Inspection Reports for
Courtyards Community Living Center
907 East Walker Street, Fulton, MS, 38843
Back to Facility Profile44 Reports
Inspection Report — Jul 7, 2026
Annual Inspection
Date: Jul 7, 2026
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual recertification/complaint survey completed on 05/18/26-05/21/26.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency is recommending the facility be placed back in compliance effective 07/01/26.
Report Facts
Deficiencies cited: 0
Inspection Report — May 21, 2026
Annual Inspection
Date: May 21, 2026
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigation (CI), MS #3005320 at the facility from 5/18/2026 through 5/21/2026. CI MS #3005320 was investigated with no citations related to allegations of mold in the building.
Complaint Details
Complaint Investigation (CI), MS #3005320 was investigated with no citations related to allegations of mold in the building.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing six deficiencies related to care planning, ADL care, infection control, resident rights, environment, and assessment accuracy.
Deficiencies (6)
F0656 - The facility failed to develop and implement comprehensive ADL care plans addressing nail care needs for two residents and failed to implement established nail care interventions for one resident.
F0677 - The facility failed to provide necessary ADL care to maintain personal hygiene for two residents, as evidenced by long, jagged fingernails posing risk of skin tears and infection.
F0880 - The facility failed to maintain infection control practices by improperly storing respiratory equipment and failing to properly discard soiled items for two residents.
F0550 - The facility failed to ensure residents were treated with dignity and respect by leaving one resident exposed with the door open and privacy curtain undrawn during care.
F0584 - The facility failed to ensure a clean, homelike environment for one resident, as evidenced by heavy dust accumulation in the resident's room.
F0641 - The facility failed to ensure the Minimum Data Set assessment accurately reflected the resident's status, incorrectly coding a fall with major injury for one resident.
Report Facts
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
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Inspection Report — May 20, 2026
Life Safety
Date: May 20, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Sep 25, 2025
Complaint Investigation
Date: Sep 25, 2025
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI) MS #2578773 at the facility on 09/25/25.
Complaint Details
Complaint number CI MS #2578773 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Jun 23, 2025
Annual Inspection
Date: Jun 23, 2025
Visit Reason
On 06/23/25 the State Agency conducted a desk review of the information provided related to the annual survey completed on 05/22/25. The facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 06/20/25. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 20, 2025
Life Safety
Date: Jun 20, 2025
Visit Reason
On 06/20/25 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey conducted on 05/22/25. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 06/20/25.
Inspection Report — May 22, 2025
Life Safety
Date: May 22, 2025
Visit Reason
Survey conducted on 5/22/25 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all emergency preparedness requirements. No deficiencies were cited.
Inspection Report — May 22, 2025
Life Safety
Date: May 22, 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 was found to have deficiencies in protecting hazardous areas and corridor doors. Specifically, unsealed ceiling penetrations were observed in the boiler room and soiled linen room, and corridor doors to the clean linen and electrical rooms did not positively latch.
Deficiencies (2)
K0321 - Hazardous areas were not properly protected as required by NFPA 101; unsealed ceiling penetrations were found in the boiler room and soiled linen room on the 100 hall.
K0363 - Corridor doors to the clean linen room and electrical room on the 100 hallway did not positively latch, failing to resist the passage of smoke as required.
Report Facts
Deficiencies cited: 2
Inspection Report — May 22, 2025
Annual Inspection
Date: May 22, 2025
Visit Reason
The State Agency conducted an Annual Re-certification Survey with one (1) Complaint Investigation (CI MS # 29016) at the facility from 5/19/25-5/22/25. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation and cited F565, F578, F582, F656, F677, F725, F761, and F880. There were no deficiencies cited for CI MS#29016 related to the environment, rodents, Quality of Care and treatment.
Complaint Details
CI MS #29016 was investigated during the survey. The SA determined the facility was in compliance with no deficiencies cited related to the environment, rodents, Quality of Care and treatment for this complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in resident/family group response, advance directives, Medicaid/Medicare coverage notices, comprehensive care plans, ADL care, nursing staff sufficiency, medication storage, and infection prevention and control.
Deficiencies (8)
F0565 - Resident/Family Group and Response. The facility failed to make prompt efforts to resolve a grievance from resident council meetings regarding sheets not being changed on shower days over multiple meetings.
F0578 - Request/Refuse/Discontinue Treatment; Formulate Advance Directive. The facility failed to honor a resident's right to make healthcare decisions for one resident by not asking about code status and not updating records accordingly.
F0582 - Medicaid/Medicare Coverage/Liability Notice. The facility failed to provide the required Advanced Beneficiary Notice to two residents discharged from Part A who continued to live in the facility with skilled benefit days remaining.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement comprehensive care plans for two residents, resulting in missed nail care and showers.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide nail care, shaving, and scheduled showers for two residents in accordance with their care plans.
F0725 - Sufficient Nursing Staff. The facility failed to ensure sufficient nursing staff to meet residents' ADL needs, resulting in missed showers, hygiene care, and nail care for two residents.
F0761 - Label/Store Drugs and Biologicals. The facility failed to safely store medications for two residents by leaving medication unattended at bedside and leaving liquid potassium at bedside after partial consumption.
F0880 - Infection Prevention & Control. The facility failed to use standard precautions during medication administration for one resident and failed to use Enhanced Barrier Precautions during catheter care for another resident.
Report Facts
Deficiencies cited: 8
Complaint investigations: 1
Inspection Report — Apr 30, 2025
Complaint Investigation
Date: Apr 30, 2025
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS #28663 and CI MS #28734) at the facility on 04/30/25.
Complaint Details
Complaint investigation CI MS #28663 and CI MS #28734 found the facility in compliance with no deficiencies cited.
Findings
The SA determined that the facility was in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm, state licensure requirements and there were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jan 23, 2025
Complaint Investigation
Date: Jan 23, 2025
Visit Reason
The State Agency conducted a complaint survey, MS #27498, MS #27592, MS #27682 at the facility from 1/21/25 through 1/23/25.
Complaint Details
Complaint survey MS #27498, MS #27592, MS #27682 was conducted and the complaints were not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited during this complaint survey.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 23, 2025
Follow-Up
Date: Jan 23, 2025
Visit Reason
On 1/23/25, the State Agency (SA) conducted an onsite revisit related to the complaint survey that was completed on 12/11/24. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 1/16/25. No deficiencies were cited in this revisit.
Inspection Report — Dec 17, 2024
Complaint Investigation
Date: Dec 17, 2024
Visit Reason
On 12/17/24 the State Agency (SA) conducted an onsite complaint investigation, CI MS #27346. Although the current investigation resulted in no deficiencies being cited, the facility remains Out of Compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm due to deficiencies cited on the 12/11/24-12/12/24 survey.
Complaint Details
Complaint investigation CI MS #27346 was conducted and resulted in no deficiencies being cited.
Findings
The complaint investigation conducted on 12/17/24 found no deficiencies. The facility remains out of compliance due to prior deficiencies cited on the 12/11/24-12/12/24 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 11, 2024
Complaint Investigation
Date: Dec 11, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #27064 and CI MS #27213) at the facility from 12/11/24 through 12/12/24. The facility was found not in compliance for CI MS #27213 with cited deficiencies F550 and F585, and no deficient practice was found for CI MS #27064.
Complaint Details
Two complaint investigations were conducted (CI MS #27064 and CI MS #27213). Deficiencies were cited for CI MS #27213 (F550 and F585), while no deficient practice was found for CI MS #27064.
Findings
The facility failed to honor residents' rights to dignity and respect for two residents and failed to make prompt efforts to resolve and thoroughly investigate grievances from Resident Council meetings for eight of the last nine meetings.
Deficiencies (2)
F0550 - Resident Rights/Exercise of Rights. The facility failed to honor a resident's right to be treated with dignity and respect for two of four residents reviewed, including incidents where a resident was rudely told to leave the nurses' station area and another resident was spoken to rudely by staff.
F0585 - Grievances. The facility failed to make prompt efforts to resolve and thoroughly investigate grievances from Resident Council meetings for eight of the last nine meetings, including repeated concerns about staff phone use, delayed care, and bed linens not being changed, and failed to keep residents informed of grievance resolutions.
Report Facts
Deficiencies cited: 2
Inspection Report — Sep 18, 2024
Follow-Up
Date: Sep 18, 2024
Visit Reason
The State Agency conducted an onsite revisit related to the complaint survey that was completed on 8/1/24. The information reviewed 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
CI MS# not explicitly stated; the revisit was related to a complaint survey completed on 8/1/24. The facility was found to have corrected the deficiencies and was placed back in compliance.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 9/9/24.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 17, 2024
Complaint Investigation
Date: Sep 17, 2024
Visit Reason
The State Agency conducted three complaint investigations (CI MS #26460, CI MS #26462, and CI MS #26473) at the facility from 9/16/24 through 9/17/24.
Complaint Details
Three complaints (CI MS #26460, CI MS #26462, and CI MS #26473) alleging quality of care, resident safety/falls, responsible party notification, resident neglect, resident abuse, and physical environment issues were investigated and not substantiated.
Findings
The facility was found in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. No deficiencies were cited related to the complaints investigated.
Report Facts
Complaint investigations conducted: 3
Inspection Report — Aug 14, 2024
Complaint Investigation
Date: Aug 14, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI #26119, CI MS #26145, and CI MS #26152) at the facility from 8/13/24 through 8/14/24. The investigations related to pharmacy services for medications, resident rights for grievances concerning call lights, and resident abuse.
Complaint Details
Three complaint investigations were conducted: CI MS #26119 related to pharmacy services and cited F755; CI MS #26145 related to resident rights for grievances concerning call lights and cited F585; and CI MS #26152 related to resident abuse and cited F600.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to failure to promptly resolve grievances about call lights, failure to protect a resident from abuse by staff, failure to control pain for a resident due to unavailable medication, and failure to maintain accurate pharmacy records.
Deficiencies (4)
F0585 - Grievances. The facility failed to make prompt efforts to resolve grievances and communicate steps towards resolution concerning call lights not being answered timely for two of five monthly grievance logs reviewed.
F0600 - Free from Abuse and Neglect. The facility failed to protect one resident from physical, verbal, and mental abuse by a Certified Nursing Assistant who hit the resident's testicles, pinched his nipples, and made humiliating remarks.
F0697 - Pain Management. The facility failed to control pain for a resident who missed two doses of pain medication due to unavailability, resulting in intense pain.
F0755 - Pharmacy Services. The facility failed to have available and administer an ordered pain medication for one resident, resulting in missed doses and uncontrolled pain.
Report Facts
Deficiencies cited: 4
Inspection Report — Aug 14, 2024
Complaint Investigation
Date: Aug 14, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility from 8/13/24 through 8/14/24. The SA investigated CI MS #26119 related to pharmacy services for medications, CI MS #26145 for resident rights for grievances concerning call lights, and CI MS #26152 for resident abuse.
Complaint Details
Complaint investigations CI MS #26119, #26145, and #26152 were conducted. The facility was found not in compliance. CI MS #26119 related to pharmacy services and medication availability, CI MS #26145 related to resident rights and grievances about call lights, and CI MS #26152 related to resident abuse. Deficiencies were cited.
Findings
The facility failed to promptly resolve grievances regarding call lights not being answered timely and failed to protect a resident from physical, verbal, and mental abuse by a staff member. Additionally, the facility failed to have available and administer an ordered pain medication for one resident.
Deficiencies (2)
M500 - Residents' rights. The facility failed to promptly resolve grievances about call lights not being answered timely and failed to protect a resident from physical, verbal, and mental abuse by a staff member.
M700 - General. The facility failed to have available and administer an ordered pain medication for one resident, resulting in missed doses and uncontrolled pain.
Report Facts
Deficiencies cited: 2
Inspection Report — Aug 1, 2024
Complaint Investigation
Date: Aug 1, 2024
Visit Reason
The State Agency conducted Complaint Investigations at the facility from July 31, 2024 through August 1, 2024. The investigation cited F0689 for failure to ensure the supervision and safety of a resident during facility transport related to CI MS #25671. CI MS #26013 was investigated related to an allegation of abuse and no deficiencies were cited.
Complaint Details
Complaint investigation CI MS #25671 cited deficiency F0689 for failure to ensure resident safety during transport. Complaint CI MS #26013 was investigated with no deficiencies cited.
Findings
The facility failed to ensure a resident was kept free from an accident resulting in injury during transport when the resident's wheelchair was not properly secured, causing the resident to roll and sustain a severe leg laceration. The facility confirmed the wheelchair was not locked and the resident was left unattended briefly, resulting in the injury.
Deficiencies (1)
F0689 - The facility failed to ensure the supervision and safety of a resident during transport when the resident's wheelchair was not locked, causing the resident to roll and sustain a severe laceration to the left leg.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 1, 2024
Complaint Investigation
Date: Aug 1, 2024
Visit Reason
The State Agency conducted Complaint Investigations at the facility from July 31, 2024 through August 1, 2024. The investigation cited M640 for failure to ensure the safety of a resident during facility transport related to CI MS #25671. CI MS# 26013 was also investigated related to an allegation of abuse and no deficiencies were cited.
Complaint Details
CI MS# 25671 was investigated for failure to ensure resident safety during transport and deficiencies were cited. CI MS# 26013 was investigated for an allegation of abuse and no deficiencies were cited.
Findings
The facility failed to ensure the safety of a resident during transport when the resident's wheelchair was not properly secured, resulting in a severe leg laceration. The facility did not provide adequate supervision and failed to prevent the accident.
Deficiencies (1)
M640 - The facility failed to ensure a resident was kept free from an accident resulting in injury during facility transport when the resident's wheelchair was not properly secured and the resident was left unattended, causing a severe leg laceration.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 3, 2024
Follow-Up
Date: Apr 3, 2024
Visit Reason
The State Agency (SA) conducted a revisit survey at the facility from 4/2/24 through 4/3/24.
Findings
The SA determined that the facility was back in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with the completion date of 3/19/24.
Inspection Report — Apr 1, 2024
Complaint Investigation
Date: Apr 1, 2024
Visit Reason
The State Agency conducted a complaint survey, MS #24653 at the facility on 4/1/24.
Complaint Details
Complaint MS #24653 regarding resident's rights related to not being treated with dignity and respect was investigated and not substantiated; no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaint regarding resident's rights related to dignity and respect was not substantiated and no deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Mar 12, 2024
Complaint Investigation
Date: Mar 12, 2024
Visit Reason
The State Agency conducted a complaint investigation survey for CI MS #24285 and CI MS #24235 at the facility from 3/11/24 through 3/12/24 with no deficiencies cited.
Complaint Details
Complaint investigation for CI MS #24285 and CI MS #24235 with no deficiencies cited.
Findings
The facility was found to have no deficiencies and remained out of compliance with Medicare and Medicaid participation requirements from 2/20/24.
Report Facts
Complaints investigated: 2
Inspection Report — Feb 20, 2024
Annual Inspection
Date: Feb 20, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation (CI MS# 23999) at the facility from 2/11/24 through 2/20/24. The complaint investigation was related to resident abuse and misappropriation of property.
Complaint Details
Complaint Investigation CI MS# 23999 involved allegations of resident abuse and misappropriation of property. The facility failed to investigate and report an allegation of abuse for Resident #8. The allegation was ultimately unsubstantiated, but the facility did not follow proper reporting procedures.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements and cited multiple deficiencies including an Immediate Jeopardy related to failure to address Resident #13's nutritional needs. The complaint investigation found failures in investigating and reporting an allegation of abuse for Resident #8 and medication errors affecting residents.
Deficiencies (20)
F0580 - Notification of Changes. The facility failed to notify appropriate parties timely regarding significant changes in resident condition.
F0600 - Freedom from Abuse, Neglect, and Exploitation. The facility failed to prevent abuse and properly investigate and report an allegation of abuse involving Resident #8.
F0604 - Abuse Prevention. The facility failed to prevent abuse as evidenced by the incident involving Resident #8.
F0641 - Resident Rights. The facility failed to ensure residents' rights related to abuse prevention and reporting were protected.
F0656 - Comprehensive Care Plans. The facility failed to develop and implement comprehensive care plans.
F0658 - Resident Assessment. The facility failed to conduct accurate resident assessments.
F0677 - Quality of Care. The facility failed to provide quality care related to nutrition and abuse prevention.
F0684 - Nursing Services. The facility failed to provide adequate nursing services to prevent harm.
F0692 - Nutrition/Hydration Status Maintenance. The facility failed to maintain adequate nutrition and hydration for residents.
F0695 - Physician Services. The facility failed to notify physicians timely of significant changes.
F0700 - Infection Control. The facility failed to maintain infection control standards.
F0726 - Medical Records. The facility failed to maintain accurate medical records.
F0759 - Free of Medication Error Rates 5 Percent or More. The facility had a medication error rate of 7.69%, including missed and incorrect medication administration.
F0760 - Residents are Free of Significant Medication Errors. The facility failed to ensure residents were free of significant medication errors, including missed doses of high-risk medications.
F0801 - Resident Assessment Instrument. The facility failed to complete accurate resident assessments.
F0835 - Administration. The facility failed to ensure effective administration and oversight, including failure to timely remove Immediate Jeopardy.
F0851 - Quality Assurance and Performance Improvement (QAPI) Program. The facility failed to maintain an effective QAPI program.
F0865 - Quality Assurance and Performance Improvement (QAPI) Program. The facility failed to sustain compliance with regulatory requirements.
F0880 - Resident Rights. The facility failed to protect resident rights related to abuse and neglect.
F0919 - Resident Assessment. The facility failed to conduct accurate resident assessments.
Report Facts
Deficiencies cited: 20
Inspection Report — Feb 20, 2024
Life Safety
Date: Feb 20, 2024
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 — Sep 8, 2023
Complaint Investigation
Date: Sep 8, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI) for CI MS #22674 at the facility on 09/07/23.
Complaint Details
Complaint number CI MS #22674 was investigated and found to be unsubstantiated; no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid Services requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 22, 2023
Complaint Investigation
Date: Jun 22, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS #21719) at the facility on 06/22/23.
Complaint Details
Complaint number CI MS #21719 was investigated and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 1, 2023
Routine
Date: Jun 1, 2023
Visit Reason
The State Agency (SA) conducted a COVID-19 Focused Emergency Preparedness Survey from 5/31/23 through 6/1/23.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Nov 2, 2022
Complaint Investigation
Date: Nov 2, 2022
Visit Reason
On 11/02/22 the State Agency (SA) conducted onsite complaint investigations, MS00019669 for alleged neglect of a resident's care and MS00019734 for neglect resulting in a fall and ultimate death of a resident.
Complaint Details
Complaint investigations MS00019669 and MS00019734 for alleged neglect and abuse were not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the allegations for neglect and abuse for either complaint and no deficiencies were cited. The SA determined that the facility was in substantial compliance with the standards for participation in Medicare and Medicaid Services.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 7, 2022
Annual Inspection
Date: Sep 7, 2022
Visit Reason
On 09/07/22 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 08/04/22. 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 09/02/22.
Inspection Report — Aug 4, 2022
Annual Inspection
Date: Aug 4, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey from 08/01/22 to 08/04/22. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Findings
The facility was found not in compliance due to medication errors including a medication error rate greater than 5 percent, significant medication errors, and infection control issues during medication administration.
Deficiencies (3)
F0759 - Medication error rate greater than 5 percent. The facility failed to maintain a medication error rate of less than 5 percent as evidenced by two errors out of 27 opportunities (7.4%) involving Resident #43, including administering medication via the wrong route and not holding enteral feeding as ordered.
F0760 - Significant medication errors. The facility failed to ensure residents were free from significant medication errors as evidenced by medication given by wrong route and failure to hold enteral feeding for one hour post Dilantin administration for Resident #43.
F0880 - Infection prevention and control. The facility failed to prevent the likelihood of the spread of infection as evidenced by lack of use of a barrier during medication administration for Resident #4, including placing medications on surfaces without disinfecting and no policy regarding use of barriers.
Report Facts
Deficiencies cited: 3
Inspection Report — Aug 2, 2022
Life Safety
Date: Aug 2, 2022
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 — Jul 11, 2022
Complaint Investigation
Date: Jul 11, 2022
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey conducted on 06/02/22. 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 investigation was substantiated but the facility corrected the deficient practice and was placed back in compliance effective 06/29/22.
Findings
The facility was found to be in compliance as of 06/29/22 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 5, 2022
Complaint Investigation
Date: Jul 5, 2022
Visit Reason
On 07/05/2022 the State Agency (SA) conducted a complaint survey for MS00019243.
Complaint Details
Complaint MS00019243 alleged quality of treatment related to pressure ulcers, facility staffing, activities of daily living, and notification of changes; the complaint was not substantiated and no deficiencies were cited.
Findings
The SA determined that the facility followed the requirements for participation in Medicare and Medicaid and did not substantiate the complaint allegation for Quality of treatment related to pressure ulcers, Facility Staffing, Activities of Daily Living (ADLS), or Notification of changes. No deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Jun 2, 2022
Complaint Investigation
Date: Jun 2, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility from 5/31/22 through 6/2/22, for CI#18429 related to pressure ulcer care and treatment, and for facility reported incidents CI#18101 related to drug diversion and CI#18859 related to reported verbal abuse of a resident.
Complaint Details
Complaint investigation for CI#18429 related to pressure ulcer care was not substantiated. Facility reported incidents CI#18101 (drug diversion) and CI#18859 (verbal abuse) were substantiated with deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Two deficiencies were cited related to verbal abuse of a resident and misappropriation of resident property (drug diversion). The complaint for pressure ulcer care was not substantiated.
Deficiencies (2)
F0600 - The facility failed to prevent verbal abuse of a resident as evidenced by an employee calling a resident a profane name. The employee was suspended and terminated following investigation.
F0602 - The facility failed to prevent misappropriation of a resident's medications by a Licensed Practical Nurse who signed out medications for a hospitalized resident and diverted some doses. The nurse was suspended and terminated after investigation.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 14, 2021
Complaint Investigation
Date: Jul 14, 2021
Visit Reason
On 7/14/21 the State Agency conducted a desk review of the information provided related to the complaint investigation conducted on 06/09/21. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Federal and State requirements.
Complaint Details
CI MS#26995 complaint investigation was conducted on 06/09/21. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with both Federal and State requirements based on the desk review of the complaint investigation.
Inspection Report — Jun 30, 2021
Complaint Investigation
Date: Jun 30, 2021
Visit Reason
The State Agency conducted a complaint survey investigation CI MS# 17839 at the facility from 6/29/2021 through 6/30/2021.
Complaint Details
Complaint investigation CI MS# 17839 was conducted and the complaint was not substantiated; no deficiencies were cited.
Findings
The complaint could not be substantiated and no deficiencies were cited. The facility remains in non-compliance due to deficiencies cited on the previous survey.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 9, 2021
Complaint Investigation
Date: Jun 9, 2021
Visit Reason
The State Agency conducted a complaint survey investigating MS CI #17402 from 6/7/2021 through 6/9/2021. The SA substantiated the complaint and deficiencies were cited at F609 related to reporting and F726 related to competent nursing staff.
Complaint Details
Complaint investigation MS CI #17402 was substantiated with deficiencies cited at F609 and F726 related to reporting and competent nursing staff.
Findings
The facility was found not in compliance due to failure to notify the State Agency of an allegation of neglect for one resident and failure to establish a consistent method of weighing residents accurately, resulting in unrecognized significant weight loss for Resident #1.
Deficiencies (2)
F0609 - Reporting of Alleged Violations. The facility failed to notify the State Agency of an allegation of neglect for one resident, Resident #1, after the Resident Representative reported concerns about massive weight loss and neglect.
F0726 - Competent Nursing Staff. The facility failed to establish a consistent method of weighing residents and accurately monitor weight loss for one resident, Resident #1, resulting in unrecognized significant weight loss and inaccurate weight documentation.
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 29, 2020
Routine
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/29/20. The facility was not in substantial compliance with Infection Control.
Findings
F0880 - Infection Prevention & Control. The facility failed to prevent the likelihood of the spread of COVID-19 by not using proper hand hygiene between residents for three of six employees observed delivering lunch trays.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the likelihood of the spread of COVID-19 by not using proper hand hygiene between residents for three of six employees observed delivering lunch trays.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 29, 2020
Routine
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/29/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Aug 24, 2020
Routine
Date: Aug 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/24/20.
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 — Aug 4, 2020
Routine
Date: Aug 4, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/4/20. 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.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
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 — Oct 31, 2019
Annual Inspection
Date: Oct 31, 2019
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at Courtyard CLC from October 29, 2019 to October 31, 2019. During the survey, The State Agency determined that facility was in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found in compliance with Medicare and Medicaid requirements of participation during the annual re-certification survey.
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