Inspection Reports for
Diversicare of Ripley
101 Cunningham Drive, Ripley, MS, 38663
Back to Facility Profile51 Reports
Inspection Report — Mar 16, 2026
Complaint Investigation
Date: Mar 16, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS# 2785666) at the facility on 3/16/26.
Complaint Details
Complaint number CI MS# 2785666 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 1
Inspection Report — Mar 16, 2026
Follow-Up
Date: Mar 16, 2026
Visit Reason
On 3/16/26 the State Agency conducted an onsite revisit for the annual survey completed 2/8/26 through 2/11/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the requirements of the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 3/6/26.
Inspection Report — Feb 11, 2026
Life Safety
Date: Feb 11, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and no deficiencies were cited during this survey.
Inspection Report — Feb 11, 2026
Annual Inspection
Date: Feb 11, 2026
Visit Reason
The State Agency (SA) conducted an Annual Re-certification survey at the facility from 2/8/26 through 2/11/26. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited in grievances, care planning, ADL care, pressure ulcer treatment, staffing, medication security, assistive devices, payroll reporting, and infection control.
Deficiencies (9)
F0585 - Grievances. The facility failed to ensure concerns voiced during Resident Council meetings about food quality and service were addressed and resolved to residents’ satisfaction over a five-month period.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the comprehensive care plan for one resident, who was not shaved as required by the plan.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide necessary grooming and personal hygiene care, including shaving, for one resident.
F0686 - Treatment/Svcs to Prevent/Heal Pressure Ulcer. The facility failed to provide necessary treatment and services to promote healing of a pressure wound for one resident, including failure to replace soiled wound dressings.
F0725 - Sufficient Nursing Staff. The facility failed to provide sufficient nursing staff to meet resident needs, resulting in delayed call light response, toileting, and assistance with activities of daily living for multiple residents.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure medication carts were secured to prevent unauthorized access for two medication carts observed unlocked and unattended.
F0810 - Assistive Devices - Eating Equipment/Utensils. The facility failed to provide required adaptive eating equipment, specifically a divided plate, to one resident during meals.
F0851 - Payroll Based Journal. The facility failed to accurately submit staffing data into the Payroll Based Journal system for the fourth quarter of 2025 due to inability to capture certain direct care hours.
F0880 - Infection Prevention & Control. The facility failed to utilize enhanced barrier precautions while providing care for residents with wounds and indwelling devices, increasing risk of infection transmission.
Report Facts
Deficiencies cited: 9
Inspection Report — Dec 22, 2025
Complaint Investigation
Date: Dec 22, 2025
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS# 2674192) at the facility on 12/22/25.
Complaint Details
Complaint number CI MS# 2674192 was investigated and found to have no deficiencies cited; the facility was in compliance.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 3, 2025
Complaint Investigation
Date: Sep 3, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI) #2588078 and CI #2561815 at the facility on 9/3/25.
Complaint Details
Complaint investigation numbers CI #2588078 and CI #2561815 were conducted; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and there were no deficiencies cited.
Report Facts
Complaint investigations: 2
Inspection Report — Jul 31, 2025
Complaint Investigation
Date: Jul 31, 2025
Visit Reason
The State Agency (SA) conducted a Complaint Survey for 2561805 and 2574020 the facility on 07/31/25.
Complaint Details
Complaint numbers 2561805 and 2574020 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The SA determined that the facility was in compliance with Medicare and Medicaid requirements of participation and there were no deficiencies cited.
Report Facts
Complaint count: 2
Inspection Report — Feb 18, 2025
Follow-Up
Date: Feb 18, 2025
Visit Reason
On 2/18/25 the SA conducted an onsite revisit for the annual survey that was completed on 12/18/24. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Minimum Standards for Institutions for the Aged or Infirm, as of 1/15/25. However, the facility remains out of compliance due to deficiencies cited on the 1/21/25 complaint survey.
Findings
This document is a follow-up revisit confirming corrective actions taken after the annual survey. The facility remains out of compliance due to deficiencies cited on the 1/21/25 complaint survey.
Inspection Report — Jan 21, 2025
Routine
Date: Jan 21, 2025
Visit Reason
The inspection was conducted to evaluate the facility's compliance with regulations regarding food and nutrition services, specifically focusing on staffing adequacy and food quality.
Findings
The facility failed to ensure sufficient dietary staffing to meet residents' nutritional needs, resulting in cold meals and delayed service. Additionally, the food was often overcooked, tough, mushy, and unpalatable, causing dissatisfaction among residents.
Deficiencies (2)
F 0802: The facility failed to provide sufficient dietary staff to prepare and serve meals timely, resulting in cold meals and prolonged delays for eight of twelve sampled residents.
F 0804: The facility failed to ensure food was palatable, attractive, and served at a safe and appetizing temperature for eight of twelve sampled residents.
Report Facts
Sampled residents with deficiencies: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Dietary Manager #1 | Regional Dietary Manager | Reported staffing shortages and involvement in meal preparation |
| Regional Dietary Manager #2 | Regional Dietary Manager | New replacement manager, noted lack of steamer and food temperature issues |
| Administrator | Administrator | Discussed kitchen staffing transitions and efforts to address dietary concerns |
| Registered Nurse #1 | Registered Nurse | Reported resident complaints about food quality |
Inspection Report — Jan 21, 2025
Complaint Investigation
Date: Jan 21, 2025
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) MS #27676 at the facility on 1/21/25. During the survey, the SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid and cited F804 related to palatable food and F802 related to sufficient staff in the kitchen.
Complaint Details
CI MS #27676. The complaint investigation found deficiencies related to insufficient dietary staffing and unpalatable food. The facility was not in compliance.
Findings
The facility failed to ensure sufficient staffing in the dietary department to meet residents' nutritional needs, resulting in cold meals and prolonged delays. The food was often unpalatable, improperly cooked, and served cold, affecting eight of twelve sampled residents.
Deficiencies (2)
F0802 - Sufficient Dietary Support Personnel. The facility failed to ensure adequate dietary staff to prepare and serve meals timely, resulting in cold meals and delays for eight of twelve sampled residents.
F0804 - Nutritive Value/Appear, Palatable/Prefer Temp. The facility failed to provide food that was palatable, attractive, and served at a safe and appetizing temperature for eight of twelve sampled residents, with reports of cold, overcooked, tough, and mushy food.
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 18, 2024
Annual Inspection
Date: Dec 18, 2024
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity by not covering urinary catheter bags, failure to implement care plans for activities of daily living and respiratory care, insufficient nursing staff to meet resident needs, improper medication storage, failure to accommodate resident food preferences, unsafe food handling practices in the kitchen, improper garbage disposal, and inaccurate submission of staffing data to the Payroll Based Journal system.
Deficiencies (10)
F 0550: The facility failed to honor residents' dignity by leaving urinary catheter bags and tubing uncovered for three residents, exposing them to view and causing distress.
F 0656: The facility failed to develop and implement complete care plans for activities of daily living and respiratory care for four residents, resulting in unmet needs such as unclean fingernails, missed showers, and unchanged oxygen tubing.
F 0677: The facility failed to provide care and assistance for activities of daily living for residents who were unable, including failure to clean fingernails and provide scheduled showers.
F 0695: The facility failed to provide safe and appropriate respiratory care by not changing oxygen tubing and humidifier bottles as ordered for one resident.
F 0725: The facility failed to provide sufficient nursing staff to meet residents' activities of daily living needs, resulting in unmet care such as untrimmed nails and missed showers.
F 0761: The facility failed to ensure medications were stored appropriately and not left unattended in a resident's room, risking unauthorized access.
F 0806: The facility failed to accommodate resident allergies, intolerances, and preferences by serving unwanted food items and denying alternative food requests.
F 0812: The facility failed to prevent foodborne illness by thawing meat at room temperature and improperly handling raw chicken skin in the kitchen.
F 0814: The facility failed to properly contain and dispose of kitchen garbage, resulting in overflowing trash and potential contamination.
F 0851: The facility failed to submit accurate direct care staffing data to the Payroll Based Journal system, underreporting staff hours for one quarter.
Report Facts
Residents requiring two-person assist: 46
PBJ quarters reviewed: 4
PBJ quarter with inaccurate data: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #5 | Confirmed catheter bags were supposed to be covered and acknowledged dignity issue. | |
| Assistant Director of Nursing (ADON) | Confirmed catheter bags should be covered and dignity issues. | |
| Licensed Practical Nurse (LPN) #1 | Confirmed uncovered catheter bags were dignity issues and oxygen tubing not changed as ordered. | |
| Director of Nurses (DON) | Confirmed catheter bag dignity issues, care plan noncompliance, staffing shortages, and medication storage issues. | |
| Certified Nurse Assistant (CNA) #4 | Reported resident nails and beard unkempt due to staffing issues. | |
| Human Resource Coordinator | Responsible for submitting staffing schedule changes; acknowledged delays causing inaccurate PBJ data. | |
| Workforce Management Coordinator | Confirmed facility did not accurately report staffing hours to PBJ. | |
| Regional Dietary Manager | Confirmed unsafe food handling practices and improper garbage disposal in kitchen. | |
| Dietary Manager | Confirmed resident food preference issues and medication storage concerns. |
Inspection Report — Dec 18, 2024
Annual Inspection
Date: Dec 18, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification at the facility from 12/15/24 through 12/18/24. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F550, F656, F677, F695, F725, F761, F806, F812, F814 and F851.
Findings
The facility was found not in compliance with multiple requirements including resident dignity, care planning, ADL care, respiratory care, staffing, medication storage, food preferences, food safety, garbage disposal, and payroll based journal reporting.
Deficiencies (10)
F0550 - Resident Rights/Exercise of Rights. The facility failed to provide dignity to residents by leaving indwelling urinary catheter bags and tubing uncovered for three residents.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plans for activities of daily living and respiratory care for four residents.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide needed services for residents unable to carry out their activities of daily living for three residents.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure oxygen tubing and humidifier water bottle were changed as ordered for one resident.
F0725 - Sufficient Nursing Staff. The facility failed to provide sufficient nursing staff to meet residents' ADL needs for three residents.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure medications were stored appropriately and not left unsecured in a resident's room for one resident.
F0806 - Resident Allergies, Preferences, Substitutes. The facility failed to provide alternative food items and honor food preferences for two residents.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to prevent the possibility of foodborne illness by thawing meat at room temperature and using unsafe food handling practices.
F0814 - Dispose Garbage and Refuse Properly. The facility failed to keep kitchen trash properly contained and disposed of safely.
F0851 - Payroll Based Journal. The facility failed to submit accurate direct care staffing data to CMS for one quarter.
Report Facts
Deficiencies cited: 10
Inspection Report — Dec 16, 2024
Life Safety
Date: Dec 16, 2024
Visit Reason
Survey conducted on 12/16/24 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements. The facility meets the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
No deficiencies were cited during this survey.
Inspection Report — Oct 8, 2024
Complaint Investigation
Date: Oct 8, 2024
Visit Reason
On 10/08/24 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 09/11/24. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Complaint Details
Complaint survey completed on 09/11/24; the facility was found in compliance after corrective measures were confirmed.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 10/04/24.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 11, 2024
Complaint Investigation
Date: Sep 11, 2024
Visit Reason
The inspection was conducted following a complaint investigation regarding a resident fall caused by use of the wrong lift sling, and concerns about food quality and palatability for multiple residents.
Complaint Details
The complaint investigation was substantiated. Resident #1 fell due to use of the wrong lift sling which broke during transfer, causing fractures and actual harm. Multiple residents complained about food quality issues including tough, overcooked, and hard-to-chew meals.
Findings
The facility failed to ensure proper use of lift slings resulting in a resident fall with fractures and actual harm. Additionally, the facility failed to provide palatable, attractive, and safe meals for five residents, with multiple complaints about overcooked, tough, and hard-to-chew food.
Deficiencies (3)
F 0656: The facility failed to implement a comprehensive care plan for a dependent resident, resulting in use of the wrong size lift sling which broke and caused a fall with fracture. Corrective actions were implemented prior to survey.
F 0689: The facility failed to ensure safety during lift transfers by using the wrong lift sling, causing a resident to fall and sustain fractures. Corrective actions were completed prior to survey.
F 0804: The facility failed to provide palatable, attractive, and safe meals for five residents, with observations and interviews revealing overcooked, tough, and hard food that residents could not eat.
Report Facts
Residents reviewed for falls: 3
Residents reviewed for food palatability: 5
Resident #1 weight: 376.3
Lift sling weight ranges - blue sling: 275
Lift sling weight ranges - green sling: 175
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in fall incident involving use of wrong lift sling |
| CNA #2 | Certified Nursing Assistant | Named in fall incident involving use of wrong lift sling |
| Administrator | Administrator | Interviewed regarding fall incident and corrective actions |
| Family Nurse Practitioner | Family Nurse Practitioner | Assessed Resident #1 immediately after fall |
| Director of Clinical Education | Director of Clinical Education | Educated staff on proper lift sling use and conducted audits |
| Assistant Director of Nursing | Assistant Director of Nursing | Verified lift sling guidelines and care plan compliance |
| District Dietary Manager | District Dietary Manager | Interviewed regarding food quality issues and improvement plans |
| Social Worker | Social Worker | Handled grievances related to food complaints |
Inspection Report — Sep 11, 2024
Complaint Investigation
Date: Sep 11, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #25363 and CI MS #26271) at the facility on 09/11/24. CI MS #25363 related to non-palatable food and CI MS #26271 related to a resident fall with injury.
Complaint Details
Two complaint investigations were conducted: CI MS #25363 for non-palatable food and CI MS #26271 for a resident fall with injury. Deficiencies were cited for both complaints.
Findings
The facility was found not in compliance due to failure to provide palatable food to residents and failure to ensure safe lift transfers, resulting in a resident fall with injury.
Deficiencies (3)
F0656 - The facility failed to implement a comprehensive care plan for a dependent resident who was transferred using the wrong size sling, resulting in the sling breaking and the resident sustaining a fall with fracture.
F0689 - The facility failed to ensure the safety of a dependent resident during a lift transfer by using the wrong lift sling, resulting in a strap breaking and the resident falling to the floor with fractures.
F0804 - The facility failed to provide meals that included palatable food for five residents, with food often being hard, tough, overcooked, and unappetizing.
Report Facts
Deficiencies cited: 3
Inspection Report — May 13, 2024
Complaint Investigation
Date: May 13, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS# 24588 and CI MS #24815) at the facility on 05/13/24. The SA investigated Physical Environment related to sufficient supplies, dietary services, and resident falls.
Complaint Details
Two complaint investigations (CI MS# 24588 and CI MS #24815) were conducted related to physical environment, sufficient supplies, dietary services, and resident falls. The complaints were not substantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services. There were no deficiencies cited during this survey.
Report Facts
Complaint investigations: 2
Inspection Report — Feb 28, 2024
Follow-Up
Date: Feb 28, 2024
Visit Reason
The State Agency (SA) conducted a revisit to the facility on 02/28/24 to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and was placed back into compliance from previous citations effective 02/02/2024.
Inspection Report — Jan 22, 2024
Complaint Investigation
Date: Jan 22, 2024
Visit Reason
The inspection was conducted due to a complaint investigation following the elopement of Resident #1 who left the facility unnoticed and unsupervised on 01/07/24, posing immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was triggered by Resident #1's elopement on 01/07/24, which was the second incident after a prior elopement on 12/14/23. The State Agency identified Immediate Jeopardy and Substandard Quality of Care beginning on 01/07/24. The facility submitted a Removal Plan and the Immediate Jeopardy was removed on 01/13/24.
Findings
The facility failed to provide adequate supervision and implement effective care plans to prevent Resident #1, diagnosed with Alzheimer's and Dementia, from eloping the facility twice. The facility also failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program to monitor and prevent such incidents.
Deficiencies (4)
F 0600 - The facility failed to protect Resident #1 from neglect by not preventing her second elopement on 01/07/24, which placed her and other residents at risk of serious injury or death.
F 0656 - The facility failed to develop and implement a comprehensive care plan with effective interventions to prevent Resident #1's elopement risk, despite her known wandering behavior and previous elopement.
F 0689 - The facility failed to provide adequate supervision and maintain a safe environment to prevent Resident #1's elopement on 01/07/24, despite prior knowledge of her exit-seeking behavior and unlocked kitchen door.
F 0867 - The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) program to monitor and prevent Resident #1's elopement, resulting in immediate jeopardy to resident safety.
Report Facts
Residents affected: 3
Temperature at time of elopement: 39
Resident vital signs: 135
Resident vital signs: 72
Resident vital signs: 75
Resident vital signs: 18
Resident vital signs: 96.8
Resident vital signs: 92
Distance resident found from facility: 1850
Time resident unaccounted for: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #1 wandering and last saw her before elopement |
| Administrator | Provided statements about elopement investigation and corrective actions | |
| Director of Nursing | DON | Provided statements about supervision, door locks, and staff in-service |
| Certified Nursing Assistant #1 | CNA | Reported Resident #1 wandering and assisted in search |
| Dietary Aide #1 | Dietary Aide | Observed Resident #1 entering kitchen and assisted her out |
| Dietary Aide #2 | Dietary Aide | Observed Resident #1 entering kitchen and passing out snacks |
| Police Officer | Found Resident #1 walking outside and returned her to facility | |
| LPN #2 | Licensed Practical Nurse | Documented Resident #1's wandering behavior and care notes |
| LPN #3 | Licensed Practical Nurse | Last staff to see Resident #1 before elopement and received resident from police |
| Assistant Director of Nursing | ADON | Interviewed regarding care plan and monitoring failures |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding QAPI meetings and incident reporting |
| Senior Director of Clinical Operations | Provided training on abuse and neglect identification | |
| Director of Clinical Education | Initiated staff training on supervision and abuse/neglect | |
| Senior President of Operations | Educated Administrator on QAPI expectations and corrective actions |
Inspection Report — Jan 22, 2024
Complaint Investigation
Date: Jan 22, 2024
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI MS#23810) on 01/09/24 through 01/22/24 related to an elopement of a resident who left the facility unnoticed and unsupervised.
Complaint Details
CI MS#23810 related to an elopement of Resident #1 who left the facility unnoticed and unsupervised on 01/07/24. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to provide adequate supervision and implement effective care plans to prevent Resident #1, diagnosed with Alzheimer's and Dementia, from eloping the facility on 01/07/24. The resident was found outside the facility without shoes or coat, placing her and others at risk of serious harm.
Deficiencies (4)
F0600 - Free from Abuse and Neglect. The facility failed to protect Resident #1 from neglect by not communicating and implementing measures to prevent her second elopement on 01/07/24, despite her known wandering risk and previous elopement.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement an effective care plan for Resident #1 to prevent elopement, despite her known wandering behavior and previous elopement incidents.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and maintain secure environment to prevent Resident #1 from eloping on 01/07/24, allowing her to exit through an unlocked kitchen door.
F0867 - QAPI/QAA Improvement Activities. The facility failed to sustain an effective Quality Assurance and Performance Improvement program to prevent Resident #1's elopement and address ongoing exit-seeking behavior, resulting in repeated incidents and delayed corrective actions.
Report Facts
Deficiencies cited: 4
Licensed beds: 140
Inspection Report — Jan 5, 2024
Complaint Investigation
Date: Jan 5, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI), MS #23637 and MS #23664, at the facility on 12/19/23 related to an elopement.
Complaint Details
Complaint Investigations (CI), MS #23637 and MS #23664, related to an elopement. The complaint was substantiated with deficiencies cited.
Findings
The facility failed to provide supervision to prevent the elopement of Resident #1, a cognitively impaired resident, who left the facility unnoticed and unsupervised and was found at another nursing home 380 yards away. The facility identified an Immediate Jeopardy on 12/14/23 due to this failure but implemented corrective actions by 12/16/23, and the IJ was removed prior to the survey.
Deficiencies (1)
M640 - The facility failed to provide adequate supervision to prevent the elopement of Resident #1, who was a wandering risk and left the facility unnoticed through an unarmed door due to a malfunctioning door alarm antenna, placing the resident and others at risk of serious injury or death.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 19, 2023
Complaint Investigation
Date: Dec 19, 2023
Visit Reason
The inspection was conducted following a complaint investigation triggered by the elopement of Resident #1, who was at risk for wandering and elopement, from the facility on 12/14/2023.
Complaint Details
The complaint investigation was substantiated. Resident #1, who had dementia and was at risk for elopement, left the facility unnoticed on 12/14/23 and was found at another nursing home 380 yards away. The facility failed to prevent the elopement due to a malfunctioning door alarm system and inadequate supervision.
Findings
The facility failed to implement the care plan and provide adequate supervision to prevent the elopement of Resident #1, who left the facility unnoticed and unsupervised. An Immediate Jeopardy (IJ) was identified due to the risk posed to Resident #1 and others. The IJ was removed after corrective actions were implemented between 12/14/23 and 12/15/23, including door repairs, staff in-services, and increased monitoring.
Deficiencies (2)
42 CFR 483.21(b)(1) - The facility failed to develop and implement a complete care plan that met Resident #1's needs to prevent elopement.
42 CFR 483.25(d)(1)(2) - The facility failed to provide adequate supervision and prevent the elopement of Resident #1 through an unarmed door unnoticed.
Report Facts
Residents reviewed: 3
Distance walked by resident: 380
Time resident unaccounted for: 45
Date of admission: Apr 14, 2017
Assessment Reference Date: Oct 27, 2023
Temperature at time of elopement: 52
Date of corrective action completion: Dec 15, 2023
Date Immediate Jeopardy removed: Dec 16, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Reported elopement and assisted in returning Resident #1 to facility |
| Certified Nursing Assistant #1 | CNA | Assisted in returning Resident #1 to facility and provided observations about the elopement |
| Administrator | Administrator | Interviewed regarding elopement and facility system failures |
| Maintenance Supervisor | Maintenance Supervisor | Reported malfunctioning door antenna and corrective actions taken |
| Director of Nursing | Director of Nursing | Initiated investigation, staff in-services, and corrective actions post-elopement |
| Executive Director | Executive Director | Notified resident's responsible party and reported elopement to state agency |
Inspection Report — Dec 19, 2023
Complaint Investigation
Date: Dec 19, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI) MS #23637 and MS #23664 at the facility on 12/19/23 related to an elopement.
Complaint Details
Complaint Investigations (CI) MS #23637 and MS #23664 were conducted related to an elopement of Resident #1. The complaint was substantiated with deficiencies cited including Immediate Jeopardy for failure to prevent elopement and failure to implement the care plan.
Findings
The facility was found out of compliance for failing to implement the care plan and provide supervision to prevent the elopement of Resident #1, a cognitively impaired resident who left the facility unnoticed and unsupervised and was found at another nursing home 380 yards away. Immediate Jeopardy was identified but removed prior to the survey entrance after corrective actions were implemented.
Deficiencies (2)
F0656 - The facility failed to implement the comprehensive care plan for Resident #1 who was at risk for elopement, allowing her to leave the facility unnoticed and unsupervised, placing her and others at risk of serious injury or death.
F0689 - The facility failed to provide adequate supervision and prevent accidents by allowing Resident #1, an elopement risk, to exit through an unarmed door unnoticed and unsupervised, resulting in an Immediate Jeopardy.
Report Facts
Deficiencies cited: 2
Inspection Report — Oct 3, 2023
Annual Inspection
Date: Oct 3, 2023
Visit Reason
On 10/03/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 08/31/23. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 09/29/23. No deficiencies were cited in this desk review.
Inspection Report — Aug 31, 2023
Routine
Date: Aug 31, 2023
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide adequate resident accommodations such as proper sling availability and restroom access, failure to maintain a clean and homelike environment, incomplete pre-admission screening, inadequate care plan development and implementation, failure to provide necessary nail care, lack of supervision and assessment for smoking residents, improper medication labeling, and poor food storage and ice machine sanitation.
Deficiencies (8)
F 0558: Facility failed to provide the correct size sling for Resident #26 requiring total lift and failed to provide easy access to Resident #99's personal restroom due to hazardous waste containers blocking access.
F 0584: Facility failed to maintain a clean, comfortable, and homelike environment for Resident #99, including presence of sticky substances, trash, and unemptied urinals in the resident's room.
F 0645: Facility failed to ensure accurate Pre-admission Screening (PASARR) for Resident #1, omitting major mental illness diagnosis of Schizophrenia, resulting in no Level II screening.
F 0656: Facility failed to develop and implement comprehensive care plans related to nail care for Residents #61 and #68 and failed to develop a smoking care plan for Resident #77.
F 0677: Facility failed to provide necessary nail care for Residents #61 and #68, evidenced by long, thick, overgrown toenails.
F 0689: Facility failed to supervise and complete a smoking assessment for Resident #77 who smokes outside the facility premises.
F 0761: Facility failed to label and date eye drops on one medication cart, risking use of expired medication.
F 0812: Facility failed to label food items in refrigerator and freezer and failed to maintain a clean ice maker, with black substance observed inside ice machine door.
Report Facts
Residents reviewed for accommodations: 121
Residents reviewed for care plans: 33
Medication carts observed: 5
Kitchen tours conducted: 3
Urine volume in Resident #99's urinals: 900
Urine volume in Resident #99's urinals: 750
Urine volume in Resident #99's urinals: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Assistant (CNA) #1 | Confirmed only one blue sling available for Resident #26. | |
| Certified Nurse Assistant (CNA) #2 | Confirmed only one blue sling available for Resident #26. | |
| Laundry Staff #1 | Reported no quick washing of slings and no blue sling currently in laundry. | |
| Director of Nurses (DON) | Confirmed sling availability, care plan issues, and smoking assessment deficiencies. | |
| Licensed Practical Nurse (LPN) #2 | Confirmed only one blue sling available for Resident #26. | |
| Registered Nurse (RN) #1 | Confirmed only one blue sling available for Resident #26 and care plan issues. | |
| Administrator | Acknowledged sling shortage and food labeling and ice machine cleaning issues. | |
| Certified Nursing Assistant (CNA) #4 | Observed unemptied urinals and unclean room for Resident #99. | |
| Housekeeping | Reported cleaning schedules and challenges with Resident #99's room. | |
| Housekeeping Supervisor | Suggested increased cleaning frequency for Resident #99's room. | |
| Social Service Director | Confirmed inaccurate PASARR screening for Resident #1. | |
| Treatment Nurse | Confirmed nail care needs for Residents #61 and #68. | |
| Assistant Director of Nurses (ADON) | Confirmed care plan and smoking care deficiencies. | |
| Licensed Practical Nurse (LPN) #4 | Confirmed care plan not followed for nail care. | |
| Maintenance Supervisor | Reported ice machine cleaning routine and responsibilities. | |
| Dietary Manager (DM) | Reported unlabeled food items and unclean ice machine. | |
| Licensed Practical Nurse (LPN) #5 | Confirmed unlabeled eye drops and discard policy. |
Inspection Report — Aug 31, 2023
Annual Inspection
Date: Aug 31, 2023
Visit Reason
The State Agency (SA) conducted an annual re-certification survey and Complaint Investigation (CI) MS #22574 at the facility from 08/29/23 through 08/31/23. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid regulations for participation and cited regulatory deficiencies at F558, F584, F645, F656, F677, F689, F761, and F812. CI MS #22574 was investigated related to Quality of Care and Resident verbal abuse and the facility was found to be in compliance.
Complaint Details
Complaint Investigation (CI) MS #22574 was investigated related to Quality of Care and Resident verbal abuse and the facility was found to be in compliance.
Findings
The facility was found not in compliance with multiple regulatory requirements including reasonable accommodations, safe and clean environment, PASARR screening, comprehensive care planning, ADL care, accident hazards related to smoking, medication labeling, and food safety. Deficiencies were cited for failure to provide adequate sling accommodations, maintain cleanliness, complete accurate PASARR screening, implement care plans, provide nail care, supervise smoking residents, label medications properly, and maintain food storage and ice machine cleanliness.
Deficiencies (8)
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to provide the correct size sling for a resident needing a total lift and failed to provide easy access to a resident's personal restroom for two residents.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to ensure a resident resided in a clean, comfortable homelike environment as evidenced by sticky brown substance, trash debris, and unemptied urinals in a resident's room.
F0645 - PASARR Screening for MD & ID. The facility failed to ensure a resident admitted had an accurate Pre-Admission Screen (PAS) listing a major mental illness diagnosis, resulting in no Level II PASARR evaluation.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement comprehensive care plans related to nail care for two residents and failed to develop a smoking care plan for one resident.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide necessary nail care for two residents with long, thick, overgrown toenails.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to supervise and complete a smoking assessment for a resident who smoked independently and kept cigarettes and lighter in his room.
F0761 - Label/Store Drugs and Biologicals. The facility failed to label and date eye drops on a medication cart, resulting in use of expired medication.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to label food items in the refrigerator and freezer and failed to maintain a clean ice maker, with black substance inside the ice machine door.
Report Facts
Deficiencies cited: 8
Inspection Report — Aug 29, 2023
Life Safety
Date: Aug 29, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Jun 26, 2023
Complaint Investigation
Date: Jun 26, 2023
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI MS#21733) at the facility on 06/26/23.
Complaint Details
Complaint number CI MS#21733 was investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid Services and there were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Mar 20, 2023
Complaint Investigation
Date: Mar 20, 2023
Visit Reason
The State Agency conducted two complaint investigations (CI MS #20947 and CI MS #20968) at the facility on 03/20/23.
Complaint Details
Two complaint investigations were conducted: CI MS #20947 related to non-palatable and insufficient food, and CI MS #20968 related to unclean environment. Both complaints were found to be without deficiencies.
Findings
The facility was found in compliance with Medicare and Medicaid Services requirements. No deficiencies were cited for either complaint related to non-palatable and insufficient food or unclean environment.
Report Facts
Complaint investigations conducted: 2
Inspection Report — May 11, 2022
Complaint Investigation
Date: May 11, 2022
Visit Reason
The State Agency conducted a complaint survey CI MS #18647 and CI MS #18779 along with the staff vaccination section of the Infection Prevention, Control and Immunization pathway at the facility from 05/10/2022 to 05/11/2022.
Complaint Details
Complaint numbers CI MS #18647 and CI MS #18779 were investigated; the complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the requirements for The Aged and Infirmed. The SA could not substantiate the complaints for CI MS #18647 Resident Rights and nursing services or CI MS #18779 related to resident/client abuse and neglect and there were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Dec 28, 2021
Follow-Up
Date: Dec 28, 2021
Visit Reason
The State Agency conducted a post-certification revisit for Infection Control with deficiency F0880 related to Hand hygiene and disinfecting equipment, F0689 related to Hazardous chemical storage, F0695 related to dating and storage of oxygen and nebulizer tubing, and F0761 related to storage of drugs at the facility on 12/27/2021 to 12/28/2021.
Findings
The State Agency determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid related to infection control, dating and storage of tubing, storage of chemicals and drugs and no deficiencies were cited.
Report Facts
Deficiencies cited: 4
Inspection Report — Nov 10, 2021
Life Safety
Date: Nov 10, 2021
Visit Reason
Survey conducted on 11/10/21 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Nov 10, 2021
Routine
Date: Nov 10, 2021
Visit Reason
The inspection was conducted to assess compliance with nursing home regulations including safety, respiratory care, medication storage, and infection prevention.
Findings
The facility failed to maintain a safe environment by leaving hazardous chemicals unsecured, improperly stored respiratory equipment, unlocked medication carts during administration, and inadequate infection control practices including poor hand hygiene and improper cleaning of shared equipment.
Deficiencies (4)
F 0689: The facility failed to provide a safe environment as a can of chemical disinfectant spray was found unsecured on an open linen cart during the survey.
F 0695: The facility failed to store nebulizer tubing properly and failed to date oxygen tubing for three residents, risking infection spread.
F 0761: Medication carts were left unlocked and unattended during medication administration on multiple occasions, risking resident safety.
F 0880: The facility failed to prevent infection spread by inadequate hand hygiene during meal distribution, improper cleaning of medication carts, ice scoops, and glucometers across multiple hallways.
Report Facts
Residents affected: 4
Residents affected: 3
Medication administration opportunities: 9
Hallways: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed about unsecured disinfectant spray on linen cart |
| CNA #3 | Certified Nursing Assistant | Confirmed chemical spray should not be on linen cart |
| Director of Nursing | Director of Nursing | Interviewed regarding chemical spray, oxygen tubing policies, medication cart security, and infection control |
| RN #1 | Registered Nurse | Observed leaving medication cart unlocked and improper glucometer cleaning |
| LPN #2 | Licensed Practical Nurse | Observed leaving medication cart unlocked and improper glucometer cleaning |
| CNA #4 | Certified Nursing Assistant | Observed failing to perform hand hygiene during meal tray distribution |
| LPN #1 | Licensed Practical Nurse | Observed cleaning glucometer improperly |
| CNA #1 | Certified Nursing Assistant | Observed improper ice scoop use and infection control practices |
| RN #2 | Supervisor | Interviewed about ice passing procedures |
Inspection Report — Nov 10, 2021
Life Safety
Date: Nov 10, 2021
Visit Reason
The State Agency conducted an emergency preparedness survey to evaluate the emergency status at the facility from 11/07/21 through 11/10/21.
Findings
The State Agency found the facility to be in compliance with participation for Medicare and Medicaid Services and no deficiencies were cited.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 10, 2021
Annual Inspection
Date: Nov 10, 2021
Visit Reason
The State Agency (SA) conducted an annual recertification survey along with a complaint investigation for MS00018141 at the facility from 11/07/21 through 11/10/21.
Complaint Details
Complaint investigation for MS00018141 was conducted but the SA was not able to substantiate the facility reported incident/complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations and cited for deficiencies related to accident hazards, respiratory/oxygen therapy, medication storage, and infection control.
Deficiencies (4)
F0689 - The facility failed to provide residents with a safe environment as evidenced by a can of chemical disinfectant spray found unsecured on an open linen cart.
F0695 - The facility failed to store nebulizer tubing and oxygen tubing properly to prevent infection spread and failed to date oxygen tubing for three residents with oxygen and nebulizer equipment.
F0761 - The facility failed to secure medication carts while unattended during medication administration on multiple hallways.
F0880 - The facility failed to prevent the possible spread of infection as evidenced by failure to conduct hand hygiene during meal tray distribution, improper cleaning and sanitizing of medication carts, ice scoop, and glucometers.
Report Facts
Deficiencies cited: 4
Inspection Report — Aug 20, 2021
Complaint Investigation
Date: Aug 20, 2021
Visit Reason
The State Agency conducted a complaint investigation (CI) for MS00017952 from 8/19/21 to 8/20/21 regarding allegations of not following physician orders for skin care and emptying of a drain.
Complaint Details
Complaint number MS00017952 involved allegations of not following physician orders for skin care and emptying of a drain. The complaint was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid related to the complaint allegations.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 20, 2021
Routine
Date: Aug 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on August 19-20, 2021. The facility was in substantial compliance with Infection Control Requirements for Long Term Care Facilities.
Findings
The facility was found to be in substantial compliance with infection control requirements and was following recommended practices and guidance during the COVID-19 pandemic.
Inspection Report — Feb 9, 2021
Complaint Investigation
Date: Feb 9, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI), CI #17478 on 2/9/2021.
Complaint Details
CI #17478: Allegations of failure to notify responsible party, physician services, failure to assess/monitor or provide care/neglect were investigated and not substantiated.
Findings
The complaint was not substantiated and the facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Inspection Report — Dec 30, 2020
Routine
Date: Dec 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/30/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Dec 30, 2020
Routine
Date: Dec 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/30/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Dec 1, 2020
Routine
Date: Dec 1, 2020
Visit Reason
A COVID-19 Emergency Preparedness Survey was conducted by the State Agency on 12/1/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Inspection Report — Dec 1, 2020
Routine
Date: Dec 1, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and complaint investigations, MS CI #17303 and MS CI #17271, was conducted by the State Agency (SA) on 12/01/20. The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations with CMS and CDC recommended practices to prepare for COVID-19 and cited F880. The facility was found to be in compliance for the complaint investigations, MS CI #17303 and MS CI #17271, which were not substantiated, with no deficiencies cited.
Complaint Details
Complaint investigations MS CI #17303 and MS CI #17271 were conducted and found not substantiated with no deficiencies cited.
Findings
F0880 - Infection Prevention & Control. The facility failed to prevent the spread of infection during a COVID-19 Infection Control Survey by not performing hand hygiene and not wearing a mask on one of two days observed. Specifically, a dietary employee entered without a mask and a Certified Nursing Assistant failed to use hand sanitizer between passing meal trays to residents.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the spread of infection during a COVID-19 Infection Control Survey by not performing hand hygiene and not wearing a mask on one of two days observed.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 26, 2020
Routine
Date: Oct 26, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on October 26, 2020.
Findings
The facility was in substantial compliance with Infection Control guidelines and was following recommended safety practices during the COVID-19 pandemic.
Inspection Report — Oct 26, 2020
Routine
Date: Oct 26, 2020
Visit Reason
A COVID-19 Emergency Preparedness Survey was conducted by the State Agency (SA) on 10/26/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Inspection Report — Oct 7, 2020
Routine
Date: Oct 7, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on October 7, 2020. The facility was not in substantial compliance with Infection Control and was cited deficient practice at F880.
Findings
The facility failed to prevent the likelihood of the spread of COVID-19 as evidenced by lack of social distancing and mask wearing by five employees eating lunch in the Minimum Data Set office. Staff interviews and policy review confirmed the failure to follow infection control guidelines despite in-service training.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the spread of COVID-19 by not ensuring staff practiced social distancing and mask wearing during lunch breaks.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 7, 2020
Routine
Date: Oct 7, 2020
Visit Reason
A COVID-19 Emergency Preparedness Survey was conducted by the State Agency (SA) on 10/07/2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b) (6).
Inspection Report — Sep 22, 2020
Routine
Date: Sep 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on September 22, 2020.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — May 10, 2019
Annual Inspection
Date: May 10, 2019
Visit Reason
A Recertification and Complaint survey, MS #15733, was conducted by Healthcare Management Solutions, LLC on behalf of Mississippi State Department of Health from 4/8/19 through 4/11/19. The complaint was substantiated for misappropriation of medication. After administrative review by the State Agency and the Regional office, additional information was received/reviewed from 5/9/19 through 5/10/19, during an onsite visit to the facility and the 2567 was amended. The facility was found not to be in substantial compliance with Medicare and Medicaid requirements of participation and cited deficiencies at F602, F623, and F921.
Complaint Details
Complaint MS #15733 was substantiated for misappropriation of medication. Deficiencies were cited related to medication diversion by a nurse and failure to provide written transfer notices.
Findings
The facility was cited for misappropriation of medications by a nurse, failure to provide written notice of transfers to residents and their representatives, and unsanitary conditions of high-rise toilet seats in resident bathrooms. The facility failed to ensure narcotic medications were not diverted by staff, and failed to notify residents or their representatives in writing when residents were transferred to hospitals. Additionally, bathroom toilet seats on Hall B were found with feces and urine stains, indicating inadequate cleaning.
Deficiencies (3)
F0602 - Free from Misappropriation/Exploitation. The facility failed to prevent diversion of narcotic medications by RN #4, who was found with multiple resident medications in his lunchbox and discrepancies in narcotic counts affecting five residents. The nurse exhibited unusual behavior and was suspended pending investigation.
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to provide written notices of transfers to the resident, responsible party, and Ombudsman for three residents transferred to hospitals, documenting only verbal notifications.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to maintain sanitary conditions for three resident bathrooms equipped with high-rise toilet seats on Hall B, which had visible feces and urine stains on the toilet bowl surfaces.
Report Facts
Deficiencies cited: 3
Residents affected: 5
Residents transferred without written notice: 3
Resident bathrooms with high-rise toilet seats: 4
Inspection Report — May 10, 2019
Annual Inspection
Date: May 10, 2019
Visit Reason
A Recertification and Complaint survey, MS #15733, was conducted by Healthcare Management Solutions, LLC on behalf of Mississippi State Department of Health from 4/8/19 through 4/11/19. The complaint was substantiated for misappropriation of medication. After administrative review by the State Agency and the Regional office, additional information was received/reviewed from 5/9/19 through 5/10/19, during an onsite visit to the facility and the 2567 was amended. The facility was found not to be in substantial compliance with Medicare and Medicaid requirements of participation and cited deficiencies at F602, F623, and F921.
Complaint Details
Complaint MS #15733 was substantiated for misappropriation of medication.
Findings
The facility was cited for misappropriation of medications by a nurse, failure to provide written notice of transfers to residents and their representatives, and unsanitary conditions of high-rise toilet seats in resident bathrooms on Hall B.
Deficiencies (3)
F0602 - Free from Misappropriation/Exploitation. The facility failed to ensure five of fourteen short-term residents were free from diversion and misappropriation of controlled substance medications by facility staff, resulting in missing narcotics and medications not administered as ordered.
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to provide written notices of facility-initiated transfers to the resident, the resident's responsible party, and/or the State Long-Term Care Ombudsman for three of four sampled residents transferred to the hospital.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to provide a sanitary environment for three of four residents with bathrooms equipped with high-rise toilet seats on Hall B, with visible feces and urine stains on the toilet bowl surfaces.
Report Facts
Deficiencies cited: 3
Residents affected: 14
Residents transferred: 4
Residents with high-rise toilet seats: 4
Missing pills: 10
Report
7 CMS Surveys
CMS Survey — Dec 19, 2023
Dec 19, 2023
CMS Survey — Jan 22, 2024
Jan 22, 2024
CMS Survey — Sep 11, 2024
Sep 11, 2024
CMS Survey — Jan 21, 2025
Jan 21, 2025
CMS Survey — Nov 10, 2021
Nov 10, 2021
CMS Survey — Aug 31, 2023
Aug 31, 2023
CMS Survey — Dec 18, 2024
Dec 18, 2024
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