Deficiencies per Year
8
6
4
2
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 23, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility on 12/22/2025 to 12/23/2025 regarding activities of daily living care, call lights, and therapy.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint investigation MS #2693324 was conducted and found no deficiencies; the facility was compliant.
Inspection Report
Complaint Investigation
Census: 91
Capacity: 102
Deficiencies: 0
Dec 22, 2025
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 12/22/25 to 12/23/25 regarding activities of daily living care, call lights, and therapy.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #2693324 was investigated for activities of daily living care, call lights, and therapy. No deficiencies were cited.
Report Facts
Licensed beds: 102
Census: 91
Inspection Report
Complaint Investigation
Census: 90
Capacity: 102
Deficiencies: 0
Dec 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2666079, related to quality of care and residents’ rights at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #2666079 was investigated related to quality of care and residents’ rights and found no deficiencies.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2666079, related to quality of care and residents’ rights at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #2666079 was investigated related to quality of care and residents’ rights and was found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 20, 2025
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2025-09-17 to assess 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, and the State Agency recommended the facility be placed back in compliance effective 2025-10-17.
Complaint Details
The visit was related to a complaint survey completed on 2025-09-17. The facility was found to be in compliance based on the desk review.
Inspection Report
Complaint Investigation
Deficiencies: 2
Sep 17, 2025
Visit Reason
The State Agency conducted complaint investigations from 2025-09-15 to 2025-09-17 related to discharge, abuse and peri care, and neglect at Chadwick Nursing and Rehabilitation Center LLC.
Findings
The facility was found not in compliance with licensure requirements related to urinary incontinence care and infection control. Specifically, a Certified Nursing Assistant failed to provide proper perineal care to Resident #4, including improper handling of feeding pump, inadequate cleaning technique, failure to wear gown and gloves properly, and lack of hand hygiene, placing the resident at risk for infection.
Complaint Details
Complaint investigations MS #2561750 (abuse and peri care), MS #2600576 (neglect), and MS #2568526 (discharge) were conducted. The facility was cited for deficiencies related to MS #2600576 (neglect). No citations were related to MS #2568526 or MS #2561750.
Deficiencies (2)
| Description |
|---|
| Failed to provide perineal care according to acceptable standards for Resident #4, including improper wiping technique and failure to clean rectal area. |
| Failed to maintain an effective infection control program as evidenced by improper hand hygiene, lack of gown use, and cross-contamination risks during perineal care for Resident #4. |
Report Facts
Complaint Investigation IDs: 3
Assessment Reference Date: Aug 18, 2025
Brief Interview for Mental Status (BIMS) score: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in findings for improper perineal care and infection control breaches |
| RN #2 | Registered Nurse, Unit Manager for the B Unit | Confirmed improper care and infection control breaches by CNA #1 |
| Executive Director | Commented on CNA #1's performance and facility expectations | |
| Director of Nursing | Provided expectations and critique of CNA #1's care and infection control practices | |
| RN #3 | Registered Nurse, Infection Preventionist | Discussed infection control training and expectations related to CNA #1's care |
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 5
Sep 17, 2025
Visit Reason
The State Agency conducted a Complaint Investigation from 09/15/2025 through 09/17/2025 related to discharge, abuse and peri care, and neglect at Chadwick Nursing and Rehabilitation Center LLC.
Findings
The facility was found non-compliant with Medicare and Medicaid participation requirements, citing deficiencies related to discharge process, comprehensive care plan implementation, bowel/bladder incontinence care, and infection prevention and control. Specific failures included lack of bed-hold notice for therapeutic leave discharge, failure to follow care plans for perineal care, improper perineal care increasing infection risk, and inadequate infection control practices.
Complaint Details
The complaint investigation included three complaint investigations: CI MS #2568526 related to discharge, CI MS #2561750 related to abuse and peri care, and CI MS #2600576 related to neglect. Deficiencies were cited related to discharge and neglect complaints; no citations were related to the abuse complaint.
Severity Breakdown
SS = E: 1
SS = D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to issue bed-hold notice when a resident went out on therapeutic leave and was discharged without proper notification or appeal process. | SS = E |
| Failed to develop and implement a comprehensive person-centered care plan consistent with resident rights, including measurable objectives and timeframes. | SS = D |
| Failed to implement the comprehensive care plan while providing perineal care for a resident, including lack of two-person assistance as required. | SS = D |
| Failed to provide appropriate treatment and services for bowel/bladder incontinence, including improper perineal care technique. | SS = D |
| Failed to establish and maintain an infection prevention and control program, including failure to follow hand hygiene, use of gowns, and proper handling of contaminated supplies during perineal care. | SS = D |
Report Facts
Licensed beds: 102
Census: 93
Deficiency severity counts: 1
Deficiency severity counts: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Provided statements regarding bed-hold policy and discharge process |
| Director of Nursing | Director of Nursing | Provided statements regarding discharge, care plan implementation, and infection control |
| Certified Nursing Assistant #1 | CNA | Observed providing deficient perineal care and improper infection control |
| Registered Nurse #2 | Unit Manager | Confirmed CNA #1 did not provide care properly and did not wear gown |
| Registered Nurse #3 | Infection Preventionist | Provided statements on infection control training and expectations |
| Social Worker | Social Worker | Provided statements regarding home health eligibility and follow-up |
| Business Office Manager | Business Office Manager | Provided statements regarding bed-hold policies |
Inspection Report
Plan of Correction
Deficiencies: 0
Sep 17, 2025
Visit Reason
The document is a desk review conducted on 11/20/2025 related to a complaint survey completed on 09/17/2025 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming 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 10/17/2025.
Complaint Details
The visit was related to a complaint survey completed on 09/17/2025. The facility's corrective actions were reviewed and found satisfactory.
Report Facts
Survey completion date: Nov 20, 2025
Complaint survey date: Sep 17, 2025
Compliance effective date: Oct 17, 2025
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 1
May 14, 2025
Visit Reason
The State Agency conducted complaint investigations related to facility staffing and a facility reported incident involving an elopement of Resident #1, who was identified as a risk for wandering and elopement.
Findings
The facility failed to provide adequate supervision to prevent Resident #1 from exiting the facility unsupervised, resulting in the resident being missing for approximately two hours and walking about one mile near a busy highway. The incident was determined to be Immediate Jeopardy and Substandard Quality of Care but was corrected prior to the survey entrance. Corrective actions included environmental safety reviews, staff in-service training, installation of keypad alarms, and one-on-one supervision for the resident.
Complaint Details
Complaint investigations MS #28829 and MS #28899 were conducted. MS #28829 related to staffing had no citations. MS #28899 investigated a facility reported incident of elopement involving Resident #1, substantiated with Immediate Jeopardy and Substandard Quality of Care identified.
Severity Breakdown
Scope and Severity "J": 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision of Resident #1, an elopement risk, who exited the facility unnoticed and unsupervised for approximately two hours. | Scope and Severity "J" |
Report Facts
Licensed beds: 102
Resident census: 93
Duration of elopement: 2
Distance walked: 1
One-on-one supervision duration: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed Resident #1 walking without walker and participated in search after elopement |
| Director of Nursing | Director of Nursing (DON) | Participated in investigation, search, and corrective actions post-elopement |
| RN #1 | Registered Nurse | Located and returned Resident #1 to facility after elopement |
| RN #2 | Registered Nurse | Notified of elopement, participated in search, notified medical staff, and assessed resident post-return |
| Dietary Aide #1 | Dietary Aide | First staff to notice Resident #1 missing and initiated search |
| CNA #1 | Certified Nursing Assistant | Assisted in search for Resident #1 after elopement |
| Housekeeping #1 | Housekeeping Staff | Observed Resident #1 attempting to exit facility and redirected him prior to elopement |
| Social Services #1 | Social Services Staff | Maintains elopement books and performed post-trauma psychosocial assessment |
Inspection Report
Complaint Investigation
Deficiencies: 1
May 14, 2025
Visit Reason
The State Agency conducted complaint investigations related to facility staffing and a facility reported incident (FRI) involving an elopement of Resident #1, who was identified as a risk for wandering and elopement.
Findings
The facility failed to provide adequate supervision to prevent Resident #1 from exiting the facility unsupervised and unnoticed, resulting in the resident being missing for approximately two hours and walking about one mile across a busy highway. Immediate Jeopardy and Substandard Quality of Care were identified but corrected prior to the survey entrance.
Complaint Details
The complaint investigation MS #28899 was triggered by a facility reported incident involving Resident #1's elopement on 05/09/25. The investigation found Immediate Jeopardy and Substandard Quality of Care due to inadequate supervision, which was corrected by 05/10/25.
Severity Breakdown
Level IV: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision of Resident #1, an elopement and wandering risk, who exited the facility unnoticed and unsupervised for approximately two hours. | Level IV |
Report Facts
Duration of unsupervised elopement: 2
Distance walked: 1
Number of residents reviewed: 4
Wander guard checks: 3
One-on-one supervision duration: 72
Date of incident: May 9, 2025
Date of survey completion: May 14, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed Resident #1 walking without walker and participated in search after elopement. |
| CNA #1 | Certified Nursing Assistant | Checked resident rooms and participated in search after Resident #1 was missing. |
| Dietary Aide #1 | Dietary Aide | First staff to notice Resident #1 missing from dining room and notified nursing staff. |
| Director of Nursing | Director of Nursing (DON) | Participated in search, assessed Resident #1 after return, and led corrective actions. |
| RN #1 | Registered Nurse | Located and returned Resident #1 to facility and participated in post-incident actions. |
| RN #2 | Registered Nurse | Notified of elopement, joined search, assessed Resident #1 after return, and notified medical staff. |
| Housekeeping #1 | Housekeeping Staff | Observed Resident #1 attempting to exit facility and participated in search. |
| Social Services #1 | Social Services Staff | Maintains elopement books and performed post-trauma psychosocial assessment. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 10, 2025
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 4/9/25 to 4/10/25 regarding client services not performed and residents left soiled for long periods of time with call bells not accessible.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #28359 and MS #28465 were investigated; MS #28359 concerned client services not performed, and MS #28465 concerned residents left soiled for long periods and inaccessible call bells. The complaints were not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 96
Capacity: 102
Deficiencies: 0
Apr 10, 2025
Visit Reason
The State Agency conducted a Complaint Investigation regarding client services not performed and residents left soiled for long periods with inaccessible call bells.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #28359 concerned client services not performed; MS #28465 concerned residents left soiled for long periods and call bells not accessible. Both complaints were investigated and found unsubstantiated with no deficiencies cited.
Report Facts
Licensed beds: 102
Census: 96
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 19, 2025
Visit Reason
The State Agency conducted a complaint investigation related to resident to resident abuse at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement, and no deficiencies were cited.
Complaint Details
Complaint MS #27666 related to resident to resident abuse was investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 94
Capacity: 102
Deficiencies: 0
Feb 19, 2025
Visit Reason
The State Agency conducted a complaint investigation related to resident to resident abuse at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #27666 related to resident to resident abuse; no deficiencies were cited.
Report Facts
Resident census: 94
Total licensed capacity: 102
Inspection Report
Follow-Up
Deficiencies: 0
Jul 23, 2024
Visit Reason
The State Agency conducted a follow-up revisit survey on 7/23/24 related to an annual recertification survey conducted from 6/2/24 through 6/5/24.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, and is recommended to be placed back in compliance effective 7/18/24.
Inspection Report
Follow-Up
Census: 92
Capacity: 102
Deficiencies: 0
Jul 23, 2024
Visit Reason
The State Agency conducted a follow-up revisit survey on 7/23/24 related to an annual recertification survey conducted from 6/2/24 through 6/5/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 7/18/24.
Inspection Report
Complaint Investigation
Census: 92
Capacity: 102
Deficiencies: 0
Jul 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25740, at the facility on 7/22/24 related to neglect concerning pressure ulcers.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited. However, the facility remains out of compliance due to deficiencies cited on the 6/5/2024 survey.
Complaint Details
Complaint Investigation MS #25740 was investigated for neglect related to pressure ulcers and found no deficiencies during this visit.
Report Facts
Licensed beds: 102
Resident census: 92
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #25740 at the facility on 7/22/24. The investigation was related to neglect concerning pressure ulcers.
Findings
During the survey, the facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited during this investigation, but the facility remains out of compliance due to deficiencies cited on the 6/5/2024 survey.
Complaint Details
Complaint Investigation MS #25740 was investigated for neglect related to pressure ulcers. No deficiencies were cited and the facility was found in compliance during this visit.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 12, 2024
Visit Reason
The State Agency conducted a desk review on 07/12/24 of information related to the annual survey conducted on 06/03/24 to verify correction of previously identified deficient practices.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited during the 06/03/24 survey. The State Agency confirmed that corrective measures were implemented and recommended the facility be placed back in compliance effective 07/12/24.
Inspection Report
Annual Inspection
Capacity: 180
Deficiencies: 4
Jun 5, 2024
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations related to staffing, call lights, neglect, equipment, incontinent care, and medications from 06/02/2024 through 06/05/2024.
Findings
The facility was found non-compliant with state licensure requirements including insufficient nursing staff leading to delayed call light responses and incontinent care, failure to honor residents' rights regarding bedrails, failure to provide timely incontinent care, and improper oxygen therapy management including undated tubing and lack of humidification.
Complaint Details
Complaint investigations were conducted for issues related to staffing, call lights, neglect, equipment, incontinent care, and medications (CI MS #24614, #24763, #24764). The facility was cited for deficiencies related to these complaints.
Severity Breakdown
Level II: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Insufficient nursing staff to meet resident needs, resulting in failure to answer call lights and provide timely incontinent care for three residents. | Level II |
| Failure to honor residents' rights to have bedrails for assistance with turning and bed mobility for two residents. | Level II |
| Failure to ensure timely incontinent care for one resident, with observations of saturated briefs and delayed care. | Level II |
| Failure to ensure oxygen therapy was delivered properly, with undated oxygen tubing and no humidifier provided for one resident. | Level II |
Report Facts
Number of sampled residents with call light and incontinent care issues: 3
Facility total licensed capacity: 180
Number of residents audited for incontinent care: 20
Number of residents audited for call light response: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Mentioned in relation to delayed incontinent care for Resident #48 | |
| Certified Nurse Aide #3 | Provided incontinent care to Resident #48 | |
| Certified Nurse Aide #4 | Confirmed urine leakage onto wheelchair seat of Resident #48 | |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staffing expectations and bedrail removal |
| Administrator | Interviewed regarding nursing staff responsibilities and bedrail removal | |
| Maintenance Director | Removed bedrails by order of Administrator | |
| Licensed Practical Nurse #1 | Interviewed about oxygen tubing and humidifier requirements |
Inspection Report
Annual Inspection
Census: 91
Capacity: 102
Deficiencies: 4
Jun 5, 2024
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigations related to staffing, call lights, neglect, equipment, incontinent care, and medications from 06/02/24 through 06/05/24.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident self-determination, ADL care, respiratory care, and sufficient nursing staff. Specific issues included failure to honor resident rights regarding bedrails, untimely incontinent care, improper oxygen therapy administration, and insufficient staffing leading to delayed call light responses and care.
Complaint Details
Complaint investigations were conducted for issues related to staffing, call lights, neglect, equipment, incontinent care, and medications (CI MS #24614, #24763, #24764).
Severity Breakdown
SS=D: 3
SS=F: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to honor residents' rights to have bedrails for assistance with turning and bed mobility for two residents. | SS=D |
| Failed to ensure timely incontinent care for one resident. | SS=D |
| Failed to ensure oxygen was delivered properly, with tubing not dated and no humidification for one resident. | SS=D |
| Failed to have sufficient nursing staff to meet resident needs, resulting in delayed call light responses and incontinent care for three residents. | SS=F |
Report Facts
Census: 91
Total Capacity: 102
Deficiencies cited: 7
BIMS score: 15
BIMS score: 9
BIMS score: 10
BIMS score: 14
BIMS score: 15
BIMS score: 15
Inspection Report
Life Safety
Census: 16
Capacity: 91
Deficiencies: 1
Jun 3, 2024
Visit Reason
The inspection was conducted to assess compliance with emergency preparedness and the 2012 Edition of the Life Safety Code, specifically focusing on fire door assemblies and means of egress.
Findings
The facility met emergency preparedness requirements but failed to annually inspect and test fire door assemblies as required by NFPA 80 (2010 edition). This deficiency affected all 16 residents present during the survey. A corrective plan was implemented including an inspection by a local vendor and monthly audits by the Maintenance Director.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to annually inspect and test fire door assemblies in accordance with NFPA 80 (2010 edition) section 5.2. | SS=D |
Report Facts
Residents affected: 16
Total licensed capacity: 91
Fire door inspection date: Jun 28, 2024
Audit duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Conducted inservice with Maintenance Department on 06/18/24 to ensure annual fire door inspections | |
| Maintenance Director | Responsible for monthly audits of fire doors and forwarding results to Quality Assurance Committee |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 9, 2024
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 2/08/24 through 2/09/24 regarding Quality of Care/Treatment related to Facility Staffing and Resident Preferences, Water Temperatures, Linens, Infection Control, and Physical Environment.
Findings
During the survey, 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.
Complaint Details
Complaint Investigation MS #23792 and MS #23913 were conducted. MS #23913 investigated Quality of Care/Treatment related to Facility Staffing. MS #23792 investigated Resident Preferences, Water Temperatures, Linens, Infection Control, and Physical Environment. No deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 98
Capacity: 102
Deficiencies: 0
Feb 9, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility from 2/08/24 through 2/09/24 regarding Quality of Care/Treatment related to Facility Staffing and Resident Preferences, Water Temperatures, Linens, Infection Control, and Physical Environment.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the complaint investigations.
Complaint Details
Two complaint investigations (CI MS #23792 and MS #23913) were conducted. CI MS #23913 was related to Quality of Care/Treatment and Facility Staffing. CI MS #23792 was related to Resident Preferences, Water Temperatures, Linens, Infection Control, and Physical Environment. Both complaints were investigated and found to have no deficiencies.
Report Facts
Licensed beds: 102
Resident census: 98
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 19, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2023-11-13 to determine 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, and the facility was recommended to be placed back in compliance effective 2023-12-15.
Complaint Details
The visit was complaint-related, reviewing information from a complaint survey completed on 2023-11-13. The facility was found compliant and the complaint was effectively resolved.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 19, 2023
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2023-11-13 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2023-12-15.
Complaint Details
The visit was related to a complaint survey completed on 2023-11-13. The facility's corrective measures were reviewed and found satisfactory, leading to a recommendation for compliance reinstatement.
Report Facts
Survey completion date: Dec 19, 2023
Complaint survey date: Nov 13, 2023
Compliance effective date: Dec 15, 2023
Inspection Report
Complaint Investigation
Deficiencies: 1
Nov 13, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 11/09/23 through 11/13/23 related to Safety/Falls, Notification of Responsible Party, Medications Improperly Administered, Client Services not performed per Plan of Care or Physician Orders, Adequate Grooming, Staffing, and Resident Abuse/Verbal.
Findings
No deficient practice was determined related to the complaints; however, the facility failed to provide safe and secure storage of medications as medication carts were found unattended, unlocked, and had medications left on top. This was confirmed by staff interviews and policy review.
Complaint Details
Complaint Investigation MS #22119 was conducted from 11/09/23 through 11/13/23. The investigation included multiple complaint areas but no deficient practice was found related to the complaints themselves. The medication storage issue was cited separately.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide safe and secure storage of medications; medication cart was unattended, unlocked, and had medication packets lying on top. | Level II |
Report Facts
Medication carts observed: 3
Deficiency count: 1
Audit frequency: 3
Audit duration: 8
Audit frequency per week: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Left medication cart unattended and unlocked with medications on top |
| Director of Nurses | Director of Nurses | Confirmed medication carts were never to be left unattended and unlocked |
| Staff Development Coordinator | Staff Development Coordinator | Initiated in-service training on safe and secure medication storage |
| Interim Director of Nursing | Interim Director of Nursing | Responsible for addressing medication storage concerns and reporting audit results |
| Administrator | Administrator | Stated nurses were expected to secure all medications |
Inspection Report
Complaint Investigation
Census: 98
Capacity: 102
Deficiencies: 1
Nov 13, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (MS #23119) from 11/09/23 through 11/13/23 related to Safety/Falls, Notification of Resident Representative, Medications Improperly Administered, Client Services not performed per Plan of Care or Physician Orders, Adequate Grooming, Staffing, and Resident Abuse/Verbal.
Findings
No deficient practice was found related to the complaints; however, the facility failed to securely store medications in a locked compartment within a medication cart, resulting in a citation for F761.
Complaint Details
Complaint Investigation MS #23119 was related to Safety/Falls, Notification of Resident Representative, Medications Improperly Administered, Client Services not performed per Plan of Care or Physician Orders, Adequate Grooming, Staffing, and Resident Abuse/Verbal. No deficient practice was found related to the complaints.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Medications were not securely stored in a locked compartment within a medication cart; an unattended, unlocked medication cart was observed with medication packets lying on top. | SS=D |
Report Facts
Census: 98
Total Capacity: 102
Medication carts audited: 3
Audit frequency: 5
Audit duration: 8
Plan of Correction Completion Date: Dec 15, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Admitted leaving medication cart unattended and unlocked with medications on top |
| Director of Nurses | DON | Confirmed medications were not appropriately stored or secured and stated facility policy on medication storage |
| Administrator | Stated nurses were expected to secure all medications and leaving medications on an unattended, unlocked cart was not secure | |
| Staff Development Coordinator | SDC | Initiated in-service training for LPNs and RNs on safe and secure medication storage |
| Interim Director of Nursing | IDNS | Responsible for addressing safe and secure medication storage and reporting audit results to Quality Assurance Committee |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 28, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 9/27/23 through 9/28/23 for verbal abuse, staffing, inadequate grooming, medication administration, falls, resident assessment, and transportation safety.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #22884 was for verbal abuse, staffing, inadequate grooming and medication administration. MS #22768 was for falls and resident assessment. MS #22556 was for transportation safety. The complaints were not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 97
Capacity: 102
Deficiencies: 0
Sep 28, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 9/27/23 through 9/28/23 for verbal abuse, staffing, inadequate grooming, medication administration, falls, resident assessment, and transportation safety.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited during the complaint investigation.
Complaint Details
Complaint Investigation MS #22884 was for verbal abuse, staffing, inadequate grooming and medication administration; MS #22768 was for falls and resident assessment; MS #22556 was for transportation safety. No deficiencies were cited.
Report Facts
Licensed beds: 102
Beds set up: 100
Census: 97
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 5, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-05-18 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 placing the facility back in compliance effective 2023-06-28.
Inspection Report
Plan of Correction
Deficiencies: 0
Jul 5, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-05-18 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 2023-06-28.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 20, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for one complaint (MS #21280) on 6/20/23 regarding Quality of Care/Treatment.
Findings
No deficiencies were cited as a result of the complaint investigation; however, the facility remains out of compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm.
Complaint Details
Complaint MS #21280 was investigated for Quality of Care/Treatment and found to have no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 95
Capacity: 102
Deficiencies: 0
Jun 20, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility for one complaint (MS #21280) related to Quality of Care/Treatment.
Findings
No deficiencies were cited as a result of the complaint investigation; however, the facility remains out of compliance due to deficiencies cited on the prior 5/18/21 survey.
Complaint Details
Complaint MS #21280 was investigated for Quality of Care/Treatment and was not substantiated with any deficiencies.
Inspection Report
Annual Inspection
Deficiencies: 1
May 18, 2023
Visit Reason
The State Survey Agency conducted an annual re-certification and complaint investigation at the facility from 05/15/2023 through 05/18/2023. The complaint investigation was related to food palatability, adequate grooming, and temperature of water.
Findings
No deficiencies were cited related to the complaint investigation. However, the facility was found not in compliance with Mississippi regulations for Minimum Standards for Institutions for the Aged or Infirm, specifically for failure to properly label drugs by not dating opened insulin vials and failing to remove expired insulin pens and vials from medication carts.
Complaint Details
The complaint investigation (CI MS #21501) was for food palatability, adequate grooming, and temperature of water and cited no deficiencies related to the complaint.
Deficiencies (1)
| Description |
|---|
| Facility failed to date an opened insulin vial and failed to remove an expired insulin pen and insulin vial from medication carts for two of three medication carts reviewed. |
Report Facts
Medication carts reviewed: 3
Medication carts audited: 4
Audit frequency: 2
Audit duration: 8
Days insulin can be used after opening: 28
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Unit Manager | Confirmed nurses should date insulin when opened and discard after 28 days. |
| LPN #2 | Licensed Practical Nurse | Observed with undated insulin vial and acknowledged failure to discard undated insulin. |
| Director of Nurses | Director of Nursing (DON) | Confirmed insulin must be discarded after 28 days and nurses should date opened medication. |
| Director of Nursing Service | Director of Nursing Service (DNS) | Initiated in-service training on dating open insulin vials and removal of expired insulin pens and vials. |
Inspection Report
Annual Inspection
Census: 94
Capacity: 100
Deficiencies: 5
May 18, 2023
Visit Reason
The State Survey Agency conducted an annual re-certification and complaint investigation at the facility from 05/15/2023 through 05/18/2023. The complaint investigation was for food palatability, adequate grooming, and water temperature.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in advance directives, transfer notices, comprehensive care plans, behavioral health services, and medication labeling/storage.
Complaint Details
Complaint investigation MS #21501 was conducted for food palatability, adequate grooming, and temperature of water. No deficiencies were cited related to the complaint.
Severity Breakdown
SS=E: 2
SS=D: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to ensure residents without Advance Directives received information or assistance in formulating an Advance Directive for 10 of 10 residents reviewed. | SS=E |
| Failed to ensure written notification of transfer included the reason for transfer for 1 of 2 residents reviewed. | SS=D |
| Failed to develop and implement a comprehensive care plan including necessary behavioral health services per physician orders for 1 of 2 residents reviewed. | SS=D |
| Failed to provide necessary behavioral health services per physician orders for 1 of 2 residents reviewed. | SS=D |
| Failed to label and store drugs and biologicals properly, including failure to date opened insulin vials and removal of expired insulin pens and vials on medication carts for 2 of 3 carts reviewed. | SS=E |
Report Facts
Residents reviewed for Advance Directives: 10
Licensed bed capacity: 100
Current census: 94
Deficiencies cited: 5
Insulin vial expiration days: 28
Audit frequency: 10
Audit duration: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding advance directives process and documentation | |
| Admissions Coordinator | Interviewed regarding advance directives inquiry and documentation | |
| Executive Director | Interviewed regarding facility policy and documentation on advance directives | |
| Director of Nursing Service | DNS | Responsible for audits and corrective actions related to deficiencies |
| Business Manager | Interviewed regarding discharge/transfer notice process | |
| Director of Nurses | DON | Responsible for filling out discharge/transfer notices and care plan oversight |
| Licensed Practical Nurse #1 | LPN/Unit Manager | Interviewed regarding insulin labeling and care plan completion |
| Licensed Practical Nurse #2 | LPN | Observed medication cart and insulin labeling |
| Registered Nurse/Unit Manager | RN/Unit Manager | Interviewed regarding behavioral health services and resident behaviors |
| Certified Nurse Assistant #1 | CNA | Interviewed regarding resident behavior |
| Certified Nurse Assistant #2 | CNA | Interviewed regarding resident behavior |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding care plan completion |
Inspection Report
Annual Inspection
Deficiencies: 1
May 18, 2023
Visit Reason
The State Survey Agency conducted an annual re-certification and Complaint Investigation at the facility from 05/15/2023 through 05/18/2023. The complaint investigation was for food palatability, adequate grooming, and temperature of water.
Findings
No deficiencies were cited related to the complaint investigation. However, the facility was found not in compliance with Mississippi regulations for Minimum Standards for Institutions for the Aged or Infirm and was cited for M715.
Complaint Details
Complaint Investigation MS #21501 was investigated for food palatability, adequate grooming, and temperature of water and no deficiencies related to the complaint were cited.
Deficiencies (1)
| Description |
|---|
| Facility was not in compliance with Mississippi regulations for Minimum Standards for Institutions for the Aged or Infirm and cited M715. |
Inspection Report
Annual Inspection
Census: 94
Capacity: 100
Deficiencies: 5
May 18, 2023
Visit Reason
The State Survey Agency conducted an annual re-certification and Complaint Investigation at the facility from 05/15/2023 through 05/18/2023 to investigate complaints regarding food palatability, adequate grooming, and water temperature.
Findings
No deficiencies were cited related to the complaint investigation. However, the facility was found not in compliance with Medicare and Medicaid participation requirements and cited for deficiencies F578, F623, F656, F740, and F761.
Complaint Details
Complaint Investigation MS #21501 was conducted for food palatability, adequate grooming, and temperature of water; no deficiencies were cited related to the complaint.
Deficiencies (5)
| Description |
|---|
| Deficiency F578 cited |
| Deficiency F623 cited |
| Deficiency F656 cited |
| Deficiency F740 cited |
| Deficiency F761 cited |
Report Facts
Census: 94
Total licensed capacity: 100
Deficiencies cited: 5
Inspection Report
Life Safety
Deficiencies: 0
May 17, 2023
Visit Reason
The survey was conducted to assess 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 with no deficiencies cited during this survey.
Inspection Report
Deficiencies: 0
May 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 and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for four complaints related to Accidents/Falls, Resident Abuse, Quality of Care related to Facility Staffing, and Quality of Care related to resident grooming.
Findings
The survey determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies.
Complaint Details
The State Agency investigated complaints MS #20692 and MS #20484 for Accidents/Falls and Resident Abuse, MS #21012 for Quality of Care related to Facility Staffing, and MS #20480 for Quality of Care related to resident grooming and found no deficiencies.
Report Facts
Number of complaints investigated: 4
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 14, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for four complaints related to Accidents/Falls, Resident Abuse, Quality of Care related to Facility Staffing, and Quality of Care related to resident grooming.
Findings
The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies.
Complaint Details
The survey investigated complaints MS #20692 and MS #20484 for Accidents/Falls and Resident Abuse, MS #21012 for Quality of Care related to Facility Staffing, and MS #20480 for Quality of Care related to resident grooming, with no deficiencies cited.
Report Facts
Number of complaints investigated: 4
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 0
Mar 14, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for four complaints related to Accidents/Falls, Resident Abuse, Quality of Care related to Facility Staffing, and Quality of Care related to resident grooming.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation of the complaints.
Complaint Details
The survey investigated complaints MS #20692 and MS #20484 for Accidents/Falls and Resident Abuse, MS #21012 for Quality of Care related to Facility Staffing, and MS #20480 for Quality of Care related to resident grooming, with no deficiencies cited.
Report Facts
Number of complaints: 4
Licensed beds: 102
Resident census: 93
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 29, 2022
Visit Reason
The State Agency conducted a Complaint Investigation from 6/27/22 through 6/29/22 based on complaint numbers MS #18596, #18913, and #18816.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #18596, #18913, and #18816 was conducted and found no deficiencies; the facility was in compliance.
Inspection Report
Complaint Investigation
Census: 91
Capacity: 100
Deficiencies: 0
Jun 29, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 6/27/22 through 6/29/22 related to three complaint cases MS #18596, MS #18913, and MS #18816.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints were not substantiated and no deficiencies were cited.
Complaint Details
The State Agency did not substantiate MS #18596 and MS #18816 for abuse. The SA did not substantiate MS #18913 for Responsible Representative not notified of a resident's change in condition, physical abuse, or facility staffing.
Report Facts
Complaint cases investigated: 3
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 29, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 6/27/22 through 6/29/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 29, 2022
Visit Reason
The State Agency conducted a Complaint Investigation from 6/27/22 through 6/29/22 based on complaint numbers MS #18596, #18913, and #18816.
Findings
The facility was found to be in compliance with the Mississippi Regulations Minimum Standards for Institutions for the Aged or Infirm, and no deficiencies were cited.
Complaint Details
Complaint Investigation MS #18596, #18913, and #18816 was conducted and found no deficiencies; the facility was in compliance.
Report Facts
Complaint investigation dates: 3
Inspection Report
Complaint Investigation
Census: 91
Capacity: 100
Deficiencies: 0
Jun 29, 2022
Visit Reason
The State Agency conducted a complaint investigation at the facility from 6/27/22 through 6/29/22 related to multiple complaint numbers.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding abuse and failure to notify the responsible representative were not substantiated. No deficiencies were cited.
Complaint Details
The State Agency did not substantiate complaints MS #18596 and MS #18816 for abuse, nor MS #18913 for Responsible Representative not notified of a resident's change in condition, physical abuse, or facility staffing.
Report Facts
Licensed beds: 100
Census: 91
Inspection Report
Routine
Deficiencies: 0
Jun 29, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from 6/27/22 through 6/29/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 0
Dec 16, 2021
Visit Reason
The State Agency conducted a complaint investigation for MS #18031 at the facility on 12/16/2021.
Findings
The complaint for quality of care/treatment was not substantiated. 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.
Complaint Details
Complaint investigation for MS #18031 was conducted and the complaint was not substantiated.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 0
Dec 16, 2021
Visit Reason
The State Agency conducted a complaint investigation for MS #18031 at the facility on 12/16/2021.
Findings
The State Agency determined that the facility was in compliance with Medicare and Medicaid requirements, did not substantiate the complaint for Quality of Care and Rehabilitation Services, and cited no deficiencies.
Complaint Details
Complaint MS #18031 was not substantiated for Quality of Care and Rehabilitation Services.
Inspection Report
Complaint Investigation
Census: 93
Capacity: 102
Deficiencies: 0
Dec 16, 2021
Visit Reason
The State Agency conducted a complaint investigation for MS #18031 at the facility on 12/16/2021.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no deficiencies were cited.
Complaint Details
Complaint MS #18031 was investigated and not substantiated for Quality of Care and Rehabilitation Services.
Report Facts
Census: 93
Total licensed capacity: 102
Inspection Report
Complaint Investigation
Census: 80
Capacity: 100
Deficiencies: 1
Jun 10, 2021
Visit Reason
The State Agency conducted a complaint investigation related to an elopement incident where the facility failed to provide supervision to prevent Resident #1, diagnosed with Alzheimer's Disease and Dementia with Behavioral Disturbance, from leaving the facility unsupervised on 2021-05-31.
Findings
The facility was found non-compliant with state licensure requirements due to inadequate supervision leading to Resident #1's elopement. Resident #1 was located approximately 0.5 miles from the facility after being unsupervised for about 1 hour and 28 minutes. Corrective actions including in-services, elopement drills, wander guard checks, and audits were implemented and validated by the State Agency.
Complaint Details
The complaint investigation substantiated the facility's failure to prevent Resident #1's elopement on 5/31/2021. Immediate Jeopardy and Substandard Quality of Care were identified but later removed after corrective actions were implemented. The incident was reported to the State and Attorney General's office.
Severity Breakdown
Level IV: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 5/31/2021. | Level IV |
Report Facts
Time Resident #1 was unsupervised: 88
Distance Resident #1 was found from facility: 0.5
Census: 80
Total licensed beds: 100
Frequency of wander guard system testing: 14
Frequency of elopement alarm drills: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Held the door open allowing Resident #1 to exit unsupervised; suspended after the incident. | |
| Maintenance Staff #1 | Located Resident #1 approximately 0.5 miles from the facility and monitored her until RN #2 arrived. | |
| Registered Nurse (RN) #2 | Registered Nurse | Assisted Resident #1 back to the facility and assessed her with no adverse findings. |
| Licensed Practical Nurse (LPN) #1 | Licensed Practical Nurse | Called Dr. Wander and participated in search efforts; confirmed Dietary Aide #1's statement. |
| Administrator | Facility Administrator | Conducted investigation, reported incident to State and Attorney General, and led corrective actions. |
| Social Service Director | Updated Elopement Books and initiated elopement alarm drills. | |
| Director of Nursing (DON) | Director of Nursing | Participated in corrective actions and audits. |
| Staff Development Coordinator (SDC) | Initiated mandatory in-services on elopement prevention and supervision. | |
| Dietary Manager (DM) | Conducted in-service on importance of knowing residents and keeping them safe. | |
| Maintenance Supervisor | Initiated testing of the Wander Guard System and assisted with elopement drills. |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 100
Deficiencies: 1
Jun 10, 2021
Visit Reason
The State Agency conducted a complaint investigation related to an elopement incident where the facility failed to provide supervision to prevent Resident #1 from leaving the facility unsupervised on 5/31/2021.
Findings
The facility failed to provide adequate supervision to prevent Resident #1, diagnosed with Alzheimer's Disease and Dementia with Behavioral Disturbance, from eloping. Resident #1 exited the facility unnoticed and was found approximately 0.5 miles away. The facility implemented corrective actions including increased supervision, elopement drills, and staff in-services.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent Resident #1's elopement on 5/31/2021. Immediate Jeopardy and Substandard Quality of Care were identified but later removed after corrective actions were implemented.
Severity Breakdown
Scope/Severity "J": 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 5/31/2021. | Scope/Severity "J" |
Report Facts
Census: 80
Total Capacity: 100
Duration of Elopement: 88
Distance from Facility: 0.5
Time Resident Found: 7.26
Time Resident Left: 5.54
Frequency of Visual Checks: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide #1 | Held the door open allowing Resident #1 to exit the facility, implicated in the elopement incident | |
| Licensed Practical Nurse #1 | LPN | Called Dr. Wander and participated in search efforts |
| Registered Nurse #2 | RN | Located Resident #1 with Maintenance Staff and assessed Resident #1 upon return |
| Maintenance Staff #1 | Located Resident #1 approximately 0.5 miles from the facility and notified RN #2 | |
| Housekeeping Staff #1 | Participated in search for Resident #1 | |
| Administrator | Oversaw investigation, suspended Dietary Aide #1, and led corrective actions | |
| Director of Nursing | DON | Provided information on facility policies and observation practices |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 102
Deficiencies: 0
May 25, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #17580) on 5/25/21 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated for quality of care/treatment or staffing, and no deficiencies were cited.
Complaint Details
Complaint investigation CI MS #17580 was not substantiated for quality of care/treatment or staffing.
Inspection Report
Complaint Investigation
Census: 83
Capacity: 102
Deficiencies: 0
May 25, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #17580) on 5/25/21 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated for quality of care/treatment or staffing, and no deficiencies were cited.
Complaint Details
Complaint investigation CI MS #17580 was not substantiated for quality of care/treatment or staffing.
Report Facts
Census: 83
Total licensed capacity: 102
Inspection Report
Abbreviated Survey
Census: 84
Capacity: 102
Deficiencies: 0
Jan 21, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and COVID-19 preparedness.
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. Staffing complaints were substantiated with no deficiencies cited, and a neglect complaint was not substantiated.
Complaint Details
The survey substantiated complaints CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. Complaint CI MS #17109 for neglect was not substantiated.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 102
Deficiencies: 0
Jan 20, 2021
Visit Reason
The State Agency conducted a complaint investigation into CI MS #17033, CI MS #17109, and CI MS #17333 from 1/19/21 through 1/20/21.
Findings
The facility was found to be in compliance with the Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirm. The SA substantiated CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. CI MS #17109 was not substantiated for neglect.
Complaint Details
The complaint investigation substantiated CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. CI MS #17109 was not substantiated for neglect.
Report Facts
Census: 84
Total Capacity: 102
Inspection Report
Routine
Census: 84
Capacity: 102
Deficiencies: 0
Jan 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and CMS/CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations. The State Agency substantiated two complaints regarding staffing with no deficiencies cited and did not substantiate a neglect complaint.
Complaint Details
The State Agency substantiated CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. CI MS #17109 was not substantiated for neglect.
Report Facts
Census: 84
Total licensed capacity: 102
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 1/19/21 through 1/20/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 84
Capacity: 102
Deficiencies: 0
Jan 20, 2021
Visit Reason
The State Agency conducted a complaint investigation into CI MS #17033, CI MS #17109, and CI MS #17333 from 1/19/21 through 1/20/21.
Findings
The facility was found in compliance with the Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirm. The SA substantiated CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. CI MS #17109 was not substantiated for neglect.
Complaint Details
The complaint investigation substantiated CI MS #17333 and CI MS #17033 regarding staffing with no deficiencies cited. CI MS #17109 was not substantiated for neglect.
Report Facts
Census: 84
Total licensed capacity: 102
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jan 20, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 1/19/21 through 1/20/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Census: 91
Capacity: 102
Deficiencies: 0
May 26, 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
Census: 91
Capacity: 102
Deficiencies: 0
May 26, 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
Complaint Investigation
Deficiencies: 0
Sep 17, 2019
Visit Reason
A complaint investigation survey was conducted on 09-16-19 to 09-17-19 in the facility.
Findings
The complaints were unsubstantiated and no deficiencies were cited.
Complaint Details
Complaints were unsubstantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 17, 2019
Visit Reason
The State Agency conducted a complaint investigation for complaints MS 16106 and MS 16136 on 09/16/19 - 09/17/19.
Findings
The complaints were unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaints MS 16106 and MS 16136 were investigated and found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 17, 2019
Visit Reason
The State Agency conducted a complaint investigation based on complaints MS 16106 and MS 16136 on 09/16/19 - 09/17/19.
Findings
The complaints were unsubstantiated and no deficiencies were cited during the investigation.
Complaint Details
Complaints MS 16106 and MS 16136 were investigated and found to be unsubstantiated with no deficiencies cited.
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