Inspection Reports for
Compere‘s Nursing Home

865 North St, Jackson, MS 39202, United States, MS, 39202

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35 Reports

2020–2026

Inspection Report — Jul 28, 2026

Follow-Up
Date: Jul 28, 2026

Visit Reason
The State Agency conducted a follow-up revisit at the facility from 7/27/26 through 7/28/26 related to an annual recertification survey that was conducted from 6/08/26 through 6/11/26.

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 7/20/28.

Report Facts
Deficiencies cited: 0

Inspection Report — Jul 28, 2026

Follow-Up
Date: Jul 28, 2026

Visit Reason
The State Agency conducted a follow-up revisit at the facility from 7/27/26 through 7/28/26 related to an annual recertification survey that was conducted 6/08/26 through 6/11/26.

Findings
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 7/20/28.

Inspection Report — Jul 28, 2026

Complaint Investigation
Date: Jul 28, 2026

Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3070363 and CI MS #3104867) at the facility from 7/27/26 through 7/28/26. CI MS #3070363 was related to quality of care with no deficiency cited. CI MS #3104867 was a facility reported incident regarding the use of unauthorized physical restraints.

Complaint Details
Complaint investigation CI MS #3104867 involved a facility reported incident regarding unauthorized physical restraints. The deficiency was substantiated with one deficiency cited. CI MS #3070363 related to quality of care was investigated with no deficiency cited.
Findings
One deficiency was cited at past noncompliance, F0604, for the unauthorized use of physical restraints on Resident #1. The facility failed to prohibit the use of physical restraint to unnecessarily inhibit freedom of movement for one of five sampled residents.

Deficiencies (1)
F0604 - The facility failed to prohibit the use of physical restraint to unnecessarily inhibit freedom of movement for one resident. Resident #1 was found restrained with a sheet tied to bed rails without physician order, violating resident rights and facility policy.
Report Facts
Deficiencies cited: 1 Complaint investigations: 2

Inspection Report — Jul 28, 2026

Complaint Investigation
Date: Jul 28, 2026

Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #3070363 and CI MS #3104867) at the facility from 7/27/26 through 7/28/26. CI MS #3070363 was related to quality of care with no deficiency cited. CI MS #3104867 was a facility reported incident regarding the use of unauthorized physical restraints.

Complaint Details
CI MS #3104867 was investigated regarding the use of unauthorized physical restraints. Deficiency M500 was cited. CI MS #3070363 related to quality of care had no deficiency cited.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, but cited M500 as Past Non-compliance. The facility failed to prohibit the use of physical restraint to unnecessarily inhibit freedom of movement for one resident, Resident #1, who was found restrained with a sheet tied across her torso to bed rails without a physician's order. The staff responsible was terminated and in-service training was provided to all nursing staff.

Deficiencies (1)
M500 - Residents' Rights. The facility failed to prohibit the use of unauthorized physical restraints on Resident #1, who was found restrained with a sheet tied across her torso to bed rails without a physician's order, violating resident rights and facility policy.
Report Facts
Complaint Investigations: 2 Deficiencies cited: 1

Inspection Report — Jul 20, 2026

Life Safety
Date: Jul 20, 2026

Visit Reason
On 07/20/26 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 06/11/26. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.

Findings
The facility was found to be in compliance with the Life Safety Code based on the desk review conducted on 07/20/26. No deficiencies were cited.

Inspection Report — Jun 12, 2026

Life Safety
Date: Jun 12, 2026

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 failed to provide fire sprinkler protection in the newly installed freezer in the kitchen, affecting one of five smoke compartments. No other deficiencies were cited.

Deficiencies (1)
K0353 - Sprinkler system maintenance and testing. The facility failed to provide fire sprinkler protection for the newly installed freezer in the kitchen, which was installed in May 2026 and was not protected by the sprinkler system.
Report Facts
Deficiencies cited: 1

Inspection Report — Jun 11, 2026

Annual Inspection
Date: Jun 11, 2026

Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 6/8/26 through 6/11/26. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F812, F803 and F550.

Findings
The facility was found not in compliance with deficiencies related to resident rights and meal choices, menu posting and nutritional adequacy, and food procurement and storage practices. The facility failed to ensure residents were informed of alternate meal choices, failed to post alternate menus, and failed to maintain food safety standards in the kitchen.

Deficiencies (3)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure residents were informed of available alternate meal choices, limiting their ability to make informed dining preferences for one resident.
F0803 - Menus Meet Resident Needs/Prepared in Advance/Followed. The facility failed to ensure resident alternative menus were posted and met the resident's preferences for one resident.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food in accordance with professional standards related to undated and expired foods and moisture in dry bins during kitchen observations.
Report Facts
Deficiencies cited: 3

Inspection Report — Jun 11, 2026

Annual Inspection
Date: Jun 11, 2026

Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 6/8/26 through 6/11/26. During the survey, the SA determined the facility was not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M815.

Findings
The facility failed to store food in accordance with professional standards for food service safety related to food items not dated, expired foods, and moisture in the dry bins observed during kitchen inspections.

Deficiencies (1)
M0815 - Safe Food Handling Procedures. The facility failed to store food properly, including expired and undated items, and allowed moisture in dry bins, risking bacterial growth.
Report Facts
Deficiencies cited: 1

Inspection Report — Aug 6, 2025

Plan of Correction
Date: 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 — Jul 2, 2025

Annual Inspection
Date: 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.

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.
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.

Deficiencies (2)
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).
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.
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
NameTitleContext
CNA #1Certified Nursing AssistantNamed in grooming deficiency related to Resident #34
Director of NursingDirector of NursingInterviewed regarding CNA responsibilities for grooming
Registered Nurse SupervisorRegistered Nurse SupervisorEducated CNA #1 on proper ADL care
Dietary ManagerCertified Dietary ManagerNamed in food safety deficiencies and responsible for food quality and safety
Cook #1CookObserved and interviewed regarding unsanitary food preparation practices
Cook #2CookObserved and interviewed regarding unsanitary food preparation practices
AdministratorAdministratorInterviewed regarding awareness and expectations for food safety

Inspection Report — Jul 2, 2025

Annual Inspection
Date: 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.

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.
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.

Deficiencies (3)
The facility failed to accurately code the Minimum Data Set (MDS) assessments for anticoagulant and hypnotic medications for six residents, resulting in incorrect reporting.
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.
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.
Report Facts
Number of MDS assessments reviewed: 18 Residents with inaccurate MDS coding: 6 Residents sampled for ADL care: 18 Days of survey: 3

Employees mentioned
NameTitleContext
Registered Nurse #1Registered NurseCompleted Section N of MDS and acknowledged errors in medication coding
Director of NursingDirector 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 #1Certified Nursing Assistant (CNA)Assigned to Resident #34 and educated on proper ADL care after failure to provide facial hair grooming
Certified Dietary ManagerCertified Dietary Manager (CDM)Responsible for food quality and safety; acknowledged food safety deficiencies and planned additional training and monitoring
Cook #1CookObserved engaging in unsanitary food preparation practices and received in-service training
Cook #2CookObserved engaging in unsanitary food preparation practices and received in-service training
AdministratorFacility AdministratorAcknowledged awareness of deficiencies and responsibility expectations for food safety

Inspection Report — Jul 1, 2025

Life Safety
Date: 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 — Apr 17, 2025

Complaint Investigation
Date: 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.

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.
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.

Inspection Report — Apr 17, 2025

Complaint Investigation
Date: 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.

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

Report Facts
Licensed beds: 60

Inspection Report — Feb 19, 2024

Annual Inspection
Date: 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 — Feb 19, 2024

Plan of Correction
Date: 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 — Jan 11, 2024

Annual Inspection
Date: 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.

Complaint Details
Complaint Investigation MS #23785 was conducted related to dietary services and environment, including bathing dependent residents in a cold shower room.
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.

Deficiencies (1)
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.
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
NameTitleContext
Certified Nursing Assistant #1CNAInterviewed regarding Resident #13's care and stated resident was taken out of room every other day
Registered Nurse #1RNInterviewed and stated CNAs must get all residents out of rooms daily unless acuity forbids
Activities DirectorActivities DirectorInterviewed about resident activity participation and notification procedures
Director of NursingDONInterviewed about resident rights and documentation of refusals to get up
AdministratorAdministratorInterviewed about staff expectations to encourage residents to get up daily

Inspection Report — Jan 11, 2024

Annual Inspection
Date: 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.

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.
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.

Deficiencies (3)
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.
Failure to ensure the shower room was at a comfortable temperature while providing showers for three residents.
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.
Report Facts
Licensed beds: 60 Deficiency count: 3 PRN Klonopin doses: 3 PRN Klonopin doses: 7

Employees mentioned
NameTitleContext
Licensed Practical Nurse #2LPNProvided information about Resident #42's behavior and medication compliance
Certified Nurse Aide #2CNAProvided information about Resident #42's cooperation with care
Director of NursingDONProvided multiple interviews regarding resident rights, shower room temperature, and psychotropic medication management
AdministratorFacility AdministratorProvided interviews regarding staff expectations and regulatory compliance
Maintenance DirectorMaintenance DirectorConfirmed heater issues and repairs in shower room
Activities DirectorActivities DirectorDiscussed resident activity participation and communication with staff
Pharmacy ConsultantPharmacy ConsultantDiscussed psychotropic medication monitoring and regulatory compliance
Advanced Registered Nurse PractitionerAPRNDiscussed understanding of psychotropic medication regulations

Inspection Report — Jan 11, 2024

Life Safety
Date: 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 — Jan 11, 2024

Date: 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 — Jul 18, 2023

Complaint Investigation
Date: 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.

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.
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.

Inspection Report — Jul 18, 2023

Complaint Investigation
Date: 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.

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.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited during the investigation.

Report Facts
Licensed beds: 60

Inspection Report — Jan 11, 2023

Annual Inspection
Date: 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.

Complaint Details
Complaint Investigation MS #23785 was conducted related to dietary services and environment.
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.

Deficiencies (2)
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 — Jan 9, 2023

Date: 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.

Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7

Inspection Report — Jan 9, 2023

Plan of Correction
Date: 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.

Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7

Inspection Report — Aug 30, 2022

Plan of Correction
Date: 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 — Jul 20, 2022

Annual Inspection
Date: 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.

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.
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.

Deficiencies (2)
Facility failed to notify the Resident Representative in writing the reason for a transfer to an acute care hospital for Resident #35.
Facility failed to conduct a Level I Pre-Admission Screening (PASARR) prior to admission for five residents (#3, #5, #12, #22, and #25).
Report Facts
Licensed beds: 60 Number of residents without PASARR screening: 5

Inspection Report — Jul 20, 2022

Annual Inspection
Date: 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.

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.
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.

Inspection Report — Jul 18, 2022

Life Safety
Date: 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 — Jul 18, 2022

Date: 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 — Apr 19, 2021

Plan of Correction
Date: 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.

Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7

Inspection Report — Apr 12, 2021

Plan of Correction
Date: 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.

Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7

Inspection Report — Aug 5, 2020

Routine
Date: 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

Inspection Report — May 26, 2020

Routine
Date: 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 — Feb 27, 2020

Annual Inspection
Date: 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.

Deficiencies (3)
Facility failed to accurately code the Minimum Data Set related to a diagnosis of Psychosis for one resident.
Facility failed to refer a resident for a Level II PASARR screening related to a new psychiatric diagnosis change.
Facility failed to employ a qualified professional related to the Dietary Manager position.
Report Facts
Deficiencies cited: 3

Employees mentioned
NameTitleContext
LPN #1Minimum Data Set NurseInterviewed regarding inaccurate coding of diagnosis in MDS assessment
Director of NursingDirector of NursingSigned facility statements, confirmed diagnosis legitimacy, and involved in staff in-service and corrective actions
Dietary ManagerDietary ManagerInterviewed regarding qualifications and certification status
AdministratorAdministratorInterviewed regarding hiring efforts for Certified Dietary Manager and oversight responsibilities

4 CMS Surveys

Inspection Report — Jul 2, 2025

Annual Inspection
Date: Jul 2, 2025

Visit Reason
The State Agency conducted an annual recertification survey at the facility on 07/02/2025.

Findings
The facility was found to have deficiencies in accurate resident assessments, activities of daily living assistance, and food safety practices.

Deficiencies (3)
F0641 - The facility failed to accurately code the Minimum Data Set (MDS) to reflect residents' assessments for anticoagulant and hypnotic medications for six of eighteen MDS assessments reviewed.
F0677 - The facility failed to ensure a resident who is unable to carry out activities of daily living received necessary services to maintain good grooming and personal hygiene for one resident.
F0812 - The facility failed to maintain food quality and safety standards related to overly ripe produce, exposed foods, undated and unlabeled foods, expired foods, and unsanitary meal preparation practices over two of three survey days.
Report Facts
Deficiencies cited: 3

Inspection Report — Jan 11, 2024

Annual Inspection
Date: Jan 11, 2024

Visit Reason
The State Agency conducted an annual recertification survey at the facility.

Findings
The facility failed to ensure the shower room was at a comfortable temperature while providing showers for three of fifteen sampled residents. Residents reported the shower room was cold, the heater was not working, and staff did not dry residents' hair properly, which could cause them to get sick.

Deficiencies (1)
F0584 - The facility failed to maintain a safe, clean, and comfortable environment by not ensuring the shower room was heated during showers for residents #8, #9, and #23, causing them to be cold and at risk of illness.
Report Facts
Deficiencies cited: 1

Inspection Report — Jan 11, 2024

Annual Inspection
Date: Jan 11, 2024

Visit Reason
The State Agency conducted an annual recertification survey at the facility on 01/11/2024.

Findings
The facility was found to have deficiencies related to honoring residents' rights to self-determination, maintaining a safe and comfortable environment in the shower room, and proper management of psychotropic medications.

Deficiencies (3)
F0561 - The facility failed to honor residents' rights or choices by not allowing Resident #13 to get out of her room daily as she wished.
F0584 - The facility failed to ensure the shower room was at a comfortable temperature during showers for Residents #8, #9, and #23, exposing them to cold conditions.
F0758 - The facility failed to ensure PRN psychotropic medications were discontinued or limited to a 14-day duration without adequate clinical rationale for continued use for Resident #42.
Report Facts
Deficiencies cited: 3

Inspection Report — Jul 20, 2022

Complaint Investigation
Date: Jul 20, 2022

Visit Reason
The State Agency conducted a complaint investigation at the facility. The investigation focused on notification failures related to resident transfers and the completion of Pre-admission Screening (PAS) for certain residents.

Complaint Details
Complaint investigation CI MS# not explicitly stated. The complaint involved failure to notify the Resident Representative in writing of the reason for hospital transfer and failure to complete Pre-admission Screening for certain residents. Deficiencies were cited.
Findings
The facility failed to notify the Resident Representative in writing the reason for a transfer to an acute care hospital for one sampled resident. Additionally, the facility failed to conduct Level I Pre-admission Screening prior to admission for five sampled residents.

Deficiencies (2)
F0623 - Provide timely notification to the resident and resident representative before transfer or discharge, including appeal rights. The facility failed to notify the Resident Representative in writing the reason for a transfer to an acute care hospital for one of one sampled residents.
F0645 - PASARR screening for Mental disorders or Intellectual Disabilities. The facility failed to conduct a Level I Pre-admission Screening prior to admission for five of 17 sampled residents.
Report Facts
Deficiencies cited: 2

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