Inspection Report Summary
The most recent inspection on November 17, 2025, found the facility in compliance following a desk review confirming corrective measures were implemented after the September 18, 2025 survey, which cited deficiencies related to failure to implement care plans for PEG site care and nail care. Earlier inspections showed a pattern of care plan implementation issues, including inadequate nail care and oral hygiene, medication administration errors, and some documentation problems. Complaint investigations were mostly unsubstantiated, except for a substantiated case in late 2024 involving misappropriation of a resident’s debit card by an agency CNA, which was addressed with staff termination and reimbursement. The facility did not face fines or license actions in the available reports. Recent findings suggest improvement as the facility has corrected prior deficiencies and maintained compliance in subsequent reviews.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
76% occupied
Based on a September 2025 inspection.
Occupancy over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-09-18 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility is recommended to be placed back in compliance effective 2025-10-20.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 17, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2025-09-18 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2025-10-20.
Report Facts
Survey completion date: Nov 17, 2025
Annual survey date: Sep 18, 2025
Compliance effective date: Oct 20, 2025
Inspection Report
Routine
Deficiencies: 4
Date: Sep 18, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care plan implementation, specifically regarding Percutaneous Endoscopic Gastrostomy (PEG) site care and nail care for dependent residents, based on observation, resident and staff interviews, record review, and facility policy review.
Findings
The facility failed to implement residents' care plans for PEG site care for Residents #2 and #9, and nail care for Residents #7 and #48. Observations revealed PEG sites without drainage sponges as ordered and residents with long, jagged fingernails despite care plans specifying nail care. The Director of Nursing acknowledged these failures and confirmed expectations for care plan adherence.
Deficiencies (4)
Failed to implement residents' care plans for PEG site care, including not applying drainage sponges as ordered for Residents #2 and #9.
Failed to provide nail care for dependent residents #7 and #48, resulting in long, jagged fingernails and potential risk for skin issues.
Failed to provide care and assistance to perform activities of daily living for residents unable to do so, specifically nail care for Residents #7 and #48.
Failed to provide appropriate treatment and care according to orders by not utilizing and changing drainage sponges at PEG tube insertion sites for Residents #2 and #9.
Report Facts
Care plans reviewed: 19
Residents affected: 4
BIMS score: 4
BIMS score: 14
BIMS score: 3
Fingernail length: 0.375
Fingernail length: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed no drainage sponge present around Resident #2's PEG tube site during medication administration |
| LPN #4 | Licensed Practical Nurse | Confirmed Resident #7 had long fingernails and care plan for nail care was not followed |
| LPN #2 | Licensed Practical Nurse | Confirmed Resident #9's PEG site was not cleaned properly and lacked drainage sponge |
| LPN #5 | Licensed Practical Nurse | Responsible for cutting Resident #7's fingernails every two weeks and acknowledged risk of skin breakdown |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Confirmed Resident #48 had long, dirty fingernails and brownish yellow substance on hand |
| Director of Nursing | Director of Nursing | Acknowledged failure to follow care plans for PEG site care and nail care; confirmed expectations for care plan adherence and daily PEG site cleaning |
Inspection Report
Annual Inspection
Census: 91
Capacity: 120
Deficiencies: 1
Date: Sep 18, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from September 15 through September 18, 2025, to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to failure to provide adequate nail care for residents requiring assistance with activities of daily living. Specifically, two residents (Resident #7 and Resident #48) had excessively long and unclean fingernails, posing risks for skin issues and infection.
Deficiencies (1)
Failure to provide nail care for residents requiring assistance with activities of daily living, evidenced by long, jagged, and unclean fingernails on Resident #7 and Resident #48.
Report Facts
Census: 91
Total Capacity: 120
Sampled Residents: 19
Residents with Deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #4 | Confirmed Resident #7 had long fingernails and acknowledged risk due to contracture | |
| Licensed Practical Nurse (LPN) #5 | Responsible for cutting Resident #7's fingernails every two weeks and acknowledged risk | |
| Certified Nursing Assistant (CNA) #2 | Confirmed Resident #48 had long, dirty fingernails and explained risks | |
| Director of Nursing (DON) | Provided expectations for nail care frequency and confirmed observations regarding Residents #7 and #48 |
Inspection Report
Annual Inspection
Census: 91
Capacity: 120
Deficiencies: 3
Date: Sep 18, 2025
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 9/15/2025 through 9/18/2025 to determine compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations, citing deficiencies related to failure to implement comprehensive care plans for PEG site care and nail care, failure to provide necessary ADL care including nail care, and failure to provide quality care by not properly maintaining PEG tube sites as ordered.
Deficiencies (3)
Failed to implement residents' care plans for Percutaneous Endoscopic Gastrostomy (PEG) site care and nail care for dependent residents for four of 19 care plans reviewed.
Failed to provide nail care for residents who required assistance with Activities of Daily Living (ADLs) for 2 of 19 sampled residents.
Failed to ensure treatment and care were provided in accordance with professional standards and physician orders by not utilizing and changing a drainage sponge at the PEG tube insertion site for 2 of 3 residents with PEG tubes.
Report Facts
Census: 91
Total Capacity: 120
Care plans reviewed: 19
Residents with care plan deficiencies: 4
Residents sampled for ADL care: 19
Residents with ADL care deficiencies: 2
Residents with PEG tube care deficiencies: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #3 | Confirmed no drainage sponge present around Resident #2's PEG tube site during medication administration observation | |
| Licensed Practical Nurse (LPN) #4 | Confirmed Resident #7 had long fingernails and care plan for nail care was not followed | |
| Licensed Practical Nurse (LPN) #2 | Confirmed Resident #9's PEG site was not cleaned and had no drainage sponge | |
| Director of Nursing (DON) | Confirmed care plans were not followed for PEG site care and nail care; explained expectations for care | |
| Certified Nursing Assistant (CNA) #2 | Confirmed Resident #48 had long, dirty fingernails and brownish yellow substance on hand | |
| Licensed Practical Nurse (LPN) #1 | Confirmed Resident #9's PEG tube site condition and floor nurses' responsibility for PEG care | |
| Licensed Practical Nurse (LPN) #5 | Reported responsibility for cutting Resident #7's fingernails every two weeks | |
| MDS Nurse | Explained purpose of comprehensive care plan and confirmed care plans were personalized |
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
The survey was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements at the facility.
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited. Additionally, the facility met all federal, state, and local emergency preparedness requirements with no deficiencies.
Inspection Report
Complaint Investigation
Census: 92
Capacity: 120
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility related to room temperatures.
Complaint Details
Complaint investigation CI MS #27499 was conducted; the complaint was related to room temperatures and was found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited regarding the physical environment or room temperatures.
Inspection Report
Complaint Investigation
Census: 92
Capacity: 120
Deficiencies: 0
Date: Feb 12, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI MS #27499) at the facility on 02/12/25.
Complaint Details
Complaint investigation CI MS #27499 was conducted and found no deficiencies; the facility was in compliance.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Report Facts
Census: 92
Total licensed capacity: 120
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's debit card by a staff member at the facility.
Complaint Details
The complaint investigation substantiated that an agency CNA misappropriated Resident #1's debit card, making unauthorized purchases totaling $242.82. The facility reimbursed the resident and took corrective actions. The incident was reported to the State Department of Health, Attorney General's Office, Local Police Department, and the staffing agency. The CNA was terminated and barred from returning.
Findings
The facility failed to protect Resident #1 from misappropriation of property when an agency CNA used the resident's debit card for unauthorized purchases totaling $242.82. The facility conducted an immediate investigation, reported the incident to authorities, terminated the CNA, reimbursed the resident, and implemented corrective actions including staff in-service and updated policies.
Deficiencies (1)
Failed to protect a resident's right to be free from misappropriation of property when an agency CNA used Resident #1's debit card for unauthorized purchases.
Report Facts
Unauthorized debit card charges: 242.82
Agency CNA shift duration: 7.82
Date of incident notification: Oct 10, 2024
Date of reimbursement: Oct 11, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Agency Certified Nursing Assistant | Identified as the staff member who misappropriated Resident #1's debit card and made unauthorized purchases. |
| Administrator | Administrator (ADM) | Interviewed regarding the incident, investigation, and corrective actions. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding the incident, investigation, and corrective actions. |
| Social Worker | Social Worker (SW) | Assisted Resident #1 with canceling the debit card and participated in the investigation. |
| Registered Nurse #1 | Registered Nurse (RN #1) | Notified ADM and DON about the missing debit card. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 120
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a complaint investigation related to misappropriation of property at the facility.
Complaint Details
The complaint investigation (CI MS #26743) was substantiated with findings of misappropriation of property by an agency CNA. The facility was found to be in compliance as of 10/11/24 after corrective actions were implemented.
Findings
The facility failed to protect a resident's right to be free from misappropriation of property when an agency CNA used Resident #1's debit card for unauthorized purchases totaling $242.82. The facility conducted an immediate investigation, reported the incident to authorities, reimbursed the resident, and implemented corrective actions including staff in-service and policy changes.
Deficiencies (1)
Failed to protect a resident's right to be free from misappropriation of property.
Report Facts
Unauthorized debit card charges: 242.82
Census: 95
Total licensed capacity: 120
Agency CNA shift duration: 7.82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Victim of misappropriation of property. |
| Administrator | Administrator | Conducted investigation and reported incident. |
| Director of Nursing | Director of Nursing | Involved in notification and investigation of the incident. |
| Social Worker | Social Worker | Assisted resident with canceling debit card and investigation. |
| Certified Nursing Assistant #1 | Agency CNA | Staff member who misappropriated Resident #1's debit card. |
| Registered Nurse #1 | Registered Nurse | Notified administration of lost debit card. |
Inspection Report
Complaint Investigation
Census: 95
Capacity: 120
Deficiencies: 1
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 11/25/2024 regarding resident rights and misappropriation of property involving Resident #1.
Complaint Details
The complaint investigation was substantiated as past non-compliance. The facility reimbursed Resident #1 for unauthorized debit card charges totaling $242.82 made by an agency CNA. The CNA was terminated and placed on a 'do not return' status. The incident was reported to the State Department of Health, Attorney General's Office, local police, and staffing agency.
Findings
The facility was found to have past non-compliance related to misappropriation of Resident #1's debit card by an agency CNA, resulting in unauthorized charges totaling $242.82. The facility conducted an immediate investigation, reimbursed the resident, terminated the responsible staff, and implemented corrective actions including staff in-service and new procedures for handling resident cash and cards.
Deficiencies (1)
Failed to protect a resident's right to be free from misappropriation of property for Resident #1.
Report Facts
Unauthorized debit card charges: 242.82
Resident census: 95
Total licensed capacity: 120
Agency CNA shift hours: 7.82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #1 | Resident | Victim of misappropriation of property. |
| Administrator | Administrator | Notified of missing debit card, led investigation, and reported incident. |
| Director of Nursing | Director of Nursing | Involved in investigation and corrective actions. |
| Social Worker | Social Worker | Assisted Resident #1 with canceling debit card and investigation. |
| RN #1 | Registered Nurse | Notified Administrator and DON of missing debit card. |
| CNA #1 | Certified Nursing Assistant | Agency staff who misappropriated Resident #1's debit card. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-07-18 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-08-26.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 2, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-07-18 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficiencies and sustain compliance with Medicare and Medicaid participation requirements. The State Agency recommended the facility be placed back in compliance effective 2024-08-26.
Report Facts
Annual survey date: Jul 18, 2024
Inspection Report
Routine
Deficiencies: 7
Date: Jul 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, staffing, infection control, and facility safety at Desoto Healthcare Center.
Findings
The facility was found deficient in several areas including failure to have physician orders for physical restraints, late completion of quarterly resident assessments, incomplete implementation of care plans especially related to oral hygiene, medication administration errors, potential food cross-contamination, and inaccurate staffing data submission.
Deficiencies (7)
Failure to ensure a physician's order for a bolster sheet used as a physical restraint for Resident #81.
Failure to complete Quarterly Minimum Data Set (MDS) resident assessments within the required fourteen-day timeframe for Residents #54 and #59.
Failure to implement an Activities of Daily Living (ADL) care plan for Resident #93, specifically related to daily oral care.
Failure to provide daily oral care to Resident #93, resulting in poor oral hygiene.
Failure to prevent the possibility of an accident by medication being found in Resident #52's bed.
Failure to prevent cross contamination to food by not performing hand hygiene after picking up a soiled item during steam table temperature checks.
Failure to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for two quarters of 2024.
Report Facts
Residents sampled: 27
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication dosage: 150
Date of survey completion: Jul 18, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #81's falls and use of bolster sheet without physician order; confirmed medication administration procedures |
| Director of Nursing | Director of Nursing (DON) | Confirmed Resident #81's use of bolster sheet without order; discussed expectations for MDS completion and oral care; acknowledged medication administration protocols and staffing issues |
| LPN/QA #2 | Licensed Practical/Quality Assurance Nurse | Confirmed Resident #81's bolster sheet use without order |
| MDS Nurse | MDS Nurse | Confirmed late completion of MDS assessments for Residents #54 and #59 |
| LPN #1 | Licensed Practical Nurse | Confirmed poor oral hygiene of Resident #93 and failure to provide daily oral care |
| CNA #1 | Certified Nursing Assistant | Confirmed failure to provide daily oral care to Resident #93 |
| LPN #3 | Licensed Practical Nurse | Confirmed medication found in Resident #52's bed |
| LPN #5 | Licensed Practical Nurse | Gave medication to Resident #52 and discussed importance of supervision during medication administration |
| LPN #6 | Licensed Practical Nurse | Gave medication to Resident #52 and discussed supervision during medication administration |
| Dietary Staff #1 | Dietary Staff | Observed failing to wash hands after picking up pen from floor during food temperature checks |
| Administrator | Administrator | Discussed staffing data submission issues and acknowledged food safety concern |
| Payroll Coordinator | Payroll Coordinator | Responsible for submitting staffing data; discussed issues with PBJ system and low staffing triggers |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jul 18, 2024
Visit Reason
The State Agency conducted an annual re-certification survey along with a complaint investigation at the facility from 7/15/24 through 7/18/24 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Complaint Details
The complaint investigation CI MS #25745 was conducted during the survey period, but no deficiencies were cited related to this complaint.
Findings
The facility was found not in compliance with state licensure requirements, citing deficiencies in activities of daily living, accident prevention, and safe food handling procedures. No deficiencies were cited related to the complaint investigation.
Deficiencies (3)
Failure to ensure Activities of Daily Living care was provided daily, evidenced by a resident not receiving daily oral care.
Failure to prevent the possibility of an accident, evidenced by a physician ordered medication found in a resident's bed.
Failure to prevent the possibility of cross contamination to food, evidenced by failure to perform hand hygiene after picking up a soiled item during steam table temperature checks.
Report Facts
Residents reviewed for ADL care: 26
Residents sampled for accident prevention: 27
Medication dosage: 150
Number of kitchen observations: 3
Audit frequency for medication administration: 4
Audit duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Completed oral hygiene for Resident #93 and confirmed failure to provide daily oral care |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding oral care responsibilities and confirmed oral care was not provided |
| Director of Nursing | Director of Nursing | Confirmed oral care responsibilities and medication administration procedures |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Confirmed medication found in resident's bed and proper medication administration procedures |
| Registered Nurse #1 | Registered Nurse | Confirmed medication administration procedures |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Resident #52's nurse who administered medication and described medication administration procedures |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Resident #52's nurse who administered medication and described medication administration procedures |
| Dietary Staff #1 | Dietary Staff | Failed to perform hand hygiene after picking up a soiled item during steam table temperature checks |
| Administrator | Administrator | Acknowledged dietary staff failure to prevent cross contamination |
Inspection Report
Annual Inspection
Census: 99
Capacity: 120
Deficiencies: 7
Date: Jul 18, 2024
Visit Reason
The State Agency conducted an annual re-certification survey along with a complaint investigation at the facility from 7/15/24 through 7/18/24 to determine compliance with Medicare and Medicaid requirements.
Complaint Details
The visit included a complaint investigation CI MS #25745; however, no deficiencies were cited related to this complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited multiple deficiencies including failure to obtain physician orders for restraints, late quarterly assessments, incomplete care plans, inadequate oral care, medication administration errors, food safety violations, and inaccurate payroll-based journal staffing data submissions.
Deficiencies (7)
Failed to ensure a physician's order for a bolster sheet used as a physical restraint for Resident #81.
Failed to complete Quarterly Minimum Data Set (MDS) resident assessments within the required 14-day timeframe for Residents #54 and #59.
Failed to implement an Activities of Daily Living (ADL) care plan, specifically oral care, for Resident #93.
Failed to provide daily oral care to Resident #93, resulting in poor oral hygiene.
Failed to ensure adequate supervision during medication administration; medication was found in Resident #52's bed.
Failed to prevent cross contamination in food service; dietary staff did not perform hand hygiene after picking up a soiled item from the floor.
Failed to accurately submit staffing data into the Payroll-Based Journal (PBJ) system for two quarters in 2024.
Report Facts
Residents sampled: 27
Residents reviewed for care plans: 26
Deficiencies cited: 7
Census: 99
Total capacity: 120
Audit weeks: 4
Audit weeks: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed poor oral hygiene and failure to provide daily oral care for Resident #93 |
| Certified Nursing Assistant #1 | CNA | Responsible for oral care and personal hygiene of Resident #93; received in-service training |
| Director of Nursing | DON | Confirmed deficiencies related to restraint orders, oral care, and MDS assessments; involved in staff education and corrective actions |
| Registered Nurse #1 | RN | Interviewed regarding restraint use and medication administration |
| Licensed Practical Nurse #3 | LPN | Confirmed medication found in Resident #52's bed |
| Licensed Practical Nurse #5 | LPN | Resident #52's nurse; discussed medication administration procedures |
| Licensed Practical Nurse #6 | LPN | Resident #52's nurse; discussed medication administration procedures |
| Payroll Coordinator | Responsible for submitting Payroll-Based Journal staffing data; involved in audit and corrective actions | |
| Dietary Staff #1 | Failed to perform hand hygiene after picking up a soiled item during food temperature checks |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jul 16, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements and the Life Safety Code (LSC) provisions.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited. Additionally, there were no Life Safety Code deficiencies identified during the survey.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 0
Date: May 14, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 05/14/24 based on complaint investigations CI MS #24209 and CI MS #25051.
Complaint Details
Complaint investigations CI MS #24209 and CI MS #25051 were conducted and found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements, with no deficiencies cited.
Report Facts
Census: 86
Total licensed capacity: 120
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 0
Date: May 14, 2024
Visit Reason
The State Agency conducted a complaint investigation related to Misappropriation of Property and Accidents at the facility.
Complaint Details
The complaint investigation involved allegations of Misappropriation of Property and Accidents. No deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during this complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
The inspection was conducted following a complaint and incident involving Resident #1 who sustained a fracture due to failure of staff to follow the resident's care plan for transfers using a mechanical lift.
Complaint Details
The complaint investigation revealed that Resident #1 was transferred three times on 12/28/23 without using the required total lift and two staff assistance, resulting in a fracture. The CNAs admitted to manual and sit to stand transfers contrary to the care plan. The facility notified the State Agency and Attorney General, suspended and terminated the CNAs, and conducted staff in-services.
Findings
The facility failed to implement the comprehensive person-centered care plan for Resident #1, resulting in three improper transfers without the required total lift and two staff assistance. This led to a closed nondisplaced fracture of the medial condyle of the right femur. The facility conducted an investigation, suspended and terminated the involved CNAs, and implemented corrective actions including staff in-services and QA meetings.
Deficiencies (2)
Failed to implement a complete care plan that meets all the resident's needs, specifically failing to use a mechanical lift for transfers as required.
Failed to ensure adequate supervision and assistance devices to prevent accidents, resulting in a fracture due to improper transfers.
Report Facts
Residents sampled: 11
Residents affected: 1
Transfers performed improperly: 3
CNA terminations: 3
BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Admitted to manual transfers and sit to stand lift use contrary to care plan; terminated after investigation |
| CNA #2 | Certified Nurse Aide | Admitted to manual transfers contrary to care plan; involved in training CNA #1; terminated after investigation |
| CNA #3 | Certified Nurse Aide | Assisted with manual transfer contrary to care plan; terminated after investigation |
| Administrator | Provided information on investigation, staff training, and corrective actions | |
| Director of Nursing | Director of Nursing (DON) | Led investigation, confirmed staff training and notification to authorities |
| Nurse Practitioner | Nurse Practitioner (NP) | Ordered X-rays and hospital evaluation for Resident #1's pain and fracture |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 1
Date: Jan 30, 2024
Visit Reason
The State Agency conducted twelve complaint investigations at the facility from 2024-01-23 through 2024-01-30 to assess compliance with Minimum Standards and state licensure requirements.
Complaint Details
The complaint investigation involved Resident #1 who was transferred improperly by three CNAs on 2023-12-28, resulting in a fracture. The CNAs admitted to not using the required total lift and were terminated. The facility notified the State Agency and Attorney General's office timely and implemented corrective actions including staff training and audits.
Findings
The facility was found to be in compliance with most complaint investigations except for one involving Resident #1, who suffered a closed nondisplaced fracture of the medial condyle of the right femur due to improper transfers by three CNAs. The facility failed to ensure adequate supervision and use of assistance devices as required by the resident's care plan. The CNAs were suspended and terminated, and corrective actions including staff in-services and audits of care plans were implemented prior to the survey.
Deficiencies (1)
Failed to ensure adequate supervision and assistance devices to prevent accidents for Resident #1, resulting in a fracture due to improper transfers.
Report Facts
Number of residents sampled: 11
Number of complaint investigations: 12
Number of CNAs involved: 3
Number of beds licensed: 120
Census: 86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Admitted to improper manual transfers and sit to stand lift without assistance, involved in Resident #1's injury |
| CNA #2 | Certified Nurse Aide | Admitted to assisting with improper manual transfers of Resident #1 |
| CNA #3 | Certified Nurse Aide | Admitted to assisting with improper manual transfers of Resident #1 |
| Administrator | Notified of Resident #1's injury, initiated investigation and corrective actions | |
| Director of Nursing | DON | Led investigation, confirmed training and notification to State Agency and Attorney General |
| Nurse Practitioner | NP | Ordered X-rays and hospital transfer for Resident #1 |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 2
Date: Jan 30, 2024
Visit Reason
The State Agency conducted twelve complaint investigations at the facility from 1/23/24 through 1/30/24, including one related to Quality of Care/treatment when a resident was transferred improperly resulting in a major injury.
Complaint Details
The complaint investigations included multiple issues, with the key complaint related to Resident #1's improper transfer causing a major injury. The facility was found in compliance with other complaint investigations. The deficient practice related to Resident #1 was determined to be past non-compliance with corrective actions implemented prior to survey entrance.
Findings
The facility failed to implement the comprehensive person-centered care plan for one resident (Resident #1) by not using the required total mechanical lift with two staff during transfers, resulting in a closed nondisplaced fracture of the medial condyle of the right femur. The facility conducted an investigation, suspended and terminated the involved CNAs, and implemented corrective actions including staff in-services and audits.
Deficiencies (2)
Failed to implement the comprehensive person-centered care plan for Resident #1 by not using the required total mechanical lift with two staff during transfers, resulting in a fracture.
Failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for Resident #1, resulting in a fracture due to improper transfers.
Report Facts
Complaint Investigations conducted: 12
Resident census: 86
Total licensed capacity: 120
Number of inappropriate transfers: 3
Tylenol dosage: 650
Date of fracture X-ray: Dec 30, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Admitted to manually transferring Resident #1 twice and using sit to stand lift once without assistance, leading to fracture |
| CNA #2 | Certified Nurse Aide | Admitted to assisting with manual transfers of Resident #1 contrary to care plan |
| CNA #3 | Certified Nurse Aide | Assisted CNA #1 with manual transfer of Resident #1 contrary to care plan |
| Administrator | Notified of fracture, initiated investigation, suspended and terminated involved CNAs, and implemented corrective actions | |
| Director of Nursing | DON | Led investigation, obtained statements, notified State Agency and Attorney General, and conducted staff in-services |
| Nurse Practitioner | NP | Ordered X-rays and hospital evaluation for Resident #1 due to pain and suspected injury |
Inspection Report
Complaint Investigation
Census: 99
Capacity: 120
Deficiencies: 0
Date: Oct 26, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 10/25/23 and 10/26/23 to investigate allegations including neglect, quality of care, medication pass observations, resident hygiene, Responsible Party notification, skin assessments, following medical orders, call light response, and resident safety/falls.
Complaint Details
The complaint investigation involved multiple allegations including neglect, quality of care/treatment issues, medication pass observations, resident hygiene, Responsible Party notification, skin assessments, following medical orders, call light response, and resident safety/falls, all of which were found to have no deficiencies.
Findings
The survey determined that the facility was in compliance with Medicare and Medicaid requirements with no deficiencies cited related to the complaint allegations.
Report Facts
Licensed beds: 120
Census: 99
Inspection Report
Complaint Investigation
Census: 99
Capacity: 120
Deficiencies: 0
Date: Oct 24, 2023
Visit Reason
The State Agency conducted a complaint investigation at the facility on 10/24/23 based on multiple complaint investigations (CI MS #22956, CI MS #23007, and CI MS #23169).
Complaint Details
The investigation covered neglect, quality of care/treatment including grooming, medication pass observations, residents left wet and/or soiled, Responsible Party notification, skin assessments, following medical doctor orders, call lights not answered, and resident safety/falls, with no deficiencies cited.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for the Institutions of Aged or Infirm. No deficiencies were cited related to neglect, quality of care, medication pass observations, resident safety, or other investigated areas.
Report Facts
Licensed beds: 120
Census: 99
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey that was completed on 2023-08-10.
Complaint Details
The visit was complaint-related and the facility was found to be in compliance with standards.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 26, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2023-08-10 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey completed on 2023-08-10. The desk review confirmed corrective actions were implemented and compliance was restored.
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 facility was recommended to be placed back in compliance effective 2023-09-21.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to follow care plans and medical orders for one resident, specifically concerning the premature collection of lab work without a proper medical order.
Complaint Details
The complaint investigation found that the facility failed to follow medical orders for lab work for Resident #1. The Nurse Practitioner ordered lab work to be drawn in one week, but the lab was drawn the next day without an MD order. The error was discovered on 07/26/2023 after a family member inquired about the lab draw site.
Findings
The facility failed to follow the care plan and medical orders for Resident #1 by collecting lab work (CBC and BMP) one day early without a Medical Doctor's order. The error was discovered when a family member inquired about the lab draw site, and the lab collection was marked as an error in the facility's lab log. Interviews with staff confirmed the lab was drawn prematurely contrary to the Nurse Practitioner's order.
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs with measurable timetables and actions.
Failed to provide or obtain laboratory tests/services when ordered and promptly inform the ordering practitioner of the results.
Report Facts
Residents sampled: 4
Residents affected: 1
BIMS score: 6
Lab collection date: Jul 26, 2023
Lab order date: Jul 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Quality Assurance Nurse | Named in relation to the lab error and quality assurance regarding lab collection |
| Nurse Practitioner | Named as ordering physician who did not authorize early lab collection | |
| Director of Nurses | Interviewed regarding care plan adherence and lab order procedures |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 120
Deficiencies: 0
Date: Aug 10, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 8/9/23 through 8/10/23 to investigate complaints related to resident rights and quality of care including grooming, services not performed, and resident assessment.
Complaint Details
Complaint Investigation CI MS #22182 and CI MS #22193 were investigated. CI MS #22193 for resident rights found no citations. CI MS #22182 for quality of care related to grooming, services not performed, and resident assessment found the facility in compliance.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm with no citations for both resident rights and quality of care complaints.
Report Facts
Licensed beds: 120
Census: 92
Inspection Report
Complaint Investigation
Census: 92
Capacity: 120
Deficiencies: 2
Date: Aug 10, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility on 8/9/23 through 8/10/23 related to resident rights and quality of care issues including grooming, services not performed, and resident assessment.
Complaint Details
The complaint investigation included two complaint investigations MS #22182 and MS #22193. The facility was compliant with resident rights (MS #22193) but non-compliant for quality of care issues (MS #22182) related to grooming, services not performed, and resident assessment.
Findings
The facility was found in compliance with resident rights but not in compliance with quality of care requirements, resulting in citations for failure to develop and implement a comprehensive care plan and failure to follow physician orders for laboratory services. Specifically, lab work was drawn earlier than ordered without a medical doctor's order, and the care plan was not properly followed.
Deficiencies (2)
Failed to follow care plan for one resident related to lab work being collected without a medical doctor's order.
Failed to follow physician orders for laboratory services; lab work was collected early without an MD order.
Report Facts
Licensed beds: 120
Census: 92
Deficiencies cited: 2
Plan of correction completion date: 9/21/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse, Quality Assurance Nurse | Signed lab error report and interviewed regarding lab order error |
| NP | Nurse Practitioner | Ordered lab work and involved in lab error report |
| Director of Nurses | Director of Nursing | Interviewed regarding care plan compliance and lab order error |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 04/19/23 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the State Agency recommended the facility be placed back in compliance effective 05/22/23.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: May 31, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-04-19 to confirm corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming that corrective measures were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2023-05-22.
Inspection Report
Routine
Deficiencies: 2
Date: Apr 19, 2023
Visit Reason
The inspection was conducted to assess compliance with resident rights and medication storage regulations, including resident choice in dining location and proper storage of controlled medications.
Findings
The facility failed to provide residents an opportunity to choose their dining location, with all evening and weekend meals served in resident rooms without resident choice. Additionally, the facility failed to store controlled medications in permanently affixed locked compartments within locked refrigerators in medication storage rooms.
Deficiencies (2)
Failed to provide residents an opportunity to choose a dining location, with all evening and weekend meals served in resident rooms.
Failed to store controlled medications in separately locked, permanently affixed compartments in locked refrigerators of medication storage rooms.
Report Facts
Survey days: 4
Residents affected: 2
Medication storage rooms observed: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | Certified Nurse Aide | Reported residents were not allowed to eat in the dining room on weekends and informed the Administrator |
| Registered Nurse #1 | Registered Nurse | Weekend supervisor who stated all meals were served in residents' rooms on weekends |
| Certified Nurse Aide #2 | Certified Nurse Aide | Reported supper meals Monday through Friday and all weekend meals were served in residents' rooms |
| Director of Nursing | Director of Nursing | Confirmed residents were not eating in the dining room due to COVID-19 and that eating location was Administrator's decision |
| Administrator | Administrator | Confirmed residents were not given choice about dining location and acknowledged the dining room should have been opened |
Inspection Report
Annual Inspection
Census: 86
Capacity: 110
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The annual recertification survey was conducted from 4/16/23 through 4/19/23 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to failure to provide residents the opportunity to choose their dining location, with all evening and weekend meals served in resident rooms without resident choice. The facility has since taken corrective actions to reopen the dining room for all meals and notify residents of their rights and choices.
Deficiencies (1)
Failure to provide residents an opportunity to choose a dining location, with all evening and weekend meals served in resident rooms.
Report Facts
Census: 86
Total Capacity: 110
BIMS score: 15
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Interviewed regarding dining room meal service and resident choice |
| Registered Nurse #1 | Registered Nurse | Interviewed as weekend supervisor about meal service |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed about weekend meal service and resident preferences |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed about meal service schedule and staffing |
| Director of Nursing | Director of Nursing | Interviewed about dining room meal service and resident choice |
Inspection Report
Annual Inspection
Census: 86
Capacity: 110
Deficiencies: 2
Date: Apr 19, 2023
Visit Reason
The State Agency conducted an annual re-certification survey along with one Complaint Investigation (CI MS #21321) at the facility from April 16 through April 19, 2023.
Complaint Details
Complaint Investigation (CI MS #21321) was related to Quality of Care and the facility was found to be in compliance.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations and cited for deficiencies F 561 (Self-Determination) and F 761 (Label/Store Drugs and Biologicals). The complaint investigation related to Quality of Care was found to be in compliance.
Deficiencies (2)
Facility failed to provide residents an opportunity to choose a dining location, as all evening and weekend meals were served in resident rooms without choice, affecting residents #8 and #15.
Facility failed to store controlled medications in separately locked, permanently affixed compartments in locked refrigerators of medication storage rooms for two medication storage rooms observed.
Report Facts
Census: 86
Total Capacity: 110
Plan of Correction Completion Date: May 22, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident #8 | Named in deficiency related to dining location choice | |
| Resident #15 | Named in deficiency related to dining location choice | |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding weekend meal service in rooms |
| Certified Nurse Aide #2 | Certified Nurse Aide | Interviewed regarding meal service and staffing |
| Registered Nurse #1 | Registered Nurse | Weekend supervisor interviewed about meal service |
| Director of Nursing | Director of Nursing | Interviewed about dining room meal service and medication storage |
| Administrator | Administrator | Interviewed about dining room meal service and medication storage |
Inspection Report
Life Safety
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Date: Apr 17, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The State Agency conducted a complaint survey from 3/21/23 to 3/23/23 investigating multiple complaints regarding discharge rights, neglect, abuse, resident rights, incontinent care, pressure ulcers, falls, environment, quality of care, following MD orders, and safety.
Complaint Details
The survey investigated complaints MS CI #20999, MS CI #21000, MS CI #21007, MS CI #20910, and MS CI #20603 for allegations including discharge rights, neglect, abuse, resident rights, incontinent care, pressure ulcers, falls, environment, quality of care, following MD orders, and safety, and cited no deficiencies.
Findings
The survey found the facility in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 120
Census: 85
Inspection Report
Complaint Investigation
Census: 85
Capacity: 120
Deficiencies: 0
Date: Mar 23, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility from 3/21/23 to 3/23/23 involving multiple complaint investigation numbers.
Complaint Details
The complaint survey included investigations MS CI #20999, MS CI #21000, MS CI #21007, MS CI #20910, and MS CI #20603. None of the complaints were substantiated.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding discharge rights, neglect, abuse, resident rights, incontinent care, pressure ulcers, falls, environment, quality of care, following MD orders, and safety were not substantiated and no deficiencies were cited.
Report Facts
Licensed beds: 120
Census: 85
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 23, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 01/16/2023 to 01/22/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during the required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Census: 83
Capacity: 120
Deficiencies: 0
Date: Jul 30, 2021
Visit Reason
The State Agency conducted an onsite complaint investigation concerning alleged physical abuse.
Complaint Details
The complaint investigation was related to alleged physical abuse, which was determined to be unsubstantiated.
Findings
The allegation of abuse was unsubstantiated, no deficiencies were cited, and the facility was found to be in substantial compliance with Medicare and Medicaid standards.
Inspection Report
Complaint Investigation
Census: 83
Capacity: 120
Deficiencies: 0
Date: Jul 30, 2021
Visit Reason
The State Agency conducted an onsite complaint investigation concerning alleged physical abuse.
Complaint Details
Complaint investigation CI MS #17937 regarding alleged physical abuse was unsubstantiated.
Findings
The allegation of abuse was unsubstantiated and no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid standards.
Report Facts
Facility census: 83
Total licensed capacity: 120
Inspection Report
Follow-Up
Census: 84
Capacity: 120
Deficiencies: 0
Date: Jul 13, 2021
Visit Reason
The State Agency conducted a revisit to the complaint survey of 6/10/2021 from 7/12/2021 through 7/13/2021 to determine compliance with Medicare and Medicaid program requirements.
Complaint Details
This was a revisit to a complaint survey conducted on 6/10/2021. The facility was found to be in compliance during the revisit.
Findings
During the revisit, the State Agency determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid program.
Inspection Report
Follow-Up
Census: 84
Capacity: 120
Deficiencies: 0
Date: Jul 13, 2021
Visit Reason
The State Agency conducted a revisit to the complaint survey of 6/10/2021 from 7/12/2021 through 7/13/2021 to determine compliance with Medicare and Medicaid program requirements.
Complaint Details
Revisit to complaint survey of 6/10/2021; facility found in compliance.
Findings
During the revisit, the State Agency determined that the facility was in compliance with the requirements of participation in the Medicare and Medicaid program.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
The State Agency conducted a complaint survey from 6/7/21 to 6/11/21 due to complaints including ants in the building and other issues such as falls and pressure ulcers. The survey focused on substantiating these complaints and assessing compliance with state licensure requirements.
Complaint Details
The complaint survey substantiated MS #17551 for ants in the building. Other complaints related to falls, pressure ulcers, and involuntary discharge were not substantiated.
Findings
The facility was found not in compliance due to failure to maintain effective pest control against ants, evidenced by repeated sightings and numerous ant bites to a resident. The facility had multiple ant sightings over time despite routine pest control visits. Resident #1 suffered ant bites requiring emergency treatment. Other residents reported occasional ant sightings but no bites. The facility implemented corrective actions including cleaning, pest control treatments, staff education, and ongoing audits.
Deficiencies (1)
Failure to maintain effective pest control against ants, resulting in repeated sightings and numerous ant bites to a resident.
Report Facts
Licensed beds: 120
Resident census: 86
Ant sightings: 26
Ant sightings: 18
Pest control visits: 2
Call back visits: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Found Resident #1 covered in ants and involved in initial response | |
| Licensed Practical Nurse #2 | Assisted in removing ants from Resident #1 and cleaning | |
| Certified Nursing Assistant #2 | Assisted in cleaning Resident #1 and feeding | |
| Director of Nursing | Director of Nursing | Notified of ant infestation and involved in investigation and corrective actions |
| Nurse Practitioner | Nurse Practitioner | Notified of Resident #1 condition and involved in treatment |
| Maintenance Staff #1 | Maintenance Supervisor | Reported pest control procedures and ant sightings |
| Pest Control Technician | Performed pest control treatments and inspections | |
| Administrator | Administrator | Oversaw pest control contract and corrective actions |
| Licensed Practical Nurse #1 | Reported pest control routine visits and ant sightings | |
| Certified Nursing Assistant #1 | Reported ant sightings in resident rooms | |
| Department Manager | Pest Control Company Department Manager | Provided information on pest control visits and response times |
| Licensed Practical Nurse #2 | Worked night of ant incident with Resident #1 |
Inspection Report
Complaint Investigation
Census: 86
Capacity: 120
Deficiencies: 1
Date: Jun 10, 2021
Visit Reason
The State Agency conducted a complaint survey from 6/7/21 to 6/11/21 to investigate complaints including ants in the building and failure to report a fall with major injury, pressure ulcers, falls, assessment/monitoring, and involuntary discharge.
Complaint Details
The complaint survey substantiated MS #17551 for ants in the building and cited F689. The SA did not substantiate MS #17339 for failure to report a fall with major injury, MS #17509 and MS #17215 for pressure ulcer, fall, and assessment/monitoring, and MS#17113 for involuntary discharge.
Findings
The facility was found not in compliance due to failure to maintain effective pest control against ants, resulting in repeated sightings and numerous ant bites to one resident. Other complaints were unsubstantiated and no deficiencies were cited for them. The facility had ongoing pest control measures but ants were still present, especially during rainy seasons.
Deficiencies (1)
Failure to maintain an effective pest control against ants, evidenced by repeated sightings and numerous ant bites to a resident.
Report Facts
Licensed beds: 120
Resident census: 86
Ant sightings: 26
Ant sightings: 18
Pest control visits: 2
Call back visits: 2
Pest control follow-up visits: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | First person to find Resident #1 covered in ants and involved in resident care and notification | |
| Licensed Practical Nurse #2 | Involved in care of Resident #1 during ant incident | |
| Certified Nursing Assistant #2 | Assisted in cleaning Resident #1 during ant incident | |
| Director of Nursing | Director of Nursing | Notified about ant incident, involved in investigation and follow-up inspections |
| Nurse Practitioner | Nurse Practitioner | Notified about ant incident and involved in resident treatment |
| Maintenance Supervisor #1 | Maintenance Supervisor | Reported pest control procedures and treatments |
| Pest Control Technician | Provided pest control services and described ant control measures | |
| Administrator | Administrator | Oversaw pest control contract and facility response to ant problem |
| Certified Nursing Assistant #1 | Reported seeing ants in facility | |
| Housekeeping Staff #2 | Reported seeing ants in resident rooms | |
| Licensed Practical Nurse #1 | Reported pest control routine visits and knowledge of ant sightings | |
| Department Manager from pest control company | Described pest control visit schedules and emergency response | |
| Respiratory Therapist | Reported seeing ants in facility | |
| Certified Nursing Assistant #2 | Observed Resident #1 during ant incident | |
| LPN #2 | Worked night of ant incident with Resident #1 |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Mar 31, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #17681) from 03/30/2021 through 03/31/2021.
Complaint Details
Complaint investigation CI MS #17681 was not substantiated for abuse nor for failure to notify the family.
Findings
The facility was found to be in compliance with the Minimum Standards for the Aged or Infirm. The complaint was not substantiated for abuse or failure to notify the family. No deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 0
Date: Mar 31, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI MS #17681) from 03/30/2021 through 03/31/2021.
Complaint Details
Complaint investigation CI MS #17681 was not substantiated for abuse nor failure to notify the family.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated for abuse or failure to notify the family. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Census: 82
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 6, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on January 6, 2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Abbreviated Survey
Census: 73
Capacity: 120
Deficiencies: 0
Date: Aug 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/31/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 73
Capacity: 120
Deficiencies: 0
Date: Aug 31, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 94
Capacity: 120
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/10/2020 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 94
Capacity: 120
Deficiencies: 0
Date: Aug 10, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/10/2020 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/13/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 95
Capacity: 120
Deficiencies: 0
Date: Jul 13, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 7/13/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 93
Capacity: 120
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 6/23/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 93
Capacity: 120
Deficiencies: 0
Date: Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 6/23/2020 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 92
Capacity: 120
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 92
Capacity: 120
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 5/28/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Complaint Investigation
Census: 111
Capacity: 120
Deficiencies: 1
Date: Feb 27, 2020
Visit Reason
The State Agency conducted a licensure and complaint survey from 2/25/2020 to 2/27/2020 related to inappropriate discharge. The complaint was not substantiated, but the facility was found not in compliance with state statute M655 regarding special needs care.
Complaint Details
The complaint was related to inappropriate discharge. The complaint was not substantiated and no deficiencies were cited related to the complaint.
Findings
The facility failed to ensure proper storage and labeling of oxygen cannula and tubing for two residents receiving oxygen therapy, risking infection or cross contamination. The Respiratory Therapist and nursing staff were counseled, and corrective actions including audits and in-service training were initiated.
Deficiencies (1)
Failed to ensure resident's oxygen cannula and tubing was stored to prevent infection or cross contamination for two residents receiving oxygen therapy.
Report Facts
Census: 111
Total Capacity: 120
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Confirmed oxygen tubing was not stored properly for Resident #22 |
| Quality Assurance Nurse #1 | Quality Assurance Nurse | Stored oxygen tubing for Resident #36 and initiated daily audits |
| Respiratory Therapist | Respiratory Therapist | Received counseling and changed oxygen tubing and bags |
| Assistant Director of Nursing | Assistant Director of Nursing | Assessed residents for infection and initiated audits |
| Director of Nursing | Director of Nursing | Interviewed regarding oxygen tubing orders and care plan |
Inspection Report
Annual Inspection
Census: 111
Capacity: 120
Deficiencies: 3
Date: Feb 27, 2020
Visit Reason
The State Agency conducted an annual recertification and complaint survey related to inappropriate discharge from 2/25/2020 to 2/27/2020.
Complaint Details
Complaint related to inappropriate discharge was investigated but not substantiated; no deficiencies were cited related to the complaint.
Findings
The complaint was not substantiated and no deficiencies were cited related to it. However, the facility was found not in compliance with Medicare and Medicaid participation requirements, citing deficiencies in comprehensive care planning, respiratory care, and infection prevention and control.
Deficiencies (3)
Failure to develop and implement a comprehensive care plan for oxygen use, storage of oxygen cannula and tubing, and use of heel boots for pressure area prevention for multiple residents.
Failure to store residents' oxygen cannula and tubing properly to prevent infection or cross contamination for two residents.
Failure to prevent potential spread of infection during medication administration due to inadequate hand hygiene by Licensed Practical Nurse.
Report Facts
Census: 111
Total Capacity: 120
Deficiencies cited: 3
Audit start dates: Mar 2, 2020
Audit duration: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Minimum Data Set Coordinator | Interviewed regarding lack of oxygen care plan for Resident #22 |
| Licensed Practical Nurse #2 | Confirmed oxygen tubing was not dated or stored properly for Resident #22 | |
| Licensed Practical Nurse #3 | Observed failing to perform hand hygiene during medication administration to Resident #29 | |
| Registered Nurse #1 | Interviewed about Resident #22 oxygen use | |
| Director of Nursing | Director of Nursing | Applied heel boots to Resident #3 and provided statements about care plan and resident resistance |
| Respiratory Therapist | Respiratory Therapist | Interviewed about oxygen orders and care plan documentation |
| Quality Assurance Nurse #1 | Initiated audits for oxygen orders and storage | |
| Quality Assurance Nurse #2 | Initiated audits for heel boot use | |
| Assistant Director of Nursing | Assistant Director of Nursing | Assessed residents and confirmed hand hygiene expectations |
| Care Plan Nurse | Care Plan Nurse | Interviewed about care plan revisions and MDS process |
| Staff Education Nurse | Staff Education Nurse | Conducted in-service training on care plans, oxygen use, and hand hygiene |
Inspection Report
Complaint Investigation
Census: 109
Capacity: 120
Deficiencies: 0
Date: Jan 9, 2020
Visit Reason
The State Agency conducted a complaint investigation (#16529) related to allegations of verbal abuse at the facility.
Complaint Details
Complaint Investigation #16529 was not substantiated for verbal abuse.
Findings
The complaint investigation was not substantiated for verbal abuse, no deficiencies were cited, and the facility was found to be in substantial compliance with Medicare and Medicaid participation requirements.
Inspection Report
Annual Inspection
Census: 106
Capacity: 120
Deficiencies: 4
Date: Apr 7, 2019
Visit Reason
The recertification survey was conducted from 04/01/19 through 04/07/19 to assess compliance with federal and state requirements for nursing home licensure and certification.
Findings
The facility was found not in compliance with federal requirements related to residents' rights, abuse prevention, range of motion services, nutrition, and meal service. Deficiencies included failure to prevent and investigate abuse and neglect, failure to follow therapy recommendations for range of motion, failure to ensure therapeutic diet orders were followed, and failure to provide appropriate meal service for residents on dialysis.
Deficiencies (4)
Failed to recognize and prevent abuse and neglect for three residents, including verbal abuse and neglect allegations involving staff.
Failed to ensure Resident #14 received appropriate range of motion services and therapy recommendations to prevent contractures, resulting in bilateral upper and lower extremity contractures.
Failed to ensure Resident #75 received therapeutic diet orders for nectar thickened liquids and was served thin liquids instead.
Failed to ensure Resident #29 received a meal that was appetizing and at the appropriate temperature after returning from dialysis, as meal trays were left at bedside until resident returned.
Report Facts
Census: 106
Total Capacity: 120
Deficiencies cited: 4
Grievances reviewed: 26
Residents interviewed for abuse: 85
Residents assessed for abuse: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #30 | Director of Nursing | Named in findings related to failure to recognize and prevent abuse and neglect, and failure to properly investigate allegations |
| Social Worker #90 | Social Worker and Grievance Officer | Named in findings related to failure to recognize and prevent abuse and neglect, and failure to properly investigate allegations |
| Certified Nursing Assistant #143 | CNA | Named in findings related to verbal abuse and neglect allegations |
| Licensed Practical Nurse #142 | LPN | Named in findings related to verbal abuse allegations |
| Licensed Practical Nurse #105 | LPN | Named in findings related to serving incorrect liquid consistency to Resident #75 |
| Occupational Therapist #1 | Occupational Therapist | Named in findings related to failure to follow therapy recommendations for Resident #14 |
| Restorative Program Licensed Practical Nurse #38 | Restorative Program LPN | Named in findings related to restorative program knowledge and implementation |
| Director of Nursing #12 | Director of Nursing | Named in findings related to meal tray delivery for Resident #29 |
Inspection Report
Annual Inspection
Census: 106
Capacity: 120
Deficiencies: 4
Date: Apr 7, 2019
Visit Reason
The recertification survey was conducted from 04/01/19 through 04/07/19 to assess compliance with federal and state licensure requirements and minimum standards of operation for the facility.
Findings
The facility was found not in compliance with federal requirements and state licensure standards in multiple areas including residents' rights, abuse prevention, range of motion services, nutrition, and meal service. Specific deficiencies included failure to prevent and investigate abuse, failure to follow therapy recommendations for range of motion, failure to ensure therapeutic diet orders were followed, and failure to provide appropriate meal service for residents on dialysis.
Deficiencies (4)
Failed to recognize and prevent abuse and neglect for three residents, including verbal abuse and neglect allegations involving staff.
Failed to ensure Resident #14 received appropriate range of motion services and therapy recommendations, resulting in bilateral upper and lower extremity contractures.
Failed to ensure Resident #75 received therapeutic diet orders for nectar thickened liquids and was served thin liquids instead.
Failed to ensure Resident #29 received a fresh meal upon return from dialysis; meal trays were left at bedside and food was not appetizing.
Report Facts
Census: 106
Total Capacity: 120
Deficiencies cited: 4
Grievances reviewed: 26
Residents interviewed for abuse and neglect: 85
Residents assessed for abuse and neglect: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing #30 | Director of Nursing | Named in findings related to failure to recognize and prevent abuse and neglect, and failure to properly investigate allegations. |
| Social Worker #90 | Social Worker and Grievance Officer | Named in findings related to failure to recognize and prevent abuse and neglect, and failure to properly investigate allegations. |
| Certified Nursing Assistant #143 | CNA | Involved in allegations of verbal abuse and neglect. |
| Licensed Practical Nurse #142 | LPN | Involved in allegation of verbal abuse. |
| Licensed Practical Nurse #105 | LPN | Named in findings related to serving thin liquids to Resident #75. |
| Occupational Therapist #1 | Occupational Therapist | Provided therapy recommendations for Resident #14. |
| Restorative Program Licensed Practical Nurse #38 | Restorative Nurse | Interviewed regarding restorative services for Resident #14. |
| Director of Nursing #12 | Director of Nursing | Interviewed regarding meal tray delivery for Resident #29. |
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