Inspection Reports for
Diversicare of Tupelo
2273 S. Eason Boulevard, Tupelo, MS, 38804
Back to Facility Profile65 Reports
Inspection Report — Aug 19, 2026
Complaint Investigation
Date: Aug 19, 2026
Visit Reason
The State Agency conducted Complaint Investigations (CIs) MS #3008523, CI MS #3131885, and CI MS #3022294 at the facility from 8/18/2026 through 8/19/2026. CI MS #3008523 was investigated for environmental, accidents, resident rights, and hospitalizations and F925 was cited. CI MS #3131885 was investigated for neglect, resident rights, and accidents and there were no citations related to this complaint. CI MS #3022294 was investigated for quality of care, resident rights, and hospitalizations and there were no citations related to this complaint.
Complaint Details
Complaint Investigations MS #3008523, #3131885, and #3022294 were conducted. Only CI MS #3008523 was substantiated with a deficiency cited (F925) related to environmental issues including pest control. The other complaints had no citations.
Findings
The facility was found not in compliance due to failure to maintain an effective pest control program, evidenced by the presence of live and dead roaches in multiple resident bathrooms and common areas. Staff and residents confirmed ongoing pest issues, and the facility's pest control measures were insufficient to prevent infestations.
Deficiencies (1)
F0925 - The facility failed to maintain an effective pest control program to prevent and control roaches, with live and dead roaches observed in resident bathrooms and common areas over two days of survey.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 26, 2026
Complaint Investigation
Date: Mar 26, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2796874, CI MS #2796972 and CI MS #2804417) at the facility from 03/25/26 through 03/26/26.
Complaint Details
Three complaint investigations (CI MS #2796874, CI MS #2796972 and CI MS #2804417) were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm and state licensure requirements with no deficiencies cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Feb 26, 2026
Life Safety
Date: Feb 26, 2026
Visit Reason
On 2/26/26 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 1/13/26. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The State Agency is recommending that the facility be placed back in compliance effective 02/12/26. No deficiencies were cited during the Emergency Preparedness survey conducted on 01/13/26.
Inspection Report — Feb 19, 2026
Follow-Up
Date: Feb 19, 2026
Visit Reason
On 2/18/26 through 2/19/26, the State Agency (SA) conducted an onsite revisit related to the annual survey that was completed on 1/14/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The SA is recommending that the facility be placed back in compliance effective 2/13/26.
Inspection Report — Jan 14, 2026
Complaint Investigation
Date: Jan 14, 2026
Visit Reason
The inspection was conducted following a complaint/allegation of sexual abuse involving Resident #56 touching Resident #14 inappropriately.
Complaint Details
The complaint was substantiated. Resident #56 was observed touching Resident #14 inappropriately. Resident #56 acknowledged the behavior and was placed on one-to-one supervision. Resident #14 was cognitively impaired and unable to recall the incident.
Findings
The facility failed to ensure a resident's right to be free from sexual abuse. Resident #56 was observed touching Resident #14's breast, and the facility initiated an investigation and placed Resident #56 on one-to-one supervision.
Deficiencies (1)
F 0600: The facility failed to protect residents from sexual abuse when Resident #56 touched Resident #14's breast. The incident was witnessed by staff and reported to the State Agency.
Report Facts
Residents in initial pool: 32
Residents affected: 1
BIMS score: 11
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #6 | Interviewed regarding the abuse incident and supervision of Resident #56 | |
| Social Worker | Interviewed Resident #56 and documented statements about the incident | |
| Director of Nursing | Interviewed about the incident and facility's responsibility to protect residents | |
| Certified Nurse Aide (CNA) #4 | Witnessed the abuse incident and reported it to nursing staff | |
| Dietary Staff #1 | Observed interactions between residents related to the incident |
Inspection Report — Jan 14, 2026
Routine
Date: Jan 14, 2026
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and infection control at Diversicare of Tupelo nursing home.
Findings
The facility was found deficient in multiple areas including failure to notify the State Long-Term Care Ombudsman of resident transfers, incomplete and unimplemented care plans, inadequate assistance with activities of daily living, insufficient supervision for a resident with suicidal ideation, improper catheter care, lack of monitoring for anticoagulant medication effects, and failure to maintain infection prevention practices such as dating oxygen equipment and following enhanced barrier precautions.
Deficiencies (8)
F 0628: The facility failed to notify the State Long-Term Care Ombudsman of a resident's hospital transfer, not ensuring required notification procedures for one of four hospitalizations reviewed.
F 0656: The facility failed to implement comprehensive care plans for two residents, including lack of monitoring for bleeding in a resident on anticoagulants and failure to provide scheduled hair washing.
F 0657: The facility failed to revise a resident's care plan after a fall, omitting an intervention to keep the bed in a low position to prevent injury.
F 0677: The facility failed to provide activities of daily living care, specifically hair washing, according to a resident's assessed needs and care plan.
F 0689: The facility failed to ensure adequate supervision and monitoring for a resident expressing suicidal ideation, despite emergency room recommendations for psychiatric follow-up.
F 0690: The facility failed to perform catheter care correctly for a resident with an indwelling catheter, including improper cleaning sequence and not rinsing soap.
F 0757: The facility failed to ensure ongoing monitoring for adverse effects of anticoagulant medication for a resident, lacking orders to monitor for bleeding signs and symptoms.
F 0880: The facility failed to maintain oxygen equipment by not dating oxygen tubing and humidifier water bottles for two residents and failed to follow Enhanced Barrier Precautions by not wearing a gown during catheter care for a resident requiring it.
Report Facts
Residents sampled for care plan implementation: 28
Residents reviewed for catheter care: 6
Residents reviewed for medication monitoring: 5
Residents sampled for infection prevention: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed failure to notify Ombudsman, lack of monitoring orders for anticoagulant, failure to revise care plan post-fall, expectation for hair washing, and infection control expectations. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Confirmed oxygen tubing and water bottles were not dated and explained policy changes. |
| Certified Nurse Aide #4 | Certified Nurse Aide | Performed improper catheter care without gown and acknowledged the error. |
| Registered Nurse #1 | Registered Nurse | Confirmed resident's hair appeared unwashed. |
| Social Services | Social Services | Made referral for psychiatric follow-up and discussed resident behavior. |
| MDS Coordinator | MDS Coordinator | Confirmed hair washing included in care plan but lacked specific schedule. |
Inspection Report — Jan 14, 2026
Life Safety
Date: Jan 14, 2026
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with NFPA 101 and related fire safety standards.
Findings
The facility was found to have a deficiency in maintaining the fire alarm system, specifically failing to provide a complete sensitivity inspection of all smoke detectors during the last inspection in 2021.
Deficiencies (1)
K0345 - Fire Alarm System - Testing and Maintenance. The facility failed to provide a properly maintained fire alarm system as all smoke detectors were not tested during the last sensitivity inspection in 2021.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 14, 2026
Annual Inspection
Date: Jan 14, 2026
Visit Reason
The State Agency conducted an Annual Recertification survey and six Complaint Investigations and one Facility Reported Incident at the facility from 1/11/26 through 1/14/26. The facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies.
Complaint Details
Six complaint investigations (CI MS #2700059, CI MS #2693699, CI MS #2704745, CI MS #2688890, CI MS #2698633, CI MS #2699004) were investigated with no deficiencies cited. One Facility Reported Incident (FRI) MS #2715132 was investigated and cited for abuse (F600).
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for nine deficiencies related to abuse prevention, discharge process, comprehensive care planning, ADL care, accident hazards, medication monitoring, infection control, and catheter care.
Deficiencies (9)
F0600 - Free from Abuse and Neglect. The facility failed to ensure a resident's right to be free from sexual abuse for one of 32 residents, evidenced by an incident where Resident #56 touched Resident #14 inappropriately and the facility's response and supervision were inadequate.
F0628 - Discharge Process. The facility failed to notify the State Long-Term Care Ombudsman of a resident’s transfer to the hospital for one of four hospitalizations reviewed, Resident #46, and failed to document the transfer appropriately.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the comprehensive care plan for two of 28 residents sampled, including lack of monitoring for bleeding for Resident #39 on anticoagulants and failure to provide scheduled hair washing for Resident #58.
F0657 - Care Plan Timing and Revision. The facility failed to revise the comprehensive care plan following a fall for one of 28 residents sampled, Resident #83, by not adding an intervention to keep the bed in a low position.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to ensure a resident who required assistance received grooming and personal hygiene care, specifically hair washing, for Resident #58.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure adequate supervision and monitoring for one of 28 residents reviewed, Resident #8, who expressed suicidal ideation and did not receive appropriate psychiatric follow-up after an emergency room visit.
F0690 - Bowel/Bladder Incontinence, Catheter, UTI. The facility failed to ensure proper catheter care was performed correctly for one of six residents with indwelling catheters, Resident #70, including improper cleaning sequence and not rinsing soap.
F0757 - Drug Regimen is Free from Unnecessary Drugs. The facility failed to ensure ongoing monitoring for adverse effects of anticoagulant medication for one of five residents reviewed, Resident #39, lacking orders to monitor for signs and symptoms of bleeding.
F0880 - Infection Prevention & Control. The facility failed to maintain oxygen equipment by not dating oxygen tubing and humidifier water bottles for Residents #37 and #93 and failed to ensure staff followed Enhanced Barrier Precautions by not wearing a gown during Foley catheter care for Resident #70.
Report Facts
Deficiencies cited: 9
Complaint investigations: 6
Facility Reported Incidents: 1
Inspection Report — Nov 19, 2025
Complaint Investigation
Date: Nov 19, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI) #2655655 at the facility on 11/19/25.
Complaint Details
Complaint investigation CI #2655655 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 9, 2025
Follow-Up
Date: Sep 9, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 09/09/25 related to a complaint recent survey that was conducted on 08/11/25.
Findings
The State Agency determined the facility was in compliance with the minimum requirements for The Aged and Infirm, state licensure requirements and recommends the facility be placed back in compliance effective 08/29/25.
Inspection Report — Sep 8, 2025
Complaint Investigation
Date: Sep 8, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2608926) at the facility on 9/8/25. Although there were no deficiencies cited during the complaint investigation, the facility will remain out of compliance due to deficiencies cited on the 08/11/25 survey.
Complaint Details
CI MS #2608926: Complaint investigation conducted with no deficiencies cited; the complaint was not substantiated.
Findings
No deficiencies were cited during this complaint investigation. The facility remains out of compliance due to prior deficiencies cited on the 08/11/25 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 11, 2025
Complaint Investigation
Date: Aug 11, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall incident where staff allegedly failed to follow the resident's care plan requiring two-person assistance for bed mobility and toileting.
Complaint Details
The complaint investigation found that staff did not follow the required two-person assist for Resident #1, resulting in a fall with injury. The incident was substantiated by interviews with CNAs, the Director of Nursing, and the Administrator, as well as record reviews including the resident's Kardex and medical records.
Findings
The facility failed to ensure staff followed the resident's Kardex requiring two-person assistance, resulting in Resident #1 falling from the bed and sustaining actual harm including a skin tear, facial swelling, bruising, and a maxillary hematoma. Interviews and record reviews confirmed the failure to provide required assistance and subsequent injury requiring new pain medication.
Deficiencies (1)
F0689: The facility failed to ensure staff followed Resident #1's Kardex requiring two-person assistance for bed mobility and toileting. This failure caused Resident #1 to fall from the bed, sustaining a skin tear, facial swelling, bruising, and a maxillary hematoma requiring new pain medication.
Report Facts
Medication doses: 6
Medication dose: 1
Medication dosage: 50
Dates: Jul 25, 2025
Inspection Report — Aug 11, 2025
Complaint Investigation
Date: Aug 11, 2025
Visit Reason
The State Agency conducted an investigation of a facility reported incident (Incident # 2573436) at the facility on 8/11/25. During the survey the SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid and cited F0689. The SA investigated abuse and accidents and hazards.
Complaint Details
Incident # 2573436 involved abuse and accidents and hazards. The facility was found not in compliance and cited for failure to follow the resident's care plan, resulting in harm to Resident #1.
Findings
F0689 - The facility failed to ensure staff followed the resident's Kardex requiring two-person assistance for bed mobility and toileting, resulting in Resident #1 falling from the bed and sustaining injuries including a skin tear, facial swelling, bruising, and maxillary hematoma, with increased pain requiring new medication orders.
Deficiencies (1)
F0689 - Free of accident hazards and adequate supervision. The facility failed to ensure staff followed the resident’s Kardex requiring two-person assistance for bed mobility and toileting, resulting in Resident #1 falling from the bed and sustaining injuries including a skin tear, facial swelling, bruising, and maxillary hematoma.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide timely pharmacy services and medications to residents admitted from the hospital.
Complaint Details
The complaint investigation found that Resident #1 and Resident #2 did not receive ordered antibiotics and respiratory medications timely after admission from the hospital. The facility acknowledged delays due to pharmacy delivery schedules and medication system start times. The issue was substantiated.
Findings
The facility failed to provide timely pharmacy services and administer ordered medications to two residents admitted from the hospital, resulting in missed doses of critical antibiotics and respiratory treatments. Interviews and record reviews confirmed delays in medication delivery from an offsite pharmacy and lapses in medication administration.
Deficiencies (1)
F 0755: The facility failed to provide pharmaceutical services to meet the needs of residents and employ or obtain the services of a licensed pharmacist. Two residents did not receive timely medications ordered by physicians upon admission.
Report Facts
Residents affected: 2
Date of survey completed: Jun 18, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding Resident #1's medication administration and condition. |
| Director of Nursing | Director of Nursing | Interviewed about medication delivery processes and acknowledged medication delays. |
| Administrator | Administrator | Interviewed and acknowledged facility failed to provide timely medications to residents. |
Inspection Report — Jun 18, 2025
Complaint Investigation
Date: Jun 18, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28953 and CI MS #29165) at the facility on 6/17/25 through 6/18/25. During the survey, the facility was found not in compliance with Medicare and Medicaid participation requirements and cited for pharmacy services deficiencies.
Complaint Details
Two complaint investigations (CI MS #28953 and CI MS #29165) were conducted. Deficiencies were cited related to pharmacy services, specifically failure to provide timely medications to residents.
Findings
F0755 - The facility failed to provide timely pharmacy services and obtain medications for two residents admitted from the hospital, resulting in missed doses of critical antibiotics and respiratory treatments.
Deficiencies (1)
F0755 - The facility failed to provide timely pharmacy services for obtaining and administering medications for two residents admitted from the hospital, resulting in missed doses of antibiotics and respiratory treatments.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 9, 2025
Complaint Investigation
Date: Feb 9, 2025
Visit Reason
On 02/09/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 01/17/25. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 01/17/25; the facility was found to have corrected the deficient practice and was placed back in compliance effective 02/07/25.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 02/07/25. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 17, 2025
Complaint Investigation
Date: Jan 17, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to honor residents' rights to vote in the 2024 presidential election.
Complaint Details
The complaint investigation found that residents who expressed the desire to vote were not given the opportunity on election day. The Social Services staff failed to research the proper absentee ballot request process, and the facility did not assist residents adequately. The Administrator confirmed the failure to assist residents in exercising their voting rights.
Findings
The facility failed to ensure that residents who wished to vote were assisted properly, resulting in some residents not receiving absentee ballots or being taken to the polls. The Social Services staff and Administrator confirmed the facility did not provide adequate assistance for residents to exercise their voting rights.
Deficiencies (1)
F 0550: The facility failed to honor the residents' right to a dignified existence, self-determination, communication, and to exercise their rights by not assisting residents to vote in the 2024 election. Three of six sampled residents were unable to vote due to lack of assistance with absentee ballots or transportation to the polls.
Report Facts
Residents who desired to vote: 47
Residents who voted with absentee ballots: 9
Residents who voted at the poll: 4
Residents who declined to go to the poll: 6
Residents sampled for rights review: 6
Residents affected by deficiency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services #1 | Social Services Staff | Confirmed failure to assist residents with voting and absentee ballot process |
| Administrator | Confirmed facility failed to ensure residents were assisted to vote |
Inspection Report — Jan 17, 2025
Complaint Investigation
Date: Jan 17, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI) MS #26911 and CI MS #27157 at the facility from 1/15/25 through 1/17/25. The facility was found not in compliance for CI MS #27157 regarding residents rights and cited M500. The facility was found in compliance for CI MS #26911 regarding quality of life with no deficiencies cited.
Complaint Details
Complaint investigation CI MS #27157 was substantiated with deficiencies cited related to residents' rights. Complaint CI MS #26911 was found in compliance with no deficiencies cited.
Findings
The facility failed to honor residents' right to vote in the 2024 election for three of six residents sampled. The Social Services staff did not properly ensure absentee ballots were received or that residents were assisted to vote, resulting in residents being unable to vote as they desired.
Deficiencies (1)
M500 - Residents' rights. The facility failed to ensure that residents who wished to vote in the 2024 election were given the opportunity, resulting in at least three residents not being able to vote due to lack of assistance with absentee ballots or transportation to the polls.
Report Facts
Complaints investigated: 2
Deficiencies cited: 1
Residents registered to vote: 47
Residents who voted absentee: 9
Residents who voted at poll: 4
Residents who declined to vote: 6
Inspection Report — Oct 31, 2024
Follow-Up
Date: Oct 31, 2024
Visit Reason
On 10/30/24 through 10/31/24, the State Agency conducted an onsite revisit related to the annual survey that was completed on 9/19/24. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 10/28/24. No deficiencies were cited during this revisit.
Report Facts
Deficiencies cited: 0
Inspection Report — Sep 19, 2024
Annual Inspection
Date: Sep 19, 2024
Visit Reason
The State Agency conducted an annual recertification survey and a complaint investigation (CI) MS #25787 at the facility from 9/16/24 through 9/19/24.
Complaint Details
Complaint investigation CI MS #25787 was conducted but the facility was found in compliance related to this complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited multiple deficiencies. The facility was found in compliance related to the complaint investigation CI MS #25787.
Deficiencies (18)
F0550 - Not detailed in the provided text.
F0561 - The facility failed to honor a resident's choice for sweet tea with meals for one of twenty-two sampled residents, despite the meal ticket indicating sweetened iced tea.
F0565 - Not detailed in the provided text.
F0578 - Not detailed in the provided text.
F0583 - Not detailed in the provided text.
F0584 - Not detailed in the provided text.
F0606 - Not detailed in the provided text.
F0656 - Not detailed in the provided text.
F0657 - Not detailed in the provided text.
F0658 - Not detailed in the provided text.
F0677 - Not detailed in the provided text.
F0689 - Not detailed in the provided text.
F0700 - Not detailed in the provided text.
F0761 - Not detailed in the provided text.
F0804 - Not detailed in the provided text.
F0835 - Not detailed in the provided text.
F0867 - Not detailed in the provided text.
F0880 - Not detailed in the provided text.
Report Facts
Deficiencies cited: 18
Inspection Report — Sep 19, 2024
Date: Sep 19, 2024
Visit Reason
The inspection was conducted to assess compliance with resident rights and quality of life policies, specifically regarding honoring resident choices.
Findings
The facility failed to honor a resident's choice for sweet tea with meals for one of twenty-two sampled residents. Observations and interviews confirmed the resident repeatedly received unsweetened tea despite meal tickets indicating sweetened tea.
Deficiencies (1)
F 0561: The facility failed to honor Resident #44's choice for sweet tea with meals, providing unsweetened tea despite meal tickets indicating sweetened tea. This issue was confirmed by observation, resident and staff interviews, and policy review.
Report Facts
Residents sampled: 22
Assessment Reference Date: Jul 1, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding meal preparation and resident preferences |
Inspection Report — Sep 19, 2024
Annual Inspection
Date: Sep 19, 2024
Visit Reason
Annual recertification survey and complaint investigation of Diversicare of Tupelo nursing home.
Findings
The facility was cited for multiple deficiencies including failure to maintain resident dignity related to uncovered urinary catheter bags, failure to inform residents of council meetings and resolve grievances, incomplete advance directives, privacy violations, unsafe environment hazards, incomplete background checks, incomplete and unimplemented care plans, medication administration and storage errors, inadequate infection control practices, and ineffective quality assurance and performance improvement.
Deficiencies (16)
F 0550: The facility failed to maintain resident dignity by leaving urinary catheter bags uncovered for two residents, Resident #52 and Resident #190.
F 0565: The facility failed to ensure residents were informed about resident council meetings and failed to resolve grievances related to food complaints for multiple residents.
F 0578: The facility failed to ensure advance directives were addressed or correct for three residents, including Resident #43, Resident #63, and Resident #84.
F 0583: The facility failed to keep resident personal and medical records confidential when a medication cart was left unattended with visible resident information.
F 0584: The facility failed to maintain a clean and safe environment, evidenced by a dirty wheelchair for Resident #71 and exposed electrical wires on Resident #12's bed control.
F 0606: The facility failed to ensure a new employee had a background check completed within two years prior to hire.
F 0656: The facility failed to implement comprehensive care plans related to activities of daily living for Residents #22, #58, and #59, including smoking safety and nail care.
F 0657: The facility failed to revise and update Resident #33's care plan to include a raised perimeter air mattress used for fall prevention.
F 0658: The facility failed to follow nursing standards of practice for Resident #20 with incomplete documentation of intravenous antibiotic administration.
F 0677: The facility failed to provide necessary assistance with activities of daily living for Residents #7, #58, and #59, including incontinent care and nail care.
F 0689: The facility failed to ensure a resident environment free from accident hazards, evidenced by smoking paraphernalia in Resident #22's room and medications left at bedside for Resident #34.
F 0700: The facility failed to properly assess and obtain consent for bed rails for Residents #33 and #60, and failed to correctly install and maintain bed rails.
F 0761: The facility failed to ensure medications were stored securely in locked medication carts or storage rooms, with medications left unattended on carts.
F 0804: The facility failed to serve food that met residents' choices and failed to serve food in an attractive and palatable manner for Residents #20, #27, #43, and #50.
F 0835: The facility failed to administer in a manner that allowed effective use of resources, with repeated deficiencies and ineffective follow-up on quality assurance measures.
F 0880: The facility failed to fully implement Enhanced Barrier Precautions (EBP) and infection control measures, including failure to don gowns during care and improper disposal of soiled items.
Report Facts
Residents affected: 2
Residents affected: 7
Residents affected: 3
Residents affected: 22
Residents affected: 4
Residents affected: 11
Medication carts: 4
Residents reviewed: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Left medications unsecured on medication cart |
| RN Unit Manager | Registered Nurse Unit Manager | Responsible nurse for undocumented IV antibiotic administration |
| Administrator | Administrator | Interviewed regarding multiple deficiencies and quality assurance |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies and infection control |
| Assistant Director of Nurses | Assistant Director of Nurses | Interviewed regarding catheter bag privacy and background check |
| Certified Nurse Assistant #7 | Certified Nurse Assistant | Observed incontinent care failure |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Failed to don gown during Enhanced Barrier Precautions |
| Registered Nurse #1 | Registered Nurse | Left medication cards unattended on medication cart |
Inspection Report — Sep 18, 2024
Life Safety
Date: Sep 18, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to meet the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited.
Inspection Report — Jul 16, 2024
Complaint Investigation
Date: Jul 16, 2024
Visit Reason
On 07/16/24 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 06/12/24. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 06/12/24; the facility was found in compliance after corrective measures were confirmed.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 07/15/24. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Jun 12, 2024
Complaint Investigation
Date: Jun 12, 2024
Visit Reason
The inspection was conducted based on a complaint alleging that a resident was not treated with dignity when requesting assistance with toileting and that care plans for activities of daily living were not properly implemented for certain residents.
Complaint Details
The complaint was substantiated. Resident #1 was denied toileting assistance and told to use her brief instead. Care plans for Residents #1 and #8 were not followed regarding shaving and oral care.
Findings
The facility failed to ensure dignity for Resident #1 when staff refused toileting assistance. Additionally, the facility failed to implement care plans related to shaving and oral care for Residents #1 and #8, resulting in unmet personal hygiene needs.
Deficiencies (3)
F 0557: The facility failed to honor Resident #1's right to dignity by refusing toileting assistance when requested, resulting in the resident being told to use her brief instead of being helped to the bathroom.
F 0656: The facility failed to implement Activities of Daily Living care plans for Residents #1 and #8, including failure to remove facial hair as scheduled and provide oral care.
F 0677: The facility failed to provide oral care for Resident #8 and failed to shave Residents #1 and #8 as required, despite care plans specifying these needs.
Report Facts
Residents reviewed: 8
Residents affected: 2
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Refused toileting assistance to Resident #1 |
| LPN #1 | Licensed Practical Nurse | Acknowledged CNA #1 should have assisted Resident #1 and reported incident to DON |
| DON | Director of Nursing | Confirmed refusal to assist Resident #1 was unacceptable and care plans were not followed for Residents #1 and #8 |
| Administrator | Facility Administrator | Stated refusal to assist Resident #1 was unacceptable |
| LPN #2 | Licensed Practical Nurse | Confirmed facial hair and oral care deficiencies for Residents #1 and #8 and planned corrective actions |
| CNA #2 | Certified Nursing Assistant | Described responsibilities for mouth care and shaving, confirmed lack of assistance to Resident #8 |
| CNA #3 | Certified Nursing Assistant | Assigned to Resident #8, confirmed no mouth care provided |
| CNA #4 | Certified Nursing Assistant | Confirmed shaving and mouth care responsibilities during baths/showers |
Inspection Report — Jun 12, 2024
Complaint Investigation
Date: Jun 12, 2024
Visit Reason
The State Agency conducted seven Complaint Investigations (CI MS #24744, CI MS #24745, CI MS #24944, CI MS #24945, CI MS #24947, CI MS #25168 and CI MS #25260) at the facility from 06/11/24 through 06/12/24. The investigations included improperly dressed residents, infection control concerns, poor quality food, residents not treated with dignity and respect, not answering call lights timely, incontinence care, medications left unattended, residents not receiving baths, and residents not groomed adequately.
Complaint Details
Seven Complaint Investigations (CI MS #24744, CI MS #24745, CI MS #24944, CI MS #24945, CI MS #24947, CI MS #25168, CI MS #25260) were conducted. Four complaints (CI MS #24945, CI MS #24947, CI MS #25168, CI MS #25260) regarding improperly dressed residents, infection control, and poor quality food were not substantiated with deficiencies. Three complaints (CI MS #24744, CI MS #24745, CI MS #24944) regarding residents not treated with dignity and respect, untimely call light response, incontinence care, unattended medications, lack of baths, and grooming issues were substantiated with deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Deficiencies were cited for failure to treat residents with dignity, failure to develop and implement comprehensive care plans, and failure to provide adequate activities of daily living care including shaving and oral care for residents.
Deficiencies (3)
F0557 - The facility failed to ensure a resident was treated with dignity when a staff member refused to assist a resident with toileting and told the resident to use the bathroom in her brief.
F0656 - The facility failed to implement comprehensive care plans for two residents, including failure to follow care plans for shaving and oral care.
F0677 - The facility failed to provide oral care and shaving for two residents as required, resulting in residents having unshaved facial hair and lack of oral hygiene supplies and assistance.
Report Facts
Deficiencies cited: 3
Complaint Investigations: 7
Inspection Report — Mar 18, 2024
Complaint Investigation
Date: Mar 18, 2024
Visit Reason
On 03/18/24 the State Agency (SA) conducted a desk review of the information that was provided related to the complaint survey completed on 02/08/24.
Complaint Details
Complaint survey completed on 02/08/24; the facility was found in compliance and no deficiencies were cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that the facility be placed back in compliance effective 03/11/24.
Inspection Report — Feb 8, 2024
Complaint Investigation
Date: Feb 8, 2024
Visit Reason
The inspection was conducted due to a complaint regarding inadequate care for Resident #1, specifically failure to provide scheduled baths and proper nail care.
Complaint Details
The complaint involved failure to provide scheduled baths and proper nail care for Resident #1. The complaint was substantiated based on observations, interviews, and record reviews confirming missed care and inadequate implementation of the care plan.
Findings
The facility failed to implement a comprehensive care plan for Resident #1, resulting in missed baths and improperly clipped fingernails that caused skin indentations and a foul odor. Documentation confirmed missed baths on four days in January 2024, and staff interviews acknowledged lapses in care.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including timely and measurable actions. Resident #1's care plan was not followed, as her fingernails were not clipped and she missed scheduled baths.
F 0677: The facility failed to provide care and assistance for activities of daily living, including scheduled baths and nail care for Resident #1. Missed baths and long fingernails caused skin indentations and a foul odor.
Report Facts
Missed bath days: 4
Residents reviewed: 9
Fingernail length: 0.5
BIMS Score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed long fingernails causing indentations and foul odor in Resident #1's hand. |
| Administrator | Acknowledged missed baths and long fingernails could cause wounds and confirmed care plan was not followed. | |
| Director of Nursing | DON | Confirmed that missed baths and unclipped fingernails indicated care plan was not followed and resident was not receiving needed care. |
| Certified Nursing Assistant #1 | CNA | Stated that sometimes baths or showers get missed due to workload. |
Inspection Report — Feb 8, 2024
Complaint Investigation
Date: Feb 8, 2024
Visit Reason
The State Agency conducted a complaint investigation (CI) MS #24046 at the facility from 02/07/24 through 02/08/24 for residents not turned/repositioned timely, residents not treated with dignity and respect, inappropriate feeding assistance, residents not assessed after change in condition, pressure sores, residents not groomed adequately.
Complaint Details
CI MS #24046 investigated allegations of residents not turned/repositioned timely, residents not treated with dignity and respect, inappropriate feeding assistance, residents not assessed after change in condition, pressure sores, and residents not groomed adequately. Deficiencies were cited.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to implement a comprehensive care plan and failure to provide scheduled baths and nail care for one resident reviewed for Activities of Daily Living.
Deficiencies (2)
F0656 - The facility failed to ensure that a comprehensive care plan was implemented for one of nine residents reviewed for Activities of Daily Living, as evidenced by Resident #1's missed nail care and baths, and failure to follow care plan interventions.
F0677 - The facility failed to ensure that a resident received scheduled baths and nail care, resulting in Resident #1 having long fingernails causing indentations and redness on her hand, missed baths in January, and poor hygiene.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 1, 2023
Complaint Investigation
Date: Nov 1, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS# 22928) at the facility on 11/01/23 regarding resident personal funds related to family not reimbursed for remaining balance on resident's account following her death and misappropriation of resident funds related to missing cell phones.
Complaint Details
CI MS# 22928 investigated resident personal funds issues including family reimbursement and missing cell phones; no deficiencies were cited and the complaint was not substantiated.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited during this complaint investigation.
Report Facts
Complaint investigations: 1
Inspection Report — Aug 9, 2023
Annual Inspection
Date: Aug 9, 2023
Visit Reason
On 08/09/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 06/22/23.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 08/04/23.
Inspection Report — Aug 9, 2023
Date: Aug 9, 2023
Visit Reason
On 08/09/23 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey that was completed on 06/22/23. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 08/04/23. No deficiencies were cited in this desk review.
Inspection Report — Jun 22, 2023
Annual Inspection
Date: Jun 22, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey and a complaint investigation (CI) MS #21495 at the facility from 6/19/23 through 6/22/23.
Complaint Details
Complaint investigation CI MS #21495 was substantiated with deficiencies cited at F565, F677, F689, F690 and F725.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for multiple deficiencies including resident rights, call light accessibility, grievance resolution, environment cleanliness, transfer notices, care planning, staffing, and infection control.
Deficiencies (13)
F0550 - Resident rights were not promoted as evidenced by failure to change a wet brief for Resident #6.
F0558 - The facility failed to maintain call lights within reach for Residents #6 and #20.
F0565 - The facility failed to resolve resident grievances timely as evidenced by unresolved complaints about call light response and missing clothing for five residents.
F0584 - The facility failed to maintain a clean and safe environment as evidenced by a dirty wheelchair for Resident #26 and black substance on Resident #77's refrigerator.
F0623 - The facility failed to provide written transfer/discharge notice to Resident #84 and representative for hospital transfer.
F0625 - The facility failed to notify Resident #84 and representative of the bed-hold policy for hospital discharge.
F0656 - The facility failed to develop and implement comprehensive care plans for Residents #6, #20, #25, and #30.
F0677 - The facility failed to provide necessary ADL care including shower and nail care for Residents #25 and #30.
F0689 - The facility failed to ensure safety by not securing smoking materials for Resident #57.
F0690 - The facility failed to provide timely incontinent care for Resident #6.
F0725 - The facility failed to provide sufficient nursing staff to meet resident needs on multiple days.
F0761 - The facility failed to store controlled medications in a separately locked, permanently affixed compartment in the medication room refrigerator.
F0880 - The facility failed to prevent infection spread as evidenced by failure to use a barrier during medication administration of a respiratory inhaler for Resident #9.
Report Facts
Deficiencies cited: 13
Residents interviewed for smoking materials: 11
Residents in resident council meeting: 17
Direct care per patient day: 2.97
Residents reviewed for grievances: 17
Residents reviewed for care plans: 26
Residents reviewed for incontinent care: 67
Medications observed: 37
Inspection Report — Jun 22, 2023
Annual Inspection
Date: Jun 22, 2023
Visit Reason
The State Agency conducted an annual licensure survey at the facility on 06/22/2023. The survey included review of staffing, activities of daily living, accident prevention, and resident safety.
Findings
The facility was found to be out of compliance with state minimum standards in staffing adequacy, activities of daily living care, and accident prevention related to smoking materials. Deficiencies included insufficient staffing to meet resident needs, failure to provide scheduled showers and nail care, and failure to secure smoking materials for residents.
Deficiencies (3)
M225 - The facility failed to provide enough staff to meet the needs of residents for four days of the survey, resulting in delayed incontinent care and slow response to call lights.
M610 - The facility failed to provide care to maintain hygiene as evidenced by failure to provide scheduled showers and nail care for two residents.
M640 - The facility failed to ensure resident safety by not securing smoking materials for one resident, allowing possession of cigarettes and a lighter contrary to policy.
Report Facts
Deficiencies cited: 3
Inspection Report — Jun 22, 2023
Routine
Date: Jun 22, 2023
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including resident care, safety, staffing, and infection control.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate call light accessibility, unresolved resident grievances, unclean equipment and refrigerators, failure to provide timely transfer and bedhold notices, incomplete care plans, inadequate personal care such as nail and bathing care, unsafe storage of smoking materials, insufficient staffing levels, improper medication storage, and infection control lapses during medication administration.
Deficiencies (13)
F 0550: The facility failed to promote resident dignity by not changing a wet brief for Resident #6 since the night shift.
F 0558: The facility failed to maintain call lights within reach for Residents #6 and #20, impairing their ability to summon assistance.
F 0565: The facility failed to resolve resident grievances timely for five residents regarding call light response delays and missing clothing.
F 0584: The facility failed to maintain a clean environment as evidenced by a dirty wheelchair and black substance on a resident's refrigerator for Residents #26 and #77.
F 0623: The facility failed to provide written transfer/discharge notice to Resident #84 and their representative for a hospital transfer.
F 0625: The facility failed to notify Resident #84 or representative in writing about the bed hold policy during hospital discharge.
F 0656: The facility failed to develop or implement complete care plans for Residents #6, 20, 25, and 30 addressing incontinence, call light accessibility, nail care, and bathing.
F 0677: The facility failed to provide adequate personal care as Resident #25 had long untrimmed nails and Resident #30 did not receive scheduled showers.
F 0689: The facility failed to ensure safety by not securing smoking materials for Resident #57, who had cigarettes and a lighter accessible in her room.
F 0690: The facility failed to provide timely incontinent care to Resident #6, leaving him in a saturated brief since the night shift.
F 0725: The facility failed to provide enough nursing staff to meet resident needs on four days of survey, resulting in delayed care and unanswered call lights.
F 0761: The facility failed to store controlled medications in a permanently affixed locked compartment inside the medication room refrigerator.
F 0880: The facility failed to use a barrier during medication administration of a respiratory inhaler for Resident #9, risking contamination.
Report Facts
Residents reviewed: 67
Residents reviewed: 26
Residents reviewed: 17
Residents reviewed: 5
Residents reviewed: 37
Residents reviewed: 18
Staff hired: 20
Staff full time: 7
Staff PRN: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Named in incontinent care and call light accessibility findings for Resident #6 |
| CNA #3 | Certified Nursing Assistant | Named in incontinent care and call light accessibility findings for Resident #6 |
| Administrator | Administrator | Named in multiple interviews regarding grievances, staffing, and medication storage |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding care plans, staffing, and medication storage |
| CNA #1 | Certified Nursing Assistant | Named in bathing care and refrigerator cleanliness findings |
| LPN #2 | Licensed Practical Nurse | Named in medication storage findings |
| LPN #1 | Licensed Practical Nurse | Named in medication administration infection control finding |
| CNA #4 | Certified Nursing Assistant | Named in smoking materials control finding |
| CNA #5 | Certified Nursing Assistant | Named in smoking materials control finding |
| Workforce Scheduler | Staff Scheduler | Named in staffing shortage findings |
| Social Services | Social Services Staff | Named in grievance complaint findings |
| Human Resources Coordinator | HR Coordinator | Named in staffing findings |
| MDS Nurse #1 | Minimum Data Set Nurse | Named in care plan findings |
| MDS Nurse #2 | Minimum Data Set Nurse | Named in care plan findings |
| CNA #6 | Certified Nursing Assistant | Named in call light response findings |
| CNA #7 | Certified Nursing Assistant | Named in staffing shortage findings |
| Infection Preventionist | Infection Preventionist | Named in infection control findings |
Inspection Report — Jun 21, 2023
Life Safety
Date: Jun 21, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Apr 17, 2023
Routine
Date: Apr 17, 2023
Visit Reason
Based on the initial comments and the tag cited, the survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, potentially causing more than minimal harm to all residents.
Deficiencies (1)
F0884 - The facility failed to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 21, 2023
Complaint Investigation
Date: Mar 21, 2023
Visit Reason
The State Agency conducted a complaint survey, MS00020915, at the facility on 3/21/23.
Complaint Details
Complaint MS00020915 alleged quality of care issues related to notification of resident change and discharge rights; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid participation requirements. The complaint regarding quality of care related to a responsible party not being notified of resident change or discharge rights was not substantiated.
Report Facts
Complaint count: 1
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
The State Agency conducted a complaint investigation, CI MS# 20242 at the facility on 01/25/23.
Complaint Details
Complaint investigation CI MS# 20242 regarding quality of care, resident grooming, ambulation, resident rights, and access to water was not substantiated; no deficiencies cited.
Findings
The surveyor found the facility in compliance with no deficiencies cited related to quality of care, resident grooming, ambulation, resident rights, and access to water.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 30, 2022
Complaint Investigation
Date: Nov 30, 2022
Visit Reason
On 11/30/22 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 10/4/22. The facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint survey completed on 10/4/22; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility in compliance and recommended it be placed back in compliance effective 11/18/22. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 7, 2022
Complaint Investigation
Date: Nov 7, 2022
Visit Reason
On 11/07/22 the State Agency conducted an on site complaint investigation, MS00019760 for alleged negligence of a resident.
Complaint Details
Complaint MS00019760 alleged negligence of a resident. The complaint was not substantiated and no deficiencies were cited.
Findings
The State Agency did not substantiate the complaint and no deficiencies were cited. The facility remains out of compliance due to deficiencies cited on the complaint investigation conducted on 10/04/22.
Report Facts
Complaint investigations: 1
Inspection Report — Oct 4, 2022
Complaint Investigation
Date: Oct 4, 2022
Visit Reason
The State Agency conducted complaint investigations (CI) MS #19544, CI MS #18877, and CI MS #19538 at the facility from 9/27/22 through 10/4/22. The SA substantiated the complaints for Personal Privacy, Free from Misappropriation, Free of Accident/Hazards, and Treatment of Pressure Wounds and cited F583, F602, F686, F689.
Complaint Details
Complaint investigations CI MS #19544, CI MS #18877, and CI MS #19538 were substantiated with deficiencies cited for Personal Privacy, Free from Misappropriation, Free of Accident/Hazards, and Treatment of Pressure Wounds.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to provide privacy during medical treatment, misappropriation of resident funds, inadequate treatment and documentation of pressure ulcers, and failure to maintain a safe environment preventing accidents and ensuring proper medication administration.
Deficiencies (4)
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to provide privacy for a resident's medical treatment during an assessment conducted in the facility lobby with other residents and visitors present.
F0602 - Free from Misappropriation/Exploitation. The facility misappropriated a resident's stimulus check by applying it to the resident's account balance without the resident's consent.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to provide treatment and document skin and wound assessments for a resident with a pressure ulcer, resulting in incomplete verification of care.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure a safe environment and adequate supervision to prevent accidents, including allowing an untrained social worker to assist a resident with a transfer resulting in a fall, and leaving medications at a resident's bedside without supervision.
Report Facts
Deficiencies cited: 4
Inspection Report — Apr 1, 2022
Complaint Investigation
Date: Apr 1, 2022
Visit Reason
The State Agency conducted a complaint survey for MS #18061, MS #18639 and MS# 18090 at the facility from 03/30/2022 to 04/01/2022 along with an Employee Vaccination section of the Infection Control survey.
Complaint Details
Complaint numbers MS #18061, MS #18639, and MS #18090 were investigated. Allegations included quality of care/treatment services not received, medications not given as ordered, environment roaches, services not received as physician ordered, and short staffing. None of these complaints were substantiated and no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. No deficiencies were cited and the complaints were not substantiated.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 6, 2022
Routine
Date: Jan 6, 2022
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 1/6/2022.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report — Sep 9, 2021
Follow-Up
Date: Sep 9, 2021
Visit Reason
The State Agency conducted a revisit for the facility on 09/09/21 to determine compliance with the requirements for participation in The Aged and Infirmed effective 8/20/21.
Findings
The facility was found in compliance with the requirements for participation in The Aged and Infirmed effective 8/20/21.
Inspection Report — Sep 8, 2021
Complaint Investigation
Date: Sep 8, 2021
Visit Reason
The State Agency conducted an onsite complaint investigation, CI MS #18027, for alleged verbal abuse of a resident by a Certified Nursing Assistant (CNA) that had occurred on 08/27/2021.
Complaint Details
CI MS #18027 was substantiated for verbal abuse of a resident by a CNA. The facility was cited for a deficiency at M500 with Scope and Severity D. The facility corrected the deficiency prior to the State Agency survey.
Findings
The facility substantiated the verbal abuse of Resident #1 by CNA #1 and terminated CNA #1. The facility followed their policies and procedures for abuse and neglect and had corrected the deficiency prior to the State Agency entering the building.
Deficiencies (1)
M500 - The facility failed to prevent verbal abuse of one resident by a Certified Nursing Assistant (CNA). Resident #1 reported being verbally abused and physically mistreated by CNA #1, who used profane language and was rough in care. The facility investigated, suspended, and terminated the CNA, conducted staff in-services, and reported the incident to the State Agency.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 23, 2021
Complaint Investigation
Date: Jul 23, 2021
Visit Reason
The State Agency (SA) conducted Complaint Investigations (CI) MS #17896 and CI MS 17899 from 7/19/2021 through 7/23/2021. The SA substantiated CI MS #17896 related to an elopement. The facility was not in compliance with the requirements of participation in Medicare and Medicaid and cited F609, F622, F655, and F689.
Complaint Details
CI MS #17896 was substantiated related to an elopement of Resident #1. The facility was found not in compliance with multiple deficiencies including failure to prevent elopement, failure to report, failure to develop a care plan, and failure to allow the resident to return to the facility.
Findings
The facility was found not in compliance due to failure to prevent an elopement of Resident #1, failure to report the elopement, failure to develop and implement a baseline care plan for elopement risk, failure to allow the resident to return to the facility, and inadequate staffing to monitor the resident. The Immediate Jeopardy was removed on 7/21/2021.
Deficiencies (4)
F0609 - Reporting of Alleged Violations. The facility failed to report an elopement incident for Resident #1 in a timely manner and misclassified the event as Against Medical Advice (AMA).
F0622 - Transfer and Discharge Requirements. The facility failed to allow Resident #1 to return after elopement and did not properly discharge the resident, placing her and others at risk.
F0655 - Baseline Care Plan. The facility failed to develop and implement a baseline care plan within 48 hours for Resident #1 who was identified as an elopement risk upon admission.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide adequate supervision and interventions to prevent Resident #1's elopement, and staffing was insufficient to monitor the resident.
Report Facts
Deficiencies cited: 4
Residents at risk for elopement: 5
Residents accounted: 88
Inspection Report — Jul 14, 2021
Follow-Up
Date: Jul 14, 2021
Visit Reason
The State Agency (SA) conducted a post-certification revisit for at the facility on 7/14/21.
Findings
The SA determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid.
Report Facts
Deficiencies cited: 0
Inspection Report — May 6, 2021
Annual Inspection
Date: May 6, 2021
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 05/03/21 to 05/06/21. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid Requirements of Participation.
Findings
The facility was found not in compliance with Medicare and Medicaid Requirements of Participation with deficiencies cited in areas including ADL care, accident hazards, tube feeding management, respiratory care, infection control, and environmental safety.
Deficiencies (6)
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide nail care to a dependent resident as evidenced by long, jagged fingernails for one resident.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure a safe environment as respiratory inhalers were left unsecured at the bedside for three residents.
F0693 - Tube Feeding Mgmt/Restore Eating Skills. The facility failed to label the enteral feeding bag and ensure the correct flow rate consistent with the physician order for one resident receiving gastrostomy feedings.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure the oxygen flow rate was consistent with the physician order for one resident receiving oxygen therapy.
F0880 - Infection Prevention & Control. The facility failed to store nebulizer masks properly to prevent infection for one resident; the facility lacked a policy for cleaning nebulizer machines.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to maintain a safe environment as a staff nurse was observed vaping at the nurses desk during a shift.
Report Facts
Deficiencies cited: 6
Inspection Report — May 4, 2021
Life Safety
Date: May 4, 2021
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
Two deficiencies were cited related to life safety: blocked exit egress and a smoke barrier door that did not close properly. The facility acknowledged the findings and took immediate corrective actions.
Deficiencies (2)
K0211 - The facility failed to properly maintain exit egress as furniture, carts, and pallets blocked the front exit and C Hall exit discharge, affecting 24 of 84 residents.
K0374 - The smoke barrier door near the Therapy Unit did not properly close and latch upon activation of the fire alarm and sprinkler systems, affecting 14 of 84 residents.
Report Facts
Deficiencies cited: 2
Inspection Report — May 4, 2021
Life Safety
Date: May 4, 2021
Visit Reason
Survey conducted on 05/04/21 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Mar 22, 2021
Complaint Investigation
Date: Mar 22, 2021
Visit Reason
A Complaint Investigation (CI) was conducted by State Agency (SA) from 3/17/21 through 3/22/21 for Complaint # 17608.
Complaint Details
Complaint # 17608 was investigated and the facility was found to be in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with the regulations required by the Centers for Medicare and Medicaid (CMS).
Report Facts
Complaint count: 1
Inspection Report — Jan 20, 2021
Routine
Date: Jan 20, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency from 1/19/21 through 1/20/21. The State Agency also conducted complaint surveys investigating MS CI #17454 and MS CI #17214 during the same period.
Complaint Details
Complaint investigations MS CI #17454 and MS CI #17214 were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and the requirements of participation in Medicare and Medicaid.
Report Facts
Complaint investigations: 2
Inspection Report — Dec 14, 2020
Routine
Date: Dec 14, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on December 14, 2020.
Findings
No new observations related to infection control were noted during this survey; however, the facility remains out of compliance based on deficiencies cited during the October 14, 2020 survey.
Inspection Report — Oct 14, 2020
Routine
Date: Oct 14, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control survey, along with a complaint survey investigating MS CI 00016733 at the facility from 10/12/20 to 10/14/20.
Complaint Details
Complaint MS CI 00016733 was substantiated for Misappropriation of Property involving Resident #1; deficiencies were cited.
Findings
The facility was found not in compliance due to failure to ensure narcotics were stored and locked to prevent drug diversion, substantiating the complaint for Misappropriation of Property for Resident #1.
Deficiencies (1)
F0602 - Free from Misappropriation/Exploitation. The facility failed to ensure narcotics were stored and locked to prevent drug diversion involving medication for Resident #1.
Report Facts
Deficiencies cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
Inspection Report — Aug 11, 2020
Routine
Date: Aug 11, 2020
Visit Reason
The State Agency (SA) conducted a COVID Infection Control survey at facility on 08/11/20.
Findings
The survey determined that the facility was in compliance with Medicare and Medicaid regulations of participation.
Inspection Report — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/28/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Feb 27, 2020
Complaint Investigation
Date: Feb 27, 2020
Visit Reason
The State Agency conducted a complaint survey investigating MS CI 00016606, MS CI 00016636, and MS CI 00016662 on 02/26/20 and 02/27/20. Allegations of Quality of care, Abuse and Neglect and Resident Rights were investigated. These concerns were not substantiated, and no deficiencies were cited. The SA also completed a follow up investigation from a survey that was completed 01/02/20 and the facility was placed back in compliance.
Complaint Details
Complaint investigation MS CI 00016606, MS CI 00016636, and MS CI 00016662 involved allegations of Quality of care, Abuse and Neglect and Resident Rights. These concerns were not substantiated and no deficiencies were cited.
Findings
The survey found the facility in substantial compliance with requirements for participation in Medicare and Medicaid. No deficiencies were cited during this complaint and follow-up survey.
Report Facts
Complaints investigated: 3
Inspection Report — Jan 2, 2020
Complaint Investigation
Date: Jan 2, 2020
Visit Reason
The State Agency (SA) conducted a complaint investigation (CI) for MS #16490 and MS #16510, from 12/30/19 to 01/02/20. MS #16510 related to staffing concerns was not substantiated during the investigation. The SA determined the facility was not in compliance with the requirements of participation in Medicare and Medicaid. The SA substantiated MS #16490 for Freedom from Abuse and Neglect, and identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) 12/30/19, which began on 11/21/19, when the Assistant Director of Nursing Services (Registered Nurse (RN) #1) caused mental and verbal abuse to Resident #1 by not allowing the Certified Nursing Assistants (CNA) #1 and #2 to place the resident back to bed, when she was crying and yelling in pain.
Complaint Details
Complaint investigation CI MS #16490 substantiated for Freedom from Abuse and Neglect with Immediate Jeopardy and Substandard Quality of Care beginning 11/21/19. MS #16510 related to staffing concerns was not substantiated.
Findings
The facility failed to protect Resident #1 from verbal and mental abuse by RN #1 on 11/21/19, causing mental anguish and psychosocial harm. The Administrator was notified but failed to investigate, suspend RN #1, or report the incident timely. The facility submitted an acceptable Removal Plan and the Immediate Jeopardy was removed on 01/01/20. The facility implemented systemic changes including staff education, grievance monitoring, and psychological evaluation of Resident #1.
Deficiencies (3)
F0600 - Freedom from Abuse and Neglect. The facility failed to ensure Resident #1 was free from verbal and mental abuse by the Assistant Director of Nursing (RN #1) who prevented CNAs from putting the resident back to bed while she was crying and in pain, causing mental anguish and psychosocial harm.
F0609 - Reporting of Alleged Violations. The facility failed to report an allegation of staff to resident abuse involving RN #1 within the required two-hour timeframe after Resident #1's daughter reported the incident on 11/21/19.
F0610 - Investigate/Prevent/Correct Alleged Violation. The facility failed to thoroughly investigate and prevent further potential abuse after the allegation against RN #1 was made on 11/21/19, allowing him to continue working and failing to protect Resident #1 and others.
Report Facts
Deficiencies cited: 3
Inspection Report — Oct 17, 2019
Complaint Investigation
Date: Oct 17, 2019
Visit Reason
The State Agency conducted a complaint survey investigating CI MS# 16199 and CI MS# 16279 on 10/17/19. Concerns identified in the complaint were related to possible quality of care and dehydration of Resident #1 and an anonymous complaint related to infection control.
Complaint Details
Complaint investigation CI MS# 16199 and CI MS# 16279 related to quality of care, dehydration, and infection control were not substantiated and no deficiencies were cited.
Findings
These concerns were not substantiated, and no deficiencies were cited. During the survey the SA determined the facility was in substantial compliance with requirements for participation in Medicare and Medicaid.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 1, 2019
Complaint Investigation
Date: Aug 1, 2019
Visit Reason
A complaint investigation was conducted on August 1, 2019 in the facility.
Complaint Details
CI MS #16003: A complaint investigation was conducted and was unsubstantiated with no deficiencies cited.
Findings
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report — May 3, 2019
Complaint Investigation
Date: May 3, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation (CI MS#15797 & CI MS#15854) on 05/03/19. The result of the investigation was unsubstantiated for Quality of Care and Admission/Discharge rights with no deficiencies cited.
Complaint Details
Complaint investigation CI MS#15797 & CI MS#15854 was unsubstantiated for Quality of Care and Admission/Discharge rights with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements for participation with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 26, 2019
Complaint Investigation
Date: Mar 26, 2019
Visit Reason
A complaint investigation was conducted on March 26, 2019 in the facility.
Complaint Details
CI MS#15764: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Jan 10, 2019
Annual Inspection
Date: Jan 10, 2019
Visit Reason
The State Survey Agency (SA) conducted an annual recertification from 1/8/19 through 1/10/19. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in comprehensive care planning, psychotropic medication management, infection prevention and control, and electrical system maintenance.
Deficiencies (4)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement a comprehensive care plan to ensure infection control techniques were provided related to wound care for one resident.
F0758 - Free from Unnecessary Psychotropic Meds/PRN Use. The facility failed to provide a stop date for psychotropic medication ordered as needed for one resident.
F0880 - Infection Prevention & Control. The facility failed to provide wound care in a manner to prevent the possible spread of infection for one resident, as staff did not change gloves between removing soiled dressing and applying new dressing.
K0918 - Electrical Systems - Essential Electric System Maintenance and Testing. The facility failed to properly document records of annual testing of the generator, with the last documented test performed on 12/28/2017.
Report Facts
Deficiencies cited: 4
Inspection Report — Jan 10, 2019
Life Safety
Date: Jan 10, 2019
Visit Reason
Based on the initial comments and the form type, this was a Life Safety Code survey focused on compliance with NFPA 101 and related regulations.
Findings
M1245 - The facility failed to properly document the annual testing of the generator for 2018, with the last documented test performed on 12-28-17. This deficiency had the potential to affect the entire facility on the day of the survey.
Deficiencies (1)
M1245 - The facility failed to properly document records of annual generator testing for 2018, with the last documented test on 12-28-17.
Report Facts
Deficiencies cited: 1
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