Inspection Reports for
Courtyard Rehabilitation and Healthcare
501 South Locust Street, McComb, MS, 39648
Back to Facility Profile74 Reports
Inspection Report — Aug 10, 2026
Complaint Investigation
Date: Aug 10, 2026
Visit Reason
On 08/10/26 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 06/17/26-06/18/26. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 06/17/26-06/18/26; the facility was found to have corrected the deficient practice and sustained compliance.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 07/23/26. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 18, 2026
Complaint Investigation
Date: Jun 18, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #3018618, CI MS #3006193, and CI MS #2997080) at the facility from 6/17/26 through 6/18/26. CI MS# 3018618 was investigated related to quality of care, physical environment, admission/transfer/discharge rights, and communication/non-English language needs. CI MS#2997080 was investigated regarding quality of care, resident rights, and general (death). CI MS#3006193 was investigated regarding resident rights, and no deficiencies were cited related to this CI.
Complaint Details
Three complaint investigations were conducted: CI MS #3018618 related to quality of care, physical environment, admission/transfer/discharge rights, and communication/non-English language needs; CI MS #2997080 related to quality of care, resident rights, and general (death); and CI MS #3006193 related to resident rights with no deficiencies cited. Deficiencies were cited related to CI MS #3018618 and CI MS #2997080.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. Deficiencies were cited related to pest control and infection control practices.
Deficiencies (2)
M0970 - The facility failed to maintain an effective pest control program, resulting in the presence of houseflies, maggots, gnats, and a dead spider in multiple resident rooms and common areas, affecting five of seven sampled residents.
M1570 - The facility failed to ensure staff followed standard and transmission-based infection control precautions when a Registered Nurse did not wear a disposable gown while changing leaking catheter tubing and urine collection components for a resident with an indwelling catheter.
Report Facts
Deficiencies cited: 2
Complaint investigations: 3
Inspection Report — Jun 18, 2026
Complaint Investigation
Date: Jun 18, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #3018618, CI MS #3006193, and CI MS #2997080) at the facility from 6/17/26 through 6/18/26. Deficiencies were cited related to quality of care, physical environment, admission/transfer/discharge rights, communication/non-English language needs, and infection prevention and control.
Complaint Details
Three complaint investigations were conducted: CI MS #3018618 related to quality of care, physical environment, admission/transfer/discharge rights, and communication/non-English language needs with deficiencies cited (F558, F925); CI MS #3006193 regarding resident rights with no deficiencies cited; and CI MS #2997080 regarding quality of care, resident rights, and general (death) with deficiencies cited (F880, F925).
Findings
The facility was found not in compliance with multiple requirements including pest control, reasonable accommodations for a Spanish-speaking resident, and infection prevention and control. Specific issues included presence of pests in resident rooms, failure to provide effective language assistance, and failure to follow enhanced barrier precautions during catheter care.
Deficiencies (3)
F0925 - Maintains Effective Pest Control Program. The facility failed to maintain an effective pest control program, with observations of houseflies, maggots, gnats, and spiders in multiple resident rooms and common areas.
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to ensure a Spanish-speaking resident had access to language assistance services, with staff not trained or utilizing the provided video remote interpreting tablet, resulting in communication barriers and resident isolation.
F0880 - Infection Prevention & Control. The facility failed to ensure staff followed enhanced barrier precautions when an RN changed leaking catheter tubing and collection bag for a resident without wearing a required disposable gown.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 19, 2026
Complaint Investigation
Date: Mar 19, 2026
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #2808972, CI MS #2797066, CI MS #2792642, and CI MS #2745679) at the facility from 03/18/26 through 03/19/26. The investigations concerned accidents/fall with injury, residents' rights and misappropriation of property, and abuse.
Complaint Details
Four complaint investigations were conducted: CI MS #2745679 (accidents/fall with injury), CI MS #2797066 (residents' rights and misappropriation of property), CI MS #2792642 (abuse), and CI MS #2808972 (accidents/fall with injury). 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 conducted: 4
Inspection Report — Mar 19, 2026
Complaint Investigation
Date: Mar 19, 2026
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #2808972, CI MS #2797066, CI MS #2792642, and CI MS #2745679) at the facility from 03/18/26 through 03/19/26. The investigations covered accidents/fall with injury, residents' rights and misappropriation of property, and abuse.
Complaint Details
Four complaint investigations were conducted regarding accidents/fall with injury, residents' rights and misappropriation of property, and abuse. 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 conducted: 4
Inspection Report — Feb 18, 2026
Complaint Investigation
Date: Feb 18, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility on 2/18/26 related to infection control, physical environment and quality of care.
Complaint Details
Complaint 2711883 was investigated related to infection control, physical environment and quality of care. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint number: 2711883
Inspection Report — Feb 18, 2026
Complaint Investigation
Date: Feb 18, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility on 2/18/26 related to infection control, physical environment and quality of care.
Complaint Details
Complaint 2711883 was investigated related to infection control, physical environment and quality of care. 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 — Nov 24, 2025
Follow-Up
Date: Nov 24, 2025
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 11/24/25 related to the complaint survey that was conducted 10/16/25 through 10/20/25.
Findings
The SA found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 11/07/25.
Inspection Report — Nov 24, 2025
Follow-Up
Date: Nov 24, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 11/24/25 related to the complaint survey that was conducted 10/16/25 through 10/20/25.
Complaint Details
Complaint survey conducted 10/16/25 through 10/20/25; the facility was found in compliance with no deficiencies cited.
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 into compliance effective 11/7/25.
Inspection Report — Oct 20, 2025
Complaint Investigation
Date: Oct 20, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS # 2641013, at the facility from 10/16/25 through 10/20/25 for quality-of-care treatment and resident/patient/client rights.
Complaint Details
CI MS# 2641013 investigated quality-of-care treatment and resident/patient/client rights. The complaint was substantiated with deficiencies cited and Immediate Jeopardy identified and later removed.
Findings
The facility was found not in compliance due to failure to protect residents and staff from a resident with known violent and aggressive behaviors, resulting in ongoing threats, barricading incidents, and unsafe conditions. Immediate Jeopardy was identified but removed prior to exit after corrective actions.
Deficiencies (2)
F0600 - Free from Abuse and Neglect. The facility failed to ensure residents were free from abuse, neglect, and intimidation by retaining a resident with known aggressive behaviors without adequate supervision or protective measures, placing multiple residents at risk of serious harm.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and interventions for a resident with known aggressive behaviors, resulting in unsafe conditions and risk of serious injury to multiple residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 13, 2025
Complaint Investigation
Date: Aug 13, 2025
Visit Reason
The State Agency conducted a complaint survey at the facility for Complaint #258588, Incident #2588965 and Incident #2584981 from 8/11/25 through 8/13/25. The SA investigated Complaint 258588 for abuse with no deficiencies cited. The SA investigated Incident #2588965 for quality of care with no deficiencies cited. The SA investigated Incident #2584981 and cited F0689 at level Immediate Jeopardy (IJ) as Past Noncompliance (PNC).
Complaint Details
Complaint #258588 was investigated for abuse with no deficiencies cited. Incident #2588965 was investigated for quality of care with no deficiencies cited. Incident #2584981 was investigated and substantiated with a deficiency cited (F0689) at Immediate Jeopardy level.
Findings
The facility was found out of compliance due to failure to provide adequate supervision and elopement prevention for Resident #1, who eloped from the facility and was unsupervised in the community for approximately one hour and twenty-nine minutes. Immediate Jeopardy was identified but removed prior to the survey entrance after corrective actions were implemented.
Deficiencies (1)
F0689 - The facility failed to provide supervision and implement effective elopement prevention strategies for Resident #1, who had severe cognitive impairment and elopement risk, resulting in the resident leaving the facility unsupervised and being found two miles away. This placed the resident at risk of serious injury or death.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 13, 2025
Complaint Investigation
Date: Aug 13, 2025
Visit Reason
The State Agency conducted a complaint survey at the facility for Complaint (CI) #2585880, Incident #2588965 and Incident #2584981 from 8/11/25 through 8/12/25. The SA investigated CI# 2585880 for abuse with no deficiencies cited. The SA investigated Incident #2488965 for quality of care with no deficiencies cited. The SA investigated Incident #2584981 and determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M640 at Level IV Immediate Jeopardy (IJ) as Past Noncompliance.
Complaint Details
Complaint (CI) #2585880 was investigated for abuse with no deficiencies cited. Incident #2488965 was investigated for quality of care with no deficiencies cited. Incident #2584981 was investigated and resulted in a deficiency citation (M640) with Immediate Jeopardy identified as Past Noncompliance.
Findings
The facility was cited for one deficiency, M0640, related to accidents and supervision. The facility failed to provide adequate supervision and elopement prevention strategies for a resident with cognitive impairment, resulting in the resident eloping from the facility and being unsupervised in the community for over an hour. The Immediate Jeopardy was removed prior to the State Agency entrance after corrective actions were implemented.
Deficiencies (1)
M0640 - The facility failed to provide supervision and implement effective elopement prevention strategies for one resident with cognitive impairment, resulting in the resident exiting the facility unsupervised and being found two miles away after over an hour. Immediate Jeopardy was identified but removed after corrective actions.
Report Facts
Deficiencies cited: 1
Level IV Immediate Jeopardy: 1
Distance resident eloped: 2
Duration resident unsupervised: 89
Temperature: 89
Inspection Report — Jul 10, 2025
Complaint Investigation
Date: Jul 10, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #487648 and MS #487646 at the facility from 7/09/25 through 7/10/25. MS #487648 was investigated related to neglect and nursing services. MS #487646 was investigated related to abuse.
Complaint Details
Complaint numbers MS #487648 and MS #487646 were investigated related to neglect, nursing services, and abuse. 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 — Jul 10, 2025
Complaint Investigation
Date: Jul 10, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #487648 and MS #487646, at the facility from 7/09/25 through 7/10/25. MS #487648 was investigated related to neglect and nursing services. MS #487646 was investigated regarding abuse.
Complaint Details
Complaint investigations MS #487648 and MS #487646 were conducted related to neglect, nursing services, and abuse. 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 — Feb 25, 2025
Life Safety
Date: Feb 25, 2025
Visit Reason
On 02/25/25 the State Agency conducted a desk review of information related to the annual survey conducted on 01/07/25. The facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements and was found to be in compliance with the Life Safety Code after corrective measures were implemented.
Inspection Report — Feb 24, 2025
Annual Inspection
Date: Feb 24, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 01/09/25. The information 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 facility was found to be in compliance as of 02/19/25 with no deficiencies cited during this desk review.
Inspection Report — Feb 4, 2025
Complaint Investigation
Date: Feb 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #27661) at the facility from 2/3/2025 through 2/4/2025 regarding resident abuse.
Complaint Details
CI MS #27661 was investigated regarding resident abuse and was determined to be unsubstantiated with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this complaint investigation.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 4, 2025
Complaint Investigation
Date: Feb 4, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #27661) at the facility from 2/3/25 through 2/4/2025 regarding resident abuse.
Complaint Details
CI MS #27661: Investigation of resident abuse; the complaint was investigated and found to be unsubstantiated 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. There were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Jan 9, 2025
Annual Inspection
Date: Jan 9, 2025
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigations (CIs) at the facility from 01/06/25 through 01/09/25. The SA investigated CI MS #26789, CI MS #26809, CI MS #26810, and CI MS #27323. There were no citations related to the CIs. The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M500, M640 and M1570 related to the annual survey.
Complaint Details
The SA investigated CI MS #26789 for activities of daily living, transfer notice and dignity; CI MS #26809 for rights, quality of care and dignity; CI MS #26810 for abuse and rights; and CI MS #27323 regarding abuse, resident right and safety. There were no citations related to the complaint investigations and the facility was determined to be in compliance with respect to these complaints.
Findings
The facility was found not in compliance with state licensure requirements due to failures in maintaining residents' rights and dignity during feeding, securing hazardous chemicals, and infection control practices including hand hygiene and wound care. No deficiencies were cited related to the complaint investigations.
Deficiencies (3)
M500 - Residents' rights and dignity were not upheld during feeding as staff were observed standing while feeding a resident, which could intimidate the resident and compromise dignity.
M640 - The facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets, posing a safety hazard especially for cognitively impaired residents.
M1570 - The facility failed to maintain an effective infection control program as evidenced by improper hand hygiene and wound care practices for three residents, increasing risk of infection and delayed healing.
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 9, 2025
Annual Inspection
Date: Jan 9, 2025
Visit Reason
The State Agency conducted an Annual Recertification Survey and four Complaint Investigations (CI MS #26789, CI MS #26809, CI MS #26810, and CI MS #27323) at the facility from 01/06/25 through 01/09/25. The SA investigated the complaints for activities of daily living, transfer notice and dignity, rights, quality of care, abuse, resident right and safety. There were no citations related to the complaints. The facility was found not in compliance with Medicare and Medicaid requirements related to the annual survey.
Complaint Details
Four complaint investigations (CI MS #26789, CI MS #26809, CI MS #26810, and CI MS #27323) were conducted regarding activities of daily living, transfer notice and dignity, rights, quality of care, abuse, resident right and safety. No citations were related to these complaints and the facility was found in compliance with respect to the complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited related to resident rights, comprehensive care planning, accident hazards, dietary services, food quality, and infection prevention and control.
Deficiencies (6)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure dignity and respect during feeding for one resident, as staff fed the resident while standing rather than sitting at eye level.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plan interventions related to wound care for one resident when a nurse cleaned a pressure ulcer wound without patting it dry as ordered.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to securely safeguard hazardous chemicals in two unlocked janitor's closets, posing a safety hazard.
F0800 - Provided Diet Meets Needs of Each Resident. The facility failed to ensure dietary staff supported and respected a resident's right to make meal choices, as alternate meals were not posted or available.
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to provide palatable food at appropriate temperatures for one resident; food was served cold and bland.
F0880 - Infection Prevention & Control. The facility failed to prevent infection spread due to improper hand hygiene and wound care practices observed in three residents, including failure to perform hand hygiene before donning gloves, reuse of soiled gauze, and failure to change gloves between wound care tasks.
Report Facts
Deficiencies cited: 6
Complaint investigations: 4
Inspection Report — Jul 30, 2024
Complaint Investigation
Date: Jul 30, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #25789 and MS #25791, at the facility on 7/30/24. MS #25789 was investigated related to physical environment, dietary, quality of care, and neglect. MS #25791 was investigated related to dietary services.
Complaint Details
Complaint Investigations MS #25789 and MS #25791 were conducted related to physical environment, dietary, quality of care, neglect, and dietary 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 — Jul 30, 2024
Complaint Investigation
Date: Jul 30, 2024
Visit Reason
The State Agency (SA) conducted Complaint Investigations (CIs), MS #25789 and MS #25791, at the facility on 7/30/24. MS #25789 was investigated related to physical environment, dietary, quality of care, and neglect. MS #25791 was investigated related to dietary services.
Complaint Details
Complaint investigations MS #25789 and MS #25791 were conducted related to physical environment, dietary, quality of care, neglect, and dietary services. 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 — May 28, 2024
Complaint Investigation
Date: May 28, 2024
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 04/17/24. The facility confirmed corrective measures were implemented and sustained compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 - The complaint investigation was substantiated as the facility implemented corrective measures and was placed back in compliance effective 05/22/24.
Findings
The facility was found to be in compliance with no deficiencies cited during this desk review.
Inspection Report — Apr 17, 2024
Complaint Investigation
Date: Apr 17, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #24139, CI MS #24246 and CI MS #24470) at the facility from 4/15/24 to 4/17/24. CI MS #24139 was related to improper behavior of administrative personnel. CI MS #24246 was regarding quality of care, physical environment, and resident abuse and neglect. CI MS #24470 was regarding neglect of pressure wounds.
Complaint Details
Three complaint investigations were conducted: CI MS #24139 (improper behavior of administrative personnel), CI MS #24246 (quality of care, physical environment, resident abuse and neglect), and CI MS #24470 (neglect of pressure wounds). Deficiencies were cited related to CI MS #24246 (M610) and CI MS #24470 (M615).
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with deficiencies cited related to activities of daily living and pressure sore care.
Deficiencies (2)
M610 - The facility failed to ensure dependent residents received assistance with activities of daily living, including oral hygiene, for two of six sampled residents who were cognitively intact but did not receive daily oral care as needed.
M615 - The facility failed to provide treatment and services to promote healing and prevent complications of a pressure ulcer for one of four sampled residents, as a licensed nurse did not follow physician orders for wound care.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 17, 2024
Complaint Investigation
Date: Apr 17, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #24139, CI MS #24246 and CI MS #24470) at the facility from 04/15/2024 to 04/17/2024. CI MS #24139 was related to improper behavior of administrative personnel. CI MS #24246 was regarding quality of care, physical environment, and resident abuse and neglect. CI MS #24470 was regarding neglect of pressure wounds.
Complaint Details
Three complaint investigations were conducted: CI MS #24139 related to improper behavior of administrative personnel, CI MS #24246 regarding quality of care, physical environment, and resident abuse and neglect, and CI MS #24470 regarding neglect of pressure wounds. Deficiencies were cited related to CI MS #24246 (F656, F677) and CI MS #24470 (F686).
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited for deficiencies related to failure to implement comprehensive care plans, failure to provide adequate ADL care including oral hygiene, and failure to provide proper treatment for pressure ulcers.
Deficiencies (3)
F0656 - The facility failed to ensure the comprehensive care plan was implemented, evidenced by failure to provide oral care during Activities of Daily Living for two of six sampled residents (Residents #3 and #6).
F0677 - The facility failed to ensure dependent residents received necessary ADL care including oral hygiene for two of six sampled residents (Residents #3 and #6).
F0686 - The facility failed to provide treatment and services to promote healing and prevent complications of a pressure ulcer for one of four sampled residents with pressure ulcers (Resident #5).
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 22, 2024
Complaint Investigation
Date: Jan 22, 2024
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #23914, CI MS #23915, CI MS #23916, CI MS #23917, CI MS #23918, and CI MS #23883) at the facility from 1/19/24 through 1/22/24. The investigations covered issues including resident neglect, physical environment, dietary services, resident abuse, falsification of records, misappropriation of property, resident safety, resident rights, and following physician instructions for care and medications.
Complaint Details
Six complaint investigations were conducted (CI MS #23914, #23915, #23916, #23917, #23918, #23883) covering allegations of resident neglect, physical environment, dietary services, resident abuse, falsification of records, misappropriation of property, resident safety, resident rights, and following physician instructions. 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 conducted: 6
Inspection Report — Jan 22, 2024
Complaint Investigation
Date: Jan 22, 2024
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #23914, CI MS #23915, CI MS #23916, CI MS #23917, CI MS #23918, and CI MS #23883) at the facility from 1/19/24 through 1/22/24.
Complaint Details
Six complaint investigations were conducted related to resident neglect, physical environment, dietary services, resident abuse, falsification of records, misappropriation of property, resident safety, resident rights, and following physician instructions for care and medications. 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 conducted: 6
Inspection Report — Dec 8, 2023
Complaint Investigation
Date: Dec 8, 2023
Visit Reason
On 12/8/23 the State Agency (SA) conducted a desk review of the information that was provided related to the complaint survey completed on 10/20/23. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint survey completed on 10/20/23; the facility was found to have corrected the deficiencies and sustained compliance.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 11/28/23.
Report Facts
Deficiencies cited: 0
Inspection Report — Oct 20, 2023
Complaint Investigation
Date: Oct 20, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI), MS #22621, CI MS #22694 and CI MS #22929 at the facility from 10/18/23 through 10/20/23. CI MS #22621 was investigated related to Quality of Care, Dietary Services, Resident Rights, Resident Abuse, and Physical Environment, with no deficiencies cited. CI MS #22694 was investigated for Quality of Care and Resident Rights with no deficiencies cited. 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 requirement and cited M500 related to CI MS #22929 for Resident Rights/Abuse with deficiencies cited related to Resident Rights.
Complaint Details
Complaint Investigations CI MS #22621 and CI MS #22694 found no deficiencies. CI MS #22929 was substantiated with deficiencies cited related to Resident Rights.
Findings
The facility was found not in compliance with state licensure requirements related to Resident Rights. Two residents were found to have been treated without respect and dignity by staff, resulting in staff suspensions and terminations. The facility initiated staff education and quality assurance monitoring to address these issues.
Deficiencies (1)
M500 - The facility failed to ensure residents were treated with respect and dignity, as evidenced by two residents experiencing rude and undignified treatment by staff, including rough care and yelling, with no injuries noted but violations of Resident Rights confirmed.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 20, 2023
Complaint Investigation
Date: Oct 20, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI MS #22621, CI MS #22694 and CI MS #22929) at the facility from 10/18/23 through 10/20/23. CI MS #22621 and CI MS #22694 were investigated with no deficiencies cited. Deficiencies were cited related to Resident Rights/Abuse under CI MS #22929.
Complaint Details
Complaint Investigations CI MS #22621 and CI MS #22694 found no deficiencies. CI MS #22929 was substantiated with deficiencies cited related to Resident Rights/Abuse.
Findings
The facility was found not in compliance due to failure to ensure residents were treated with respect and dignity for two residents. Staff mistreatment and failure to provide dignified care were documented, resulting in staff termination and staff education.
Deficiencies (1)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure residents were treated with respect and dignity for two residents, including incidents of rude and mean treatment by staff and failure to provide dignified care after a fall.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 25, 2023
Follow-Up
Date: Jul 25, 2023
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility from 7/24/23 through 7/25/23 related to a complaint survey that was conducted 6/26/23 through 6/27/23.
Complaint Details
Complaint survey conducted 6/26/23 through 6/27/23; deficiencies cited then but corrected by 7/17/23 as confirmed by this follow-up.
Findings
The SA found the corrective measures put in place by the facility corrected the deficiencies cited on the 6/27/2023 survey as of 7/17/23. No deficiencies were cited during this follow-up survey.
Inspection Report — Jul 25, 2023
Follow-Up
Date: Jul 25, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 7/24/23 through 7/25/23 related to a complaint survey that was conducted from 6/26/23 through 6/27/23.
Findings
The State Agency found the corrective measures put in place by the facility corrected the deficiencies cited on the 6/27/2023 survey as of 7/17/23. No deficiencies were cited during this follow-up survey.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 17, 2023
Complaint Investigation
Date: Jul 17, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22067 at the facility on 7/17/23 regarding Resident Rights concerning respect and dignity.
Complaint Details
Complaint number CI MS#22067 investigated Resident Rights regarding respect and dignity with no deficiencies cited.
Findings
No deficiencies were cited related to the complaint investigation; however, the facility remains out of compliance due to deficiencies cited on the 5/9/23 and 6/27/23 surveys.
Report Facts
Complaint number: 22067
Inspection Report — Jun 27, 2023
Complaint Investigation
Date: Jun 27, 2023
Visit Reason
The State Agency conducted Complaint Investigations at the facility for three complaints, CI MS #21930, CI MS #21931, and CI MS #21847 from 6/26/23 through 6/27/23. The SA investigated infection control, physical environment, dietary services, and quality of care/treatment issues.
Complaint Details
Complaint investigations were conducted for CI MS #21930 (Infection Control, Dietary Services, Quality of Care/Treatment), CI MS #21931 (Infection Control related to ice maker, no deficiencies cited), and CI MS #21847 (Physical Environment related to bed bug infestation and environmental concerns). Deficiencies were cited for CI MS #21930 and CI MS #21847.
Findings
The facility was found not in compliance with state licensure requirements. Deficiencies were cited related to activities of daily living for one resident, and environmental concerns including cleanliness and maintenance issues in resident bathrooms and the dining room ice machine area.
Deficiencies (2)
M0610 - Activities of daily living. The facility failed to ensure a dependent resident received necessary grooming and personal hygiene services, evidenced by a resident wearing a shredded shirt and having long, jagged, dirty fingernails.
M1010 - Housekeeping facilities and services. The facility failed to maintain a clean and homelike environment, with issues including dirty bathrooms with foul odors, rust-colored substances on fixtures, black and gray stains on floors and walls, and standing water with staining behind the ice machine.
Report Facts
Complaints investigated: 3
Deficiencies cited: 2
Inspection Report — Jun 27, 2023
Complaint Investigation
Date: Jun 27, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility for three complaints, CI MS# 21847, CI MS# 21930 and CI MS# 21931 from 6/26/23 through 6/27/23. The SA investigated infection control, dietary services, quality of care/treatment, and physical environment concerns, citing deficiencies.
Complaint Details
Complaint investigations CI MS# 21847, CI MS# 21930, and CI MS# 21931 were conducted. Deficiencies were cited for CI MS# 21847 (Physical Environment, F584), and CI MS# 21930 (Infection Control, Dietary Services, Quality of Care, F677 and F690). No deficiencies were cited for CI MS# 21931 (Infection Control).
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to environmental cleanliness issues, inadequate ADL care for a dependent resident, and improper catheter care leading to infection risk.
Deficiencies (3)
F0584 - Safe/clean/homelike environment. The facility failed to maintain a clean and homelike environment, with dirty bathrooms, foul odors, stained floors, black and rust-colored substances on walls and fixtures, and standing water behind the ice machine.
F0677 - ADL care provided for dependent residents. The facility failed to provide necessary grooming and hygiene services to a dependent resident, who was observed wearing a shredded shirt and having long, dirty fingernails.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to ensure catheter tubing and urine collection bags were kept off the floor and secured with leg straps, increasing the risk of urinary tract infections for a resident with an indwelling catheter.
Report Facts
Deficiencies cited: 3
Complaints investigated: 3
Inspection Report — May 9, 2023
Annual Inspection
Date: May 9, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility. The survey included review of resident care and services, including physician ordered services and transportation to appointments.
Findings
The facility was found out of compliance for failure to provide physician ordered services and transportation, failure to develop and implement comprehensive care plans, failure to provide assistance with bathing for dependent residents, failure to provide necessary treatment for pressure ulcers, and failure of administration to use resources effectively to ensure resident care. Immediate Jeopardy was identified and removed after corrective actions.
Deficiencies (6)
F0600 - Freedom from Abuse, Neglect, and Exploitation. The facility neglected to provide physician ordered services necessary to avoid physical harm for five residents, resulting in serious harm including decreased mobility, hospitalizations, infections, and sepsis. Transportation issues and failure to follow up on appointments contributed to the harm.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop or implement comprehensive care plans with measurable objectives and timetables for five residents related to orthopedic care, vascular implant treatment, wound care, and suprapubic catheter management, resulting in serious harm and likelihood of harm.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide assistance with bathing for three dependent residents, resulting in inadequate hygiene and resident complaints.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide necessary treatment and services to promote healing and prevent infection of a stage 4 pressure ulcer for one resident, resulting in worsening wound and hospitalization for sepsis.
F0835 - Administration. The facility failed to use its resources effectively to ensure residents received physician ordered services and transportation, resulting in serious harm to multiple residents. The facility had transportation issues including broken vans and lack of alternative transportation, causing missed appointments and delayed care.
F0865 - Quality Assurance and Performance Improvement (QAPI) Program. The facility failed to maintain an effective QAPI program to ensure transportation was provided for outside medical services, resulting in serious harm to residents. The program lacked effective monitoring and corrective actions related to transportation and resident care.
Report Facts
Deficiencies cited: 6
Inspection Report — May 9, 2023
Annual Inspection
Date: May 9, 2023
Visit Reason
The State Agency conducted a recertification survey and Complaint Investigation (CI) MS #21376 at the facility from 5/1/23 through 5/9/23. The SA investigated CI MS #21376 for pressure sores, resident not groomed adequately, facility staffing, call bell not answered timely, insufficient food, and food not cooked and cited F677 and F686. The SA determined the facility was not in compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS #21376 was investigated for pressure sores, resident not groomed adequately, facility staffing, call bell not answered timely, insufficient food, and food not cooked. Deficiencies were cited including F677 and F686. Immediate Jeopardy was identified related to the call light system and other serious deficiencies. The IJ was removed on 5/8/23 after corrective actions.
Findings
The facility was found to have multiple deficiencies including failure to provide physician-ordered services, resulting in serious harm such as decreased mobility, hospitalization, wound infection, and sepsis for several residents. The call light system was non-functional in resident bathrooms, posing immediate jeopardy to resident safety. The facility failed to develop and implement comprehensive care plans and maintain an effective QAPI program. Immediate Jeopardy was identified and removed during the survey.
Deficiencies (7)
F0600 - Freedom from Abuse and Neglect. The facility neglected to provide physician ordered services necessary for five residents, resulting in serious harm and likelihood of harm for others.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop or implement comprehensive care plans for five residents with various medical needs, resulting in serious harm and likelihood of harm.
F0684 - Quality of Care. The facility failed to ensure two residents received outside medical services as ordered, leading to hospitalization and wound infection, and placing other residents at risk.
F0688 - Increase/Prevent Decrease in ROM/Mobility. The facility failed to provide medical services to prevent avoidable loss of range of motion and mobility for one resident, resulting in serious injury and impairment.
F0835 - Administration. The facility administration failed to use resources effectively to ensure residents received physician-ordered services, resulting in serious harm and likelihood of harm.
F0865 - QAPI Program/Plan, Disclosure/Good Faith Attempt. The facility failed to maintain an effective QAPI program to ensure transportation for outside medical services, placing residents at risk for serious harm.
F0919 - Resident Call System. The facility failed to ensure a functioning call light system was available for residents' bathrooms for 18 residents, placing them at immediate jeopardy of serious harm.
Report Facts
Deficiencies cited: 9
Residents affected by call light system: 18
Facility licensed beds: 145
Inspection Report — May 3, 2023
Life Safety
Date: May 3, 2023
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to have a deficiency in smoke barrier doors that failed to provide the required 20-minute fire resistance rating and did not close properly upon activation of the fire alarm system in three of six smoke compartments.
Deficiencies (1)
K0374 - The facility failed to provide 20-minute fire resistance rating smoke barrier doors that properly closed upon activation of the fire alarm system in three of six smoke compartments.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 17, 2023
Complaint Investigation
Date: Mar 17, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for two complaints, MS #21029 and MS #20483, from 3/15/23 through 3/17/23. The complaints involved Insufficient Food-Dietary Services and Resident Assessment and Quality of Care related to medication administration and following physician orders.
Complaint Details
Complaint MS #21029 involved Insufficient Food-Dietary Services and complaint MS #20483 involved Resident Assessment and Quality of Care related to medication administration and following physician orders. Both complaints were investigated and no deficiencies were 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 during this complaint survey.
Inspection Report — Mar 17, 2023
Complaint Investigation
Date: Mar 17, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility for two complaints, MS #21029 and MS #20483, from 3/15/23 through 3/17/23.
Complaint Details
Complaint MS #21029 alleged Insufficient Food-Dietary Services and MS #20483 alleged Resident Assessment and Quality of Care related to medication administration and following physician orders. Both complaints were investigated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 21, 2022
Complaint Investigation
Date: Dec 21, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #20226 and MS #19859 at the facility from 12/20/22 through 12/21/22.
Complaint Details
Complaint Investigation MS #20226 and MS #19859 were not substantiated and no deficiencies were 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: 2
Inspection Report — Dec 21, 2022
Complaint Investigation
Date: Dec 21, 2022
Visit Reason
The State Agency (SA) conducted a Compliant Investigation, (CI MS #20226 and CI MS #19859) at the facility from 12/20/22 through 12/21/22.
Complaint Details
Complaint Investigation CI MS #20226 was not substantiated for following physician orders or physician services and CI MS #19859 was not substantiated for facility and no deficiencies were cited.
Findings
The SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 6, 2022
Complaint Investigation
Date: Sep 6, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19545 at the facility on 9/06/22.
Complaint Details
Complaint MS #19545 alleged falls, residents not turned or repositioned, and responsible party not being notified of resident's change in condition; the complaint was not substantiated and no deficiencies were cited.
Findings
The survey did not substantiate the complaint for falls, residents not turned or repositioned, and responsible party not being notified of resident's change in condition. There were no deficiencies cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 6, 2022
Complaint Investigation
Date: Sep 6, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19545 at the facility on 9/06/22.
Complaint Details
Complaint CI MS#19545 alleged falls, residents not turned or repositioned, and lack of responsible party notification of a resident's change in condition; the complaint was not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the complaint for falls, residents not turned or repositioned, and responsible party notification of a resident's change in condition. There were no deficiencies cited.
Inspection Report — Aug 9, 2022
Routine
Date: Aug 9, 2022
Visit Reason
The State Agency (SA) conducted a COVID-19 Focused Infection Control survey and Complaint Investigation (CI), MS #19278, MS #18827, and MS #18788 at the facility from 8/8/22 through 8/9/22.
Complaint Details
Complaint Investigation (CI), MS #19278 substantiated for facility not clean with citation F584. CI MS #18827 substantiated for misappropriation of resident property with citation F602. CI MS #18788 substantiated for resident not groomed adequately with citation F677.
Findings
The facility was found in compliance with infection control regulations but was not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to maintain a clean environment, misappropriation of resident property, and inadequate grooming care for dependent residents.
Deficiencies (3)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to provide a clean environment for eight of 17 resident room observations, including dirty walls, rusted overbed tables, missing air conditioner filters, leaking bathroom fixtures, and stained privacy curtains.
F0602 - Free from misappropriation/exploitation. The facility failed to protect one resident from misappropriation of funds when a receptionist cashed four money orders totaling $1,634 instead of submitting them to the business office.
F0677 - ADL care provided for dependent residents. The facility failed to provide adequate perineal care and fingernail care for three dependent residents, with observations of incomplete perineal care and long, dirty fingernails.
Report Facts
Deficiencies cited: 3
Inspection Report — Aug 9, 2022
Routine
Date: Aug 9, 2022
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) at the facility from 8/8/22 through 8/9/22.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 9, 2022
Complaint Investigation
Date: Aug 9, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19278, MS #18827, and MS #18788 at the facility from 8/8/22 through 8/9/22.
Complaint Details
Complaint Investigation (CI), MS #19278 substantiated for facility not clean; MS #18827 substantiated for misappropriation of resident property; MS #18788 substantiated for resident not groomed adequately.
Findings
The facility was found not in compliance with Mississippi state licensure requirements. Deficiencies were cited for misappropriation of resident funds, inadequate activities of daily living care for three residents, and failure to maintain a clean environment in multiple resident rooms.
Deficiencies (3)
M500 - Residents' rights. The facility failed to protect one resident from misappropriation of funds totaling $1,634.00 by a receptionist who cashed money orders instead of submitting them to the business office.
M610 - Activities of daily living. The facility failed to provide adequate and appropriate ADL care for three dependent residents, including improper perineal care and failure to maintain clean and trimmed fingernails.
M1210 - Walls and ceilings. The facility failed to maintain a clean environment in eight resident rooms, with issues including rusted overbed tables, peeling paint, dirty air conditioner filters, leaking sinks, and stained privacy curtains.
Report Facts
Deficiencies cited: 3
Inspection Report — Apr 18, 2022
Complaint Investigation
Date: Apr 18, 2022
Visit Reason
On 04/18/22 the State Agency conducted a desk review of the information provided related to the complaint survey conducted on 2/25/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint survey conducted on 2/25/22; the facility was found in compliance after corrective measures were confirmed.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 04/14/22.
Inspection Report — Feb 25, 2022
Complaint Investigation
Date: Feb 25, 2022
Visit Reason
The State Agency conducted a complaint survey for Complaint Investigations (CI) MS#18317, CI MS #18520 and CI MS#18525 on 2/18/22 through 2/25/22. The SA substantiated CI MS #18520 related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 2/11/22 at approximately 12:30 PM. CI MS#18317 was not substantiated. CI MS #18525 related to abuse was substantiated and M500 was cited at Level II.
Complaint Details
Complaint Investigations (CI) MS#18317, CI MS #18520 and CI MS#18525 were investigated. CI MS #18520 was substantiated related to Resident #1's elopement due to inadequate supervision. CI MS#18317 was not substantiated. CI MS #18525 related to abuse was substantiated.
Findings
The facility was found not in compliance with Minimum Standards due to failure to provide adequate supervision to prevent Resident #1's elopement, placing residents at risk of serious injury. Additionally, the facility failed to protect Resident #3 from verbal abuse by a Housekeeping Supervisor. The Immediate Jeopardy related to the elopement was removed prior to the survey entrance.
Deficiencies (2)
M500 - Residents' rights were violated when the facility failed to protect Resident #3 from verbal abuse by the Housekeeping Supervisor who engaged in a verbal altercation, cursing and name-calling the resident. The Housekeeping Supervisor was suspended and terminated.
M640 - The facility failed to provide adequate staff supervision to prevent Resident #1's elopement on 2/11/22 at approximately 12:30 PM. Staff used an override door code that disabled the wander guard alarm, allowing the resident to exit unnoticed and unsupervised. Resident #1 was found approximately 23 minutes later in a ditch and transported to the emergency room. Immediate Jeopardy was identified and removed after corrective actions were implemented.
Report Facts
Deficiencies cited: 2
Inspection Report — Feb 25, 2022
Complaint Investigation
Date: Feb 25, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Survey for Complaint Investigations (CI) MS#18317, CI MS #18520 and CI MS#18525 on 2/18/22 through 2/25/22. The SA substantiated CI MS #18520 related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement from the facility on 2/11/22 at approximately 12:30 PM.
Complaint Details
CI MS#18520 was substantiated related to an elopement due to the facility's failure to provide adequate supervision to prevent Resident #1's elopement on 2/11/22. Resident #1 was missing for approximately 23 minutes and found in a ditch. The facility was cited for Immediate Jeopardy which was removed prior to survey entrance.
Findings
The facility failed to provide adequate staff supervision for Resident #1, who was an elopement risk with a current display of wandering behaviors, placing this resident and all other residents who exhibit wandering behaviors at risk with a likelihood for serious injury, harm, impairment or death. The facility also failed to ensure residents were protected from verbal abuse for one resident. The Immediate Jeopardy related to the elopement was removed prior to the survey entrance.
Deficiencies (2)
F0600 - The facility failed to ensure residents were protected from verbal abuse for one of three residents reviewed for abuse. The Housekeeping Supervisor engaged in a verbal altercation with Resident #3, using profanity and name-calling, and was terminated.
F0689 - The facility failed to provide adequate staff supervision to prevent Resident #1's elopement from the facility on 2/11/22 at approximately 12:30 PM. Resident #1 was missing and unsupervised for approximately 23 minutes and was found in a ditch near a busy highway. Staff used an incorrect override door code that disabled the Wander Guard alarm system, allowing the resident to exit unnoticed.
Report Facts
Deficiencies cited: 2
Elapsed time resident missing: 23
Cars counted near facility: 45
Cars counted near elopement site: 47
Inspection Report — Nov 18, 2021
Complaint Investigation
Date: Nov 18, 2021
Visit Reason
The State Agency conducted two Complaint Investigations (CIs), MS #18234 and MS #18297, from 11/17/21 through 11/18/21.
Complaint Details
Complaint Investigations MS #18234 and MS #18297 were conducted and not substantiated by the State Agency.
Findings
The State Agency did not substantiate the complaints and found the facility in compliance.
Report Facts
Complaint Investigations conducted: 2
Inspection Report — Nov 18, 2021
Complaint Investigation
Date: Nov 18, 2021
Visit Reason
The State Agency conducted a complaint survey at the facility for Complaint Investigation (CI) MS #18234 for Quality of Care (QOC)/residents not groomed, Abuse/employee to resident, QOC/pressure sores, Quality of Care/responsible representative not being notified of resident changes and MS #18297 for QOC/no weight loss assessment by facility and QOC/responsible representative not being notified of resident changes.
Complaint Details
Complaint Investigation CI MS #18234 and MS #18297 involved allegations of quality of care issues including residents not groomed, abuse, pressure sores, lack of weight loss assessment, and failure to notify responsible representatives of resident changes. The complaints were not substantiated.
Findings
During the survey, the State Agency did not substantiate the complaints and found the facility in compliance.
Report Facts
Complaints investigated: 2
Inspection Report — Oct 4, 2021
Complaint Investigation
Date: Oct 4, 2021
Visit Reason
The State Agency conducted a complaint survey, MS #18005 at the facility on 10/4/21.
Complaint Details
Complaint MS #18005 was investigated but not substantiated; no deficiencies were cited for this complaint.
Findings
The surveyor was unable to substantiate the complaint of allegations of substandard quality of care and cited no deficiencies. However, the facility remains out of compliance due to deficiencies cited on 9/30/21 complaint investigations for CI MS #17609 and CI MS #17315.
Report Facts
Complaints referenced: 3
Inspection Report — Sep 30, 2021
Complaint Investigation
Date: Sep 30, 2021
Visit Reason
The State Agency conducted complaint investigation (CI) MS #17609 and CI MS #17315 from 9/29/21 through 9/30/21. The SA substantiated CI MS #17609 for improper technique during incontinent care and CI MS #17315 for verbal abuse and cited M500.
Complaint Details
Complaint investigation CI MS #17609 and CI MS #17315 substantiated. CI MS #17609 involved improper technique during incontinent care. CI MS #17315 involved verbal abuse, which was substantiated and resulted in citation M500.
Findings
The facility was found not in compliance with Mississippi Regulations for Minimum Standards. The facility failed to prevent verbal abuse for one of four sampled residents (Resident #1), as evidenced by a CNA making disparaging statements within hearing of the resident. The CNA was suspended and subsequently terminated.
Deficiencies (1)
M500 - Residents' Rights. The facility failed to prevent verbal abuse for one of four sampled residents when a CNA made disparaging statements within hearing of Resident #1.
Report Facts
Complaints investigated: 2
Deficiencies cited: 1
Inspection Report — Sep 30, 2021
Complaint Investigation
Date: Sep 30, 2021
Visit Reason
The State Agency conducted complaint investigations (CI) MS #17609 and CI MS #17315 from 9/29/21 through 9/30/21. The facility was found not to be in compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaint investigations CI MS #17609 and CI MS #17315 were substantiated. CI MS #17609 involved improper technique during incontinent care causing potential infection spread and was cited as F880. CI MS #17315 involved verbal abuse and was cited as F600.
Findings
Two deficiencies were cited related to verbal abuse and infection prevention. The facility failed to prevent verbal abuse of one resident and failed to provide incontinent care in a manner to prevent the spread of infection for another resident.
Deficiencies (2)
F0600 - The facility failed to prevent verbal abuse for one of four sampled residents, evidenced by a CNA making disparaging statements within hearing of Resident #1. The CNA was suspended and terminated following investigation.
F0880 - The facility failed to provide incontinent care in a manner to prevent the possible spread of infection for one of three sampled residents. Observation revealed improper perineal care technique leaving fecal matter on the genital area of Resident #4.
Report Facts
Deficiencies cited: 2
Inspection Report — Apr 12, 2021
Date: Apr 12, 2021
Visit Reason
No initial comments text was provided in the document to specify the visit reason.
Findings
The document contains no deficiencies; the facility was found in compliance.
Inspection Report — Mar 4, 2021
Complaint Investigation
Date: Mar 4, 2021
Visit Reason
The State Agency conducted the Complaint Investigations (CI), CI #17590 from 3/2/2021 to 3/4/2021 regarding allegations of failure to follow Professional Standards of Practice for passing the medication cart, nurses being responsible for more than 50 residents at once, nurses punching out medications in advance, staffing ratios, short staffing for CNAs, use of green bedspreads for incontinent pads, residents smoking in rooms, resident on resident physical abuse, wound care, and Hospice placement.
Complaint Details
CI #17590 involved multiple allegations including medication cart passing, staffing ratios, abuse, and care concerns; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Report Facts
Complaint Investigations: 1
Inspection Report — Mar 4, 2021
Complaint Investigation
Date: Mar 4, 2021
Visit Reason
The State Agency conducted the Complaint Investigations (CI), CI #17590 from 3/2/2021 to 3/4/2021 and did not substantiate the complaint for multiple staffing and care concerns but cited F880 for failure to practice best infection control practices during wound care.
Complaint Details
CI #17590 involved allegations of failure to follow professional standards for medication cart passing, nurse staffing ratios, short staffing, use of green bedspreads, resident smoking, resident abuse, wound care referrals, and hospice placement. The complaint was not substantiated except for the cited infection control deficiency.
Findings
The facility was cited for failure to practice best infection control practices by not cleaning an overbed table during wound care, failing to clean scissors prior to cutting tape and gauze, and placing a red bag with contaminated supplies on the floor during wound care observations for three residents.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to clean an overbed table during wound care for Resident #3, failed to clean scissors prior to cutting tape and gauze for Residents #1 and #2, and placed a red bag with contaminated supplies on the floor during wound care for Resident #1.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Sep 30, 2020
Routine
Date: Sep 30, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #17101) was conducted by the State Agency (SA) on 9/30/2020.
Complaint Details
CI MS #17101 The result of the investigation was unsubstantiated with no deficiencies cited for Quality of Care related to Care Not Received Per Physicians Orders, Resident Neglect related to Assess/Monitor, Physical Environment related to Roaches in the Facility, and Nursing Services.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 30, 2020
Routine
Date: Sep 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 9/30/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Sep 8, 2020
Routine
Date: Sep 8, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 9/8/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report — Sep 8, 2020
Routine
Date: Sep 8, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 9/8/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 28, 2020
Complaint Investigation
Date: Jul 28, 2020
Visit Reason
The State Survey Agency conducted a complaint investigation on 7/28/2020 regarding Quality of Care related to No Pressure Sore Precaution and Dietary Services related to Food is Cold.
Complaint Details
CI MS #16730: Complaint investigation regarding Quality of Care related to No Pressure Sore Precaution and Dietary Services related to Food is Cold. The complaint was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/24/20.
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 — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 8, 2020
Routine
Date: Jun 8, 2020
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period in June 2020, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 24, 2019
Annual Inspection
Date: Oct 24, 2019
Visit Reason
The State Agency conducted an annual recertification survey, along with complaint investigations MS #16287, MS #16239, MS #16103, and MS #16272. The SA substantiated MS #16272 for pain medication not available and administered per orders and cited F755 related to the complaint. The SA did not substantiate the other complaints.
Complaint Details
Complaint MS #16272 was substantiated for pain medication not available and administered per orders, resulting in citation of F755. Other complaints MS #16239, MS #16103, and MS #16287 were not substantiated.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements with deficiencies cited at F641, F645, F656, F690, F755, F921, and F926. The Life Safety Code survey found deficiencies at K321, K345, K363, and K916. The Emergency Preparedness survey found the facility in compliance.
Deficiencies (11)
F0641 - Accuracy of Assessments. The facility failed to accurately complete a Minimum Data Set assessment for one resident by incorrectly coding the discharge destination.
F0645 - PASARR Screening for MD & ID. The facility failed to complete a Level II Preassessment Screening and Resident Review for one resident with mental illness diagnoses.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the comprehensive care plan related to catheter care for one resident, including improper catheter care technique by staff.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to prevent cross contamination during catheter care as evidenced by incorrect cleaning technique of catheter tubing for one resident.
F0755 - Pharmacy Services. The facility failed to provide pain medication in a timely manner for one resident, resulting in nine missed doses of Norco due to lack of timely prescription renewal and medication availability.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to have lids sealed on seven biohazard trash cans in the biohazard room where medical waste was placed.
F0926 - Smoking Policies. The facility failed to provide a safe smoking environment as plastic trash cans and plastic bags were used in the smoking area for cigarette butt disposal.
K0321 - Hazardous Areas - Enclosure. The facility had unsealed and improperly installed vent fans in the ceiling in B Hall storage and B Hall central supply rooms, allowing smoke passage and not vented properly.
K0345 - Fire Alarm System - Testing and Maintenance. The facility's fire alarm panel showed a dialer 'trouble signal' indicating a malfunction in the remote annunciator, which was inoperable and lacked power.
K0363 - Corridor - Doors. Several corridor doors including linen closets on B and C halls, kitchen door, and bi-fold doors on B hall closets failed to properly close and positively latch.
K0916 - Electrical Systems - Essential Electric System Alarm Annunciator. The remote annunciator for the facility's generator was inoperable and lacked power, impairing proper alarm notification.
Report Facts
Deficiencies cited: 9
Deficiencies cited: 4
Inspection Report — Oct 24, 2019
Date: Oct 24, 2019
Visit Reason
The document does not contain an INITIAL COMMENTS block stating the survey type or visit reason. It is a Mississippi State Form 6899 dated 10/24/2019 for a licensure survey.
Findings
The facility was found out of compliance with one deficiency related to failure to provide Resident #61's pain medication (Norco) in a timely manner for nine scheduled doses. The issue was due to a breakdown in communication and process for obtaining a hard script from the physician, resulting in the resident experiencing pain without medication for several days.
Deficiencies (1)
M500 - Residents' Rights. The facility failed to provide Resident #61's pain medication as ordered in a timely manner, resulting in the resident missing nine scheduled doses of Norco.
Inspection Report — Apr 24, 2019
Complaint Investigation
Date: Apr 24, 2019
Visit Reason
The State Agency conducted a complaint survey for CI MS #15811, #15847, and #15848 at the facility from April 22, 2019 to April 24, 2019. During the survey, the SA determined the facility was not in substantial compliance with Medicare/Medicaid requirements as evidenced by CI MS #15811 related to Dietary Services being substantiated and the SA cited F808.
Complaint Details
Complaint investigation for CI MS #15811, #15847, and #15848. CI MS #15811 related to Dietary Services was substantiated with deficiencies cited. CI MS #15847 related to Physical Environment and CI MS #15848 related to Quality of Care/Treatment were unsubstantiated with no deficiencies cited.
Findings
The facility failed to serve the physician ordered diet for one of four residents observed, as food items were not served according to the meal tray ticket for Resident #2. The dietary and nursing staff did not consistently ensure meal trays matched physician orders.
Deficiencies (2)
F0808 - Therapeutic Diet Prescribed by Physician. The facility failed to serve the physician ordered diet for one of four residents as food items were not served according to the meal tray ticket for Resident #2.
M0645 - Nutrition. The facility failed to serve the physician ordered diet for one of four residents as food items were not served according to the meal tray ticket for Resident #2.
Report Facts
Deficiencies cited: 2
Inspection Report — Mar 26, 2019
Complaint Investigation
Date: Mar 26, 2019
Visit Reason
A complaint investigation was conducted on March 26, 2019 in the facility.
Complaint Details
CI MS #15753: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Nov 14, 2018
Complaint Investigation
Date: Nov 14, 2018
Visit Reason
A complaint investigation was conducted on November 14, 2018 in your facility.
Complaint Details
CI MS #15527: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 24, 2018
Complaint Investigation
Date: Sep 24, 2018
Visit Reason
A complaint investigation was conducted on September 24, 2018 in the facility.
Complaint Details
CI MS#15420: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Aug 3, 2018
Annual Inspection
Date: Aug 3, 2018
Visit Reason
The State Agency (SA) conducted a State Licensure survey from 7/31/18 through 8/03/18. During the survey the SA determined the facility did not meet the licensure requirements for the State Minimum Standards for the Aged and Infirm.
Findings
The facility was found not in compliance with State Minimum Standards, citing deficiencies in residents' rights, urinary incontinence care, gastric feeding, and nutrition monitoring. The facility failed to ensure dignity and respect for Resident #99, proper incontinent care to prevent infection, restoration of oral eating skills for Resident #99, and accurate weight monitoring for Residents #22, #26, and #129.
Deficiencies (4)
M490 - Residents' rights were not ensured as Resident #99 was forced to watch her roommate eat despite her desire and ability to eat by mouth, with no interventions to maintain her dignity.
M620 - The facility failed to provide incontinent care to Resident #25 in a manner to prevent infection, as a CNA wiped from back to front contrary to policy.
M635 - The facility failed to ensure Resident #99 received appropriate care to restore oral eating skills, with therapy services discontinued and no follow-up despite recommendations.
M645 - The facility failed to ensure accurate weight monitoring for Residents #22, #26, and #129, with inconsistent weights recorded, lack of re-weighs, and failure to notify physicians of significant weight changes.
Report Facts
Deficiencies cited: 4
Inspection Report — Aug 3, 2018
Annual Inspection
Date: Aug 3, 2018
Visit Reason
The State Agency (SA) conducted an annual survey from 7/31/18 through 08/03/18. During the survey the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid Requirements. Deficiencies were cited in resident rights, privacy, care planning, wound care, incontinent care, nutrition, tube feeding management, and sprinkler system supervisory signals.
Deficiencies (9)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure Resident #99 was treated with dignity and respect, allowing her to watch her roommate eat despite her desire to eat and swallow.
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to provide privacy during wound care for Resident #19 as the curtain and door were left open exposing the resident.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans related to wound care, incontinent care, nutrition, and enteral tube feeding for six residents, including Resident #5, #22, #26, #99, and #129.
F0657 - Care Plan Timing and Revision. The facility failed to revise Resident #56's care plan to include a fall incident on 07/23/18 and corresponding interventions.
F0658 - Services Provided Meet Professional Standards. The facility failed to follow physician orders for wound care and vaginal cream application for Resident #5 and failed to obtain a follow-up urinalysis with culture and sensitivity for Resident #25.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to provide incontinent care to Resident #25 in a manner to prevent spread of infection by wiping from back to front instead of front to back.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to ensure accurate weight monitoring for Residents #22, #26, and #129, with inconsistent weights recorded and failure to reweigh residents with significant weight changes.
F0693 - Tube Feeding Management/Restore Eating Skills. The facility failed to provide appropriate care and services to restore oral eating skills for Resident #99 with a feeding tube, including failure to follow speech therapy recommendations and failure to provide therapy services due to lack of approval.
K0352 - Sprinkler System - Supervisory Signals. The facility failed to ensure the water shut off valve to the canopy near the kitchen was electronically monitored and supervised as required.
Report Facts
Deficiencies cited: 9
Total residents: 145
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