Inspection Reports for Diversicare of Meridian

The State Agency conducted three complaint investigations at the facility from January 26 to January 27, 2026, related to abuse, neglect, resident rights, and neglect concerning pressure sores.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Three complaint investigations (CI MS #2722461, CI MS #2722774, and CI MS #2700033) were conducted. CI MS #2722461 and CI MS #2722774 involved abuse, neglect, and resident rights, while CI MS #2700033 involved neglect related to pressure sores. No deficiencies were found.

The State Agency conducted three complaint investigations at the facility from 1/26/26 through 1/27/26 related to abuse, neglect, resident rights, and neglect related to pressure sores.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Three complaint investigations (CI MS #2722461, CI MS #2722774, and CI MS #2700033) were conducted for abuse, neglect, resident rights, and neglect related to pressure sores. The complaints were not substantiated as no deficiencies were cited.

The State Agency conducted complaint investigations related to allegations of neglect, failure to provide appropriate care, and insufficient staffing at the facility from 12/15/2025 through 12/17/2025.

The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Investigations involved four complaint cases: neglect after a resident fall, failure to provide appropriate care including wound care and staff attitudes, neglect related to a resident rash, and allegations of insufficient staffing and unsafe nurse assignments.

The State Agency conducted complaint investigations at the facility from 12/15/2025 through 12/17/2025 related to allegations of neglect, failure to provide appropriate care, and insufficient staffing.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Four complaint investigations were conducted: MS #2678116 regarding neglect after a resident fell and staff conduct; MS #2690785 regarding neglect and failure to provide care including wound care and staff attitudes; MS #2653466 regarding neglect related to a resident's rash; and MS #2638107 regarding insufficient staffing and lack of nursing leadership. No deficiencies were found.

The State Agency conducted a complaint investigation related to quality of care, accidents, and admission/discharge at the facility.

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

Complaint Investigation (CI), MS #2638321, related to quality of care, accidents, and admission/discharge. The complaint was investigated and no deficiencies were found.

The State Agency conducted a Complaint Investigation (CI), MS #2638321, related to quality of care, accidents, and admission/discharge at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #2638321 was related to quality of care, accidents, and admission/discharge. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted complaint investigations and a facility reported incident at the facility from 9/10/25 through 9/11/25 related to allegations of insufficient staffing, neglect resulting in injuries, misappropriation of resident property, and verbal abuse.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

Investigations included allegations of insufficient staffing, neglect when a resident fell and sustained injuries, neglect involving a skin tear not reported to family, misappropriation of resident property, and verbal abuse by a staff member. No deficiencies were cited.

The State Agency conducted complaint investigations and a facility reported incident at the facility from 9/10/25 through 9/11/25 related to allegations of insufficient staffing, neglect resulting in injury, misappropriation of resident property, and verbal abuse by staff.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.

Investigations included allegations of insufficient staffing, neglect when a resident fell and sustained injuries, neglect involving a skin tear not reported to family, misappropriation of resident property, and verbal abuse by a staff member. No deficiencies were cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-05-21 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2025-06-23.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-05-21 to verify compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

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 2025-06-23.

The State Agency conducted a desk review of information related to the annual survey completed on 2025-05-21 to verify compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation. The State Agency recommended the facility be placed back in compliance effective 2025-06-23.

The State Agency conducted a desk review related to the annual survey completed on 2025-05-21 to verify corrective measures and compliance with Medicare and Medicaid requirements.

The facility provided information confirming corrective actions were implemented to address deficiencies, and the State Agency recommended the facility be placed back in compliance effective 2025-06-23.

The State Agency conducted a complaint investigation at the facility on 2025-06-11 regarding falls, neglect, and quality of care.

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

Complaint investigation (CI MS #29044) for falls, neglect, and quality of care; no deficiencies cited.

The State Agency conducted a complaint investigation related to falls, neglect, and quality of care at the facility.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint investigation MS #29044 related to falls, neglect, and quality of care. No deficiencies were cited.

The State Agency conducted an annual recertification survey and two complaint investigations at the facility from 2025-05-18 through 2025-05-21.

No deficiencies were cited related to the two complaint investigations regarding nursing services, quality of care/treatment, resident neglect, and abuse. However, during the annual recertification survey, the facility was found not in compliance with state licensure requirements and cited for deficiencies M 225, M 815, and M 1020.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The State Agency conducted an annual recertification survey and two complaint investigations at the facility from 5/18/25 through 5/21/25. The complaint investigations were regarding nursing services, quality of care, neglect, and abuse, with no deficiencies cited. The annual survey identified noncompliance with state licensure requirements.

The facility was found deficient in staffing levels, food safety and storage, and housekeeping/maintenance issues. Specifically, insufficient nursing staff were available during shift changes, food items were overly ripe or improperly stored, and several resident rooms had exposed sheetrock and other maintenance issues.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The State Agency conducted an annual recertification survey and two complaint investigations at the facility from 2025-05-18 through 2025-05-21.

The complaint investigations regarding nursing services, quality of care, neglect, and abuse resulted in no deficiencies cited. However, the annual recertification survey found the facility not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment, and resident neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The State Agency conducted an annual recertification survey and two complaint investigations at the facility from 5/18/25 through 5/21/25. The complaint investigations were regarding nursing services, quality of care, neglect, and abuse with no deficiencies cited. The annual survey determined noncompliance with Medicare and Medicaid participation requirements.

The facility was found deficient in multiple areas including resident/family group response, safe and homelike environment, accuracy of assessments, care plan timing and revision, sufficient nursing staff, food procurement and storage, and payroll based journal reporting. Deficiencies included failure to promptly resolve resident grievances, unsafe and unclean environment in some rooms, inaccurate MDS coding, outdated care plans, insufficient nursing staff during shift changes, improper food storage, and inaccurate staffing data submission.

Two complaint investigations were conducted: CI MS#28756 regarding nursing services, quality of care/treatment and resident/patient client neglect with no deficiencies cited; and CI MS#29038 regarding abuse with no deficiencies cited.

The inspection was conducted as an annual survey to assess compliance with emergency preparedness and Life Safety Code requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited. The State Agency conducted a desk review confirming corrective measures and recommended the facility be placed back in compliance effective 06/23/25.

The inspection was conducted to assess compliance with the Life Safety Code, specifically focusing on the facility's performance and documentation of fire drills as required by NFPA 101 section 19.7.1.2.

The facility failed to provide complete and proper documentation of fire drills for the calendar year 2024 and the first and second quarters of 2025. A 100% audit was conducted, and fire drills were subsequently performed on each shift between 5/29/25 and 5/30/25. The Administrator provided in-service training to the Maintenance Director on fire drill policies and documentation.

The inspection was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements, including fire safety, smoke barrier doors, fire drills, and electrical systems maintenance.

The facility met emergency preparedness requirements but failed to meet several Life Safety Code standards, including smoke barrier doors not properly closing and latching, incomplete fire drill documentation, and inadequate documentation of generator testing. These deficiencies affected multiple smoke compartments and all 98 residents.

The State Agency conducted a Complaint Investigation at the facility on 04/08/2025 related to three complaint cases: MS #28296 concerning resident grooming and neglect, MS #28495 concerning resident safety, and MS #28503 concerning quality of care.

No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance due to deficiencies cited in a prior survey conducted on 03/13/2025.

Complaint Investigation conducted for MS #28296 (resident not groomed and neglect), MS #28495 (resident safety), and MS #28503 (quality of care). No deficiencies were cited during this investigation.

The State Agency conducted a Complaint Investigation related to three complaint numbers concerning resident grooming and neglect, resident safety, and quality of care at the facility on 4/8/25.

No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance due to deficiencies cited in a prior survey conducted on 03/13/25.

Complaint Investigation (CI), MS #28296, MS #28495, and MS #28503 were investigated related to resident grooming and neglect, resident safety, and quality of care respectively. No deficiencies were cited during this investigation.

The State Agency conducted five complaint investigations at the facility from 3/11/25 through 3/13/25, triggered by multiple complaints including improper medical equipment and pain management, call bells, resident care issues, dietary and quality of care, neglect, and resident rights.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to provide effective and timely pain management for one resident with multiple cancer diagnoses, resulting in unmanaged pain and delayed medication administration. Other complaint investigations related to neglect and resident rights found no deficiencies.

Five complaint investigations were conducted (CI MS #27547, CI MS #27597, CI MS #28040, CI MS #28066, and CI MS #28088). CI MS#28040 was substantiated with deficiencies related to improper medical equipment and pain management. CI MS#27547 and CI MS#27597 involved issues such as call bells, resident care, dietary, and quality of care. CI MS#28066 and CI MS#28088 investigated neglect and resident rights with no deficiencies cited.

The State Agency conducted five complaint investigations at the facility from 3/11/25 through 3/13/25 related to various concerns including improper medical equipment, pain management, call bells, resident hygiene, falls, food quality, dietary and quality of care, neglect, and resident rights.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited during the complaint investigations.

Five complaint investigations (MS #27547, MS #27597, MS #28040, MS #28066, and MS #28088) were conducted. Issues investigated included improper medical equipment and pain, call bells, resident left wet, resident not groomed, falls, food not palatable, dietary and quality of care/treatment, neglect, and resident rights. No deficiencies were cited.

The State Agency conducted a Complaint Investigation at the facility on 11/20/2024 regarding Resident Neglect related to pressure sores, Quality of Care/Treatment related to responsible party not being notified of changes to the resident's condition, and Quality of Life.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint MS #27063 was investigated for Resident Neglect related to pressure sores, Quality of Care/Treatment related to responsible party notification, and Quality of Life. The complaint was found to be unsubstantiated as no deficiencies were cited.

The State Agency conducted a complaint investigation related to Resident Neglect concerning pressure sores, Quality of Care/Treatment regarding notification of responsible parties about changes in resident condition, and Quality of Life.

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

Complaint investigation MS #27063 focused on Resident Neglect related to pressure sores, Quality of Care/Treatment related to responsible party notification, and Quality of Life; no deficiencies were found.

The State Agency conducted a Complaint Investigation at the facility on 11/04/2024 related to resident rights, misappropriation of property, resident neglect, rehabilitation services, and quality of care/treatment related to grooming.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #26579 and MS #26509 were conducted. MS #26509 investigated resident rights and misappropriation of property. MS #26579 investigated resident rights, resident neglect, rehabilitation services, and quality of care/treatment related to grooming. The complaints were not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation related to resident rights, misappropriation of property, resident neglect, rehabilitation services, and quality of care/treatment related to grooming.

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

Complaint Investigation MS #26579 and MS #26509 regarding resident rights, misappropriation of property, resident neglect, rehabilitation services, and quality of care/treatment related to grooming. No deficiencies were cited.

The State Agency conducted a complaint investigation triggered by a facility reported incident regarding an allegation of abuse.

The investigation determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

Complaint Investigation CI #25517 regarding an allegation of abuse; no deficiencies cited.

The State Agency conducted a Complaint Investigation, CI #25517, at the facility from 2024-08-06 to 2024-08-07. The complaint was a facility reported incident regarding an allegation of abuse.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.

Complaint Investigation CI #25517 regarding an allegation of abuse; no deficiencies cited and facility found in compliance.

The State Agency conducted a Complaint Investigation (CI, MS #24864) at the facility on 6/13/24 regarding client services not performed per plan of care and physicians' orders.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.

Complaint Investigation (CI, MS #24864) was for client services not performed per plan of care and physicians' orders; no deficiencies were found.

The State Agency conducted a Complaint Investigation (CI), MS #24864, related to client services not performed per plan of care and physician's orders.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state license requirement. There were no deficiencies cited.

Complaint Investigation MS #24864 was substantiated by the survey, but no deficiencies were cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2024-01-25 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was found to be in compliance based on the information provided, and the State Agency recommended the facility be placed back in compliance effective 2024-02-28.

The State Agency conducted a Complaint Investigation at the facility from 02/12/24 through 02/13/24 related to pressure sores, residents left wet for extended periods, services not provided per the care plan, and resident discharge rights.

No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance with state licensure requirements due to deficiencies cited during the 01/25/24 survey.

Complaint Investigation MS #24080 involved pressure sores, residents left wet for extended periods, and services not provided per the care plan. Complaint Investigation MS #24036 involved resident discharge rights. No deficiencies were cited during this investigation.

The State Agency conducted a complaint investigation related to pressure sores, resident left soiled for an extended time, services not performed per the care plan, and discharge rights.

No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance due to deficiencies cited during a prior survey on 2024-01-25.

Complaint Investigation MS #24080 involved pressure sores, resident left soiled for an extended time, and services not performed per the care plan. Complaint Investigation MS #24036 involved discharge rights. No deficiencies were cited during this investigation.

The State Agency conducted an Annual Recertification Survey at Diversicare of Meridian from January 22 to January 25, 2024, to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with residents' rights and activities of daily living standards. Deficiencies included staff using cell phones in resident rooms and failure to provide shaving assistance to a resident who required it. The facility implemented corrective actions including staff education, resident council meetings, and ongoing monitoring.

The State Agency conducted an annual recertification survey at the facility from 1/22/24 to 1/25/24 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with several requirements including resident rights, accuracy of assessments, comprehensive care planning, ADL care, and activities programming. Deficiencies included staff using cell phones in resident rooms, inaccurate MDS coding for medications, failure to implement care plans for activities, failure to provide shaving for a dependent resident, and failure to assist a resident with activities.

The State Agency conducted a desk review related to the annual survey completed on 01/25/24 to verify corrective measures and compliance with Medicare and Medicaid requirements.

The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance. The State Agency recommended the facility be placed back in compliance effective 02/28/24.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited.

The State Agency conducted a desk review of information related to a complaint survey completed on 2023-11-29 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-01-03.

The visit was related to a complaint survey completed on 2023-11-29. The facility was found to be in compliance based on the desk review.

The State Agency conducted a desk review related to a complaint survey completed on 2023-11-29 to verify corrective measures taken by the facility.

The information provided by the facility confirmed that corrective measures were implemented to address the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-01-03.

The visit was complaint-related, reviewing corrective actions following a complaint survey conducted on 2023-11-29. The facility's corrective measures were accepted and compliance restored.

The inspection was conducted as a complaint investigation (CI MS #23089) due to ongoing unresolved resident complaints regarding poor quality food, meals not served timely, cold meals, and meal preferences not honored.

The facility failed to immediately honor and resolve food/meal grievances and requests from residents, with multiple residents reporting cold food, lack of meat at breakfast, and untimely meal service. Observations confirmed uncovered and cold food served, late meal delivery, and discrepancies between menu and food served. The facility had not posted meal service times and had unresolved grievances dating back several months. The Administrator acknowledged the need for improvement and implemented corrective actions.

The complaint investigation was triggered by resident complaints of poor quality food, meals not served timely, cold meals, and meal preferences not honored. The Ombudsman reported ongoing unresolved issues despite assurances from facility leadership. Multiple grievances were documented from January to October 2023, all related to dietary concerns. The complaint was substantiated with deficiencies cited.

The State Agency conducted three onsite complaint investigations related to unresolved resident complaints about poor quality food, untimely meal service, cold meals, and unhonored meal preferences.

The facility failed to promptly resolve food and meal grievances from residents, with multiple residents reporting cold food, lack of meat at breakfast, and untimely meal delivery. Observations confirmed uncovered and cold food served, inaccurate tray contents, and lack of posted meal service times. The facility acknowledged deficiencies and implemented corrective actions including serving breakfast meat, in-servicing staff, and monitoring meal service.

Complaint Investigation MS #23089 was triggered by ongoing unresolved resident complaints about poor quality food, untimely meal service, cold meals, and unhonored meal preferences. The investigation confirmed deficiencies related to food quality and grievance resolution. Other complaint investigations (MS #23450 and MS #23479) concerning resident rights for dignity and privacy were not cited.

The State Agency conducted a Complaint Investigation at the facility from 10/10/23 through 10/11/23 related to improper incontinence care and services not performed per the plan of care, including resident not turned and repositioned, resident not groomed, and resident left wet for extended periods.

During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.

The complaint investigation involved MS #22898 related to improper incontinence care and MS #22752 for services not performed per the plan of care. The facility was found to be in compliance with no deficiencies cited.

The State Agency conducted two complaint investigations related to improper incontinence care and failure to perform services per the plan of care, including residents not turned and repositioned, not groomed, and left wet for extended periods.

During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.

Two complaint investigations (CI MS #22898 and CI MS #22752) were conducted. The complaints involved improper incontinence care and failure to perform services per the plan of care. The complaints were not substantiated as no deficiencies were cited.

The State Agency conducted a Complaint Investigation at the facility for two complaints from 5/15/23 through 5/16/23.

The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited related to residents left wet, food choices, call bells, and personal items.

The investigation involved two complaints (CI MS #20825 and CI MS #21510) and found no deficiencies.

The State Agency conducted a Complaint Investigation at the facility for two complaints, CI MS #20825 and CI MS #21510, from 5/15/23 through 5/16/23.

During the survey, the State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The investigation of residents left wet, food choices, call bells, and personal items resulted in no deficiencies cited.

The complaint investigation involved two complaints (CI MS #20825 and CI MS #21510) and was substantiated by finding no deficiencies.

The State Agency conducted a Complaint Investigation at the facility from 11/03/22 through 11/04/22 regarding multiple complaint numbers.

The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited and the complaints were not substantiated.

Complaints MS #19620, MS #19638, and MS #19648 were investigated and not substantiated. Issues investigated included physical environment, infection control, quality of care related to medications, incontinent care, pressure ulcers, staffing, dietary services, grooming, and equipment cleanliness.

The State Agency conducted a Complaint Investigation at the facility from 11/03/22 through 11/04/22 involving multiple complaint survey numbers.

The facility was found to be in compliance with Medicare and Medicaid participation requirements. None of the complaints related to physical environment, quality of care, staffing, or dietary services were substantiated, and no deficiencies were cited.

The complaint investigation included MS #19620, MS #19638, and MS #19648. None of the complaints were substantiated.

The State Agency conducted a Complaint Investigation at the facility from 5/16/22 to 5/17/22.

The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.

Complaint Investigation MS #18648 and MS #18649 was conducted and found no deficiencies; the facility was in compliance.

A COVID-19 Focused Infection Control Survey and Complaint Investigation (CI), MS #18648 and MS #18649, was conducted at the facility by the State Agency from 5/16/22 through 5/17/22.

The facility was found to be in compliance with infection control regulations and CMS and CDC recommended practices for COVID-19. The State Agency did not substantiate the complaints related to neglect, resident care, and grooming. No deficiencies were cited.

The State Agency did not substantiate MS #18648 for neglect, resident not turned, weight loss, resident not groomed, and responsible party notification. The State Agency did not substantiate MS #18649 for services not performed per the care plan and resident not groomed.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 5/16/22 through 5/17/22.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The State Agency conducted a Complaint Investigation at the facility from 5/16/22 to 5/17/22.

The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.

Complaint Investigation MS #18648 and MS #18649; no deficiencies cited.

A COVID-19 Focused Infection Control Survey and Complaint Investigation (CI), MS #18648 and MS #18649 was conducted at the facility by the State Agency from 5/16/22 through 5/17/22.

The facility was found to be in compliance with infection control regulations and CMS and CDC recommended practices for COVID-19. The State Agency did not substantiate complaints related to neglect, resident care, and grooming. No deficiencies were cited.

The State Agency did not substantiate MS #18648 for neglect, resident not turned, weight loss, resident not groomed, and responsible party notification. The State Agency did not substantiate MS #18649 for services not performed per the care plan and resident not groomed.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 5/16/22 through 5/17/22.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The State Agency conducted a desk review of information related to the annual survey conducted on 2021-12-03 to verify compliance with Minimum Standards of Operation and state licensure requirements.

The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements. The agency recommended the facility be placed back in compliance effective 2022-01-19.

The State Agency conducted a desk review related to the annual survey conducted on 12/3/21 to verify corrective measures and compliance with Medicare and Medicaid requirements.

The facility provided information confirming that measures were put in place to correct deficient practices and sustain compliance. The State Agency recommended the facility be placed back in compliance effective 01/19/22.

The State Agency conducted an annual recertification survey at the facility from 11/30/2021 to 12/3/2021 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with residents' rights and urinary incontinence care standards. Deficiencies included failure to maintain resident dignity during incontinent care and improper catheter insertion technique, affecting two residents.

The State Agency conducted an annual survey from 11/30/21 through 12/03/21 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to resident dignity during care, failure to follow comprehensive care plans, improper incontinent and catheter care, and infection prevention and control issues.

The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the 2012 Edition of the Life Safety Code (LSC).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No Life Safety Code deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable Federal, State, and local emergency preparedness requirements during the survey.

The State Agency conducted one complaint investigation (#18050) from 9/22/21 through 9/23/21 to evaluate the quality of care at the facility.

The complaint was not substantiated. The facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

Complaint investigation #18050 was conducted and the complaint for Quality of Care was not substantiated.

A COVID-19 Focused Infection Control Survey with Complaint Investigation (CI) #18050 was conducted by the State Agency on 9/22/21 through 9/23/21.

The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. Complaint #18050 was unsubstantiated for Quality of Care.

Complaint Investigation (CI) #18050 was unsubstantiated for Quality of Care.

A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 9/22/21 through 9/23/21.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

The State Agency conducted a complaint investigation (#18050) from 9/22/21 through 9/23/21 regarding quality of care concerns.

The complaint was not substantiated, and the facility was found to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.

Complaint investigation #18050 was conducted and the complaint for quality of care was not substantiated.

A COVID-19 Focused Infection Control Survey with Complaint Investigation (CI) #18050 was conducted by the State Agency on 9/22/21 through 9/23/21.

The facility was found to be in compliance with infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19. Complaint #18050 was unsubstantiated for Quality of Care.

Complaint Investigation (CI) #18050 was unsubstantiated for Quality of Care.

A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 9/22/21 through 9/23/21.

The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.

The State Agency conducted a desk review of information related to a complaint investigation conducted on 2021-06-17 to verify corrective measures taken by the facility.

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Federal and State requirements.

The visit was related to a complaint investigation conducted on 2021-06-17. The desk review confirmed corrective actions were implemented.

The State Agency conducted a desk review related to a complaint investigation that was conducted on 2021-06-17.

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with both Federal and State requirements of participation.

Complaint investigation conducted on 2021-06-17; the desk review confirmed corrective measures were implemented.

The State Agency conducted a complaint survey from 06/15/21 through 06/17/21 for multiple Complaint Investigations related to Quality of Care, Neglect, and unqualified personnel. The visit was triggered by complaints including resident grooming, treatment by staff, and staff qualifications.

The facility was found not in compliance with Minimum Standards of Operation Institutions for the Aged or Infirm and State Licensure requirements. One complaint regarding unqualified personnel was substantiated involving a Certified Nursing Assistant who falsely represented herself as a Licensed Practical Nurse. Other complaints were unsubstantiated.

Complaint Investigations #17832 for Quality of Care (resident not transferred), #16756 for Quality of Care (resident grooming), #17316 for Neglect (resident reported mean treatment), and #17040 for unqualified personnel. CI #17040 was substantiated and cited; others were unsubstantiated.

The State Agency conducted a complaint survey from 06/15/21 through 06/17/21 for multiple complaint investigations related to Quality of Care, Neglect, and unqualified personnel.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to employing an incompetent nursing staff member who falsely represented herself as a Licensed Practical Nurse (LPN). The complaint regarding incompetent nursing staff was substantiated, while other complaints were not substantiated.

The complaint investigation substantiated that CNA #1 was incompetent nursing staff, falsely representing herself as an LPN. Other complaints regarding quality of care, grooming, and neglect were not substantiated.

A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on September 23, 2020.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

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.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

The State Agency conducted an on-site complaint investigation for a facility self-reported incident, CI MS #16415.

The complaint investigation was substantiated, but no facility deficiencies were cited. The facility was found to be in substantial compliance with Medicaid and Medicare requirements.

The complaint investigation CI MS #16415 was substantiated with no deficiencies cited.

The State Agency conducted an on-site complaint investigation for a facility self-reported incident, CI MS #16415.

The complaint investigation was substantiated but no facility deficiencies were cited. The facility was determined to be in substantial compliance with Medicaid and Medicare requirements.

The complaint investigation CI MS #16415 was substantiated with no deficiencies cited.

The State Agency conducted an on-site complaint investigation for a facility self-reported incident, CI MS #16415.

The complaint investigation was substantiated, but no facility deficiencies were cited. The facility was determined to be in substantial compliance with Medicaid and Medicare requirements.

The complaint investigation CI MS #16415 was substantiated with no deficiencies cited.

The State Agency conducted a Complaint Investigation survey triggered by a complaint regarding failure to provide continued Cardiopulmonary Resuscitation (CPR) on a resident with a documented full code status.

The facility failed to continuously provide CPR per American Heart Association guidelines on Resident #1, who had a full code status, resulting in the resident's death and placing other residents at risk. An Immediate Jeopardy was identified and later removed after corrective actions including staff suspension, audits, education, and policy reinforcement.

The complaint was substantiated for failure to provide continued CPR on a resident with a full code status. Immediate Jeopardy and Substandard Quality of Care were identified beginning 8/15/2019. The facility failed to continue CPR until EMS arrival, resulting in resident death.

Complaint investigation triggered by a complaint regarding failure to provide continued CPR on a resident with a full code status until EMS arrival.

The facility failed to continuously provide CPR to Resident #1, who had a full code Advance Directive, resulting in the resident's death. The facility also failed to develop an accurate Baseline Care Plan reflecting the resident's code status. The facility took corrective actions including staff education, audits, and suspension/termination of responsible staff.

The complaint was substantiated for failure to provide continued CPR on a resident with a full code status until EMS arrival or without a Do Not Resuscitate order. The facility was found noncompliant with Medicare and Medicaid participation requirements.

The State Agency conducted an annual recertification survey along with a complaint investigation from 3/25/2019 through 3/28/2019 to determine compliance with Medicare and Medicaid requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to notice requirements before transfer/discharge, coordination and certification of assessments, and food procurement and sanitation. The complaint investigation was unsubstantiated.

Complaint investigation (CI MS #15730) was conducted and found to be unsubstantiated.

The State Agency conducted a recertification survey from March 25, 2019 through March 28, 2019 to determine compliance with the Minimum Standards for the Age & Infirm.

The facility was found not in compliance due to failure to store and handle food in a sanitary manner, including personal items being stored on kitchen prep tables causing potential cross-contamination and wet nesting of dishes. The dietary manager acknowledged these issues and corrective actions were planned.