Inspection Report Summary
The most recent inspection on August 18, 2025, found the facility in compliance with no deficiencies cited during complaint investigations. Prior inspections showed a mixed record, with a significant number of deficiencies identified in early 2025, particularly related to failure to implement resident care plans, improper transfer techniques causing injury, inadequate activities of daily living (ADL) care, environmental cleanliness, infection control, and medication management. A substantiated complaint in March 2025 found the facility failed to follow a resident’s care plan during transfers, resulting in a fracture, but follow-up inspections in April 2025 confirmed corrective actions were implemented and compliance was restored. Several complaint investigations over the past years were unsubstantiated, and enforcement actions such as fines or license suspensions were not listed in the available reports. The trend suggests improvement since early 2025, with recent inspections showing no deficiencies and effective correction of prior issues.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
26.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
589% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
97% occupied
Based on a August 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility based on complaint investigation numbers CI #2569723, CI #500417, and CI #500419.
Complaint Details
Complaint investigation based on CI #2569723, CI #500417, and CI #500419; facility found compliant with no deficiencies.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Census: 136
Total Capacity: 140
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Date: Aug 18, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility on 08/18/2025 based on complaint investigation numbers CI #2569723, CI #500417, and CI #500419.
Complaint Details
Complaint investigation numbers CI #2569723, CI #500417, and CI #500419 were investigated and found to be unsubstantiated as no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements with no deficiencies cited during the complaint investigation.
Inspection Report
Re-Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 03/20/25.
Findings
The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The facility is recommended to be placed back in compliance effective 04/16/25.
Inspection Report
Follow-Up
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 2025-03-20.
Findings
The review confirmed that the facility had implemented measures to correct the deficient practices and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The facility was recommended to be placed back in compliance effective 2025-04-16.
Inspection Report
Re-Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the complaint investigation that was completed on 03/26/25 to verify correction of previously identified deficiencies.
Complaint Details
This visit was a follow-up complaint investigation confirming correction of deficiencies identified in the complaint investigation completed on 03/26/25.
Findings
The information reviewed confirmed the facility had put measures in place to correct the deficient practice as of 04/16/25. The State Agency is recommending the facility be placed back in compliance with Medicare and Medicaid participation requirements for the prior surveys.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Follow-Up
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the complaint investigation that was completed on 2025-03-26 to verify correction of previously identified deficiencies.
Complaint Details
This visit was a follow-up to a complaint investigation completed on 2025-03-26. The findings confirmed correction of deficiencies and compliance was restored as of 2025-04-16.
Findings
The facility had put measures in place to correct the deficient practice as of 2025-04-16, and the State Agency recommended the facility be placed back in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Annual Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 2025-03-20.
Complaint Details
The visit included a complaint investigation completed on 2025-03-20; the revisit confirmed correction of deficiencies.
Findings
The review confirmed the facility had implemented measures to correct the deficient practices and sustain compliance with Medicare and Medicaid participation requirements. The facility was recommended to be placed back in compliance effective 2025-04-16.
Report Facts
Census: 137
Total licensed capacity: 140
Inspection Report
Re-Inspection
Census: 137
Capacity: 140
Deficiencies: 0
Date: Apr 22, 2025
Visit Reason
The State Agency conducted an onsite revisit for the annual survey and complaint investigation that was completed on 2025-03-20.
Complaint Details
The visit was related to a complaint investigation completed on 2025-03-20; the revisit confirmed correction of deficiencies.
Findings
The facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The State Agency is recommending that the facility be placed back in compliance effective 2025-04-16.
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility on 3/26/2025 due to allegations of failure to implement a resident's care plan and improper transfer techniques resulting in injury.
Complaint Details
The complaint investigation (CI MS# 28356) substantiated that the facility failed to implement Resident #1's care plan, resulting in improper transfer and a right femur fracture.
Findings
The facility was found non-compliant for neglecting to follow the resident's care plan during transfers, resulting in a resident sustaining a right femur fracture. The facility failed to ensure staff used the proper assistive device and number of staff members for transfers as required by the care plan and Kardex.
Deficiencies (2)
Failure to ensure a resident's right to be free from neglect when staff failed to refer to the Kardex and used improper transfer methods causing injury.
Failure to develop and implement a comprehensive care plan consistent with resident needs, resulting in improper transfer and injury.
Report Facts
Census: 134
Total Capacity: 140
Residents reviewed: 3
Staff observations: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in neglect finding for improper transfer of Resident #1 |
| Administrator | Verified facility investigation and expectations for care plan adherence | |
| Nurse Practitioner | Nurse Practitioner | Notified of resident's injury and ordered transfer to hospital |
| Registered Nurse | Registered Nurse | Assessed resident after improper transfer |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The State Agency conducted a complaint investigation at the facility on 3/26/25 due to a failure to transfer a resident correctly, resulting in injury.
Complaint Details
The complaint investigation (CI MS# 28356) found that staff neglected to refer to the kiosk Kardex to ensure proper transfer methods and assistive devices were used for Resident #1, leading to injury. The resident was transferred improperly by CNA #1, causing a fracture. CNA #1 admitted to not checking the Kardex and using an incorrect transfer method.
Findings
The facility was found non-compliant with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, specifically failing to ensure a resident's right to be free from neglect by not following proper transfer procedures, which resulted in a resident sustaining a right femur fracture.
Deficiencies (1)
Failure to transfer a resident from the chair to the bed correctly, resulting in a right femur fracture.
Report Facts
Census: 134
Total Capacity: 140
Date of Incident: Mar 14, 2025
Date of Resident Discharge: Mar 20, 2025
Assessment Reference Date: Feb 9, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in the finding for improper transfer of Resident #1 leading to injury |
| Administrator | Verified facility investigation findings regarding the transfer incident | |
| Nurse Practitioner | NP | Notified of resident's injury and ordered transfer to hospital |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a resident's care plan, specifically related to improper transfer methods and insufficient staff assistance during transfers for Resident #1.
Complaint Details
The complaint investigation found that Resident #1 was transferred improperly on 3/14/25, resulting in a fracture. The investigation included staff interviews, record reviews, and policy reviews. CNA #1 admitted to not following the care plan and using the wrong transfer method. The Administrator confirmed expectations for staff to follow care plans and use the kiosk for guidance. Resident #1 was diagnosed with dementia and required maximal assistance for transfers.
Findings
The facility failed to follow the care plan for Resident #1, resulting in the resident being transferred using an incorrect method without the required number of staff or proper assistive devices. This led to the resident sustaining a right femoral shaft fracture. Interviews and record reviews confirmed staff did not adhere to the care plan instructions, and the facility's policies and procedures were not properly followed.
Deficiencies (2)
Failed to implement a resident's care plan when Resident #1 was transferred without the required number of staff members and the use of the proper assistive devices.
Failed to ensure a resident's environment was free from accident hazards by not referring to the kiosk to ensure proper transfer methods and staff assistance.
Report Facts
Residents care plans reviewed: 3
Residents affected: 1
Date of incident: Mar 14, 2025
Date of fracture diagnosis: Mar 20, 2025
Date of admission: Apr 10, 2018
Assessment Reference Date: Feb 9, 2025
Lift Transfer Evaluation Date: Apr 7, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Admitted to transferring Resident #1 using the wrong method and not following the care plan |
| Administrator | Verified the investigation findings and confirmed expectations for staff to follow care plans and use the kiosk | |
| Registered Nurse (RN) | Registered Nurse | Assessed Resident #1 after the fall and found no immediate injury |
| Nurse Practitioner (NP) | Nurse Practitioner | Notified of Resident #1's condition and ordered transfer to hospital after fracture diagnosis |
Inspection Report
Annual Inspection
Census: 134
Capacity: 140
Deficiencies: 9
Date: Mar 20, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and seven Complaint Investigations at the facility from 3/17/25 through 3/20/25 to determine compliance with Medicare and Medicaid requirements.
Findings
The facility was found not in compliance with multiple Medicare and Medicaid requirements including environmental issues, failure to implement care plans, failure to provide Activities of Daily Living (ADL) care, inaccessible call lights, hydration issues, privacy breaches, unsafe environment, medication administration errors, infection control failures, and inaccurate staffing data submission.
Deficiencies (9)
Resident call lights were not within reach for two residents, limiting their ability to request assistance.
Facility failed to secure electronic health records; EMAR visible on unattended medication carts for two residents.
Facility failed to provide a safe, clean, and homelike environment for nine residents, including broken furniture, pest infestation, and unsafe conditions.
Facility failed to implement care plans for ADL assistance and fluid restriction for four residents.
Medication cart was left unlocked with medications unsecured.
Facility failed to safeguard resident-identifiable information and maintain accurate medical records for a resident with a PICC line.
Facility failed to submit accurate Payroll Based Journal staffing data for the first quarter of 2025.
Facility failed to implement infection prevention and control practices including failure to use enhanced barrier precautions and improper cleaning for residents on isolation.
Facility failed to maintain an effective pest control program; mice droppings found in resident's dresser drawers.
Report Facts
Deficiencies cited: 12
Residents observed: 134
Licensed beds: 140
Fluid restriction days exceeded: 9
Fingernail length: 1.5
Mattress sagging area: 12
Mattress peeling area: 36
Hole size: 4
Hole size: 6
Window gap: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Named in medication cart left unlocked and EMAR visible finding | |
| Director of Nursing | Confirmed multiple deficiencies including medication cart security, infection control, and care plan implementation | |
| Certified Nurse Assistant #4 | Observed not wearing gown during enhanced barrier precautions | |
| Licensed Practical Nurse #3 | Confirmed resident fingernails needed trimming | |
| Housekeeping Supervisor | Confirmed use of ineffective cleaning chemicals for C. diff and housekeeping cart lock issues | |
| Infection Preventionist | Responsible for infection control program and notification of housekeeping for isolation rooms | |
| Administrator | Interviewed regarding staffing data submission and infection control issues |
Inspection Report
Annual Inspection
Census: 134
Capacity: 140
Deficiencies: 10
Date: Mar 20, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and seven Complaint Investigations at the facility from 3/17/25 through 3/20/25 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm.
Complaint Details
Seven complaint investigations were conducted (CI MS #27183, CI MS #27690, CI MS #27865, CI MS #28043, CI MS #28193, CI MS #28208, and CI MS #28282). Non-compliance was identified in several complaints related to activities of daily living, hydration, and environment. Three complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with multiple standards including residents' rights, activities of daily living, hydration, medication storage, housekeeping, infection control, and environmental safety. Deficiencies included call lights not within reach, inadequate ADL care, improper fluid intake monitoring, unsecured medication carts, pest control issues, maintenance deficiencies, and failure to follow infection control precautions.
Deficiencies (10)
Resident call lights were not within reach for two residents, limiting their ability to request assistance.
Facility failed to provide activities of daily living care for three residents dependent on staff assistance.
Housekeeping carts were not locked and hazardous chemicals were accessible to residents.
Resident's window had a 3-inch gap with no screen, exposing the room to outside elements.
Presence of mice droppings in resident's dresser drawers posing contamination risk.
Resident rooms had housekeeping issues including stained curtains, cluttered floors, broken bed rails, and unclean equipment.
Hole in resident's wall with vent cover hanging out posing injury hazard.
Facility failed to maintain an effective infection control program including improper use of enhanced barrier precautions and improper disposal of contaminated materials.
Facility failed to accurately monitor and document fluid intake for a resident on dialysis, resulting in exceeding fluid restrictions.
Medication cart was left unlocked with medications unsecured, posing risk to residents.
Report Facts
Residents observed: 134
Licensed capacity: 140
Deficiency count: 10
Fluid restriction: 1
Medication cart audit frequency: 3
Housekeeping cart audit frequency: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in medication cart unlocked and unsecured medication finding |
| Director of Nursing | DON | Named in multiple findings including call light accessibility, ADL care, fluid restriction monitoring, medication storage, infection control |
| Director of Clinical Education | Provided staff education on call light accessibility, ADL care, chemical storage, medication cart security, maintenance reporting, and infection control | |
| Housekeeping Supervisor | Named in chemical storage and infection control cleaning findings | |
| Maintenance Director | Named in findings related to environmental repairs and maintenance | |
| Infection Preventionist | Named in infection control findings regarding enhanced barrier precautions and communication failures |
Inspection Report
Annual Inspection
Census: 134
Capacity: 140
Deficiencies: 5
Date: Mar 20, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and seven Complaint Investigations at the facility from 3/17/25 through 3/20/25 to determine compliance with Medicare and Medicaid requirements.
Complaint Details
Seven complaint investigations were conducted (CI MS #27183, CI MS #27690, CI MS #27865, CI MS #28043, CI MS #28193, CI MS #28208, and CI MS #28282). Deficiencies were cited in four of these complaints related to call light accessibility, care plan implementation, ADL care, and hydration. Three complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with multiple Medicare and Medicaid requirements, including issues with call light accessibility, environmental safety, care plan implementation, ADL care, and hydration monitoring. Several deficiencies were cited related to resident safety, hygiene, and facility maintenance.
Deficiencies (5)
Resident call lights were not within reach for two residents, limiting their ability to request assistance.
Facility failed to provide a safe, clean, and homelike environment for nine residents, including broken furniture, pest issues, and unsafe room conditions.
Failure to implement care plans for activities of daily living and fluid restrictions for four residents.
Failure to provide ADL care for three residents dependent on staff assistance.
Failure to accurately monitor and document fluid intake for one resident receiving dialysis.
Report Facts
Census: 134
Total Capacity: 140
Deficiencies cited: 12
Fluid intake exceedance days: 9
Fluid intake exceedance dates: 3/3/25, 3/5/25, 3/8/25, 3/9/25, 3/10/25, 3/12/25, 3/13/25, 3/14/25, 3/17/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed residents after deficiencies and confirmed expectations for call light accessibility, care plan implementation, and fluid restriction monitoring |
| Maintenance Director | Maintenance Director | Responsible for facility repairs and maintenance; acknowledged unawareness of some maintenance issues until survey |
| RN #1 | Registered Nurse | Confirmed environmental and resident care issues including broken equipment and hygiene concerns |
| LPN #1 | Licensed Practical Nurse | Discussed fluid restriction monitoring and documentation for Resident #32 |
| Nurse Practitioner | Nurse Practitioner | Reviewed fluid restriction orders and care plans for Resident #32 |
| Certified Nurse Aide #6 | Certified Nurse Aide | Observed poor oral care for Resident #12 |
Inspection Report
Annual Inspection
Census: 134
Capacity: 140
Deficiencies: 6
Date: Mar 20, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and seven Complaint Investigations at the facility from 3/17/25 through 3/20/25 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm.
Complaint Details
Seven complaint investigations were conducted (CI MS #27183, #27690, #27865, #28043, #28193, #28208, #28282). Non-compliance was identified in several complaints including failure to provide ADLs, hydration, and environmental issues. Some complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with multiple standards including residents' rights, activities of daily living, hydration, environment, housekeeping, and maintenance. Deficiencies were identified related to call light accessibility, ADL care, fluid intake monitoring, environmental safety, and facility maintenance.
Deficiencies (6)
Resident call lights were not within reach for two residents, limiting their ability to request assistance.
Failure to provide activities of daily living care for three residents dependent on staff assistance, including oral care and nail trimming.
Failure to accurately monitor and document fluid intake for one resident receiving dialysis, exceeding fluid restrictions on multiple days.
Open window with a 3-inch gap and no screen exposing resident to outside elements, towels used to block gap.
Presence of multiple housekeeping issues including stained curtains, broken bed rail, dirty oxygen concentrator, and cluttered supplies in resident rooms.
Hole in wall beside resident's bed with metal vent cover hanging out, posing a hazard.
Report Facts
Census: 134
Total Capacity: 140
Fluid restriction: 1
Deficiency count: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed residents after deficiencies, confirmed expectations for call light accessibility and ADL care, and involved in corrective actions |
| Registered Nurse #1 | Registered Nurse | Confirmed environmental and resident care deficiencies including broken bed rail and dirty curtains |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Documented fluid intake and acknowledged issues with monitoring fluid restrictions |
| Maintenance Director | Maintenance Director | Responsible for repairs and maintenance, acknowledged unawareness of some deficiencies, and implemented corrective actions |
Inspection Report
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited.
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 134
Deficiencies: 4
Date: Mar 17, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident safety, care, environment, and care plan implementation at Diversicare of Southaven.
Findings
The facility failed to ensure call lights were within reach for residents, maintain a safe and clean environment, provide timely maintenance and repairs, implement complete care plans for activities of daily living, and accurately monitor and document fluid intake for residents on fluid restrictions.
Deficiencies (4)
Failed to ensure resident call lights were within reach, limiting ability to request assistance for 2 of 134 residents.
Failed to provide a safe, clean, and homelike environment for 9 of 134 residents, including issues with leaking air conditioner, broken furniture, pest droppings, holes in walls, and clutter.
Failed to implement activities of daily living (ADL) care plans for 3 of 5 residents dependent on staff assistance, including inadequate oral and nail care.
Failed to accurately monitor and document fluid intake for 1 of 6 residents receiving dialysis, resulting in exceeding fluid restriction on multiple days.
Report Facts
Residents observed: 134
Residents affected by call light deficiency: 2
Residents affected by environment deficiency: 9
Residents reviewed for ADL care plans: 45
Residents with failed ADL care plan implementation: 4
Days fluid intake exceeded 1 liter: 9
Length of sagging mattress area: 12
Length of peeling mattress area: 36
Hole size in wall: 24
Length of Resident #111's fingernails: 1.5
Length of Resident #118's fingernails: 0.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Confirmed staff are expected to ensure call lights are within reach and acknowledged failures in care plan implementation and fluid monitoring. |
| CNA #4 | Certified Nursing Assistant | Confirmed call light was inaccessible to Resident #42. |
| RN #2 | Registered Nurse | Verified call light was out of reach for Resident #32 and exposed wires on bed remote control. |
| CNA #2 | Certified Nursing Assistant | Admitted leaving call light out of reach for Resident #32. |
| Housekeeper #2 | Housekeeper | Reported air conditioner leaking and towels changed daily. |
| Maintenance Supervisor | Maintenance Supervisor | Unaware of some maintenance issues including leaking air conditioner and broken headboard. |
| RN #1 | Registered Nurse | Confirmed mice droppings, broken equipment, and clutter in resident rooms. |
| Maintenance Director | Maintenance Director | Confirmed lack of notification about maintenance issues and bed/mattress disrepair. |
| CNA #6 | Certified Nurse Aide | Confirmed poor oral care for Resident #12. |
| LPN #1 | Licensed Practical Nurse | Admitted incomplete monitoring of Resident #32's fluid intake. |
| Nurse Practitioner | Nurse Practitioner | Agreed failure to monitor fluid intake could exacerbate resident's condition. |
| CNA #5 | Certified Nurse Aide | Assigned to Resident #111 and confirmed long jagged fingernails not reported. |
| LPN #3 | Licensed Practical Nurse | Confirmed responsibility for trimming nails of diabetic Resident #111. |
Inspection Report
Routine
Census: 134
Deficiencies: 10
Date: Mar 17, 2025
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to ensure resident call lights were within reach, failure to secure electronic health records, unsafe and unclean resident environments, failure to implement care plans for activities of daily living and fluid restrictions, unsafe storage of hazardous chemicals, inaccurate staffing data submission, failure to follow infection prevention protocols including enhanced barrier precautions, and ineffective pest control.
Deficiencies (10)
Failure to ensure resident call lights were within reach, limiting residents' ability to request assistance (Residents #32 and #42).
Failure to secure electronic health records as evidenced by visible EMAR information on unattended medication carts (Residents #86 and #104).
Failure to provide a safe, clean, and homelike environment including leaking air conditioner, broken furniture, pest droppings, and unsafe room conditions affecting multiple residents.
Failure to implement activities of daily living care plans for dependent residents and failure to implement fluid restriction care plan for Resident #32.
Failure to safely store and lock hazardous cleaning chemicals on housekeeping carts.
Failure to accurately submit staffing data into the Payroll-Based Journal system for the first quarter of 2025.
Failure to ensure medication cart was locked and medications secured when unattended.
Failure to ensure accurate documentation of care and services for a resident with a PICC line (Resident #430).
Failure to implement infection prevention and control practices including improper use of enhanced barrier precautions and improper disposal of contaminated materials (Residents #4, #118, and #125).
Failure to maintain an effective pest control program to address mice droppings in resident's dresser drawers (Resident #70).
Report Facts
Residents observed: 134
Residents affected by call light deficiency: 2
Residents affected by EMAR privacy deficiency: 2
Residents affected by unsafe environment: 9
Residents reviewed for ADL care plans: 45
Residents with deficient ADL care plans: 4
Days fluid intake exceeded 1 liter: 9
Residents on dialysis reviewed: 6
Survey days medication cart unsecured: 1
Quarters with inaccurate PBJ data: 1
Residents on contact isolation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Confirmed EMAR visibility on medication cart and fluid intake documentation issues |
| DON | Director of Nursing | Confirmed multiple deficiencies including call light accessibility, EMAR privacy, infection control, medication cart security, and fluid intake monitoring |
| CNA #4 | Certified Nursing Assistant | Confirmed call light accessibility issues for Resident #42 |
| RN #2 | Registered Nurse | Confirmed call light accessibility and exposed wires on bed remote control |
| Housekeeper #5 | Housekeeper | Confirmed housekeeping cart lock issues and chemical storage |
| Administrator | Facility Administrator | Acknowledged deficiencies in environment, staffing data, infection control, and housekeeping |
| RN #1 | Registered Nurse | Confirmed mice droppings and infection control lapses |
| Maintenance Supervisor | Maintenance Supervisor | Acknowledged unreported maintenance issues including mice droppings and broken equipment |
Inspection Report
Complaint Investigation
Census: 130
Capacity: 140
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 11/25/24 related to dietary services, misappropriation of funds, quality of care, administration, environment, falls, nursing services, and quality of care.
Complaint Details
Complaint investigation for Cl MS #26562 related to dietary services, misappropriation of funds, quality of care, and administration and Cl MS #26598 related to environment, falls, nursing services, and quality of care. No deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for the Minimum Standards of Operation for Institutions of Aged or Infirm and there were no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 130
Capacity: 140
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 11/25/2024 related to dietary services, misappropriation of funds, quality of care, administration, environment, falls, nursing services, and quality of care.
Complaint Details
Complaint investigation for CI MS #26562 related to dietary services, misappropriation of funds, quality of care, and administration; and CI MS #26598 related to environment, falls, nursing services, and quality of care. No deficiencies were cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Census: 130
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 131
Capacity: 140
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 9/5/24 related to allegations of verbal abuse.
Complaint Details
Complaint investigation CI MS# 25402 regarding allegations of verbal abuse was not substantiated; no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. No deficiencies were cited related to the complaint.
Inspection Report
Complaint Investigation
Census: 131
Capacity: 140
Deficiencies: 0
Date: Sep 5, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI MS# 25402) at the facility related to allegations of verbal abuse.
Complaint Details
Complaint investigation CI MS# 25402 regarding allegations of verbal abuse was not substantiated; no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. No deficiencies were cited related to the allegations of verbal abuse.
Report Facts
Census: 131
Total Capacity: 140
Inspection Report
Follow-Up
Census: 125
Capacity: 140
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The State Agency conducted a follow-up survey at the facility on 6/4/24 related to the complaint survey conducted from 3/18/24 through 3/20/24.
Complaint Details
The follow-up survey was related to a prior complaint survey conducted from 3/18/24 through 3/20/24. The facility was found compliant during the follow-up.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm, and the State Agency recommended the facility be placed back in compliance effective 6/3/24.
Report Facts
Facility census: 125
Total bed capacity: 140
Inspection Report
Follow-Up
Census: 125
Capacity: 140
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The State Agency conducted a follow-up survey at the facility on 6/4/24 related to the complaint survey conducted from 3/18/24 through 3/20/24.
Complaint Details
Follow-up survey related to a prior complaint survey conducted 3/18/24 through 3/20/24; facility found in compliance.
Findings
The survey determined that the facility was in compliance with Medicare and Medicaid participation requirements, and the facility is recommended to be placed back in compliance effective 6/3/24.
Inspection Report
Follow-Up
Census: 125
Capacity: 140
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
The State Agency conducted a follow-up survey at the facility on 6/4/24 related to the complaint survey conducted on 5/8/24.
Complaint Details
The visit was related to a complaint survey conducted on 5/8/24. The facility was found to be in compliance during the follow-up survey.
Findings
During the survey, the State Agency determined that the facility was in compliance with Medicare and Medicaid requirements of participation and recommended the facility be placed back in compliance effective 6/3/24.
Inspection Report
Complaint Investigation
Census: 133
Capacity: 140
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 05/30/24.
Complaint Details
Two complaint investigations (CI MS #25064 and CI MS #25066) were conducted with no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigations; however, the facility remains out of compliance due to deficiencies cited in prior surveys on 03/20/24 and 05/08/24.
Inspection Report
Complaint Investigation
Census: 133
Capacity: 140
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 05/30/2024, focusing on facility staffing, infection control, misappropriation of property, and nursing services.
Complaint Details
Two complaint investigations (CI MS #25064 and CI MS #25066) were conducted, investigating staffing, infection control, misappropriation of property, and nursing services. No deficiencies were cited during these investigations.
Findings
No deficiencies were cited during the complaint investigations; however, the facility remains out of compliance due to deficiencies cited in prior surveys conducted on 03/20/2024 and 05/08/2024.
Report Facts
Census: 133
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 133
Capacity: 140
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 05/30/2024.
Complaint Details
Two complaint investigations (CI MS #25064 and CI MS #25066) were conducted with no deficiencies cited.
Findings
No deficiencies were cited during the complaint investigations; however, the facility remains out of compliance due to deficiencies cited in prior surveys on 03/20/2024 and 05/08/2024.
Inspection Report
Complaint Investigation
Census: 133
Capacity: 140
Deficiencies: 0
Date: May 30, 2024
Visit Reason
The State Agency conducted two complaint investigations at the facility on 05/30/2024 to investigate facility staffing, infection control, misappropriation of property, and nursing services.
Complaint Details
Complaint investigations CI MS #25064 and CI MS #25066 were conducted, focusing on staffing, infection control, misappropriation of property, and nursing services. No deficiencies were cited during this investigation.
Findings
No deficiencies were cited during the complaint investigation; however, the facility remains out of compliance with Medicare and Medicaid participation requirements due to deficiencies cited in prior surveys on 03/20/2024 and 05/08/2024.
Report Facts
Census: 133
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 8, 2024
Visit Reason
The State Agency conducted Complaint Investigations MS #24852 and MS #25031 at the facility on 5/8/24.
Complaint Details
Complaint Investigations MS #24852 and MS #25031 were conducted and found to be without deficiencies.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for Aged or Infirm and state licensure requirements. No deficiencies were cited for the complaint investigations.
Inspection Report
Complaint Investigation
Census: 123
Capacity: 140
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The State Agency conducted a complaint investigation at the facility on 5/8/2024 related to two complaint investigations (CI MS #24852 and CI MS #25031). The investigation focused on compliance with Medicare and Medicaid Services requirements, specifically regarding quality of care and discharge.
Complaint Details
The complaint investigation MS #24852 was substantiated with a deficiency cited for failure to provide services according to professional standards. Complaint investigation MS #25031 related to discharge had no deficiencies cited.
Findings
The facility was found non-compliant for failure to provide services in accordance with professional standards of practice, specifically failing to change a negative pressure wound therapy system dressing as ordered for one resident. No deficiencies were cited related to discharge for the second complaint. The wound vac dressing was not changed as ordered, leading to foam adherence to the wound and potential harm.
Deficiencies (1)
Failure to change the negative pressure wound therapy system dressing as ordered for one resident with wound care.
Report Facts
Census: 123
Total Capacity: 140
Deficiency Completion Date: Jun 3, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding wound vac dressing and documentation |
| Director of Clinical Education | Director of Clinical Education | Provided education to licensed nurses on treatment and documentation |
| Director of Nursing Services | Director of Nursing Services | Responsible for reviewing treatment documentation and auditing compliance |
| Administrator | Administrator | Interviewed and agreed wound vac dressing should have been changed as ordered |
| Wound Care Nurse Practitioner | Nurse Practitioner | Provided progress notes and verified wound vac dressing adherence |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 8, 2024
Visit Reason
The inspection was conducted following a complaint regarding failure to change the negative pressure wound therapy system dressing as ordered for Resident #1.
Complaint Details
Complaint investigation confirmed failure to change wound vac dressing as ordered. Resident Representative notified staff about the need for dressing change. The deficiency was substantiated with actual harm to the resident.
Findings
The facility failed to ensure that Resident #1's wound vac dressing was changed as ordered, resulting in the foam dressing adhering to the wound bed and causing actual harm. Interviews and record reviews confirmed the dressing was not changed on scheduled dates and fragments remained in the wound after removal.
Deficiencies (1)
Failure to change the negative pressure wound therapy system dressing as ordered for Resident #1, resulting in foam dressing adhered to the wound bed and actual harm.
Report Facts
Residents affected: 3
Residents affected: 1
Dates wound vac dressing not changed: 3
Wound vac pressure: 125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding wound vac dressing and documentation |
| NP #1 | Wound Care Nurse Practitioner | Completed progress note and interviewed regarding wound vac dressing adherence and harm |
| Director of Nursing | Director of Nursing | Involved in wound vac removal and responsible for wound care at the time |
| Administrator | Administrator | Interviewed and agreed wound vac dressing should have been changed as ordered |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 9, 2024
Visit Reason
The inspection was conducted following a complaint investigation triggered by the elopement of Resident #1, who exited the facility unsupervised and undetected on 03/31/24, posing immediate jeopardy to resident health and safety.
Complaint Details
The complaint investigation was initiated due to Resident #1 eloping from the facility on 03/31/24, remaining missing for approximately 10-20 minutes. The State Agency identified Immediate Jeopardy and Substandard Quality of Care beginning on 03/31/24. The facility implemented corrective actions by 04/01/24, and the Immediate Jeopardy was removed on 04/02/24 prior to the State Agency's entrance on 04/05/24.
Findings
The facility failed to implement an effective elopement/wandering risk care plan for Resident #1, who had a documented history of wandering and elopement attempts. Resident #1 exited the facility through an unsecured kitchen door that lacked an alarm, resulting in a 10-20 minute unsupervised absence. The facility initiated corrective actions including staff in-services, installation of new door locks and alarms, 24/7 door monitoring, and updated care plans. The immediate jeopardy was removed after corrective actions were validated by the State Agency.
Deficiencies (2)
Failed to implement an elopement/wandering risk plan of care for Resident #1 who wore a wander guard.
Failed to provide adequate supervision to prevent Resident #1 from exiting the facility unnoticed and unsupervised.
Report Facts
Times wander guard not checked: 28
Residents at risk for elopement: 4
Distance from facility to apartment complex: 200
Date of elopement: Mar 31, 2024
Date of corrective action completion: Apr 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse Supervisor | Assessed Resident #1 after elopement, notified administration, and participated in investigation and staff in-services. |
| ADM | Administrator | Received Immediate Jeopardy template, led investigation, contacted State Agency and Attorney General's Office, and oversaw corrective actions. |
| ADON | Assistant Director of Nursing / Interim Director of Nurses | Confirmed kitchen door was unsecured, participated in staff in-services, and confirmed care planning for Resident #1. |
| RN #2 | MDS/Care Plan Nurse | Completed and revised care plan for Resident #1 including elopement risk. |
| Maintenance Director | Checked and confirmed malfunctioning kitchen door alarms, coordinated installation of new locks and alarms. | |
| CNA #3 | Certified Nursing Assistant | Participated in locating Resident #1 after elopement and reported Resident #1's wandering behavior. |
| CNA #4 | Certified Nursing Assistant | Assigned to Resident #1, redirected him before elopement, and participated in locating Resident #1. |
| Resident Representative | Provided background on Resident #1's wandering history and consented to behavioral health evaluation. |
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The inspection was conducted on 4/2/2024 as two complaint investigations related to abuse and physical environment, maintenance of equipment, and falls.
Complaint Details
Two complaint investigations were conducted: CI MS #24633 related to abuse and CI MS #24634 related to physical environment, maintenance of equipment, and falls. Both complaints were found to be unsubstantiated as no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited during this visit. However, the facility remains out of compliance due to deficiencies cited on the 3/20/2024 survey.
Report Facts
Licensed beds: 140
Resident census: 134
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: Apr 2, 2024
Visit Reason
The State Agency conducted two complaint investigations on 4/2/2024 related to abuse and physical environment, maintenance of equipment, and falls.
Complaint Details
Two complaint investigations (CI MS #24633 related to abuse and CI MS #24634 related to physical environment, maintenance of equipment, and falls) were conducted and found no deficiencies.
Findings
The facility was found to be in compliance with Medicaid and Medicare standards with no deficiencies cited during this investigation; however, the facility remains out of compliance due to deficiencies cited in a prior survey on 3/20/2024.
Report Facts
Licensed beds: 140
Resident census: 134
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 5
Date: Mar 20, 2024
Visit Reason
The State Agency conducted seven complaint investigations related to various complaint investigation numbers and found the facility was not in compliance with state licensure requirements and Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was triggered by seven complaint investigations (CI MS #23878, #23901, #23910, #24000, #24186, #24221, #24352). Non-compliance was found in multiple complaint investigations with citations issued. The facility was in compliance related to CI MS #24000 and CI MS #23901.
Findings
The facility failed to provide sufficient nursing staff, failed to provide assistance with activities of daily living for several residents, failed to maintain a safe and clean environment including damaged floors and unclean areas, failed to provide adequate linens and blankets, and failed to ensure call lights were functioning properly for residents.
Deficiencies (5)
Failed to provide sufficient staff as evidenced by staff not providing assistance with bathing, grooming and personal hygiene for three sampled residents and failed to meet the state minimum nursing care hours per resident.
Failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside.
Failed to provide assistance with activities of daily living including bathing, grooming, dressing, toileting for three sampled residents.
Failed to maintain floors in a safe, clean, and homelike environment as evidenced by damaged floors on the East Wing, trash buildup, unclean floors, and no clean linens for two of three wings.
Failed to ensure call lights were functioning in all resident rooms as evidenced by call lights not functioning for two sampled residents.
Report Facts
Resident census: 135
Total bed capacity: 140
Staffing ratio: 2.69
Staffing ratio: 2.7
Number of complaint investigations: 7
Floor repair completion date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Confirmed Resident #2's condition and staffing issues |
| Licensed Practical Nurse #2 | LPN | Confirmed bathing schedule and shaving for Resident #6 |
| Licensed Practical Nurse #5 | LPN | Confirmed staffing issues and resident care concerns |
| Director of Nurses | DON | Confirmed staffing and care deficiencies, call light issues |
| Administrator | Acknowledged staffing, linen, and environmental issues | |
| Certified Nurse Assistant #1 | CNA | Reported staffing shortages and resident care delays |
| Certified Nurse Assistant #3 | CNA | Confirmed linen shortages and resident care issues |
| Maintenance Staff #2 | Confirmed floor damage and washer repair details | |
| Housekeeper #4 | Confirmed cleaning deficiencies in resident rooms | |
| Laundry Staff #3 | Assistant Supervisor | Reported washer breakdown and staffing issues |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 5
Date: Mar 20, 2024
Visit Reason
The State Agency conducted seven complaint investigations at the facility from 3/18/24 through 3/20/24 due to multiple complaints regarding resident care, environment, staffing, and other issues.
Complaint Details
The complaint investigations were triggered by multiple complaints including failure to provide a safe clean environment, failure to provide timely showers and incontinent care, insufficient staffing, and issues with resident rights and call light systems.
Findings
The facility was found non-compliant with Medicare and Medicaid requirements, citing failures in providing a safe, clean environment, timely showers and incontinent care, sufficient staffing, and proper resident rights. Specific deficiencies included lack of linens, damaged floors, unclean environment, insufficient staff to meet resident needs, and malfunctioning call lights.
Deficiencies (5)
Failure to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside.
Failure to provide a safe, clean, homelike environment including damaged floors, trash buildup, unclean floors, and no clean linens in multiple wings.
Failure to implement a comprehensive care plan for residents requiring assistance with activities of daily living including bathing, shaving, dressing, and toileting.
Failure to provide sufficient nursing staff to meet resident care needs including bathing, grooming, and personal hygiene.
Failure to ensure resident call lights were functioning properly in all resident rooms.
Report Facts
Complaint Investigations: 7
Census: 135
Total Capacity: 140
Laundry Equipment: 1
Floor Repair Duration: 9
Floor Repair Scheduled Date: 2024
Staffing: 3
Resident Wait Time: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Confirmed Resident #2's nurse and discussed lack of linens and open window. |
| Certified Nurse Assistant #3 | CNA | Resident #2's CNA who confirmed lack of linens and window open. |
| Director of Nurses | DON | Confirmed deficiencies in care plans, staffing, and resident care. |
| Administrator | Confirmed issues with linens, staffing, and environmental concerns. | |
| Laundry Staff #1 | Reported no clean linens available during inspection. | |
| Maintenance Staff #2 | Confirmed floor damage and call light issues. | |
| Licensed Practical Nurse #5 | LPN | Reported staffing issues and inadequate showers. |
| Workforce Manager | Acknowledged staffing scheduling problems and lack of training. |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, safety, care planning, staffing, environment, and call system functionality at Diversicare of Southaven nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide adequate linens and blankets to residents, unsafe and damaged flooring, unclean environment, insufficient assistance with activities of daily living (ADLs) for several residents, inadequate staffing levels impacting resident care, and malfunctioning call light systems in resident rooms.
Deficiencies (6)
Failed to provide a resident with sheets and a blanket while their bedroom window was open and 38 degrees outside.
Failed to provide a safe, clean, homelike environment as evidenced by damaged floors, trash buildup, unclean floors, and no clean linens for two of three wings.
Failed to implement a comprehensive care plan for residents requiring assistance with ADLs for three residents.
Failed to provide assistance with ADLs for residents requiring help for three residents.
Failed to provide enough nursing staff to meet the needs of residents, resulting in inadequate assistance with bathing, grooming, and personal hygiene for three residents.
Failed to ensure that call lights were functioning in all resident rooms as evidenced by two residents' call lights not functioning.
Report Facts
Residents on sample: 11
Residents affected: 1
Residents affected: 2
Residents affected: 3
Nurse aides on night shift: 3
Residents per nurse aide: 20
Square feet of flooring ordered: 470.86
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Resident #2's nurse, confirmed lack of linens and open window |
| Certified Nurse Assistant #3 | CNA | Resident #2's CNA, confirmed lack of linens and frequent occurrence |
| Administrator | Confirmed issues with linens, window open, laundry problems, and floor hazards | |
| Director of Nurses | DON | Confirmed resident rights violations and staffing issues |
| Laundry Staff #1 | Confirmed no clean linens or blankets available | |
| Licensed Practical Nurse #4 | LPN | Confirmed floor hazards and use of yellow poles |
| Maintenance Staff #2 | Confirmed floor damage and washer issues | |
| Certified Nurse Assistant #5 | CNA | Reported complaints about cleanliness and garbage buildup |
| Environmental Manager | New manager, unaware of washer breakdown and linen issues | |
| Licensed Practical Nurse #5 | LPN | Reported staffing issues and inadequate showers |
| Workforce Manager | Untrained in staffing scheduling, unaware of staffing shortages |
Inspection Report
Follow-Up
Census: 131
Capacity: 140
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The State Agency conducted a Follow-up Survey at the facility from 12/4/23 to 12/6/23 for the Annual Survey conducted from 10/30/23 to 11/2/23.
Findings
No additional deficiencies were cited during this survey. The facility was placed back in compliance with Medicare and Medicaid regulations effective 11/27/2023.
Inspection Report
Follow-Up
Census: 131
Capacity: 140
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The State Agency conducted a Follow-up Survey at the facility from 12/4/23 to 12/6/23 for the Annual Survey conducted from 10/30/23 to 11/2/23.
Findings
The facility was placed back in compliance with the Mississippi Regulation for Minimum Standards for Institutions for Aged and Infirm with no additional deficiencies cited during this survey effective 11/27/2023.
Inspection Report
Follow-Up
Census: 131
Capacity: 140
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The State Agency conducted a Follow-up Survey from 12/4/23 to 12/6/23 to verify correction of deficiencies from the Annual Survey conducted from 10/30/23 to 11/2/23.
Findings
No additional deficiencies were cited during this follow-up survey. The facility was determined to be back in compliance with Medicare and Medicaid regulations effective 11/27/2023.
Inspection Report
Follow-Up
Census: 131
Capacity: 140
Deficiencies: 0
Date: Dec 6, 2023
Visit Reason
The State Agency conducted a Follow-up Survey from 12/4/23 to 12/6/23 to verify compliance after the Annual Survey conducted from 10/30/23 to 11/2/23.
Findings
The facility was placed back in compliance with the Mississippi Regulation for Minimum Standards for Institutions for Aged and Infirm with no additional deficiencies cited during this survey effective 11/27/2023.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 6, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during a required seven-day period, specifically between 10/30/2023 and 11/05/2023, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 6
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to assess compliance with care plan development and implementation, provision of activities of daily living (ADL) care including shaving, medication management, assistive device use, and environmental safety in the nursing home.
Findings
The facility failed to develop and implement complete care plans for shaving for two residents, failed to keep a call light within reach for one resident, failed to consult a physician for medication changes for one resident, failed to apply a splint for one resident with assistive devices, and failed to maintain a safe and sanitary environment in one resident's room due to dirty air conditioner filters and residue on the wall.
Deficiencies (6)
Failed to develop/implement care plans for shaving for two residents (Resident #90 and Resident #173).
Failed to ensure call light was in reach of one resident (Resident #102).
Failed to consult a physician for medication changes for one resident (Resident #15) after high blood sugar reading.
Failed to apply a splint for one resident (Resident #108) with assistive device needs.
Failed to provide ADL care, shaving, for two residents (Resident #90 and Resident #173).
Failed to provide a safe, clean, and comfortable environment due to gray/black residue on wall and dirty air conditioner filter in Resident #83's room.
Report Facts
Residents sampled: 26
Residents reviewed for ADL care: 125
Resident rooms observed: 75
Days of survey: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #4 | Confirmed Resident #90 wanted to be shaved | |
| Certified Nursing Assistant (CNA) #4 | Assigned to Resident #90 and shaved him | |
| Director of Nursing (DON) | Interviewed regarding shaving care plans and staff responsibilities | |
| Certified Nursing Assistant (CNA) #1 | Interviewed about shaving residents during baths/showers | |
| Minimum Data Set Nurse (MDS) | Confirmed care plan noncompliance for call light and medication notification | |
| Licensed Practical Nurse (LPN) #1 | Confirmed shaving care and environmental issues in Resident #83's room | |
| District Manager for Housekeeping | Confirmed residue and air conditioner filter issues in Resident #83's room | |
| Administrator | Confirmed environmental deficiencies and potential resident health risks |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 3
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 10/30/2023 through 11/2/2023 to assess compliance with Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements.
Complaint Details
The complaint investigation (CI MS #22673) was related to environment and Activities of Daily Living, with cited deficiencies including failure to apply hand splints and issues with resident nourishment refrigerators.
Findings
The facility was found not in compliance with several standards including failure to apply recommended hand splints to prevent contractures, inadequate cleaning and maintenance of kitchen equipment and resident nourishment refrigerators, and improper infection control related to oxygen tubing storage. Deficiencies were cited in range of motion treatment, kitchen sanitation, and infection control.
Deficiencies (3)
Failed to apply a recommended hand splint to prevent worsening of contracture for one resident, resulting in loss of range of motion.
Failed to clean one of two ice machines, failed to check dishwater temperature in the three-compartment sink for six days, and failed to label, date, clean, and remove expired food in three resident nourishment refrigerators.
Failed to prevent possible spread of infection when oxygen tubing was found laying on the floor under a resident's wheelchair and not stored in a plastic bag.
Report Facts
Facility licensed beds: 140
Facility census: 125
Deficiency count: 3
Audit frequency: 5
Audit frequency: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Named in infection control deficiency related to oxygen tubing storage |
| Director of Nursing | Director of Nursing | Involved in assessment and corrective actions for hand splint and oxygen tubing deficiencies |
| District Dietary Manager | District Dietary Manager | Involved in dietary staff in-service and monitoring of dishwashing temperatures and ice machine cleaning |
| Maintenance Supervisor | Maintenance Supervisor | Responsible for cleaning ice machine and monitoring |
| Certified Nurse Aide #2 | Certified Nurse Aide | Mentioned in relation to hand splint deficiency and nourishment refrigerator cleanliness |
| Occupational Therapist | Occupational Therapist | Provided evaluation and treatment recommendations for resident's hand splint |
| Administrator | Administrator | Confirmed deficiencies related to ice machine cleanliness and nourishment refrigerator conditions |
| Assistant Director of Nursing | Assistant Director of Nursing | Responsible for ensuring Unit Secretaries clean resident nourishment refrigerators |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 7
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 10/30/23 through 11/2/23 to determine compliance with Medicare and Medicaid requirements.
Complaint Details
The complaint investigation (Cl MS #22673) found noncompliance related to environment and Activities of Daily Living, citing deficiencies F677 and F921.
Findings
The facility was found not in compliance with multiple regulatory requirements including reasonable accommodations, notification of changes, comprehensive care plans, range of motion/mobility, accident hazards, food safety, and infection prevention and control. Deficiencies were cited related to call light accessibility, failure to notify physician of elevated blood sugar, incomplete care plans, failure to apply splints, unsecured oxygen cylinders, unclean ice machine, improper dishwashing temperatures, and unsanitary resident nourishment refrigerators.
Deficiencies (7)
Failed to ensure a resident's call light was placed within reach.
Failed to notify the resident's physician of an elevated blood sugar of 466.
Failed to develop/implement comprehensive care plans for multiple residents including shaving, call light accessibility, medication changes, and assistive devices.
Failed to apply a hand splint recommended by Occupational Therapy to prevent worsening of contracture.
Failed to ensure a resident was free from accident hazards due to unsecured free standing portable oxygen cylinder.
Failed to clean the ice machine, failed to check dishwashing water temperature, and failed to label, date, clean, and remove expired food in resident nourishment refrigerators.
Failed to prevent possible spread of infection when a resident's oxygen tubing was laying on the floor and not stored in a plastic bag.
Report Facts
Deficiencies cited: 7
Census: 125
Total licensed capacity: 140
Elevated blood sugar: 466
Oxygen flow rate: 3
BIMS score: 6
BIMS score: 12
BIMS score: 9
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Failed to notify physician of elevated blood sugar for Resident #15. |
| CNA #3 | Certified Nurse Assistant | Confirmed Resident #102's call light was on the floor and not in reach. |
| Director of Nursing | Director of Nursing | Assessed residents, confirmed deficiencies, and provided oversight of corrective actions. |
| District Dietary Manager | Dietary Manager | Confirmed improper dishwashing temperatures and unclean ice machine. |
| Maintenance Director | Maintenance Director | Responsible for ice machine cleaning. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Removed oxygen tubing from floor and replaced it for Resident #49. |
| Occupational Therapist | Occupational Therapist | Evaluated Resident #108 and confirmed splint was not applied. |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 1
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation (CI) MS #22673 at the facility from 10/30/23 through 11/2/23 to assess compliance with Minimum Standards of Operation and state licensure requirements.
Complaint Details
The complaint investigation MS #22673 found noncompliance related to environment and activities of daily living, specifically citing failure to provide shaving assistance to residents.
Findings
The facility was found not in compliance with standards related to activities of daily living, specifically failure to provide shaving assistance to two residents. Deficiencies were cited at M625, M935, M1570, and M610 related to environment and activities of daily living.
Deficiencies (1)
Failure to provide activities of daily living care, specifically shaving, for two residents.
Report Facts
Licensed beds: 140
Resident census: 125
Residents affected: 2
Audit frequency: 5
Audit duration weeks: 8
Audit duration weeks: 4
Quality Assurance review start date: Nov 27, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Assessed Resident #90 and confirmed no negative effects from deficient practice; interviewed regarding shaving policy |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed confirming Resident #90 wanted to be shaved and staff should provide shaving |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Assigned to Resident #90 and provided shaving on 11/1/2023 |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about shaving residents during baths or showers |
Inspection Report
Annual Inspection
Census: 125
Capacity: 140
Deficiencies: 3
Date: Nov 2, 2023
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation at the facility from 10/30/2023 through 11/2/2023 to determine compliance with Medicare and Medicaid requirements.
Complaint Details
The complaint investigation (Cl MS #22673) found noncompliance related to environment and Activities of Daily Living, citing deficiencies F677 and F921.
Findings
The facility was found not in compliance with multiple Medicare and Medicaid requirements, including deficiencies in comprehensive care plans, activities of daily living care (shaving), safe and sanitary environment, and medication management. Specific issues included failure to develop/implement care plans for shaving, failure to keep call lights within reach, failure to consult physicians for medication changes, failure to apply assistive devices, and environmental concerns such as dirty air conditioner filters and residue on walls.
Deficiencies (3)
Failed to develop/implement care plans for shaving, call light accessibility, medication consultation, and assistive device application for multiple residents.
Failed to provide activities of daily living care, specifically shaving, for two residents.
Failed to provide a safe, functional, sanitary, and comfortable environment due to dirty air conditioner filter and gray/black residue on resident room wall.
Report Facts
Residents sampled: 26
Residents with care plan deficiencies: 5
Residents reviewed for ADL care: 125
Residents with ADL care deficiencies: 2
Resident census: 125
Total licensed capacity: 140
Blood sugar reading: 466
Audit frequency: 5
Audit duration: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | LPN | Confirmed Resident #90 wanted to be shaved |
| Certified Nursing Assistant #4 | CNA | Assigned to Resident #90 and performed shaving |
| Director of Nursing | DON | Assessed residents, confirmed care plan requirements, and provided interviews regarding care plan and shaving practices |
| Certified Nursing Assistant #1 | CNA | Confirmed shaving should be part of bathing/showering |
| Licensed Practical Nurse #1 | LPN | Confirmed shaving practices and environmental concerns |
| Nurse Practitioner | NP | Assessed Resident #15 after elevated blood sugar and Resident #109's hand |
| District Manager for Housekeeping | Housekeeping Manager | Confirmed environmental issues with residue and air conditioner |
| Administrator | Facility Administrator | Confirmed environmental issues and corrective actions |
| Director of Clinical Education | Clinical Education Director | Provided in-service training on care plans, shaving, and environmental reporting |
| Corporate Nursing Home Administrator | Administrator | In-serviced maintenance staff on air conditioner cleaning and maintenance |
Inspection Report
Routine
Deficiencies: 7
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Diversicare of Southaven.
Findings
The facility was found deficient in multiple areas including failure to keep call lights within reach of residents, failure to notify physicians of critical blood sugar levels, incomplete care plans for residents, failure to apply prescribed splints, unsecured oxygen cylinders, unclean ice machine and resident nourishment refrigerators, and improper infection control practices related to oxygen tubing.
Deficiencies (7)
Failed to ensure a resident's call light was placed within reach.
Failed to notify the resident's physician of an elevated blood sugar of 466.
Failed to develop/implement care plans for shaving, call light accessibility, medication consultation, and splint application for multiple residents.
Failed to apply a hand splint recommended by Occupational Therapy resulting in loss of range of motion.
Failed to ensure a resident was free from accident hazards due to unsecured portable oxygen cylinder.
Failed to clean the ice machine, check dish water temperature, and properly label, date, clean, and remove expired food in resident nourishment refrigerators.
Failed to prevent possible spread of infection by allowing oxygen tubing to lay on the floor and not stored in a plastic bag.
Report Facts
Residents sampled: 26
Blood sugar level: 466
Water temperature: 90
Water temperature: 110
Water temperature: 135
Water temperature range: 135-150
Water temperature range: 150-185
BIMS score: 6
BIMS score: 12
BIMS score: 9
BIMS score: 15
Resident nourishment refrigerators: 3
Ice machine cleaning frequency: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding blood sugar notification and care plan compliance |
| Licensed Practical Nurse #2 | LPN | Confirmed unsecured oxygen cylinder and oxygen tubing on floor |
| Licensed Practical Nurse #3 | LPN | Did not notify NP of elevated blood sugar for Resident #15 |
| Certified Nurse Assistant #1 | CNA | Interviewed about shaving residents and refrigerator cleanliness |
| Certified Nurse Assistant #2 | CNA | Confirmed resident nourishment refrigerator uncleanliness |
| Certified Nurse Assistant #3 | CNA | Confirmed call light placement issue for Resident #102 |
| Certified Nurse Assistant #4 | CNA | Interviewed about shaving Resident #90 |
| Director of Nursing | DON | Multiple interviews confirming deficiencies and care plan issues |
| Occupational Therapist | OT | Confirmed splint not applied to Resident #108 and worsening contracture |
| District Dietary Manager | Manager | Confirmed ice machine uncleanliness and dishwashing temperature issues |
| Administrator | Administrator | Confirmed multiple deficiencies including ice machine and nourishment refrigerators |
| Minimum Data Set Nurse | MDS Nurse | Confirmed care plan non-compliance and impact on resident care |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The State Agency conducted a desk review on 12/14/2023 of information related to the annual survey conducted on 10/30/2023 to verify correction of deficient practices.
Findings
The facility provided information confirming measures were put in place to correct deficient practices and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 12/13/2023.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no Life Safety Code deficiencies cited during the survey.
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on the fire alarm system installation and functionality.
Findings
The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, with a trouble signal observed on the fire alarm panel that could not be reset to normal. The issue affected all smoke compartments and all residents on the day of the survey.
Deficiencies (1)
Failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal on the fire alarm panel that could not be reset.
Report Facts
Deficiency completion date: Dec 13, 2023
Inspection time: 1530
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Performed manual fire alarm panel reset and was educated on importance of fire alarm panel transmission | |
| Maintenance Supervisor | Unable to reset fire alarm panel to normal and verified observation during exit interview | |
| Administrator | Acknowledged finding and educated Maintenance Director and Assistant on fire alarm panel importance |
Inspection Report
Life Safety
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code, specifically regarding the fire alarm system functionality and maintenance.
Findings
The facility failed to maintain a complete manual fire alarm system as required by NFPA 72 and NFPA 101, evidenced by a trouble signal on the fire alarm panel that could not be reset during the inspection. The deficiency affected all smoke compartments and all residents on the day of the survey.
Deficiencies (1)
Facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10 and NFPA 101 section 9.6, with a trouble signal on the fire alarm panel that could not be reset.
Report Facts
Date of fire alarm panel reset: Oct 30, 2023
Scheduled repair completion date: Dec 1, 2023
Date of fire alarm system inspection: Nov 9, 2023
Quality Assurance meeting date: Dec 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Unable to reset fire alarm panel to normal mode; verified observation during exit interview | |
| Administrator | Acknowledged the finding and educated Maintenance Director and Assistant on fire alarm panel importance | |
| Maintenance Director | Performed manual fire alarm panel reset to normal on 10/30/2023 and received education on fire alarm panel importance | |
| Maintenance Assistant | Educated on importance of ensuring fire alarm panel transmits normally |
Inspection Report
Deficiencies: 0
Date: Oct 30, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no Life Safety Code deficiencies cited during the survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete COVID-19 information to the NHSN during the required seven-day reporting period between 08/07/2023 and 08/13/2023, as determined by CMS based on CDC data.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 14, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/07/2023 to 08/13/2023 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Complaint Investigation
Census: 129
Capacity: 140
Deficiencies: 0
Date: Jun 22, 2023
Visit Reason
The State Agency conducted three complaint investigations at the facility from 2023-06-21 through 2023-06-22, investigating Dietary services, Nursing Services Quality of Care, Treatment, Physical Environment, and Neglect.
Complaint Details
Three complaint investigations (CI MS #21612, CI MS #21816, and CI MS #21887) were conducted with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, with no deficiencies cited in the investigated areas.
Report Facts
Licensed beds: 140
Census: 129
Inspection Report
Complaint Investigation
Census: 129
Capacity: 140
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 6/21/2023 through 6/22/2023 to investigate Dietary Services, Nursing Services, Quality of Care Treatment, Physical Environment, and Neglect.
Complaint Details
Complaint Investigation (CI MS #21612, CI MS #21816, and CI MS #21887) was conducted with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 129
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 5/9/23 through 5/10/23 to investigate pressure sores, neglect, and accidents.
Complaint Details
The complaint investigation involved allegations related to pressure sores, neglect, and accidents, and no deficiencies were cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm, with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 134
Capacity: 140
Deficiencies: 0
Date: May 10, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 5/9/23 through 5/10/23 to investigate pressure sores, neglect, and accidents.
Complaint Details
Complaint Investigation (CI MS #21424 and CI MS #20962) regarding pressure sores, neglect, and accidents was conducted and found no deficiencies.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, with no deficiencies cited during the investigation.
Report Facts
Licensed beds: 140
Census: 134
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
The State Agency conducted a desk review of information related to a complaint survey completed on 2022-12-28 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Complaint Details
The visit was related to a complaint survey completed on 2022-12-28; the desk review confirmed compliance.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm; no deficiencies were noted in this plan of correction document.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 7, 2023
Visit Reason
The State Agency conducted a desk review related to a complaint survey completed on 2022-12-28 to verify corrective measures taken by the facility.
Complaint Details
The visit was related to a complaint survey completed on 2022-12-28. The facility's corrective actions were reviewed and found satisfactory, leading to a recommendation for compliance reinstatement.
Findings
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 2023-01-31.
Inspection Report
Complaint Investigation
Census: 136
Capacity: 140
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a complaint survey from 1/18/23 to 1/19/23 to investigate complaint MS #20454 regarding Quality of Care/Treatment and Accidents/Unwitnessed Fall Resident #1.
Complaint Details
Complaint MS #20454 was not substantiated for Quality of Care/Treatment Call Bell Not Answered In A Timely Manner By Staff and Accidents/Unwitnessed Fall Resident #1.
Findings
The State Agency did not substantiate the complaint and determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 136
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 0
Date: Jan 19, 2023
Visit Reason
The State Agency conducted a complaint survey at the facility from January 18 to January 19, 2023, to investigate allegations related to Quality of Care/Treatment, Call Bell response times, and Accidents/Unwitnessed Falls.
Complaint Details
Complaint survey MS CI #20454 was conducted; the complaint for Quality of Care/Treatment, Call Bell Not Answered In A Timely Manner By Staff, and Accidents/Unwitnessed Fall was not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited during this survey; however, the facility remains out of compliance due to deficiencies cited in a prior complaint survey conducted on December 28, 2022.
Report Facts
Licensed beds: 140
Census: 135
Inspection Report
Complaint Investigation
Census: 138
Capacity: 140
Deficiencies: 0
Date: Dec 28, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility on 12/28/22.
Complaint Details
Complaint survey CI# 20239 was conducted and the facility was found compliant with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Licensed beds: 140
Census: 138
Inspection Report
Complaint Investigation
Census: 138
Capacity: 140
Deficiencies: 1
Date: Dec 28, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility on 12/28/2022 due to a complaint regarding the physical environment.
Complaint Details
The complaint was substantiated for physical environment issues related to cleanliness and sanitation.
Findings
The facility failed to maintain a clean, comfortable environment as evidenced by thick, pink and black substances in and around toilets and bathtub drains in four of 75 bathrooms observed. Interviews with staff confirmed the unsanitary conditions and acknowledged the potential risk to residents.
Deficiencies (1)
Facility failed to maintain a safe, clean, comfortable, and homelike environment due to thick, pink and black substances in and around toilets and bathtub drains in four bathrooms.
Report Facts
Licensed beds: 140
Census: 138
Bathrooms observed: 75
Bathrooms with deficiencies: 4
Rooms monitored: 5
Monitoring frequency: 5
Monitoring frequency: 3
Monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Confirmed black and pink substances in bathtub and toilet in room W24 |
| Housekeeping Supervisor | Confirmed presence of black substances around toilets and acknowledged cleaning issues | |
| Housekeeping District Manager | Confirmed unsanitary conditions and potential resident risks; responsible for in-service training and monitoring | |
| Administrator | Confirmed unsanitary conditions and potential resident risks; involved in monitoring and corrective action | |
| Floor Technician #1 | Confirmed dried black and pink substances in bathroom |
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a complaint survey from 11/28/22 to 11/30/22 related to complaints MS #19768 and MS #19808 concerning resident rights, environment, responsible party, notification, and resident assessment.
Complaint Details
Complaints MS #19768 and MS #19808 were investigated and found not substantiated for resident rights, environment, responsible party, notification, and resident assessment.
Findings
The State Agency did not substantiate the complaints and determined the facility was in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Licensed beds: 140
Census: 135
Inspection Report
Complaint Investigation
Census: 135
Capacity: 140
Deficiencies: 0
Date: Nov 30, 2022
Visit Reason
The State Agency conducted a complaint survey at the facility from 11/28/22 to 11/30/22 to investigate complaints identified as MS CI #19768 and MS CI #19808.
Complaint Details
The complaint investigation did not substantiate the complaints related to resident rights, environment, responsible party notification of change, and resident assessment.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding resident rights, environment, responsible party notification of change, and resident assessment were not substantiated, and no deficiencies were cited.
Report Facts
Licensed beds: 140
Census: 135
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-07-27 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2022-09-09.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-07-27 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2022-09-09.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Sep 15, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-07-27 to verify corrective measures taken by the facility.
Findings
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 2022-09-09.
Report Facts
Annual survey completion date: Jul 27, 2022
Compliance effective date: Sep 9, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2022
Visit Reason
The State Agency conducted a complaint survey MS #19487 on 8/22/22 to investigate allegations of Neglect and Abuse.
Complaint Details
Complaint MS #19487 alleging Neglect and Abuse was investigated and not substantiated.
Findings
The complaint was not substantiated and no deficiencies were cited during this complaint survey. However, the facility remains out of compliance due to deficiencies cited on the 7/27/2022 survey.
Report Facts
Complaint survey date: Aug 22, 2022
Previous survey date: Jul 27, 2022
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 22, 2022
Visit Reason
The State Agency conducted a complaint survey CI MS #19487 on 8/22/22 to investigate allegations of Neglect and Abuse.
Complaint Details
Complaint CI MS #19487 was investigated and found not substantiated for allegations of Neglect and Abuse.
Findings
The complaint was not substantiated and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 7/27/2022 survey.
Report Facts
Complaint ID: 19487
Previous survey date: Jul 27, 2022
Inspection Report
Routine
Deficiencies: 3
Date: Jul 27, 2022
Visit Reason
The inspection was conducted as a routine survey to assess compliance with state regulations regarding resident care, facility environment, and safety systems.
Findings
The facility was found deficient in providing adequate nail care to a dependent resident, maintaining a clean and safe physical environment with multiple maintenance issues, and ensuring a properly functioning resident call system on the East Wing.
Deficiencies (3)
Failed to provide nail care for a dependent resident, resulting in dirty fingernails with brownish material under the nails.
Failed to maintain a clean and safe environment evidenced by missing tiles, missing baseboard, missing air conditioner vent covers, damaged furniture, and standing water with electrical cords running through it in resident rooms.
Failed to maintain a properly functioning call system on the East Wing; audible alarms were not working though lights were functional.
Report Facts
Residents reviewed for nail care: 5
Rooms observed for environmental issues: 32
Wet area width: 2
Vent covers missing: 6
Residents assessed for call system: 100
Rounds for nail care audit: 5
Rounds for maintenance checks: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN)/Clinical Director | Interviewed regarding nail care policy and resident #125's condition. | |
| Certified Nursing Assistant (CNA) #1 | Interviewed and observed regarding nail care and call system. | |
| RN #1 | Confirmed need for nail care to prevent skin breakdown or infection. | |
| Maintenance Director | Responsible for repairs and maintenance; interviewed about environmental issues and call system repairs. | |
| Housekeeping Supervisor | Interviewed about reporting maintenance issues and cleaning schedules. | |
| Facility Administrator | Interviewed about facility policies, environmental issues, and call system functionality. | |
| Licensed Practical Nurse (LPN) #7 | Interviewed regarding call system alarm issues and resident safety. | |
| Licensed Practical Nurse (LPN) #8 | Interviewed regarding housekeeping and call system. | |
| Certified Nursing Assistant (CNA) #2 | Interviewed about call system usage and reliance on visual signals. | |
| Licensed Practical Nurse (LPN) #5 | Reported call system audible alarm not working for weeks/months. | |
| Licensed Practical Nurse (LPN) #6 | Reported residents were given bells due to call system alarm failure. | |
| Certified Nursing Assistant (CNA) #3 | Reported call system sound alarm not working. |
Inspection Report
Annual Inspection
Census: 118
Capacity: 140
Deficiencies: 4
Date: Jul 27, 2022
Visit Reason
The State Agency conducted an annual recertification and complaint investigations from 07/17/22 to 07/21/22, with a return visit on 07/27/22 for investigation of possible abuse which was not substantiated.
Complaint Details
The complaint investigations included multiple complaint IDs related to call light system, activities of daily living, environment, elopement, quality of care, and infection control. The abuse allegation was not substantiated. The elopement incident was reported late beyond the required 24-hour timeframe.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated complaints related to call light system, activities of daily living, environment, and timely reporting of incidents. Deficiencies were cited in areas including safe environment, notification of incidents, care planning, pressure ulcer prevention, and medication storage.
Deficiencies (4)
Facility failed to provide a safe, clean, comfortable, and homelike environment as evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords in resident rooms.
Facility failed to notify the State Agency timely of a potential incident of resident elopement for one reported incident.
Facility failed to provide nail care for a dependent resident, with brownish material under fingernails observed over multiple days.
Facility failed to maintain a properly functioning call light system on the East Wing; audible alarm was not working for several weeks to months, potentially delaying resident assistance.
Report Facts
Census: 118
Total Capacity: 140
Deficiencies cited: 4
Elopement incident report delay: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in findings related to environmental repairs and call light system maintenance | |
| Administrator | Named in findings related to incident reporting and call light system oversight | |
| Certified Nursing Assistant #1 | CNA | Mentioned in relation to call light system observations and resident care |
| Licensed Practical Nurse #8 | LPN | Mentioned in relation to reporting room conditions and housekeeping |
| Registered Nurse / Clinical Director | RN | Mentioned in relation to nail care deficiency |
Inspection Report
Annual Inspection
Census: 118
Capacity: 140
Deficiencies: 4
Date: Jul 27, 2022
Visit Reason
The State Agency conducted an annual recertification survey along with complaint investigations from 07/17/22 to 07/21/22, and a return visit on 07/27/22 to investigate a possible abuse complaint which was not substantiated.
Complaint Details
Complaint investigations included allegations related to call light system, elopement, quality of care/treatment/staffing, infection control, and possible abuse. The abuse complaint was not substantiated. The call light system complaint was substantiated with citations.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. Deficiencies were cited related to activities of daily living, pressure ulcer treatment and assessment, housekeeping and maintenance issues, and a malfunctioning call light system on the East Wing.
Deficiencies (4)
Failed to provide nail care for a dependent resident, resulting in dirty fingernails with brownish material under nails.
Failed to provide a Registered Nurse assessment of pressure ulcers for one resident; Licensed Practical Nurses were performing wound measurements without RN verification.
Facility failed to maintain a clean and safe environment evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords on the floor in resident rooms.
Call light system on the East Wing was malfunctioning with no audible alarm despite lights being on, potentially delaying resident assistance.
Report Facts
Census: 118
Total Capacity: 140
Residents reviewed for nail care: 5
Residents reviewed for RN wound assessments: 8
Rooms observed for housekeeping: 32
Work order open date: Jan 21, 2022
Work order close date: Feb 7, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN/Clinical Director | Registered Nurse/Clinical Director | Interviewed regarding nail care policy and pressure ulcer assessments |
| Director of Nursing Services | Director of Nursing | Interviewed regarding wound assessments and facility nursing practices |
| Assistant Director of Nursing Services | Assistant Director of Nursing | Interviewed regarding wound assessments and nursing staff roles |
| Maintenance Director | Maintenance Director | Interviewed regarding facility maintenance, repairs, and call light system |
| Facility Administrator | Facility Administrator | Interviewed regarding facility environment and call light system deficiencies |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Provided pressure ulcer treatment and dressing changes |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed regarding call light system malfunction |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding call light system and resident bells |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed regarding call light system malfunction and resident bells |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding housekeeping and call light system |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding call light system and resident care |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding call light system |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding call light system |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed regarding environmental issues reporting |
Inspection Report
Annual Inspection
Census: 118
Capacity: 140
Deficiencies: 7
Date: Jul 27, 2022
Visit Reason
The State Agency conducted an annual recertification and complaint investigations from 07/17/22 to 07/21/22, with a return visit on 07/27/22 for investigation of possible abuse which was not substantiated.
Complaint Details
The survey included complaint investigations CI MS #19370, CI MS #19362, CI MS #19225, CI MS #18823, and CI MS #19414. Abuse investigation was not substantiated. Complaints substantiated included call light system, ADLs, environment, and timely notification to State Agency.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with substantiated complaints related to call light system, ADLs, environment, and other care issues. Multiple deficiencies were cited including safe environment, notice of transfer/discharge, care planning, pressure ulcer treatment, medication storage, and resident call system.
Deficiencies (7)
Failed to provide a safe, clean, comfortable, and homelike environment evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords in resident rooms.
Failed to provide notice of transfer to the hospital to the responsible party for one resident.
Failed to develop a comprehensive care plan for refusal of Activities of Daily Living (ADL) care for one resident.
Failed to provide ADL care including nail care for a dependent resident.
Failed to ensure Registered Nurse assessment and measurement of pressure ulcers; LPNs were performing wound measurements without RN verification.
Failed to store narcotics in permanently affixed locked compartments inside medication room refrigerators.
Failed to maintain a properly functioning resident call system on the East Wing; audible alarm was not working leading to potential delays in resident assistance.
Report Facts
Deficiencies cited: 9
Census: 118
Total licensed capacity: 140
Call light system malfunction report dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in findings related to environmental repairs and medication storage lock box installation. | |
| Administrator | Named in findings related to transfer notification and call light system issues. | |
| Registered Nurse #1 | RN | Named in findings related to refusal of care and nail care deficiencies. |
| Licensed Practical Nurse #3 | LPN | Named in findings related to pressure ulcer treatment and wound measurements. |
| Social Services | Named in findings related to failure to notify family of hospital transfer. | |
| Director of Nursing | DON | Named in findings related to wound care oversight and medication storage. |
| Assistant Director of Nursing | ADON | Named in findings related to wound care and medication storage. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jul 27, 2022
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 07/27/22 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 09/09/22.
Report Facts
Survey completion date: Jul 27, 2022
Inspection Report
Routine
Deficiencies: 7
Date: Jul 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident safety, care, and facility environment, including observations of environmental conditions, resident care plans, medication storage, wound care, and call system functionality.
Findings
The facility was found deficient in maintaining a safe and clean environment, timely notification of hospital transfers, comprehensive care planning, nail care provision, pressure ulcer assessment by qualified staff, secure storage of narcotics, and proper functioning of the call system in the East Wing.
Deficiencies (7)
Failed to provide a clean and safe environment as evidenced by missing tiles, missing baseboard, missing air conditioner vent cover, damaged furniture, and standing water with electrical cords in resident rooms.
Failed to provide timely notification to the resident's responsible party of transfer to hospital for one of three residents.
Failed to develop a comprehensive care plan for refusal of Activities of Daily Living (ADL) care for one of 27 residents reviewed.
Failed to provide nail care for one dependent resident, with fingernails dirty with brownish material.
Failed to provide a Registered Nurse for assessment of pressure ulcers; Licensed Practical Nurses performed wound measurements without RN verification.
Failed to store narcotics in a permanently fixed locked box in two of three medication rooms reviewed.
Failed to maintain a properly functioning call system in the East Wing; audible alarm was not working though lights were on.
Report Facts
Rooms observed with environmental issues: 2
Residents transferred to hospital: 3
Residents care plans reviewed: 27
Residents reviewed for nail care: 5
Residents reviewed for wound assessments: 8
Medication rooms reviewed: 3
Wings observed for call system: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding maintenance rounds and call system repairs. | |
| Licensed Practical Nurse #8 | LPN | Interviewed about electronic reporting system for repairs and housekeeping. |
| Facility Administrator | Administrator | Confirmed environmental issues, call system problems, and notification policies. |
| Housekeeping Supervisor | Reported ongoing environmental issues and communication with maintenance. | |
| Licensed Practical Nurse #7 | LPN | Confirmed safety hazards and housekeeping cleaning schedules. |
| Registered Nurse #1 | RN | Confirmed resident care refusals and nail care needs. |
| Minimum Data Set Nurse | Confirmed lack of care plan for refusal of ADL care. | |
| Assistant Administrator | Confirmed documentation requirements for care refusals. | |
| Certified Nursing Assistant #1 | CNA | Reported on call system audible alarm and resident assistance. |
| Licensed Practical Nurse #3 | LPN | Performed wound treatments and measurements. |
| Nurse Practitioner | NP | Provided guidance on wound assessments. |
| Assistant Director of Nursing | ADON | Discussed wound care responsibilities and narcotics storage. |
| Director of Nursing | DON | Discussed wound care oversight and narcotics storage. |
| Licensed Practical Nurse #1 | LPN | Observed medication storage and narcotics lock box. |
| Licensed Practical Nurse #2 | LPN | Interviewed about narcotics lock box requirements. |
| Licensed Practical Nurse #5 | LPN | Reported call system audible alarm failure. |
| Licensed Practical Nurse #6 | LPN | Reported call system issues and resident bell distribution. |
| Licensed Practical Nurse #7 | LPN | Reported call system audible alarm failure and resident bell use. |
| Certified Nursing Assistant #3 | CNA | Reported call system audible alarm failure and resident bell use. |
Inspection Report
Complaint Investigation
Census: 125
Capacity: 140
Deficiencies: 0
Date: Mar 21, 2022
Visit Reason
A complaint investigation was conducted by the State Agency on 3/21/22 regarding allegations of abuse.
Complaint Details
Complaint Investigation (CI) #18558 was unsubstantiated with no deficiencies cited for allegations of abuse.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited, and the facility was found to be in compliance with Mississippi Long Term Care regulations.
Report Facts
Licensed beds: 140
Census: 125
Inspection Report
Complaint Investigation
Census: 125
Capacity: 140
Deficiencies: 0
Date: Mar 21, 2022
Visit Reason
A complaint investigation (CI) #18558 was conducted by the State Agency on 3/21/22 regarding allegations of abuse.
Complaint Details
Complaint Investigation (CI) #18558 was unsubstantiated with no deficiencies cited for allegations of abuse.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited. The facility was found to be in compliance with CMS regulations.
Report Facts
Licensed beds: 140
Census: 125
Inspection Report
Follow-Up
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 28, 2021
Visit Reason
The State Agency conducted a follow-up survey to verify the facility's compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance. Record reviews showed completion of an audit of discharge summaries for medication reconciliation, nursing staff in-services were completed, and discharge summaries are being monitored for completeness.
Inspection Report
Follow-Up
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The State Agency conducted a follow-up survey to verify the facility's compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance. Record reviews showed completion of audits on discharge summaries for medication reconciliation, nursing staff in-services were completed, and discharge summaries are being monitored for completeness.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The State Agency conducted a Complaint Investigation from 10/28/21 for complaints #MS18197, #MS18179, and #MS18217.
Complaint Details
The allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. Allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 126
Capacity: 140
Deficiencies: 0
Date: Oct 27, 2021
Visit Reason
The State Agency conducted a complaint investigation on 10/27/21 for complaints #MS18197, #MS18179, and #MS18217.
Complaint Details
The allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. Allegations of abuse, quality of care/treatment, and resident rights were unsubstantiated with no deficiencies cited.
Report Facts
Complaint numbers: 3
Inspection Report
Complaint Investigation
Census: 114
Capacity: 140
Deficiencies: 0
Date: Sep 3, 2021
Visit Reason
The State Agency conducted a complaint investigation for MS #17617, MS #17876, and MS #18025 at the facility from 9/2/21 to 9/3/21.
Complaint Details
The complaints investigated included assessment and monitoring and failure to notify physician (MS #17617), quality of care and resident rights related to safety, pressure ulcers, staffing, following physician orders and incontinence (MS #17876), and assessment and monitoring and services not performed for a PEG site, resident grooming, misappropriation of clothing and discharge medications (MS #18025). None were substantiated.
Findings
The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Aged and Infirm. No deficiencies were cited as the complaints were not substantiated.
Report Facts
Census: 114
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 114
Capacity: 140
Deficiencies: 1
Date: Sep 3, 2021
Visit Reason
The State Agency conducted a complaint investigation from 9/2/21 to 9/3/21 related to multiple complaint numbers concerning assessment and monitoring, quality of care, resident rights, and discharge medications.
Complaint Details
The complaint investigation involved three complaint numbers (MS #17617, MS #17876, MS #18025). The agency was unable to substantiate most allegations except for MS #18025 related to Admission, Discharge, and Transfer concerning discharge medications.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements due to failure to properly reconcile discharge medications for three residents. No deficiencies were substantiated for other complaint areas. The facility failed to ensure medication reconciliation was completed and reviewed with residents or their representatives at discharge.
Deficiencies (1)
Failure to properly reconcile discharge medications for three resident discharge summaries reviewed.
Report Facts
Census: 114
Total licensed capacity: 140
Residents with medication reconciliation deficiencies: 3
Medication bubble packs given: 8
Medication bubble packs given: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Spoke with Resident #1's husband about medication errors and confirmed reconciliation failures |
| Licensed Practical Nurse #1 | LPN | Discharged Resident #1 and did not reconcile medications properly |
| Licensed Practical Nurse #2 | LPN | Discharged Resident #1 and confirmed failure to reconcile medications |
| Licensed Practical Nurse #3 | LPN | Discharged Resident #15 and confirmed failure to check medication reconciliation box |
Inspection Report
Routine
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2/8/2021 through 2/24/2021 to assess compliance with federal regulations related to emergency preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The State Agency conducted complaint investigations at the facility from 2/8/2021 to 2/24/2021 related to multiple complaint investigation numbers.
Complaint Details
Complaint investigations MS #17256, #17196, #16871, and #17195 were conducted. CI MS #16871, #17195, #17196 were not substantiated for quality of care. CI MS #17256 was not substantiated for pressure areas.
Findings
The facility was found to be in compliance with the Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirm. Complaints related to quality of care and pressure areas were not substantiated.
Report Facts
Complaint investigations: 4
Census: 109
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 2/8/2021 through 2/24/2021, including complaint investigations related to infection control and quality of care.
Complaint Details
The State Agency conducted complaint investigations MS #17256, #17501, #17196, #16871, and #17195. None were substantiated for quality of care, infection control notification, or pressure areas.
Findings
The facility was found not to be in substantial compliance with infection control practices, specifically improper mask use by two dietary employees, leading to repeated deficient practice citations at severity level F.
Deficiencies (1)
Failure to prevent the likelihood of the spread of COVID-19 due to improper mask use by two dietary employees while working in the kitchen.
Report Facts
Census: 109
Total licensed capacity: 140
Number of dietary employees observed: 8
Number of dietary employees with improper mask use: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff #1 | Identified as not wearing PPE appropriately; educated and placed in disciplinary process | |
| Dietary Staff #2 | Identified as not wearing PPE appropriately; educated and placed in disciplinary process | |
| District Manager for Healthcare Services Group | Educated dietary staff on PPE use and placed non-compliant employees in disciplinary process | |
| Director of Clinical Education | Started education with all team members on proper PPE use | |
| Director of Nurses | Director of Nurses (DON) | Confirmed facility failed to ensure proper infection control practices |
| Dietary Manager | Provided in-services on PPE usage and precautions to prevent COVID-19 spread |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 2/8/2021 through 2/24/2021.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 0
Date: Feb 24, 2021
Visit Reason
The State Agency conducted complaint investigations at the facility from 2/8/2021 to 2/24/2021 related to multiple complaint investigation numbers.
Complaint Details
Complaint investigations CI MS #17256, CI MS #17196, CI MS #16871, and CI MS #17195 were conducted. CI MS #16871, #17195, and #17196 were not substantiated for quality of care. CI MS #17256 was not substantiated for pressure areas.
Findings
The facility was found to be in compliance with Mississippi Regulations for the Minimum Standards for the Institutions for Aged or Infirm. Complaints CI MS #16871, #17195, and #17196 were not substantiated for quality of care, and CI MS #17256 was not substantiated for pressure areas.
Inspection Report
Complaint Investigation
Census: 109
Capacity: 140
Deficiencies: 1
Date: Feb 24, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 2/8/2021 through 2/24/2021, including complaint investigations related to infection control, pressure areas, and quality of care.
Complaint Details
Complaint investigations MS #17256, #17501, #17196, #16871, and #17195 were conducted. CI #16871, #17195, #17196 were not substantiated for quality of care. CI #17501 was not substantiated for infection control notification. CI #17256 was not substantiated for pressure areas.
Findings
The facility was found not in substantial compliance with infection control practices, specifically improper mask use by two dietary employees, leading to repeated deficient practice citations at severity level 'F'. Multiple complaint investigations were not substantiated. The facility implemented re-education and daily monitoring to ensure compliance.
Deficiencies (1)
Failure to prevent the likelihood of the spread of COVID-19 as evidenced by improper mask use by two dietary employees while working in the kitchen.
Report Facts
Census: 109
Total licensed capacity: 140
Number of dietary employees observed with improper mask use: 2
Number of dietary employees in mask in-service: 2
Duration of daily monitoring: 28
Duration of thrice-weekly monitoring: 28
Duration of weekly monitoring: 28
QAPI committee monitoring duration: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Staff #1 | Identified for improper mask use; educated and placed in disciplinary process | |
| Dietary Staff #2 | Identified for improper mask use; educated and placed in disciplinary process | |
| District Manager for Healthcare Services Group | Educated dietary staff on 2/9/2021 and 2/10/2021 regarding PPE compliance | |
| Director of Clinical Education | Started education with all team members on proper PPE use on 2/10/2021 | |
| Director of Nurses | Director of Nursing (DON) | Confirmed facility failed to ensure proper infection control practices |
Inspection Report
Abbreviated Survey
Census: 105
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 1/13/21 to assess compliance with infection control regulations and COVID-19 preparedness.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 1/13/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report
Abbreviated Survey
Census: 118
Capacity: 140
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 13, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 11/13/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and Complaint Investigation were conducted due to concerns about infection control practices and delayed notification of positive COVID-19 test results among employees.
Complaint Details
Complaint Investigation MS #16968 was not substantiated related to Quality of Care. Complaint Investigation MS #17013 was substantiated related to Infection Control.
Findings
The facility failed to follow CDC guidelines for mask use and timely communication of positive COVID-19 test results to employees, resulting in two COVID-positive employees working with symptoms and potentially exposing 135 staff and 105 residents. Immediate Jeopardy was identified and later removed after corrective actions including education, monitoring, and weekly testing were implemented.
Deficiencies (2)
Failure to follow CDC guidelines for use of face masks and PPE in healthcare setting to prevent pathogen transmission.
Failure to communicate and report employee COVID-19 test results timely, resulting in positive employees working with symptoms and exposing others.
Report Facts
Positive COVID-19 employees not informed timely: 2
Facility census: 124
Facility licensed capacity: 140
Positive residents: 21
Positive employees: 25
Deaths: 3
Pending staff test results: 58
Pending resident test results: 42
Total team members: 135
Additional health care services team members: 25
Team members tested negative: 66
Residents tested negative: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed not wearing mask properly; received verbal correction and re-education. |
| LPN #2 | Licensed Practical Nurse | Observed not wearing mask properly; received verbal correction and re-education. |
| Social Worker | Tested positive for COVID-19 but was not informed timely; worked in close proximity to others without masks. | |
| MDS Nurse #4 | MDS Nurse | Worked in close proximity to COVID-positive Social Worker without mask; had not received test results. |
| Human Resources Officer | Tested positive for COVID-19 but was not informed timely; worked while symptomatic. | |
| Administrator | Facility Administrator | Delayed obtaining COVID test results from lab, failed to notify employees of positive results, suspended pending investigation. |
| Director of Nursing (DON) | Director of Nursing | Involved in infection control oversight; confirmed staff noncompliance with mask use. |
| Assistant Director of Nursing Services (ADNS) | Assistant Director of Nursing Services | Provided re-education to staff on proper PPE use. |
| Director of Clinical Operations (DCO) | Director of Clinical Operations | Provided education on PPE and infection control. |
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted due to infection control concerns related to COVID-19 positive employees and potential exposure risks.
Findings
The facility was found not in compliance with infection control regulations, with an Immediate Jeopardy identified due to two COVID-19 positive employees who were not informed of their results and continued working, potentially exposing staff and residents. The Immediate Jeopardy was removed after the facility submitted and implemented an acceptable Removal Plan.
Deficiencies (2)
Two COVID-19 positive employees were not informed of their positive test results and worked with symptoms, exposing others.
Two employees were observed not following infection control guidelines, including improper mask use and lack of social distancing.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 105
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
The inspection was conducted due to a complaint investigation related to COVID-19 infection control practices and delayed communication of positive COVID-19 test results among staff.
Complaint Details
The complaint investigation revealed that two employees tested positive for COVID-19 but were not informed of their results due to administrative delays, leading to potential exposure of 135 staff and 105 residents. Immediate Jeopardy was identified on 08/26/2020 and removed on 08/28/2020 after corrective actions.
Findings
The facility failed to follow CDC guidelines for PPE use, including improper mask wearing by staff and failure to timely communicate positive COVID-19 test results to employees, resulting in two COVID-positive employees working while symptomatic and exposing residents and staff. Immediate Jeopardy was identified and later removed after corrective actions including staff education, increased testing, and monitoring were implemented.
Deficiencies (2)
Failure to follow CDC guidelines for use of face masks and PPE in a healthcare setting to prevent pathogen transmission.
Failure to communicate and report employee COVID-19 test results to positive employees in order to quarantine and prevent further exposure.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Total team members: 135
Additional health care services team members: 25
Team member COVID test results received: 66
Residents tested: 105
Residents with negative test results: 75
Days delayed in notifying positive employees: 25
Deaths: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Failed to timely obtain and communicate COVID-19 test results, resulting in delayed notification of positive employees and suspension. | |
| Assistant Director of Nursing Services (ADNS) | Provided re-education to staff on proper PPE use after deficiencies were identified. | |
| Director of Nursing Services (DNS) | Involved in education and monitoring of staff PPE compliance and COVID-19 testing. | |
| Licensed Practical Nurse (LPN) #1 | Observed not wearing mask properly and received verbal correction. | |
| Licensed Practical Nurse (LPN) #2 | Observed not wearing mask and received verbal correction. | |
| Social Worker | Tested positive for COVID-19 but was not informed of results for weeks. | |
| Human Resources Officer | Tested positive for COVID-19 but was not informed of results for weeks. | |
| MDS Nurse #4 | Observed working without mask in close proximity to Social Worker. |
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 08/20/2020 through 08/28/2020 to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. Infection control guideline violations were also observed.
Deficiencies (2)
Failure to inform two COVID-19 positive employees of their test results, leading to potential exposure of staff and residents.
Two employees not following infection control guidelines, including improper mask use and lack of social distancing.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 124
Capacity: 140
Deficiencies: 1
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted along with Complaint Investigations MS #16968 and MS #17013 to assess compliance with infection control and quality of care during the COVID pandemic.
Complaint Details
Complaint Investigation MS #16968 related to Quality of Care was not substantiated. Complaint Investigation MS #17013 related to Infection Control was substantiated with citation F880.
Findings
The facility was found non-compliant with infection control practices recommended by CMS and CDC, substantiating complaint MS #17013 related to infection control with citation F880. An Immediate Jeopardy was identified due to failure to notify two COVID-positive employees, resulting in potential exposure to 135 staff and 105 residents. The Immediate Jeopardy was removed after the facility submitted and implemented a removal plan.
Deficiencies (1)
Failure to follow infection control safety practices during COVID-19 pandemic, including delayed notification of positive COVID-19 employees and improper use of face masks and social distancing.
Report Facts
Positive COVID-19 employees not informed: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 08/20/2020 through 08/28/2020 to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and potentially exposed 135 team members and 105 residents. The Immediate Jeopardy was removed on 08/27/2020 after corrective actions.
Deficiencies (2)
Failure to inform two COVID-19 positive employees of their test results, resulting in potential exposure to staff and residents.
Two employees not following infection control guidelines, including improper mask use and failure to social distance.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Facility census: 124
Facility licensed capacity: 140
Inspection Report
Abbreviated Survey
Census: 124
Capacity: 140
Deficiencies: 2
Date: Aug 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency from 08/20/2020 through 08/28/2020 to assess compliance with infection control regulations.
Findings
The facility was found not in compliance with 42 CFR 483.80 Infection Control regulations, with an Immediate Jeopardy identified on 08/26/2020 due to failure to inform two COVID-19 positive employees, who worked while symptomatic and exposed others. Infection control guideline violations were also observed.
Deficiencies (2)
Failure to inform two COVID-19 positive employees of their test results, resulting in exposure to staff and residents.
Employees not following infection control guidelines, including improper mask use and lack of social distancing.
Report Facts
Positive COVID-19 employees: 2
Potentially exposed team members: 135
Potentially exposed residents: 105
Census: 124
Total licensed capacity: 140
Inspection Report
Routine
Census: 110
Capacity: 140
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 110
Total licensed capacity: 140
Inspection Report
Complaint Investigation
Census: 128
Capacity: 140
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The State Agency conducted a complaint survey from 03/03/2020 to 03/05/2020 investigating complaints MS #16639 and MS #16676. The survey was triggered by allegations of resident abuse and quality of care concerns.
Complaint Details
The complaint investigation was substantiated for resident abuse (MS #16676). The facility investigated an incident on 02/22/2020 where CNA #1 shoved Resident #1 into a chair after Resident #1 used racial slurs. The incident was reported to the State Agency and local police. CNA #1 was suspended and terminated. Resident #1 had no lasting physical injuries but received a psychosocial evaluation.
Findings
The survey substantiated the complaint MS #16676 for resident abuse involving a physical altercation between CNA #1 and Resident #1. The facility failed to ensure Resident #1 was protected from physical abuse. The facility took immediate action by suspending and terminating CNA #1. Psychosocial evaluation and staff education were implemented as corrective actions.
Deficiencies (1)
Facility failed to ensure one of seven residents reviewed was protected from physical abuse; Resident #1 was shoved by CNA #1 into a chair causing injury.
Report Facts
Census: 128
Total Capacity: 140
Deficiencies cited: 1
Psychosocial evaluation date: Feb 24, 2020
Incident date: Feb 22, 2020
CNA #1 hire date: Apr 24, 2017
MDS Assessment Reference Date: Jan 29, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed and intervened in the abuse incident, assessed Resident #1 for injuries, notified Administrator and Director of Nursing |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Perpetrator of physical abuse against Resident #1, suspended and terminated after substantiation |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Witnessed and attempted to calm Resident #1 during the incident |
| Director of Nursing | Director of Nursing | Confirmed psychosocial evaluation and medication changes for Resident #1, commented on CNA #1's work history |
| Dietary Worker #1 | Dietary Worker | Witnessed initial incident involving Resident #1 in the kitchen and reported Resident #1's behavior |
Inspection Report
Complaint Investigation
Census: 128
Capacity: 140
Deficiencies: 1
Date: Mar 5, 2020
Visit Reason
The State Agency conducted a complaint survey investigating complaints MS #16639 and MS #16676 from 03/03/2020 to 03/05/2020. The survey was triggered by allegations of resident abuse and quality of care concerns.
Complaint Details
The complaint investigation substantiated resident abuse involving CNA #1 pushing Resident #1 into a chair after the resident used racial slurs. The facility suspended and terminated CNA #1 and reported the incident to the State Agency and local police. Psychosocial evaluation of the resident showed no lasting negative effects.
Findings
The facility was found not in compliance with Minimum Standards of Operation. The complaint of resident abuse (MS #16676) was substantiated involving an incident where a Certified Nursing Assistant (CNA #1) physically pushed Resident #1 into a chair. The complaint regarding quality of care (MS #16639) was not substantiated and no deficiencies were cited for that. The facility took corrective actions including suspension and termination of CNA #1, staff education, and ongoing monitoring.
Deficiencies (1)
Failure to ensure one resident was protected from physical abuse when a CNA pushed the resident into a chair during an altercation.
Report Facts
Census: 128
Total Capacity: 140
Deficiency Severity Level II: 1
Dates of complaint survey: From 03/03/2020 to 03/05/2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Named in resident abuse finding for pushing Resident #1 into a chair and subsequently suspended and terminated |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Witnessed the abuse incident and assessed Resident #1 for injuries |
| Director of Nursing | Director of Nursing | Notified of the incident and involved in corrective actions |
| Administrator | Facility Administrator | Notified of the incident |
Inspection Report
Annual Inspection
Census: 130
Capacity: 140
Deficiencies: 9
Date: Feb 6, 2020
Visit Reason
Annual recertification survey conducted from 02/03/2020 to 02/06/2020 to assess compliance with Medicare and Medicaid requirements.
Findings
The facility was found not in compliance with several regulatory requirements including safe environment, restraint evaluation, accuracy of assessments, comprehensive care planning, ADL care, respiratory care, fire alarm system maintenance, fire drills, and emergency electrical system maintenance.
Deficiencies (9)
Failed to provide a clean, homelike environment in 9 of 32 resident rooms on the East Wing, including dirty bathrooms, brown rings in toilets, debris, and unclean floors.
Failed to provide ongoing evaluation of Resident #70's restraint; restraint evaluation was 29 days overdue.
Failed to accurately reflect discharge status on Resident #125's MDS assessment; discharge coded incorrectly as hospital instead of home.
Failed to develop and implement comprehensive care plans for respiratory care (Resident #99), ADL care (Residents #54, #76, #106), and restraint evaluation (Resident #70).
Failed to provide necessary ADL assistance including nail care, toileting assistance, and showers for Residents #54, #76, #93, and #106.
Failed to provide proper cleaning and storage of respiratory equipment for Resident #99, risking infection spread.
Failed to properly maintain fire alarm system; smoke detector sensitivity testing documentation missing for 2017 and 2019.
Failed to conduct and document fire drills quarterly on all shifts during 2019.
Failed to properly test emergency generator weekly and monthly as required; missing documentation for several months in 2019.
Report Facts
Deficiencies cited: 9
Residents affected: 9
Fire drill frequency: 4
Generator test frequency: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Confirmed restraint evaluation overdue, acknowledged unclean rooms, and discussed care plan deficiencies. | |
| Administrator | Directed housekeeping and maintenance actions, confirmed fire alarm and fire drill deficiencies, and oversaw corrective actions. | |
| Director of Clinical Education | Provided education on care plans, restraint assessments, and nebulizer equipment handling. | |
| Registered Nurse Assessment Coordinator (RNAC) | Conducted audits of restraint evaluations, care plans, and discharge assessments. | |
| Certified Nursing Assistant (CNA) #3 | Failed to respond timely to call light for Resident #106 and turned off call light without assistance. | |
| Certified Nursing Assistant (CNA) #4 | Aware of Resident #76's long fingernails but did not report to nurse. |
Inspection Report
Annual Inspection
Census: 130
Capacity: 140
Deficiencies: 3
Date: Feb 6, 2020
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 02/03/2020 to 02/06/2020 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm.
Findings
The facility was found not in compliance with several standards including restraint evaluation, activities of daily living assistance, and proper care and storage of respiratory equipment. Deficiencies were noted in ongoing restraint evaluations, assistance with personal hygiene and nail care for multiple residents, timely response to call lights, and cleaning and storage of nebulizer equipment.
Deficiencies (3)
Failed to provide ongoing evaluation of a resident's restraint, with the last evaluation 29 days overdue.
Failed to provide adequate assistance with activities of daily living including nail care, bathing, toileting, and answering call lights for multiple residents.
Failed to provide proper cleaning and storage of respiratory equipment, with nebulizer tubing not changed as ordered and equipment left uncovered.
Report Facts
Census: 130
Total Capacity: 140
Days overdue for restraint evaluation: 29
Call light response time: 13
Frequency of nebulizer tubing change: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding restraint evaluation and call light response |
| Certified Nursing Assistant #4 | CNA | Assigned to Resident #76 and aware of long and dirty fingernails |
| Certified Nursing Assistant #3 | CNA | Did not respond timely to Resident #106's call light |
| Director of Clinical Education | Director of Clinical Education | Provided education to staff on restraint assessments and ADL care |
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