Inspection Reports for Compere‘s Nursing Home
865 North St, Jackson, MS 39202, United States, MS, 39202
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 6, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-07-02 to verify 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 2025-08-01.
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 2, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation (CI MS #29043) at the facility from 2025-06-30 through 2025-07-02 to investigate resident neglect, medications, and quality of care.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, resulting in citations for failure to provide necessary assistance with activities of daily living for one resident and failure to maintain food safety standards related to expired, undated, unlabeled, and unsanitary food handling practices.
Complaint Details
The complaint investigation MS #29043 was related to resident neglect, medications, and quality of care; no citations were issued related to the complaint.
Severity Breakdown
Level II: 1
Level II Widespread: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene for one of eighteen sampled residents (Resident #34). | Level II |
| Failure to maintain food quality in accordance with professional standards for food safety related to overly ripe produce, exposed foods, undated and unlabeled foods, expired foods, and unsanitary meal preparation for two of three days of survey. | Level II Widespread |
Report Facts
Sampled residents: 18
Days of survey: 3
Expired produce items: 2
Overly ripe bananas: 19
Bottles of dry seasoning with open lids: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in grooming deficiency related to Resident #34 |
| Director of Nursing | Director of Nursing | Interviewed regarding CNA responsibilities for grooming |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Educated CNA #1 on proper ADL care |
| Dietary Manager | Certified Dietary Manager | Named in food safety deficiencies and responsible for food quality and safety |
| Cook #1 | Cook | Observed and interviewed regarding unsanitary food preparation practices |
| Cook #2 | Cook | Observed and interviewed regarding unsanitary food preparation practices |
| Administrator | Administrator | Interviewed regarding awareness and expectations for food safety |
Inspection Report
Annual Inspection
Census: 56
Capacity: 60
Deficiencies: 3
Jul 2, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to resident neglect, medications, and quality of care at the facility from 06/30/2025 through 07/02/2025.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in assessment accuracy, ADL care for dependent residents, and food procurement and sanitation. The complaint investigation found no citations related to the complaint.
Complaint Details
The complaint investigation (CI MS #29043) focused on resident neglect, medications, and quality of care, and no citations were issued related to the complaint.
Severity Breakdown
SS=E: 1
SS=D: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| The facility failed to accurately code the Minimum Data Set (MDS) assessments for anticoagulant and hypnotic medications for six residents, resulting in incorrect reporting. | SS=E |
| The facility failed to ensure a resident unable to carry out activities of daily living received necessary grooming and personal hygiene care, specifically facial hair trimming for Resident #34. | SS=D |
| The facility failed to maintain food quality and safety, including issues with overly ripe produce, exposed foods, undated and unlabeled foods, expired foods, and unsanitary meal preparation practices. | SS=F |
Report Facts
Census: 56
Total licensed capacity: 60
Number of MDS assessments reviewed: 18
Residents with inaccurate MDS coding: 6
Residents sampled for ADL care: 18
Days of survey: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Completed Section N of MDS and acknowledged errors in medication coding |
| Director of Nursing | Director of Nursing (DON) | In-serviced MDS nurse on proper coding and confirmed expectations for accurate MDS coding; also responsible for monitoring ADL care and staff education |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Assigned to Resident #34 and educated on proper ADL care after failure to provide facial hair grooming |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Responsible for food quality and safety; acknowledged food safety deficiencies and planned additional training and monitoring |
| Cook #1 | Cook | Observed engaging in unsanitary food preparation practices and received in-service training |
| Cook #2 | Cook | Observed engaging in unsanitary food preparation practices and received in-service training |
| Administrator | Facility Administrator | Acknowledged awareness of deficiencies and responsibility expectations for food safety |
Inspection Report
Annual Inspection
Census: 56
Capacity: 60
Deficiencies: 3
Jul 2, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation at the facility from 06/30/2025 through 07/02/2025 to assess compliance with Medicare and Medicaid participation requirements and investigate allegations of resident neglect, medications, and quality of care.
Findings
The complaint investigation found no citations related to the complaint. However, during the annual recertification survey, the facility was found non-compliant with Medicare and Medicaid participation requirements, citing deficiencies in accuracy of assessments, ADL care for dependent residents, and food procurement and sanitary practices.
Complaint Details
Complaint Investigation MS #29043 was conducted for resident neglect, medications, and quality of care; no citations were related to the complaint.
Severity Breakdown
SS=E: 1
SS=D: 1
SS=F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set (MDS) for anticoagulant and hypnotic medications for six residents, resulting in incorrect assessments. | SS=E |
| Facility failed to ensure a resident unable to carry out activities of daily living received necessary grooming and personal hygiene care, specifically facial hair trimming for Resident #34. | SS=D |
| Facility failed to maintain food quality and safety standards, including presence of overly ripe produce, exposed, undated, unlabeled, and expired foods, and unsanitary meal preparation practices. | SS=F |
Report Facts
Residents with inaccurate MDS assessments: 6
Sampled residents: 18
Residents observed for facial hair grooming: 1
Days of survey with food safety issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Completed Section N of MDS for medications and acknowledged errors in coding |
| Director of Nursing | Director of Nursing (DON) | In-serviced MDS nurse on proper coding and monitored MDS accuracy; confirmed responsibility for ADL care and acknowledged lack of triple-check system |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Assigned to Resident #34 and educated on proper ADL care after failure to trim facial hair |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Responsible for food quality and safety; acknowledged expired and unlabeled foods and unsanitary practices |
| Cook #1 | Cook | Observed using unsanitary food preparation practices and received in-service on cross-contamination |
| Cook #2 | Cook | Observed using soapy towel on resident's plate and received in-service on cross-contamination |
| Administrator | Administrator | Acknowledged awareness of deficiencies and responsibility for food safety oversight |
Inspection Report
Annual Inspection
Deficiencies: 2
Jul 2, 2025
Visit Reason
The State Agency conducted an annual recertification survey combined with a complaint investigation for resident neglect, medications, and quality of care at the facility from June 30, 2025 through July 2, 2025.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in activities of daily living care for one resident and unsafe food handling procedures including expired, undated, and improperly stored foods, as well as unsanitary meal preparation practices.
Complaint Details
Complaint Investigation MS #29043 was conducted for resident neglect, medications, and quality of care; no citations were related to the complaint.
Severity Breakdown
Level II: 1
Level II Widespread: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure a resident unable to carry out activities of daily living received necessary grooming and personal hygiene care, specifically facial hair trimming for Resident #34. | Level II |
| Failure to maintain food quality and safety related to overly ripe produce, exposed foods, undated and unlabeled foods, expired foods, and unsanitary meal preparation practices observed over two of three survey days. | Level II Widespread |
Report Facts
Sampled residents: 18
Residents affected: 1
Survey days: 3
Days with food safety deficiencies: 2
Overly ripe bananas: 19
Bottles of dry seasoning with open lids: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Assigned to Resident #34 and acknowledged failure to provide proper grooming care |
| Director of Nursing | Director of Nursing | Stated CNA responsibility for facial hair trimming and conducted resident observations |
| Certified Dietary Manager | Certified Dietary Manager | Responsible for food quality and safety; acknowledged deficiencies and planned in-service training |
| Cook #1 | Cook | Observed engaging in unsanitary food preparation practices |
| Cook #2 | Cook | Acknowledged use of soapy towel on resident's plate during food preparation |
| Administrator | Administrator | Acknowledged awareness of food safety issues and responsibility expectations |
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 2, 2025
Visit Reason
The visit was related to the annual survey conducted on 07/02/2025 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The State Agency conducted a desk review on 08/06/2025 of information provided by the facility confirming corrective measures were implemented to address deficiencies found during the annual survey. The facility was recommended to be placed back in compliance effective 08/01/2025.
Report Facts
Survey completion date: Aug 6, 2025
Annual survey date: Jul 2, 2025
Inspection Report
Life Safety
Deficiencies: 0
Jul 1, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements and the Life Safety Code provisions.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements and complied with the 2012 Edition of the Life Safety Code. No deficiencies were cited during this survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 17, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #28152, related to resident rights and quality of care 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. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #28152 was related to resident rights and quality of care and was found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 56
Capacity: 60
Deficiencies: 0
Apr 17, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #28152, related to resident rights and quality of care at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #28152 was related to resident rights and quality of care and was found to be unsubstantiated with no deficiencies cited.
Report Facts
Licensed beds: 60
Resident census: 56
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 19, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-11 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 facility was recommended to be placed back in compliance effective 2024-02-16.
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 19, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-11 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-02-16.
Report Facts
Annual survey completion date: Jan 11, 2024
Inspection Report
Plan of Correction
Deficiencies: 0
Feb 19, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-11 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance based on the information provided, and the State Agency recommended the facility be placed back in compliance effective 2024-02-16.
Inspection Report
Annual Inspection
Deficiencies: 0
Feb 19, 2024
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2024-01-11 to verify corrective measures and compliance with Medicare and Medicaid requirements.
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 2024-02-16.
Inspection Report
Annual Inspection
Deficiencies: 1
Jan 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey combined with a complaint investigation regarding dietary services and environment at the facility from 2023-01-08 through 2023-01-11.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, specifically failing to honor residents' rights by not ensuring Resident #13 was allowed to get out of bed and leave her room daily as she desired. Interviews and observations confirmed the resident was often left in bed despite requests to get up, violating her rights.
Complaint Details
Complaint Investigation MS #23785 was conducted related to dietary services and environment, including bathing dependent residents in a cold shower room.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to honor residents' rights or choices, evidenced by Resident #13 having to remain in her room despite her request to get up and interact with other residents. | Level II |
Report Facts
Number of sampled residents: 15
BIMS score: 6
Dates of survey: 2023-01-08 to 2023-01-11
Date of plan of correction completion: Feb 16, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Interviewed regarding Resident #13's care and stated resident was taken out of room every other day |
| Registered Nurse #1 | RN | Interviewed and stated CNAs must get all residents out of rooms daily unless acuity forbids |
| Activities Director | Activities Director | Interviewed about resident activity participation and notification procedures |
| Director of Nursing | DON | Interviewed about resident rights and documentation of refusals to get up |
| Administrator | Administrator | Interviewed about staff expectations to encourage residents to get up daily |
Inspection Report
Annual Inspection
Census: 50
Capacity: 60
Deficiencies: 3
Jan 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey and complaint investigation at the facility from 1/08/2024 through 1/11/2024. The complaint investigation was related to dietary services and environment.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies related to resident self-determination, safe and comfortable environment, and psychotropic medication use. Specific issues included failure to honor resident rights to get out of their rooms daily, shower room temperature being uncomfortably cold for residents, and improper management of PRN psychotropic medications.
Complaint Details
Complaint Investigation (CI MS #23785) was conducted related to dietary services and environment, specifically citing bathing dependent residents in a cold shower room.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to honor residents' rights or choices, evidenced by a resident having to remain in her room despite her request to get up and interact with others. | SS=D |
| Failure to ensure the shower room was at a comfortable temperature while providing showers for three residents. | SS=D |
| Failure to ensure PRN psychotropic medications were discontinued or limited to a 14 day duration without adequate clinical rationale for continued use for one resident. | SS=D |
Report Facts
Licensed beds: 60
Resident census: 50
Deficiency count: 3
PRN Klonopin doses: 3
PRN Klonopin doses: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Provided information about Resident #42's behavior and medication compliance |
| Certified Nurse Aide #2 | CNA | Provided information about Resident #42's cooperation with care |
| Director of Nursing | DON | Provided multiple interviews regarding resident rights, shower room temperature, and psychotropic medication management |
| Administrator | Facility Administrator | Provided interviews regarding staff expectations and regulatory compliance |
| Maintenance Director | Maintenance Director | Confirmed heater issues and repairs in shower room |
| Activities Director | Activities Director | Discussed resident activity participation and communication with staff |
| Pharmacy Consultant | Pharmacy Consultant | Discussed psychotropic medication monitoring and regulatory compliance |
| Advanced Registered Nurse Practitioner | APRN | Discussed understanding of psychotropic medication regulations |
Inspection Report
Life Safety
Deficiencies: 0
Jan 11, 2024
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 Life Safety Code with no deficiencies cited during this survey.
Inspection Report
Deficiencies: 0
Jan 11, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements and no deficiencies were cited.
Inspection Report
Annual Inspection
Census: 50
Capacity: 60
Deficiencies: 1
Jan 11, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to dietary services and environment from 1/08/23 through 1/11/23.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies including failure to maintain a comfortable shower room temperature for dependent residents. Three residents were observed and reported discomfort due to cold shower room conditions, and staff were unaware or had not addressed the heater malfunction.
Complaint Details
Complaint Investigation (CI MS #23785) was conducted for dietary services and environment, specifically citing bathing dependent residents in a cold shower room.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure the shower room was at a comfortable temperature while providing showers for three sampled residents. | SS=D |
Report Facts
Licensed beds: 60
Resident census: 50
Sampled residents with shower room temperature issues: 3
Plan of correction completion date: 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | In-serviced nursing staff and shower team on ensuring shower room temperature is comfortable; involved in plan of correction. |
| Maintenance Director | Maintenance Director | Repaired heater knob, added wall thermometer, responsible for heater maintenance and temperature monitoring. |
| Administrator | Administrator | Unaware of heater issues prior to survey; acknowledged staff knowledge of thermostat regulation. |
| CNA #1 | Certified Nursing Assistant | Bathed Resident #9; reported heater in shower room not working since employment. |
| CNA #2 | Certified Nursing Assistant | Bathed Resident #23; confirmed heater not working for over a year. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 18, 2023
Visit Reason
The State Agency conducted a Complaint Investigation for Quality of Care/Treatment related to medication administration and answering call lights, and Resident Abuse related to verbal abuse at the facility.
Findings
During the survey, 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
Complaint Investigation MS #21460 for Quality of Care/Treatment related to medication administration and answering call lights, and Resident Abuse related to verbal abuse. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 53
Capacity: 60
Deficiencies: 0
Jul 18, 2023
Visit Reason
The State Agency conducted a Complaint Investigation for Quality of Care/Treatment related to medication administration and answering call lights, and Resident Abuse related to verbal abuse 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 (CI MS #21460) for Quality of Care/Treatment related to medication administration and answering call lights, and Resident Abuse related to verbal abuse. The complaint was not substantiated as no deficiencies were cited.
Report Facts
Licensed beds: 60
Resident census: 53
Inspection Report
Annual Inspection
Deficiencies: 2
Jan 11, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation related to dietary services and environment at the facility from 2023-01-08 through 2023-01-11.
Findings
The survey found the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, citing issues related to bathing dependent residents in a cold shower room and other deficiencies.
Complaint Details
Complaint Investigation MS #23785 was conducted related to dietary services and environment.
Deficiencies (2)
| Description |
|---|
| Bathing dependent residents in a cold shower room |
| Non-compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirement |
Inspection Report
Deficiencies: 1
Jan 9, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 01/02/2023 to 01/08/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Jan 9, 2023
Visit Reason
The facility was inspected due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network as required by regulation.
Findings
The facility failed to report complete COVID-19 data to the CDC's NHSN during the seven-day period from 01/02/2023 to 01/08/2023, which has the potential to cause more than minimal harm to all residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 30, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey that was done on 07/20/22.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 30, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 07/20/22 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 08/15/22.
Report Facts
Annual survey completion date: Jul 20, 2022
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 20, 2022
Visit Reason
The State Agency conducted an annual recertification and a Complaint Investigation at the facility from 7/17/22 to 7/20/22.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited and the complaints related to a resident death and neglect were not substantiated.
Complaint Details
The complaint investigations MS #18704 related to a resident death and MS #19112 related to neglect and poor quality of care were not substantiated.
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 2
Jul 20, 2022
Visit Reason
The State Agency conducted an annual recertification and a Complaint Investigation at the facility from 7/17/22 to 7/20/22 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements related to notice before transfer/discharge and PASARR screening. The complaint investigations related to a resident death and neglect were not substantiated. Deficiencies were cited related to the annual recertification survey.
Complaint Details
Complaint investigations MS #18704 related to a resident death and MS #19112 related to neglect and poor quality of care were not substantiated.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to notify the Resident Representative in writing the reason for a transfer to an acute care hospital for Resident #35. | SS=D |
| Facility failed to conduct a Level I Pre-Admission Screening (PASARR) prior to admission for five residents (#3, #5, #12, #22, and #25). | SS=D |
Report Facts
Licensed beds: 60
Census: 59
Number of residents without PASARR screening: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 20, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey that was done on 07/20/22.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 2
Jul 20, 2022
Visit Reason
The State Agency conducted an annual recertification and a Complaint Investigation at the facility from 2022-07-17 to 2022-07-20 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. The complaint investigations related to a resident death and neglect were not substantiated. Deficiencies were cited related to the annual recertification survey.
Complaint Details
Complaint investigations MS #18704 related to a resident death and MS #19112 related to neglect and poor quality of care were not substantiated.
Deficiencies (2)
| Description |
|---|
| Deficiency F623 related to the annual recertification survey |
| Deficiency F645 related to the annual recertification survey |
Report Facts
Licensed beds: 60
Census: 59
Inspection Report
Annual Inspection
Deficiencies: 0
Jul 20, 2022
Visit Reason
The State Agency conducted an annual recertification and a Complaint Investigation at the facility from 7/17/22 to 7/20/22.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited and the complaints related to a resident death and neglect were not substantiated.
Complaint Details
The complaint investigations MS #18704 related to a resident death and MS #19112 related to neglect and poor quality of care were not substantiated.
Inspection Report
Life Safety
Deficiencies: 0
Jul 18, 2022
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, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Jul 18, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 19, 2021
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a seven-day period between 04/12/2021 and 04/18/2021 as required by regulation, potentially causing more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Apr 12, 2021
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the CDC's NHSN during a seven-day period from 04/05/2021 to 04/11/2021, which has the potential to cause more than minimal harm to residents.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period. | SS=F |
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 52
Capacity: 60
Deficiencies: 0
Aug 5, 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.
Report Facts
Census: 52
Total licensed capacity: 60
Inspection Report
Routine
Census: 52
Capacity: 60
Deficiencies: 0
Aug 5, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/5/20 to assess the facility's compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 56
Capacity: 60
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
Routine
Census: 56
Capacity: 60
Deficiencies: 0
May 26, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/26/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 3
Feb 27, 2020
Visit Reason
The State Agency conducted an annual recertification survey from February 25, 2020 through February 27, 2020 to determine compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to accuracy of assessments, coordination of PASARR and assessments, and qualified dietary staff. No life safety code deficiencies were cited during the survey.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to accurately code the Minimum Data Set related to a diagnosis of Psychosis for one resident. | SS=D |
| Facility failed to refer a resident for a Level II PASARR screening related to a new psychiatric diagnosis change. | SS=D |
| Facility failed to employ a qualified professional related to the Dietary Manager position. | SS=D |
Report Facts
Census: 59
Total Capacity: 60
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Minimum Data Set Nurse | Interviewed regarding inaccurate coding of diagnosis in MDS assessment |
| Director of Nursing | Director of Nursing | Signed facility statements, confirmed diagnosis legitimacy, and involved in staff in-service and corrective actions |
| Dietary Manager | Dietary Manager | Interviewed regarding qualifications and certification status |
| Administrator | Administrator | Interviewed regarding hiring efforts for Certified Dietary Manager and oversight responsibilities |
Inspection Report
Annual Inspection
Census: 59
Capacity: 60
Deficiencies: 1
Feb 27, 2020
Visit Reason
The State Agency conducted an annual recertification survey from February 25, 2020 through February 27, 2020 to assess compliance with the Minimum Standards of Institutions for the Aged or Infirm.
Findings
The facility was found not in compliance due to failure to employ a qualified professional for the Dietary Manager position. The current Food Service Manager lacked certification but received monthly consultations from a Registered Dietitian. Efforts to hire a certified dietary manager were ongoing.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to employ a qualified professional related to the Dietary Manager position. | Level II |
Report Facts
Census: 59
Total Capacity: 60
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