Inspection Reports for
Copiah Living Center
806 West Georgetown Rd, Crystal Springs, MS, 39059
Back to Facility Profile42 Reports
Inspection Report — Sep 2, 2026
Complaint Investigation
Date: Sep 2, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #3062954) at the facility from 9/01/26 through 9/02/26 related to resident abuse.
Complaint Details
CI MS #3062954 was investigated related to resident abuse. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Sep 2, 2026
Complaint Investigation
Date: Sep 2, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #3062954) at the facility from 9/01/26 through 9/02/26 related to resident abuse.
Complaint Details
CI MS #3062954 was investigated related to resident abuse. The SA determined the facility was in compliance with no deficiencies cited.
Findings
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.
Inspection Report — May 21, 2026
Complaint Investigation
Date: May 21, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #2994500 and CI MS #2968011) at the facility from 5/20/26 through 5/21/26. CI MS #2994500 was related to quality of care and nursing services, and CI MS #2968011 was regarding accident/incident, abuse and nursing services.
Complaint Details
CI MS #2994500 was investigated related to quality of care and nursing services. CI MS #2968011 was investigated regarding accident/incident, abuse and nursing services. The facility was found in compliance with no deficiencies cited.
Findings
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.
Report Facts
Complaint Investigations: 2
Inspection Report — May 21, 2026
Complaint Investigation
Date: May 21, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #2994500 and CI MS #2968011) at the facility from 5/20/26 through 5/21/26. CI MS #2994500 was investigated related to quality of care and nursing services. CI MS #2968011 was investigated regarding accident/incident, abuse and nursing services.
Complaint Details
Two complaint investigations were conducted: CI MS #2994500 related to quality of care and nursing services, and CI MS #2968011 regarding accident/incident, abuse and nursing services. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Dec 1, 2025
Complaint Investigation
Date: Dec 1, 2025
Visit Reason
On 12/01/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 09/25/25. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint survey was completed on 09/25/25. The facility was found to have corrected the deficient practice and sustained compliance; no deficiencies were cited.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 11/26/25. No deficiencies were cited in this desk review.
Report Facts
Complaint survey date: 09/25/25
Inspection Report — Sep 25, 2025
Routine
Date: Sep 25, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights and care standards, focusing on meal assistance and resident safety during dining.
Findings
The facility failed to ensure residents' rights to dignified care and safety during meals. Staff did not consistently position themselves properly while assisting residents with eating, and call lights were left out of reach, compromising resident safety and dignity.
Deficiencies (2)
F 0550: The facility failed to ensure resident rights to respectful, dignified care as staff did not position themselves at the resident's side while assisting with eating for one of four sampled residents.
F 0558: The facility failed to promote dignity and safety during dining as a resident was unsafely positioned during a meal and the call light was out of reach for one of four sampled residents.
Report Facts
Residents Affected: 1
Residents Affected: 1
Sampled Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed assisting Resident #2 improperly and confirmed Resident #1's call light was out of reach |
| Staff Development Nurse | Staff Development Nurse | Provided correction to LPN #1 and confirmed facility policies on meal assistance and call light placement |
| Director of Nurses | Director of Nurses | Confirmed facility policies on proper resident positioning and call light placement |
| Certified Nurse Aide #1 | Certified Nurse Aide | Provided care to Resident #1 and repositioned resident during meal |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding responsibility for Resident #1's call light placement |
Inspection Report — Sep 25, 2025
Complaint Investigation
Date: Sep 25, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #2585733 related to quality of care and abuse at the facility from 9/24/25 through 9/25/25.
Complaint Details
CI MS #2585733 was investigated related to quality of care and abuse. Deficiencies were cited.
Findings
The facility was found not in compliance with requirements and cited for two deficiencies related to resident rights and reasonable accommodations. The facility failed to ensure respectful, dignified care during feeding and failed to promote dignity by leaving a resident's call light out of reach and positioning the resident unsafely during meals.
Deficiencies (2)
F0550 - Resident rights were not ensured as staff failed to position themselves at the resident's side while assisting with eating for one of four sampled residents.
F0558 - The facility failed to promote dignity for a resident during dining as the resident was unsafely positioned during a meal and the call light was out of reach for one of four sampled residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 25, 2025
Complaint Investigation
Date: Sep 25, 2025
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) MS# 2585733 at the facility from 9/24/25 through 9/25/25 related to quality of care and abuse.
Complaint Details
Complaint Investigation CI MS# 2585733 was related to quality of care and abuse. Deficiency M500 was cited indicating the complaint was substantiated.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. The facility failed to ensure resident right to respectful, dignified care as staff did not position themselves at the resident's side while assisting with eating for one of four sampled residents.
Deficiencies (1)
M500 - The facility failed to ensure resident rights to respectful and dignified care as staff did not sit at the resident's side while assisting with eating for one of four sampled residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 6, 2025
Annual Inspection
Date: Jun 6, 2025
Visit Reason
On 06/06/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 05/08/25.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 06/04/25.
Inspection Report — Jun 6, 2025
Date: Jun 6, 2025
Visit Reason
On 06/06/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 05/08/25.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 06/04/25.
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
The inspection was conducted as an annual recertification survey to assess compliance with regulatory requirements and quality of care standards at Copiah Living Center.
Findings
The facility was cited for multiple deficiencies including failure to respect residents' dignity by staff using cell phones and earbuds during care, inaccurate coding of antipsychotic medications on the MDS, improper perineal care leading to risk of urinary tract infections, failure of the Quality Assurance and Performance Improvement (QAPI) program to sustain corrective actions, and inadequate infection prevention and control practices during perineal care.
Deficiencies (5)
F 0557: The facility failed to ensure residents' rights for respect and dignity, as staff entered rooms and provided care while using personal cell phones and wearing earbuds, which residents described as rude and disrespectful.
F 0641: The facility failed to accurately code antipsychotic medications on the Minimum Data Set (MDS) for one resident, despite medication orders and administration.
F 0690: The facility failed to provide appropriate perineal care to incontinent residents, risking urinary tract infections, with improper cleaning techniques observed for two residents.
F 0867: The facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions, resulting in repeat citations for deficiencies related to incontinent care and infection control.
F 0880: The facility failed to follow infection control practices during perineal care, including improper hand hygiene, glove use, and risk of cross-contamination for two residents.
Report Facts
Residents sampled: 18
Residents affected: 2
Residents affected: 1
Residents reviewed: 2
Residents affected: 2
Previous survey date: Nov 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Minimum Data Set (MDS) nurse | Acknowledged error in coding antipsychotic medication on MDS |
| Registered Nurse #1 | Minimum Data Set (MDS) nurse | Confirmed error in MDS medication coding and need for correction |
| Certified Nursing Assistant #3 | Acknowledged improper perineal care and infection control breaches | |
| Certified Nursing Assistant #2 | Acknowledged improper perineal care and infection control breaches | |
| Licensed Practical Nurse/Infection Preventionist | Confirmed infection control breaches and improper care practices | |
| Director of Nursing | Director of Nursing (DON) | Acknowledged deficiencies, repeated citations, and expectations for staff care |
| Nursing Home Administrator | Administrator | Commented on repeat citations and staff turnover contributing to deficiencies |
Inspection Report — May 8, 2025
Annual Inspection
Date: May 8, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 05/05/2025 through 05/08/2025. During the survey, the SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F557, F641, F690, F867, and F880.
Findings
The facility was found not in compliance with multiple deficiencies including respect and dignity, accuracy of assessments, incontinent care, quality assurance, and infection control. Deficiencies placed residents at risk for disrespect, inaccurate assessments, urinary tract infections, and infection transmission.
Deficiencies (5)
F0557 - Respect and dignity. The facility failed to ensure residents' rights for respect and dignity, as staff were observed using personal cell phones and earbuds while providing care, which residents described as rude and disrespectful.
F0641 - Accuracy of assessments. The facility failed to accurately code antipsychotic medications on the Minimum Data Set for one resident, resulting in inaccurate resident status documentation.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to ensure incontinent residents received appropriate care and services to prevent urinary tract infections, as evidenced by improper perineal care for two residents.
F0867 - QAPI/QAA improvement activities. The facility's Quality Assurance and Performance Improvement Committee failed to sustain corrective actions to prevent recurrence of previously cited deficiencies related to incontinent care and infection control.
F0880 - Infection prevention and control. The facility failed to follow infection control practices during perineal care for two residents, including failure to perform hand hygiene, improper glove use, and cross-contamination risks.
Report Facts
Deficiencies cited: 5
Inspection Report — May 6, 2025
Life Safety
Date: May 6, 2025
Visit Reason
The facility was surveyed for 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. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Apr 8, 2025
Complaint Investigation
Date: Apr 8, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #28263 and MS #27771, at the facility on 4/08/25. MS #28263 was investigated related to abuse, quality of care regarding resident's responsible party not notified and resident rights. MS #27771 was investigated regarding resident rights and misappropriation.
Complaint Details
Complaint Investigation MS #28263 was related to abuse, quality of care regarding resident's responsible party not notified and resident rights. Complaint Investigation MS #27771 was regarding resident rights and misappropriation. Both complaints were investigated and the facility was found in compliance with no deficiencies cited.
Findings
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. There were no deficiencies cited.
Inspection Report — Sep 19, 2024
Complaint Investigation
Date: Sep 19, 2024
Visit Reason
The state agency conducted a Complaint Investigation (CI), MS #25941 and MS #24389 at the facility on 9/19/24. MS #25941 was investigated for resident rights related to admission, transfer, and discharge and resident seclusion. MS #24389 was investigated related for quality of care related to following plan of care and physician orders.
Complaint Details
Complaint Investigation MS #25941 and MS #24389 were conducted regarding resident rights and quality of care. The facility was found in compliance with no deficiencies cited.
Findings
The survey 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.
Inspection Report — Sep 19, 2024
Complaint Investigation
Date: Sep 19, 2024
Visit Reason
The state agency conducted a Complaint Investigation (CI), MS #25941 and MS #24389 at the facility on 9/19/24. MS #25941 was investigated for resident rights related to admission, transfer, and discharge and resident seclusion. MS #24389 was investigated related for quality of care related to following plan of care and physician orders.
Complaint Details
Complaint Investigation MS #25941 and MS #24389 were investigated for resident rights and quality of care; the facility was found in compliance with no deficiencies cited.
Findings
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.
Inspection Report — Dec 8, 2023
Annual Inspection
Date: Dec 8, 2023
Visit Reason
On 12/8/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/2/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that your facility be placed back in compliance effective 12/1/23.
Inspection Report — Nov 2, 2023
Annual Inspection
Date: Nov 2, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigations (CIs) at the facility from 10/30/23 through 11/2/23. The SA investigated multiple complaint investigations with some deficiencies cited related to residents being left wet, not following physician orders, notification issues, grooming, pressure sores, and infection control.
Complaint Details
The SA investigated CI MS #23005 related to not following physician orders, not offering water, and residents being left wet and soiled for extended periods of time; CI MS#23078 related to admission, transfer, and discharge rights; and CI MS #23081 for rehabilitation services and pressure sores. No deficiencies were cited for these investigations. Deficiencies were cited related to CI MS #23080 for residents being left wet, not following physician orders, and improper incontinent care, and CI MS #23079 related to notification of Resident Representative, adequate grooming, pressure sores, and infection control.
Findings
The facility was found not in compliance with several deficiencies including failure to complete a timely Significant Change Minimum Data Set (MDS) assessment, inadequate incontinent care, improper food storage and labeling, ineffective quality assurance and performance improvement (QAPI) program, and failure to consistently implement infection control measures.
Deficiencies (5)
F0637 - The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days for a resident with a physical and mental decline following a fall and hip fracture.
F0690 - The facility failed to provide appropriate incontinent care to prevent urinary tract infections for a resident, as evidenced by inadequate perineal care by a Certified Nursing Assistant.
F0812 - The facility failed to ensure food items in the kitchen were properly dated, labeled, and discarded by expiration date, risking all residents receiving meals.
F0865 - The facility's Quality Assurance and Performance Improvement (QAPI) program was not sustained during leadership transitions and failed to maintain implemented procedures and monitor interventions from a prior deficiency.
F0880 - The facility failed to consistently implement infection control measures, including hand hygiene and proper care techniques, placing residents at risk of infection.
Report Facts
Deficiencies cited: 5
Inspection Report — Nov 2, 2023
Life Safety
Date: Nov 2, 2023
Visit Reason
Survey conducted on 11/2/23 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Nov 2, 2023
Annual Inspection
Date: Nov 2, 2023
Visit Reason
The inspection was conducted as part of an annual recertification survey to assess compliance with regulatory requirements in areas including resident care, infection control, food safety, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to complete a timely Significant Change Minimum Data Set (MDS) assessment for a resident with decline, inadequate perineal care leading to risk of urinary tract infections, improper food storage and labeling with expired items found, failure to sustain Quality Assurance and Performance Improvement (QAPI) activities, and inconsistent infection control practices such as improper hand hygiene by staff.
Deficiencies (5)
F 0637: The facility failed to complete a Significant Change MDS assessment within 14 days for a resident with physical and mental decline following a fall and hip fracture.
F 0690: The facility failed to ensure appropriate perineal care for an incontinent resident, risking urinary tract infection due to improper cleaning and drying.
F 0812: The facility failed to ensure kitchen food items were properly dated, labeled, and expired foods discarded, with multiple expired items found in storage.
F 0865: The facility's QAPI Committee failed to sustain infection control improvements, showing a pattern of ineffective quality assurance over multiple surveys.
F 0880: The facility failed to consistently implement infection control measures, including hand hygiene failures by staff during resident care, risking infection transmission.
Report Facts
Residents observed for incontinent care: 4
Residents sampled: 21
Dietary observations: 3
Residents sampled for infection control: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1/MDS Nurse | Named in failure to complete Significant Change MDS for Resident #6. | |
| Certified Nursing Aide (CNA) #1 | Named in failure to properly clean perineal area for Resident #27. | |
| Certified Nursing Aide (CNA) #2 | Named in failure to perform hand hygiene during perineal care for Resident #26. | |
| Registered Nurse (RN) #1 | Named in failure to perform hand hygiene during PEG tube care for Resident #33. | |
| Director of Nurses (DON) | Provided multiple confirmations of deficiencies and infection control failures. | |
| Dietary Manager (DM) | Named in failure to ensure expired foods were removed from kitchen. | |
| Licensed Practical Nurse (LPN) #2/Infection Preventionist | Confirmed infection control failures and hand hygiene issues. |
Inspection Report — Oct 4, 2023
Complaint Investigation
Date: Oct 4, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22718) at the facility on 10/4/23 related to nutrition, grooming, treatment with dignity and call bell accessibility.
Complaint Details
CI MS #22718 was investigated related to nutrition, grooming, treatment with dignity and call bell accessibility. The SA determined the facility was in compliance with no deficiencies cited.
Findings
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.
Report Facts
Complaint investigations: 1
Inspection Report — Oct 4, 2023
Complaint Investigation
Date: Oct 4, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22718) related to nutrition, grooming, treatment with dignity and call bell accessibility.
Complaint Details
CI MS #22718 was investigated related to nutrition, grooming, treatment with dignity and call bell accessibility. The complaint was not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jul 27, 2023
Complaint Investigation
Date: Jul 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for one complaint, MS #21967, on 7/27/23.
Complaint Details
Complaint MS #21967 involved Quality of Care related to physician's orders and was investigated with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Jul 27, 2023
Complaint Investigation
Date: Jul 27, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for one complaint, MS #21067 on 7/27/23. The SA also investigated MS #21967 for Quality of Care related physician's orders.
Complaint Details
Complaint MS #21067 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited during the complaint investigation.
Inspection Report — Jan 19, 2023
Complaint Investigation
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #20489 and CI MS #20472) at the facility from 11/28/22 through 11/29/22.
Complaint Details
Complaint Investigation CI MS #20489 and CI MS #20472 were conducted and no deficiencies were cited; the facility was found in compliance.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for The Aged or Inform and there were no deficiencies cited for CI MS #20489 or CI MS #20472.
Inspection Report — Jan 19, 2023
Routine
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI MS #20489 and CI MS #20472) at the facility from 1/18/23 through 1/19/23.
Complaint Details
Complaint Investigations CI MS #20489 and CI MS #20472 were conducted and no deficiencies were cited; the complaints were found to be unsubstantiated.
Findings
The facility was found to be in compliance with infection control regulations and Medicare and Medicaid participation requirements. There were no deficiencies cited related to infection control or the complaint investigations.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 19, 2023
Routine
Date: Jan 19, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) from 1/18/23 through 1/19/23.
Findings
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.
Inspection Report — Jan 5, 2022
Follow-Up
Date: Jan 5, 2022
Visit Reason
The State Agency conducted a follow up/revisit survey on 1/05/22 at the facility for the Substandard Quality of Care (SQC) cited on a complaint survey that was conducted 11/07/21 through 11/11/21.
Complaint Details
Complaint survey conducted 11/07/21 through 11/11/21 for Substandard Quality of Care (SQC). The follow-up survey found the facility in compliance with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid.
Inspection Report — Nov 10, 2021
Complaint Investigation
Date: Nov 10, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to administer medications on dialysis days and failure to provide timely notification of hospital transfers for residents.
Complaint Details
The complaint investigation focused on allegations that the facility failed to administer medications to dialysis residents on dialysis days and failed to notify families of hospital transfers. The investigation substantiated these allegations.
Findings
The facility failed to administer prescribed morning medications to two dialysis residents on dialysis days and failed to notify physicians of missed medications. The facility also failed to provide written notice of hospital transfers to residents or their representatives. Additionally, the facility inaccurately coded Minimum Data Set (MDS) assessments and failed to follow care plans and infection control protocols.
Deficiencies (9)
F 0580: The facility failed to notify the physician that dialysis residents #12 and #51 were not receiving their morning medications as prescribed on dialysis days.
F 0600: The facility failed to ensure residents #12 and #51 were free from neglect by not administering medications ordered by the physician on dialysis days.
F 0623: The facility failed to provide timely written notification of hospital transfers to residents #51 and #57 and their representatives.
F 0641: The facility failed to accurately code the Minimum Data Set (MDS) for three residents, including incorrect anticoagulant and physical restraint coding.
F 0656: The facility failed to follow comprehensive care plans for residents #12, #39, and #51, including failure to administer medications as ordered and improper incontinent care.
F 0698: The facility failed to provide appropriate dialysis care and services for residents #12 and #51, including failure to administer medications on dialysis days and lack of pharmacy consultant review of medication administration records.
F 0756: The facility's pharmacy consultant failed to perform monthly drug regimen reviews including review of Electronic Medication Administration Records (EMAR) for dialysis residents #12 and #51.
F 0760: The facility failed to ensure residents #12 and #51 were free from significant medication errors by not administering prescribed medications on dialysis days.
F 0880: The facility failed to implement infection prevention and control practices, including improper hand hygiene and peri care by staff, risking infection for residents #5 and #39.
Report Facts
Missed medication doses: 5
Missed medication doses: 5
BIMS cognitive impairment score: 9
BIMS cognitive impairment score: 5
BIMS cognitive impairment score: 14
BIMS cognitive impairment score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in findings related to failure to administer medications on dialysis days for Residents #12 and #51. |
| LPN #3 | Licensed Practical Nurse | Named in findings related to failure to administer medications on dialysis days and failure to report missed medications. |
| Physician #1 | Interviewed regarding unawareness of missed medications for Resident #51. | |
| Physician #2 | Interviewed regarding unawareness of missed medications for Resident #12 and Resident #51. | |
| RN #1 | Registered Nurse Supervisor/Wound Care Nurse | Interviewed regarding unawareness of missed medications and infection control issues. |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding failure to follow infection control procedures during peri care. |
| CNA #3 | Certified Nursing Assistant | Observed and interviewed regarding improper peri care technique risking infection. |
| LPN #4 | Licensed Practical Nurse / MDS Nurse | Interviewed regarding MDS coding errors and care plan adherence. |
| Interim Director of Nursing | Interim DON | Interviewed regarding medication administration, pharmacy consultant role, and infection control. |
| Pharmacy Consultant | Interviewed regarding lack of access to EMAR and unawareness of medication administration issues. |
Inspection Report — Nov 10, 2021
Annual Inspection
Date: Nov 10, 2021
Visit Reason
The State Survey Agency (SSA) conducted an annual recertification along with a Complaint Investigation (CI), MS #18014 from 11/07/2021 thru 11/10/2021.
Complaint Details
CI MS #18014 was substantiated related to incontinent care not being provided in a manner to prevent the possible spread of infection.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to medication administration on dialysis days, failure to notify physicians, inaccurate MDS coding, incomplete care plan implementation, medication errors, infection control lapses, and failure to provide proper transfer notices.
Deficiencies (9)
F0580 - Notify of Changes (Injury/Decline/Room, etc.) The facility failed to notify physicians that dialysis residents were not receiving their morning medications as prescribed on dialysis days for two sampled residents.
F0600 - Free from Abuse and Neglect The facility failed to ensure residents were free from neglect by failing to administer medications ordered by the physician on dialysis days for two residents.
F0623 - Notice Requirements Before Transfer/Discharge The facility failed to ensure two sampled residents received written notice of transfer following hospital transfer.
F0641 - Accuracy of Assessments The facility failed to accurately code the Minimum Data Set (MDS) for three residents, including incorrect coding of anticoagulant use and physical restraints.
F0656 - Develop/Implement Comprehensive Care Plan The facility failed to follow the comprehensive care plan for three residents, including failure to provide incontinent care per plan and failure to administer medications as ordered.
F0698 - Dialysis The facility failed to provide care and services for residents receiving dialysis by not administering medications on dialysis days as ordered for two residents.
F0756 - Drug Regimen Review, Report Irregular, Act On The facility's pharmacy consultant failed to review Electronic Medication Administration Records (EMAR) to ensure correct medication administration for two dialysis residents.
F0760 - Residents are Free of Significant Med Errors The facility failed to administer significant medications as ordered for two dialysis residents, missing multiple doses of prescribed medications on dialysis days.
F0880 - Infection Prevention & Control The facility failed to prevent the possible spread of infection during incontinent care and wound care for two residents, including failure to follow hand hygiene and proper cleansing techniques.
Report Facts
Deficiencies cited: 9
Inspection Report — Nov 10, 2021
Routine
Date: Nov 10, 2021
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Nov 10, 2021
Life Safety
Date: Nov 10, 2021
Visit Reason
Survey conducted on 11/10/21 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Nov 10, 2021
Annual Inspection
Date: Nov 10, 2021
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility on 11/10/2021.
Findings
The facility was found to have one deficiency related to failure to follow the comprehensive care plan for three residents. The deficiency involved improper incontinent care and failure to administer ordered medications on dialysis days for Residents #12, #39, and #51.
Deficiencies (1)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to follow the comprehensive care plan for three residents by not providing proper incontinent care and failing to administer ordered medications on dialysis days.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 3, 2021
Routine
Date: Aug 3, 2021
Visit Reason
The State Agency conducted a Focused Infection Control (FIC) and a Complaint survey, MS #17927 and MS #17940 from 8/2/21 through 8/3/21.
Complaint Details
Complaint numbers MS #17927 and MS #17940 were investigated and not substantiated; no deficiencies were cited.
Findings
The SA did not substantiate the complaints and determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 3, 2021
Routine
Date: Aug 3, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey and a Complaint Investigation (CI) #17927 and CI #17940 were conducted by State Agency from 08/02/2021 through 08/03/2021.
Complaint Details
Complaint Investigation (CI) #17927 was unsubstantiated for Infection Control and CI #17940 was unsubstantiated for Quality of Care.
Findings
The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. Both complaint investigations #17927 and #17940 were unsubstantiated.
Report Facts
Complaints investigated: 2
Inspection Report — Oct 6, 2020
Routine
Date: Oct 6, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 10/6/2020. The facility remains out of compliance based on deficiencies cited during the September 24, 2020 COVID-19 Focused Infection Control survey.
Findings
No new observations related to infection control were noted during this survey. The facility remains out of compliance based on prior deficiencies.
Inspection Report — Sep 24, 2020
Routine
Date: Sep 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 23-24, 2020. The facility was not in substantial compliance with Medicare regulations at 42CFR Part 483, Subpart B-Requirements for Long Term Care Facilities due to failure to follow CMS and CDC recommended practices during the COVID-19 pandemic.
Findings
F0880 - Infection Prevention & Control. The facility failed to ensure that kitchen staff did not touch or pull down their facemasks while talking, risking COVID-19 transmission. This failure occurred during the COVID-19 pandemic and affected staff and residents.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to ensure that staff did not touch or pull down their facemask exposing their nose and mouth while talking, as observed with one kitchen staff member during the COVID-19 pandemic.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 31, 2020
Routine
Date: Aug 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/31/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 31, 2020
Routine
Date: Aug 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/31/2020.
Findings
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.
Inspection Report — Jun 2, 2020
Routine
Date: Jun 2, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/2/20.
Findings
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.
Inspection Report — May 9, 2019
Annual Inspection
Date: May 9, 2019
Visit Reason
During an annual recertification survey conducted by Ascellon, on behalf of the MS State Department of Health, from 5/6/19-5/9/19, the facility was found not to be in compliance for Minimum Standards for Institutions for Aged or Infirm, licensure requirements, with deficiencies cited at M815.
Findings
The facility was found to have deficiencies related to safe food handling procedures including failure to calibrate thermometers properly, store plates and trays in a sanitary manner, maintain the kitchen ceiling in good repair, discard expired items, label and date food and beverage items, and monitor refrigerator temperatures. These issues created potential for the spread of foodborne illness to all 55 residents.
Deficiencies (1)
M815 - Safe Food Handling Procedures. The facility failed to ensure staff knew how to calibrate thermometers, store plates and trays in a sanitary and safe manner, maintain the kitchen ceiling in good repair, discard expired items, label and date food and beverage items, and monitor the temperature in the residents' pantry refrigerator, creating potential for foodborne illness.
Report Facts
Deficiencies cited: 1
Report
5 CMS Surveys
CMS Survey — Nov 2, 2023
Nov 2, 2023
CMS Survey — Sep 25, 2025
Sep 25, 2025
CMS Survey — Nov 10, 2021
Nov 10, 2021
CMS Survey — Nov 2, 2023
Nov 2, 2023
CMS Survey — May 8, 2025
May 8, 2025
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