappropriate picture to resident |
| Administrator | Administrator | Facility Administrator involved in investigation and corrective actions |
| Director of Nursing | Director of Nursing | Participated in investigation and review of findings |
| Physical Therapy Supervisor | Physical Therapy Supervisor | Reported resident's complaint and participated in investigation |
| Doctor of Physical Therapy | Doctor of Physical Therapy | Observed resident's distress and participated in investigation |
| Social Worker | Social Worker | Interviewed resident and assisted in investigation |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 60
Deficiencies: 2
Date: Apr 7, 2022
Visit Reason
On April 7, 2022, the State Agency conducted an onsite complaint investigation for alleged abuse of a resident when a staff member sent an inappropriate photo to a resident's cell phone.
Complaint Details
Complaint CI MS #18697 was substantiated. The allegation involved a staff member sending a sexually explicit photo to Resident #1's cell phone. The facility was not in substantial compliance for Medicaid and Medicare participation due to this incident.
Findings
The facility was found to have failed to prevent abuse and neglect when a staff member sent an inappropriate picture to Resident #1's cell phone. The complaint was substantiated, and deficiencies were cited. The investigation revealed inadequate staff interviews and incomplete investigation procedures.
Deficiencies (2)
Facility failed to prevent abuse and neglect when a staff member sent an inappropriate picture to Resident #1's cell phone.
Facility failed to thoroughly investigate the allegation of abuse by not obtaining written statements from staff members who reported the allegation.
Report Facts
Licensed beds: 60
Resident census: 55
Deficiency count: 2
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Supervisor | Housekeeping Supervisor | Staff member who sent inappropriate photo to Resident #1 and was terminated on 3/29/2022 |
| Physical Therapy Supervisor | Physical Therapy Supervisor | Reported the incident to Social Worker on 3/29/2022; interviewed during investigation |
| Doctor of Physical Therapy | Doctor of Physical Therapy | Interviewed during investigation; confirmed Resident #1 was upset and refused therapy on 3/29/2022 |
| Social Worker | Social Worker | Interviewed Resident #1 and reviewed cell phone; reported findings to Administrator |
| Administrator | Nursing Home Administrator | Conducted investigation, terminated Housekeeping Supervisor, and reviewed abuse policy |
| CNA #2 | Certified Nursing Assistant | Named by Resident #1 as attempting to block inappropriate photos on her phone; interviewed during investigation |
| Responsible Party | Resident's Sister and Responsible Party | Reported receiving inappropriate photo from Resident #1 and requested transfer of Resident #1 |
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The State Agency conducted a complaint investigation regarding call light systems not being answered timely on 2021-09-18.
Complaint Details
Complaint investigation CI MS #18119 was unsubstantiated with no deficiencies cited.
Findings
The complaint was determined to be unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Medicare and Medicaid standards.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Date: Feb 8, 2022
Visit Reason
The State Agency conducted a complaint investigation regarding call light systems not being answered timely on 2021-09-18.
Complaint Details
Complaint investigation CI MS #18119 was unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated, no deficiencies were cited, and the facility was determined to be in substantial compliance with Medicare and Medicaid standards.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Date: Feb 7, 2022
Visit Reason
The State Agency conducted a complaint investigation concerning call light systems not being answered timely on 09/18/2021.
Complaint Details
Complaint investigation CI MS #18119 was unsubstantiated with no deficiencies cited.
Findings
The complaint investigation was unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Report Facts
Census: 53
Total licensed capacity: 60
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: May 12, 2021
Visit Reason
The State Agency conducted a complaint survey from May 10, 2021 to May 12, 2021, triggered by complaints including verbal abuse and admission, transfer and discharge rights violations.
Complaint Details
The complaint survey substantiated verbal abuse (MS#17791) and admission, transfer and discharge rights violations (MS#16671). Other complaints regarding residents left wet, call bells not answered, and failure to notify physician or resident representative of condition changes were not substantiated.
Findings
The facility was found not in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm. The complaint of verbal abuse against Resident #1 was substantiated, involving a Certified Nursing Assistant (CNA#1) who used derogatory language and threatened the resident. The CNA was terminated following investigation. Other complaints were not substantiated.
Deficiencies (1)
Failure to prevent verbal abuse of Resident #1 by CNA#1, including use of disparaging language and threats.
Report Facts
Census: 55
Residents reviewed for abuse: 23
Date of complaint survey: 2021-05-10 to 2021-05-12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse finding; terminated for verbal abuse and threatening resident |
| RN #1 | Registered Nurse Supervisor | Intervened during verbal abuse incident and conducted interviews |
| Nursing Home Administrator | Administrator | Conducted investigation and involved in termination of CNA #1 |
| Director of Nursing | Director of Nursing | Conducted investigation regarding verbal abuse allegation |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 1
Date: May 12, 2021
Visit Reason
The State Agency conducted a complaint survey from May 10, 2021 to May 12, 2021, triggered by complaints including verbal abuse and admission, transfer, and discharge rights issues.
Complaint Details
The complaint MS#17791 for verbal abuse was substantiated. The complaint MS#16671 for Admission, Transfer and Discharge Rights was substantiated with no deficiency cited. Complaints MS#17494, MS#17731, and MS#17732 were not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to substantiated verbal abuse involving a Certified Nursing Assistant (CNA#1) and Resident #1. The CNA was terminated following the incident. Other complaints were not substantiated.
Deficiencies (1)
Failure to prevent verbal abuse of Resident #1 by CNA#1, including use of disparaging language and threats.
Report Facts
Census: 55
Residents reviewed for abuse: 23
BIMS score: 15
Completion date: Jun 21, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in verbal abuse incident and subsequent termination |
| RN #1 | Registered Nurse Supervisor | Intervened during verbal abuse incident and conducted interviews |
| Nursing Home Administrator | Administrator | Conducted investigation and provided staff in-service |
| Director of Nursing | Director of Nursing | Conducted investigation and involved in corrective action plan |
| LPN #1 | Licensed Practical Nurse | Accompanied RN #1 during termination of CNA #1 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The State Agency conducted a complaint survey from 2021-05-10 to 2021-05-12 to determine compliance with the Minimum Standards for the Institutions for the Aged and Infirm.
Complaint Details
Complaint survey conducted from 2021-05-10 to 2021-05-12; facility initially non-compliant but later found in substantial compliance effective 2021-06-21.
Findings
The facility was found not in compliance during the complaint survey but achieved substantial compliance based on an acceptable plan of correction and desk review completed on 2021-06-21.
Report Facts
Survey dates: Complaint survey conducted from 2021-05-10 to 2021-05-12
Plan of correction review date: Desk review and plan of correction completed on 2021-06-21
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 10, 2021
Visit Reason
The State Agency conducted a complaint survey from May 10, 2021 to May 12, 2021 to determine compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaint survey conducted from 5-10-21 to 5-12-21; facility initially non-compliant but achieved substantial compliance effective 6.21.21.
Findings
The facility was found not in compliance during the complaint survey but achieved substantial compliance based on an acceptable plan of correction and desk review completed on June 21, 2021.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/14/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report
Abbreviated Survey
Census: 47
Deficiencies: 0
Date: Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 41
Capacity: 60
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 41
Capacity: 60
Deficiencies: 0
Date: May 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/31/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 41
Capacity: 60
Deficiencies: 0
Date: May 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/31/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 60
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
The State Agency conducted a complaint survey triggered by complaint MS CI #16465 regarding inappropriate discharge and quality of care issues.
Complaint Details
Complaint MS CI #16465 was not substantiated for inappropriate discharge and quality of care issues related to residents being left soiled.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint about residents being left soiled for extended periods was not substantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 60
Deficiencies: 0
Date: Jan 2, 2020
Visit Reason
The State Agency conducted a complaint survey related to allegations of inappropriate discharge and Quality of Care issues concerning residents being left soiled for extended periods of time.
Complaint Details
Complaint was not substantiated for inappropriate discharge and Quality of Care issues related to residents being left soiled for extended periods of time.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements, did not substantiate the complaint, and cited no deficiencies.
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Nov 14, 2019
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations from 11/12/19 to 11/14/19 to determine compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaints MS #15923 and MS #15979 were investigated; MS #15923 for abuse and neglect and MS #15979 related to accidents with injury. Both complaints were not substantiated and no citations were issued related to them.
Findings
The facility was found not in compliance due to failure to develop comprehensive care plans for residents with Foley catheters and urinary tract infections. Complaints related to abuse, neglect, and accidents with injury were not substantiated. Additionally, a life safety code deficiency was cited related to the essential electrical system alarm annunciator being inoperable.
Deficiencies (2)
Failure to develop and implement comprehensive care plans for residents with Foley catheters and urinary tract infections.
Electrical Systems - Essential Electric System Alarm Annunciator was inoperable and failed to send signals and warnings to the generator.
Report Facts
Number of care plans reviewed: 19
Date of survey completion: Nov 14, 2019
Date of plan of correction completion: Dec 13, 2019
Date of plan of correction completion: Dec 13, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| K. Raines | Staff Development Nurse | Named in relation to auditing care plans for Foley catheters and UTIs. |
| Mark Jett | Taylor Power Systems Technician | In-serviced Maintenance Director on testing remote annunciator. |
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
The State Agency conducted an annual recertification along with complaint investigations MS #15923 and MS #15979 from 11/12/19 to 11/14/19.
Complaint Details
The State Agency did not substantiate complaint MS #15923 for abuse and neglect and did not substantiate complaint MS #15979 related to accidents with injury.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaints related to abuse, neglect, and accidents with injury were not substantiated.
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
The State Agency conducted an annual recertification along with complaint investigations MS #15923 and MS #15979 from 11/12/19 to 11/14/19.
Complaint Details
Complaints MS #15923 and MS #15979 were investigated and not substantiated.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaints MS #15923 for abuse and neglect and MS #15979 related to accidents with injury were not substantiated.
Report Facts
Census: 55
Total Capacity: 60
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 0
Date: Nov 14, 2019
Visit Reason
The State Agency conducted an annual recertification along with complaint investigations MS #15923 and MS #15979 from 11/12/19 to 11/14/19.
Complaint Details
Complaints MS #15923 and MS #15979 were investigated and not substantiated.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaints MS #15923 for abuse and neglect and MS #15979 related to accidents with injury were not substantiated.
Report Facts
Census: 55
Total Capacity: 60
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