Inspection Reports for
Coastal Health & Rehabilitation Center

CI MS#3047106 was investigated related to quality of care/treatment and hospital transfer. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigation MS #3047106 was related to quality of care/treatment and hospital transfer. The complaint was investigated and no deficiencies were cited.

The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS#26995 complaint investigation was reviewed and found to be corrected with no deficiencies cited.

The facility was found to be in compliance as of 06/16/26 following corrective measures. No deficiencies were cited in this desk review.

CI MS #2996239 was investigated related to accidents. The facility was found not in compliance and cited M640 for failure to analyze falls and implement interventions to reduce recurrence risk.

The facility was found not in compliance with state licensure requirements and cited M640 for failing to analyze falls and implement interventions to reduce the risk of recurrence for two residents. The facility did not identify root causes or develop interventions after falls for Resident #1 and Resident #2.

CI MS #2996239 was investigated related to accidents. Deficiencies were cited for failure to revise care plans and implement fall prevention interventions. The complaint was substantiated.

The facility was found not in compliance with Medicare and Medicaid requirements due to failure to revise care plans and implement interventions to prevent falls for two residents. The facility failed to update care plans and analyze falls to reduce risk of recurrence for Resident #1 and Resident #2.

Seven complaint investigations were conducted covering discharge planning, falls, staffing, residents left wet and soiled, nursing services, resident rights related to visitation, and supplies and improper incontinence care. The facility was found in compliance with no deficiencies cited.

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 2732360 was investigated related to nursing services, neglect, and quality of care. The complaint was not substantiated as no deficiencies were cited.

During the survey the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

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 9/10/25.

The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 9/10/25.

CI MS #2589973 was investigated for accidents, nursing services, physical environment, insufficient supplies, dietary issues, and weight loss. No deficiencies were cited during this investigation.

No deficiencies were cited during this survey. The facility remains out of compliance with state licensure requirements due to deficiencies cited on the 8/7/25 survey.

CI MS #2589973 was investigated related to accidents, nursing services, physical environment, insufficient supplies, dietary, insufficient foods, and weight loss. No deficiencies were cited during this survey.

No deficiencies were cited during this survey. The facility remains out of compliance due to deficiencies cited on the 8/7/25 survey.

The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.

The facility failed to maintain a safe, clean, and homelike environment due to inadequate pest control limited to common areas, persistent roach and gnat infestations, and insufficient linen supply causing care delays. Additionally, care plan interventions for incontinence and timely resident care were not consistently implemented.

The facility was found deficient in multiple areas including failure to honor resident meal preferences, unresolved resident council grievances, inadequate pest control, insufficient linen supply, improper use of physical restraints, failure to notify resident representatives of hospital transfers, incomplete PASRR evaluations, failure to implement care plans, medication errors, poor food quality and presentation, and ineffective quality assurance processes.

The facility was found not in compliance with multiple deficiencies including self-determination, resident/family group response, safe environment, right to be free from physical restraints, discharge process, PASARR screening, comprehensive care plan development and implementation, medication administration, ADL care, activities, food quality, food safety, QAPI activities, and pest control.

Two complaint investigations were conducted: CI MS #28643 for nursing services and CI MS #28830 for pressure sores, staffing, and discharge rights. The facility was found in compliance with no deficiencies cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint Investigations MS #28643 and MS #28830 were conducted; no deficiencies were cited and the facility was found in compliance.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint Investigations MS #27916, MS #28099, and MS #28135 were conducted related to resident safety, quality of care, nursing services, and resident rights. The facility was found in compliance with no deficiencies cited.

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 Investigations MS #27916, MS #28099, and MS #28135 were investigated for resident safety, quality of care, nursing services, and resident rights. The SA determined the facility was in compliance and no deficiencies were cited.

During the survey, the SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint investigations MS #27390 and MS #27474 were conducted related to abuse, dignity, quality of care, and safety. The facility was found in compliance with no deficiencies cited.

The surveyor 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 Investigation MS #27390 was related to abuse, dignity, and quality of care. Complaint Investigation MS #27474 was related to abuse, safety, and dignity. Both complaints were investigated and the facility was found in compliance with no deficiencies cited.

The surveyor determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited. The facility remains out of compliance due to deficiencies cited on the 11/26/24 survey.

CI MS #27245 was investigated related to responsible party not notified of resident change of condition, death, and quality of care. The SA determined the facility was in compliance with no deficiencies cited.

The surveyor determined the facility was in compliance with Medicare and Medicaid requirements during this investigation and no deficiencies were cited.

CI MS #27245 was investigated related to responsible party not notified of resident change of condition, death, and quality of care. The SA determined the facility was in compliance with no deficiencies cited.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited during this investigation.

Two complaint investigations were conducted: CI MS #27078 related to neglect, delay in treatment, and poor quality of care for failure to assess a resident for impaction, and CI MS #27005 related to poor quality of care for leaving a resident wet and sexual abuse. No citations were issued for CI MS #27005. Deficiencies were cited related to CI MS #27078.

The facility was found not in compliance with Medicare and Medicaid participation requirements related to CI MS #27078. The facility failed to protect a resident from neglect by not preventing fecal impaction leading to hospitalization and failed to implement and follow a comprehensive care plan and quality care standards for one resident. The facility also failed to notify the physician or medical director about the resident's impaction.

The complaint investigation found substantiated neglect when the facility failed to prevent fecal impaction for Resident #1, leading to hospitalization. Interviews with the resident's son, nursing staff, and review of records confirmed failure to notify the provider and inadequate documentation.

The facility failed to implement measures to prevent fecal impaction for Resident #1, resulting in hospitalization for dis-impaction and intravenous fluids. The care plan was not properly followed, and staff failed to notify the Nurse Practitioner or Medical Director about the resident's condition. Documentation of medication administration and impaction was missing prior to hospitalization.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 10/29/24.

The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 10/29/24.

Four complaint investigations were conducted: CI MS #26146 (dietary services, no deficiencies cited), CI MS #26246 (neglect and quality of care, deficiency F684 cited), CI MS #26268 (neglect, quality of care, pressure sores, deficiencies F686, F656, and F641 cited), and CI MS #26447 (quality of care, no deficiencies cited).

The facility was found not in compliance with Medicare and Medicaid requirements due to failures in accurate assessments, care plan implementation, quality of care, and pressure ulcer treatment for multiple residents. These failures resulted in wound infections, delayed treatments, and inconsistent wound documentation.

Complaint Investigations MS #26146, CI MS #26246, CI MS #26268, and CI MS #26447 were conducted. The complaints involved neglect, quality of care, pressure sores, and dietary services. Deficiency M615 was cited, indicating substantiated issues with pressure sore care.

The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with one deficiency cited. The facility failed to ensure consistent pressure ulcer care and treatment for three residents, resulting in one resident acquiring a wound infection with hospitalization.

The facility failed to accurately code Minimum Data Set (MDS) assessments, implement complete care plans, provide timely treatment according to physician orders, and ensure consistent pressure ulcer care and documentation. These failures resulted in actual harm, including wound infections and hospitalization for some residents.

Complaint Investigations MS #25851, MS #25857, and MS #25951 were conducted related to neglect, quality of care, abuse, and resident rights. The facility was found in compliance with no deficiencies cited.

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 investigations MS #25851, MS #25857, and MS #25951 were conducted related to neglect, quality of care, abuse, and resident rights. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Six complaint investigations were conducted covering multiple issues including resident rights, staffing, abuse, care quality, and a death. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigations MS #25236, MS #25240, MS #25261, MS #25330, MS #25386, and MS #25407 were conducted covering multiple allegations including resident rights, staffing, abuse, rehabilitation, hygiene, and a death. The facility was found in compliance with no deficiencies cited.

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 MS #24904 was investigated related to resident rights. The SA determined the facility was in compliance with no deficiencies cited.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

CI MS#24904 related to resident rights; the complaint was investigated and no deficiencies were cited.

The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid, and there were no deficiencies cited.

Complaint Investigation MS #23997 and MS #24453 were conducted regarding transfer, pressure sores, residents left soiled, body odor, and pressure sores. The facility was found in compliance with no deficiencies cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.

Complaint Investigation MS #23997 and MS #24453 regarding transfer, pressure sores, resident left soiled, body odor, and pressure sores; the complaints were investigated and no deficiencies were cited.

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.

The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 12/8/23.

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 12/8/23.

CI MS#23418 was investigated related to misappropriation of property. No deficiencies were cited during the survey.

No deficiencies were cited during the survey; however, the facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 11/15/23 survey.

Complaint number CI MS #23418 was investigated related to misappropriation of property. No deficiencies were cited during this survey.

No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance due to deficiencies cited during the 11/15/23 survey.

The facility was found not in compliance with state licensure requirements, citing deficiencies in residents' rights, activities of daily living, and safe food handling procedures. Issues included failure to honor residents' choices regarding wound care timing and food grievances, inadequate nail care and bathing for residents, and unsafe food storage and sanitation practices in the dietary department.

The facility was found deficient in multiple areas including failure to honor resident rights regarding wound care timing, failure to promptly resolve food grievances, failure to notify residents and representatives of hospital transfers and bed hold policies, inaccurate PASRR screening, incomplete care plans for several residents, failure to provide adequate activities of daily living care, failure to provide appropriate incontinent care, failure to administer pain medication as ordered, lack of RN coverage for at least 8 hours on one day, and unsanitary conditions in the dietary department.

The facility was found not in compliance with multiple requirements including resident rights, grievance resolution, transfer notifications, care planning, pain management, staffing, and food safety. Deficiencies were cited for failure to honor resident choices, resolve grievances timely, notify residents of hospital transfers and bed hold policies, complete PASRR screenings, develop and implement care plans, provide pain medication as ordered, maintain RN coverage, and maintain sanitary food service.

The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

Three complaint investigations (CI MS #22886, CI MS #22941, and CI MS #22942) were conducted related to neglect and abuse. The facility was found in compliance with no deficiencies cited.

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.

Three complaint investigations were conducted: CI MS #22886 related to neglect and abuse, CI MS #22941 related to neglect, and CI MS #22942 related to neglect. The facility was found in compliance with no deficiencies cited.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigation MS #22300 and MS #22594 were investigated relating to neglect, staffing, pressure sores, and residents left wet and soiled. No deficiencies were cited.

The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.

Complaint Investigation MS #22300 was related to neglect and MS #22594 was related to staffing, pressure sores, and residents left wet and soiled. The facility was found in compliance and no deficiencies were cited.

During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.

Complaint investigations MS #21900 for neglect and MS #21901 for grooming and staffing were conducted and found no deficiencies; the facility was in compliance.

During the survey, the SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and there were no deficiencies cited.

Complaint investigations MS #21900 for neglect and MS #21901 for grooming and staffing were conducted and no deficiencies were cited.

The SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.

Complaint number CI MS#21518 investigated for verbal abuse; no deficiencies cited and complaint was not substantiated.

The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint MS #21518 involved an allegation of verbal abuse and was investigated by the State Agency. The complaint was not substantiated and no deficiencies were cited.

The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.

The SA 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 3/28/23.

CI MS #21035 was investigated for Resident Abuse and was not substantiated; no deficiencies were cited.

The facility was found in compliance with Medicare and Medicaid requirements during this complaint investigation. No deficiencies were cited related to CI MS #21035, but the facility remains out of compliance due to deficiencies cited on the 3/6/2023 survey.

CI MS #20555 for falls, resident safety, and incontinent care; CI MS #20778 for nursing services and environment; CI MS #20860 for resident assessment, call lights, dignity/respect; CI MS #20893 for pressure sores; CI MS #20896 for environment, services, infection control, misappropriation, dietary services, grooming. Deficiencies were cited related to pressure sores and accidents.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm, citing multiple deficiencies including pressure sore care, accidents, and supervision. An Immediate Jeopardy was identified related to a resident's foot injury caused by a faulty bed and unsafe use of a mechanical lift. The facility failed to provide consistent wound care and assessments for several residents, putting them at risk for serious harm.

The complaint investigation was triggered by observations of unsafe mechanical lift use and inadequate wound care, including a resident with a foot injury caused by a broken bed and multiple residents with untreated pressure ulcers. The investigation identified immediate jeopardy conditions related to these issues.

The facility failed to implement care plan interventions for mechanical lift use and pressure ulcer treatments, failed to assess and treat bleeding in a timely manner for a resident on anticoagulants, and failed to maintain safe equipment such as beds and mechanical lifts. These failures placed residents at immediate jeopardy of serious harm. The facility provided removal plans and education to staff, and the immediate jeopardy was removed prior to exit.

Complaint Investigations CI MS #20254 related to pressure sore precautions and services not performed per Physician Orders, and CI MS #19719 related to an anonymous allegation of illegal drug activity by facility staff were both not substantiated.

The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited.

Complaint Investigation MS #20254 related to pressure sore precautions and services not performed per Physician Orders was not substantiated. Complaint MS #19719 related to an anonymous allegation of illegal drug activity by facility staff was not substantiated.

The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. No deficiencies were cited.

Complaint survey completed on 08/31/22 was reviewed and the facility was found in compliance; no deficiencies cited.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. No deficiencies were cited.

CI MS #19518 was not substantiated for failure to administer pain medication. Deficiency was cited for failure to maintain complete and accurate medical records related to medications.

The facility was found not in compliance due to failure to maintain complete and accurate medical records related to medications for one sampled resident. The facility failed to document administration of pain medication on the electronic Medication Administration Record (eMAR) despite documentation on the narcotic sheet.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

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 6/2/22.

Complaint number CI MS #18978 was investigated regarding facility staffing and physician services; the complaint was not substantiated and no deficiencies were cited.

The facility was found to have no deficiencies related to the complaint investigation conducted on 6/15/22. The facility remains out of compliance due to deficiencies cited on the 4/19/22 survey.

Complaint number CI MS#18978 was investigated regarding facility staffing and physician services and was not substantiated; no deficiencies were cited.

The facility was found to have no deficiencies related to the complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 4/19/22 survey.

Complaint Investigation (CI), MS #18699, MS #18632, MS #18707 and MS #18714. The facility was found not in compliance and cited M610.

M610 - The facility failed to provide adequate Activities of Daily Living (ADL) care, including nail care and hair care, for two of seven sampled residents. Resident #5 had long, jagged fingernails despite family requests for trimming, and Resident #7 had extremely matted hair that staff were unable to comb or brush.

Complaint Investigation (CI) for MS #18699, MS #18632, MS #18707, and MS #18714. MS #18699 was substantiated for failure to report allegations of abuse. MS #18707 was substantiated for unclean resident room and inadequate grooming. MS #18632 and MS #18714 were not substantiated.

The facility was found not in compliance due to failure to maintain a clean and homelike environment, failure to report allegations of abuse timely, and failure to provide adequate grooming for dependent residents.

Complaint Investigation (CI), MS #18308, MS #18376, and MS #18501 were not substantiated and no deficiencies were cited.

The complaints were not substantiated and the facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited during the survey.

Three complaint investigations were conducted: CI #MS 18308 regarding falls, misappropriation of property including a lost phone, and unnecessary medications causing oversedation; CI #MS 18376 regarding misappropriation of property, unclean bathrooms and resident rooms, dirty bed linens, lack of baths, unanswered call lights, care not given per physician orders including therapy, and residents left soiled/wet; CI #MS 18501 regarding inadequate grooming, residents left wet, insects in rooms, dirty linens and bathrooms, and equipment maintenance. None were substantiated.

The SSA determined the facility was in compliance with Medicare and Medicaid requirements. There were no deficiencies cited by the SSA.

Two complaints (CI MS #18235 and CI MS #18229) were investigated and not substantiated.

The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation (CI MS #18235) and (CI MS #18229) for neglect, quality of care, physical environment, and abuse allegations were not substantiated.

During the survey, the SA did not substantiate the complaints and found the facility in compliance.

The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).

The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

The facility was found to be in substantial compliance with no deficiencies cited during this revisit.

The SA substantiated complaint CI MS #17576 for leaving residents soiled for extended periods and cited F0600. Complaints CI MS #17647 (misappropriation), CI MS #17682 (unqualified personnel), CI MS #17673 (failing to provide appropriate wound care), and CI MS #17635 (medical records and staffing) were not substantiated and had no citations.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to neglect in providing personal hygiene and bathing care to residents, substantiating one complaint for leaving residents soiled for extended periods.

The SA substantiated CI MS #17576 for leaving residents soiled for extended period of time and cited F0600. The SA did not substantiate CI MS #17647 for misappropriation, CI MS #17682 for unqualified personnel, CI MS #17673 for failing to provide appropriate wound care, and CI MS #17635 for medical records and staffing with no citations related to the complaint.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for abuse and neglect, foot care, food safety, social worker qualifications, and infection prevention and control.

The facility was found deficient in providing adequate personal hygiene and abuse prevention for residents unable to perform ADLs, appropriate foot care for diabetic and non-diabetic residents, safe food handling practices, employment of a qualified social worker, and infection prevention and control practices including proper wound care, oxygen therapy equipment handling, and perineal care.

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.

The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.

Complaint Investigation CI #17200 was substantiated for verbal abuse. CI #17266 and CI #17194 were not substantiated for quality of care. The facility was cited for the verbal abuse incident involving Resident #1.

The facility was cited for failing to ensure Resident #1 was free from verbal abuse by Patient Care Assistant (PCA) #1. The facility took corrective actions including suspension and termination of PCA #1 and staff in-service on abuse prevention.

No new observations related to infection control were noted during this survey; however, the facility remains out of compliance based on deficiencies cited during the 12/10/2020 survey.

Three complaint investigations were conducted: CI MS #17266 and CI MS #17194 were not substantiated for quality of care. CI MS #17200 was substantiated for verbal abuse and deficiencies were cited.

The facility was found in compliance with infection control regulations but was cited for verbal abuse and failure to follow the care plan for one resident. The facility failed to ensure Resident #1 was free from verbal abuse by PCA #1 and failed to follow the comprehensive care plan to meet Resident #1's needs.

Complaint Investigation CI #17200 was substantiated for verbal abuse. CI #17266 and CI #17194 were not substantiated for quality of care. The facility was cited for the substantiated complaint.

The facility was found not in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements, due to substantiated verbal abuse by Patient Care Assistant (PCA) #1 against Resident #1.

The facility was found to be in compliance with Medicaid and Medicare requirements for 42 CFR 483.73 related to E-0024 (b)(6).

CI MS#17019 involved allegations of abuse of Resident #1. The complaint was substantiated by the State Agency, which found the facility not in substantial compliance and cited deficiencies related to abuse and failure to notify the resident representative.

The facility failed to ensure Resident #1 was free from physical abuse and failed to notify the resident representative timely. The complaint was substantiated and deficiencies were cited at F0550, F0600, and F0609.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

Complaint investigation CI MS#26995 was conducted on 7/13/2020. Deficiencies were cited during that investigation, resulting in the facility remaining out of compliance.

The facility was found out of compliance based on deficiencies cited during the complaint investigation conducted on 7/13/2020. No new deficiencies were noted during this COVID-19 focused infection control survey.

Complaint investigation CI MS #16894 was conducted; deficiencies were cited and the facility was found out of compliance based on this investigation.

No new observations related to the infection control survey were noted; however, the facility remains out of compliance based on deficiencies cited during the complaint investigation.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

CI MS #16894: The complaint alleged that Resident #1 was discharged with someone else's medication. The complaint was substantiated with deficiencies cited.

M640 - The facility failed to ensure Resident #1 was discharged home with her own home medications, resulting in Resident #1 receiving medications belonging to other residents. The facility lacked a policy on home medications and failed to properly check and reconcile medications upon discharge.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.

CI MS #16554 and CI MS #16569 complaint investigations were unsubstantiated with no deficiencies cited.

The investigations were unsubstantiated with no deficiencies cited. The facility was determined to be in compliance with Medicare and Medicaid requirements for participation.

CI MS #16520: Complaint investigation regarding Quality of Care, Misappropriation of Medication, Dietary Services, Staffing, and Environmental issues was unsubstantiated with no deficiencies cited.

The investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.

CI MS #16281: Quality of Care complaint investigation was unsubstantiated with no deficiencies cited.

The facility was found in compliance with Medicare and Medicaid requirements for participation with no deficiencies cited.

Complaint Investigation (CI) MS #15951 was substantiated related to failure to prevent the development of a pressure ulcer for Resident #3. The SA determined the facility was not in compliance and cited deficiencies F656 and F686. CI MS #16039 regarding timely administration of pain medications was not substantiated and no deficiencies were cited.

The facility failed to implement Resident #3's care plan for high risk of skin impairment by not performing weekly body audits to monitor and prevent pressure ulcers. Resident #3 developed an unstageable sacral pressure ulcer requiring hospitalization and wound debridement. The facility was found not in compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Minimum Standards for the Aged and Infirm, citing deficiencies related to pressure sore care and urinary incontinence care.