Inspection Reports for
Edgewood Health & Rehab
205 Byram Parkway, Byram, MS, 39272
Back to Facility Profile87 Reports
Inspection Report — Aug 27, 2026
Annual Inspection
Date: Aug 27, 2026
Visit Reason
The State Agency conducted a desk review of the information provided related to the annual recertification/complaint survey completed from 07/20/26-07/23/26.
Findings
The information provided by the facility confirmed corrective measures were implemented and compliance with Medicare and Medicaid requirements was sustained. The State Agency recommended the facility be placed back in compliance effective 08/26/26.
Report Facts
Deficiencies cited: 0
Inspection Report — Jul 23, 2026
Annual Inspection
Date: Jul 23, 2026
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI), MS #3070018 and CI MS #3104843 at the facility from 7/20/26 through 7/23/26.
Complaint Details
The SA investigated CI MS #3070018 for medication administration and cited F761 as Past Non-Compliance. CI MS #3104843 was investigated for abuse and F610 was cited.
Findings
The facility was found not in compliance during the annual recertification survey with deficiencies cited related to safe environment, abuse investigation, resident assessments, medication storage, and infection control.
Deficiencies (6)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to maintain dining room furniture in a safe and comfortable condition, with damaged chairs presenting safety hazards.
F0610 - Investigate/prevent/correct alleged violation. The facility failed to immediately protect a resident from alleged abuse by a staff member and allowed the resident to remain alone with the alleged perpetrator.
F0640 - Encoding/transmitting resident assessments. The facility failed to complete the discharge Minimum Data Set (MDS) for one resident in accordance with CMS guidelines.
F0641 - Accuracy of assessments. The facility failed to ensure a resident's MDS assessment accurately reflected the use of a suprapubic catheter and colostomy.
F0761 - Label/store drugs and biologicals. The facility failed to properly store medications, leaving medications unattended at a resident's bedside, risking missed doses or medication errors.
F0880 - Infection prevention & control. The facility failed to follow infection prevention practices during medication administration by not disinfecting the bedside table or using a barrier, risking cross-contamination.
Report Facts
Deficiencies cited: 6
Inspection Report — Jul 23, 2026
Annual Inspection
Date: Jul 23, 2026
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigation (CI), MS #3070018 and CI MS #3104843 at the facility from 7/20/26 through 7/23/26. The SA investigated CI MS #3070018 for medication administration and CI MS #3104843 for Abuse.
Complaint Details
Complaint Investigation (CI) MS #3070018 was for medication administration and no citations were issued. CI MS #3104843 was investigated for abuse and M500 was cited.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, citing M500 and M1570. The facility failed to maintain dining room furniture in a safe and homelike environment and protect a resident from abuse. Additionally, the facility failed to follow infection prevention practices during medication administration for one resident.
Deficiencies (2)
M0500 - Residents' Rights. The facility failed to maintain dining room furniture in a safe, clean, and homelike environment, with multiple chairs having missing or damaged padded armrests exposing rough metal, creating safety hazards. The facility also failed to protect Resident #62 from abuse when a CNA was observed striking the resident with a towel and nurses left the resident alone with the alleged perpetrator for several minutes.
M1570 - Infection Control. The facility failed to follow infection prevention practices during medication administration for Resident #103 when a nurse placed medications on a bedside table without disinfecting the surface or using a barrier, and allowed medication containers to contact other residents' medications, increasing the risk of infection transmission.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 21, 2026
Life Safety
Date: Jul 21, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements on 07/21/2026.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Apr 2, 2026
Follow-Up
Date: Apr 2, 2026
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 4/02/26 related to the complaint survey that was conducted on 2/25/26 through 3/02/26.
Complaint Details
Complaint survey conducted on 2/25/26 through 3/02/26; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and recommends the facility be placed back in compliance effective 3/25/26.
Inspection Report — Apr 2, 2026
Complaint Investigation
Date: Apr 2, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2960887, CI MS #2809492 and CI MS #2807484) at the facility on 4/02/26 related to misappropriation, quality of care, residents' rights, nursing services, and quality of care.
Complaint Details
Three complaint investigations (CI MS #2960887, CI MS #2809492, and CI MS #2807484) were conducted related to misappropriation, quality of care, residents' rights, nursing services, and quality of care. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Apr 2, 2026
Complaint Investigation
Date: Apr 2, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2960887, CI MS #2809492 and CI MS #2807484) at the facility on 04/02/2026. The investigations were related to misappropriation, quality of care, residents' rights, nursing services, and quality of care.
Complaint Details
Three complaint investigations were conducted: CI MS #2960887 related to misappropriation, quality of care, and misappropriation of property; CI MS #2809492 regarding residents' rights; and CI MS #2807484 related to nursing services and quality of care. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Mar 2, 2026
Date: Mar 2, 2026
Visit Reason
The State Agency conducted an onsite survey related to a facility-reported incident (Incident #2745744) from 2/25/26 through 3/2/26 involving allegations of abuse and cited F600, F609, F610, and F835. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 2/26/26.
Findings
The facility was found not in compliance due to failure to protect residents from abuse, failure to timely report and investigate allegations of abuse, and failure of administration to implement and enforce abuse policies. Immediate Jeopardy was identified but removed after corrective actions.
Deficiencies (4)
F0600 - The facility failed to ensure Resident #1 was free from verbal abuse by CNAs who used disparaging, derogatory, and humiliating language during care on 2/10/26, placing all residents at risk of serious harm.
F0609 - The facility failed to report an allegation of verbal abuse within the required two-hour timeframe, reporting it to the State Agency only on 2/16/26, placing residents at risk of harm.
F0610 - The facility failed to promptly and thoroughly investigate an allegation of verbal abuse reported on 2/14/26, delaying interviews and protective measures until 2/16/26, risking continued abuse.
F0835 - The facility failed to provide effective administrative oversight by not ensuring timely reporting, investigation, and removal of alleged perpetrators after notification of verbal abuse on 2/14/26, allowing continued risk to residents.
Report Facts
Deficiencies cited: 4
Inspection Report — Mar 2, 2026
Complaint Investigation
Date: Mar 2, 2026
Visit Reason
The State Agency conducted an onsite survey related to a facility-reported incident (Incident #2745744) from 2/25/26 through 3/2/26 involving allegations of abuse. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified on 2/26/26 due to failure to protect residents from abuse.
Complaint Details
Incident #2745744 involved allegations of abuse substantiated by an audio recording of verbal abuse toward Resident #1. Immediate Jeopardy was identified due to failure to protect residents and timely report and investigate the abuse.
Findings
The facility failed to protect Resident #1 from verbal abuse by two Certified Nurse Aides on 2/10/26, including the use of disparaging, derogatory, and humiliating language and intimidation during care. The facility also failed to timely report, investigate, and implement protective measures, placing all residents at risk. Immediate Jeopardy was identified and later removed after corrective actions.
Deficiencies (1)
M0500 - Residents' Rights. The facility failed to ensure Resident #1 was free from verbal abuse by staff on 2/10/26 and failed to timely report, investigate, and protect residents from abuse, placing all residents at risk.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 13, 2026
Complaint Investigation
Date: Feb 13, 2026
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 01/13/26. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint survey completed on 01/13/26; the facility was found to be in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance as of 02/10/26 with no deficiencies cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 13, 2026
Complaint Investigation
Date: Jan 13, 2026
Visit Reason
The State Agency conducted four Complaint Investigations (CI MS #2707987, CI MS #2709270, CI MS #2703690 and CI MS #2702875) from 1/12/26 through 1/13/26 regarding quality of care, resident rights, nursing services, neglect, infection control, admission/transfer/discharge rights, neglect and abuse. The facility was found not in compliance and cited F684 and F761 related to CI MS #2703690.
Complaint Details
CI MS #2703690 was investigated regarding nursing services and neglect. Deficiencies F684 and F761 were cited related to this complaint.
Findings
The facility failed to provide assistance with turning and repositioning for two residents requiring ADL assistance, resulting in prolonged periods without repositioning. Additionally, the facility failed to ensure accurate labeling and storage of medications, with one medication vial found inside another's package on a medication cart.
Deficiencies (2)
F0684 - Quality of care. The facility failed to provide assistance with turning and repositioning every two hours for two residents who required such care, resulting in discomfort and risk of skin damage.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure accurate labeling and storage of medications, with one medication vial stored inside the box of a different medication, risking administration errors.
Report Facts
Deficiencies cited: 2
Complaint Investigations: 4
Inspection Report — Dec 22, 2025
Complaint Investigation
Date: Dec 22, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2688864, related to an allegation of neglect and failing to transfer to an acute care hospital.
Complaint Details
CI MS#2688864 was investigated related to an allegation of neglect and failing to transfer to an acute care hospital. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 22, 2025
Complaint Investigation
Date: Dec 22, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2688864, related to an allegation of neglect and failing to transfer to an acute care hospital.
Complaint Details
Complaint number CI MS#2688864 was investigated related to an allegation of neglect and failing to transfer to an acute care hospital. The complaint was not substantiated as the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Dec 1, 2025
Follow-Up
Date: Dec 1, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 12/01/25 related to the complaint survey that was conducted on 10/28/25 through 10/29/25.
Complaint Details
Complaint survey conducted on 10/28/25 through 10/29/25; the facility was found in compliance with no deficiencies cited.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 11/26/25.
Inspection Report — Dec 1, 2025
Follow-Up
Date: Dec 1, 2025
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 12/01/25 related to the complaint survey that was conducted 10/28/25 through 10/29/25.
Complaint Details
CI MS#26995 complaint survey conducted 10/28/25 through 10/29/25; the facility was found in compliance with no deficiencies cited.
Findings
The SA determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back into compliance effective 11/26/25.
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) MS#2650942, CI MS#2650958 and Incident# 2647561 at the facility from 10/28/25 through 10/29/25. CI MS#2650942 and Incident # 2647561 were investigated related to accident/fall and CI MS #265098 was investigated related to accident/fall.
Complaint Details
Complaint Investigation (CI) MS#2650942 and Incident # 2647561 were related to accident/fall, and CI MS#2650958 was related to accident/fall. Deficiencies were cited under M640.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and cited M640 for failure to ensure adequate supervision and implementation of safety interventions to prevent accidents for two residents. The investigation revealed unsafe transfer practices and inadequate training for transportation staff.
Deficiencies (1)
M0640 - Accidents. The facility failed to ensure adequate supervision and safety interventions to prevent accidents for two residents, resulting in a resident fall with rib fracture during a mechanical lift transfer and a wheelchair tipping incident during transport in the facility van.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
The State Agency conducted three (3) Complaint Investigations (CI MS #2650942, CI MS #2650958 and CI MS #2647561) at the facility from 10/28/25 through 10/29/25. CI MS#2650942 and CI MS# 2647561 were investigated related to accident/fall and CI MS #265098 was investigated related to accident/fall.
Complaint Details
Three complaint investigations (CI MS #2650942, CI MS #2650958, CI MS #2647561) were conducted related to accident/fall incidents. Deficiencies were cited and substantiated for these complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements with three deficiencies cited related to care plan implementation, accident hazards and competent nursing staff.
Deficiencies (3)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to ensure the comprehensive person-centered care plan was implemented for one of four sampled residents, resulting in a fall with acute rib fracture due to improper transfer by staff without required assistance.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure adequate supervision and safety interventions to prevent accidents for two of four sampled residents, including a resident fall from a mechanical lift and a wheelchair tipping over during transport.
F0726 - Competent Nursing Staff. The facility failed to ensure staff performing resident transportation possessed and demonstrated necessary competencies, resulting in a resident's wheelchair tipping over in the facility van due to improper securement.
Report Facts
Deficiencies cited: 3
Complaint investigations: 3
Inspection Report — Aug 6, 2025
Complaint Investigation
Date: Aug 6, 2025
Visit Reason
On 08/06/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 6/19/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint survey completed on 6/19/25; the facility was found in compliance after corrective measures.
Findings
The facility was found to be back in compliance effective 7/22/25 following the complaint investigation and desk review.
Report Facts
Complaint surveys reviewed: 1
Inspection Report — Jul 30, 2025
Complaint Investigation
Date: Jul 30, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2564998 at the facility on 7/30/25. The complaint was investigated for staffing, nursing services, neglect, pressure sores, and quality of care/treatment.
Complaint Details
Complaint number CI MS #2564998 was investigated for staffing, nursing services, neglect, pressure sores, and quality of care/treatment. No deficiencies were cited during this complaint investigation.
Findings
No deficiencies were cited during the complaint investigation. The facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 06/19/25 survey.
Inspection Report — Jul 30, 2025
Complaint Investigation
Date: Jul 30, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #2564998 at the facility on 7/30/25. The complaint was investigated for staffing, nursing services, neglect, pressure sores, and quality of care/treatment.
Complaint Details
CI MS#2564998 investigated staffing, nursing services, neglect, pressure sores, and quality of care/treatment; no deficiencies were cited.
Findings
No deficiencies were cited during the complaint investigation. The facility remains out of compliance due to deficiencies cited on the 06/19/25 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #29237, #29232, #29204, #29188, #29210, and #29263) from 6/16/25 through 6/19/25. Deficiencies were cited related to CI MS #29210 for care not received per physician's orders and nursing services, and CI MS #29263 for failure to provide supervision to prevent an elopement.
Complaint Details
Six complaint investigations were conducted, including CI MS #29210 and CI MS #29263 which resulted in deficiencies. CI MS #29210 involved care not received per physician's orders and nursing services, and CI MS #29263 involved failure to provide supervision to prevent an elopement. Deficiencies were cited for both complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to update and revise care plans per physician orders for respiratory equipment, failure to provide services meeting professional standards, and failure to provide adequate supervision to prevent a vulnerable resident from eloping. Immediate Jeopardy was identified but removed prior to survey entrance after corrective actions.
Deficiencies (3)
F0657 - The facility failed to develop and revise a comprehensive care plan for Resident #2 to reflect a new physician order for an auto-adjusting C-Pap machine dated 1/31/25, and the interdisciplinary team did not review or implement updated interventions related to the new therapy.
F0658 - The facility failed to ensure services were provided and documented according to professional standards for Resident #2 by delaying transcription and implementation of a new C-Pap order from 1/31/25 until 5/28/25.
F0689 - The facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1 from exiting the facility unnoticed and unsupervised, resulting in an Immediate Jeopardy situation that was removed after corrective actions.
Report Facts
Deficiencies cited: 3
Complaint investigations: 6
Inspection Report — Jun 19, 2025
Complaint Investigation
Date: Jun 19, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs) MS #29237, MS #29232, MS #29204, MS #29188, MS #29210, and MS #29263 from 6/16/25 through 6/19/25. The investigations included pressure sores, quality of care, accidents and falls, injury of unknown origin, care not received per physician's orders, nursing services, admission, transfer and discharge rights, and an elopement incident.
Complaint Details
Complaint investigations MS #29237, MS #29232, MS #29204, MS #29188, MS #29210, and MS #29263 were conducted. Only MS #29263 was substantiated with a deficiency cited (M640) related to an elopement incident. Other complaints were investigated with no citations.
Findings
The facility was found not in compliance with state licensure requirements due to failure to provide adequate supervision and environmental safety, resulting in Resident #1 exiting the facility unnoticed and unsupervised. Immediate Jeopardy was identified but removed prior to the survey entrance after corrective actions were implemented.
Deficiencies (1)
M640 - The facility failed to provide adequate supervision and ensure environmental safety to prevent Resident #1, a vulnerable resident, from exiting the facility unnoticed and unsupervised, placing the resident and others at risk of serious injury or death.
Report Facts
Complaints investigated: 6
Deficiencies cited: 1
Inspection Report — May 21, 2025
Complaint Investigation
Date: May 21, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #21496 and MS #22189 at the facility from 7/31/23 through 8/2/23. MS #21496 was investigated related to pharmaceutical services, resident neglect, and misappropriation of property. MS #22189 was investigated related to resident left wet for extended periods, call light not answered, resident assessment, and facility not clean.
Complaint Details
Complaint Investigation MS #21496 and MS #22189 were investigated for pharmaceutical services, resident neglect, misappropriation of property, resident left wet for extended periods, call light not answered, resident assessment, and facility cleanliness. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Inspection Report — Apr 21, 2025
Complaint Investigation
Date: Apr 21, 2025
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 03/20/25.
Complaint Details
CI MS#26995 - The complaint investigation was substantiated and deficiencies were corrected; the facility was found in compliance after corrective measures.
Findings
The facility was found to have put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency is recommending the facility be placed back in compliance effective 04/15/25.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 14, 2025
Complaint Investigation
Date: Apr 14, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #28472 and MS #28487, at the facility on 4/14/25. MS #28472 was investigated related to injury of unknown origin. MS #28487 was investigated regarding nursing services.
Complaint Details
Complaint investigations MS #28472 and MS #28487 were conducted; no deficiencies were cited during these investigations.
Findings
No deficiencies were cited during the complaint investigations. The facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm due to deficiencies cited on the 03/20/25 survey.
Report Facts
Complaint investigations: 2
Inspection Report — Apr 14, 2025
Complaint Investigation
Date: Apr 14, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #28472 and MS #28487, at the facility on 4/14/25. MS #28472 was investigated related to an injury of unknown origin. MS #28487 was investigated regarding nursing services.
Complaint Details
Complaint investigations MS #28472 and MS #28487 were conducted related to an injury of unknown origin and nursing services respectively; no deficiencies were cited.
Findings
No deficiencies were cited during the complaint investigations. The facility remains out of compliance due to deficiencies cited on the 03/20/25 survey.
Report Facts
Complaint investigations: 2
Inspection Report — Mar 20, 2025
Complaint Investigation
Date: Mar 20, 2025
Visit Reason
The State Agency conducted six Complaint Investigations (CI MS #28268, CI MS #28258, CI MS #28206, CI MS #28098, CI MS #28106, and CI MS #28035) at the facility from 3/18/25 through 3/20/25. The facility was found not in compliance with Medicare and Medicaid requirements.
Complaint Details
Six complaint investigations were conducted, including CI MS #28268 (abuse, quality of care, resident rights), CI MS #28258 (neglect related to medication and feeding assistance), CI MS #28206 (nursing services, neglect, resident rights, no deficiencies cited), CI MS #28098 (abuse, quality of care, resident rights), CI MS #28106 (abuse, quality of care, resident rights), and CI MS #28035 (resident rights, quality of care, abuse). Deficiencies were cited in five of the six complaints.
Findings
The facility was found not in compliance due to multiple deficiencies related to abuse, care planning, activities of daily living assistance, and food service. Specific issues included physical and verbal abuse by CNAs, failure to implement care plans for feeding assistance, and serving meals that did not meet menu or palatability standards.
Deficiencies (4)
F0600 - Free from Abuse and Neglect. The facility failed to ensure two residents were free from physical and verbal abuse by certified nursing assistants, including hitting and use of degrading language.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plan interventions for a resident requiring assistance with feeding, leaving her drink unopened, cereal dry, and utensils out of reach.
F0676 - Activities Daily Living (ADLs)/Maintain Abilities. The facility failed to provide appropriate assistance with eating, including opening containers and placing utensils within reach, preventing a resident from feeding herself.
F0804 - Nutritive Value/Appearance, Palatable/Preferred Temperature. The facility served meals that were not palatable or consistent with the posted menu, including club sandwiches lacking expected ingredients and poor presentation for two residents.
Report Facts
Deficiencies cited: 9
Inspection Report — Dec 20, 2024
Complaint Investigation
Date: Dec 20, 2024
Visit Reason
On 12/20/24 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 11/26/24. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS# not explicitly stated. The complaint survey was completed on 11/26/24. 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 12/19/24. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Nov 26, 2024
Complaint Investigation
Date: Nov 26, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #26849 and CI MS #26850) at the facility from 11/25/24 through 11/26/24. CI MS #26849 was investigated related to neglect, dehydration, and left soiled for extended lengths of time. CI MS #26850 was investigated related to not following protocol for discharge.
Complaint Details
Two complaint investigations were conducted (CI MS #26849 and CI MS #26850). CI MS #26850 was substantiated with deficiencies cited related to discharge protocol. CI MS #26849 was investigated but no deficiencies cited.
Findings
The facility was found not in compliance related to CI MS #26850 and cited for failure to ensure the written contents of the notice of discharge included all required elements for one resident's discharge.
Deficiencies (1)
F0623 - Notice Requirements Before Transfer/Discharge. The facility failed to include all required information in the written discharge notice for Resident #1, such as the reason for discharge, location of discharge, and contact information for protection and advocacy agencies. The discharge notice was also not provided 30 days prior to discharge.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 26, 2024
Complaint Investigation
Date: Nov 26, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI), MS #26849 and CI MS #26850 at the facility from 11/25/24 through 11/26/24. CI MS #26849 was investigated related to neglect, dehydration, and left soiled for extended lengths of time. CI MS #26850 was investigated related to not following protocol for discharge.
Complaint Details
Complaint investigations CI MS #26849 and CI MS #26850 were conducted related to neglect, dehydration, and discharge protocol. The facility was found in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no state licensure deficiencies cited.
Report Facts
Complaint investigations: 2
Inspection Report — Oct 8, 2024
Complaint Investigation
Date: Oct 8, 2024
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS#26501, CI MS#26516, and CI MS#26517) related to resident abuse, resident rights, and quality of care/treatment including adequate grooming.
Complaint Details
Three complaint investigations were conducted: CI MS#26501 related to resident abuse and resident rights; CI MS#26516 regarding resident abuse, resident rights, and quality of care/treatment related to adequate grooming; and CI MS#26517 regarding resident abuse and resident rights. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Complaint Investigations conducted: 3
Inspection Report — Oct 8, 2024
Complaint Investigation
Date: Oct 8, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS#26501, MS#26516 and MS#26517 at the facility from 10/07/24 through 10/08/24. MS #26501 was investigated related to resident abuse and resident rights. MS #26516 was investigated regarding resident abuse, resident rights and quality of care/treatment related to adequate grooming. MS #26517 was investigated regarding resident abuse and resident rights.
Complaint Details
Complaint Investigation (CI), MS#26501, MS#26516 and MS#26517 were investigated for resident abuse, resident rights, and quality of care/treatment related to grooming. The facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 11, 2024
Follow-Up
Date: Sep 11, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 9/9/24 through 9/10/24 related to an annual recertification survey along with 13 Complaint Investigations that was conducted at the facility from 7/29/24 through 8/1/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 8/28/24.
Report Facts
Complaint Investigations: 13
Inspection Report — Sep 11, 2024
Follow-Up
Date: Sep 11, 2024
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 9/9/24 through 9/10/24 related to an annual recertification survey along with 13 Complaint Investigations (CIs) that was conducted at the facility from 7/29/24 through 8/1/24.
Findings
The SA determined the facility was in compliance with the Minimum Standards for Institutions for the aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 8/28/24.
Report Facts
Complaint Investigations: 13
Inspection Report — Sep 5, 2024
Complaint Investigation
Date: Sep 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26083, MS #26172, MS #26184, 26199, MS #26230, MS #26231, MS #26233, MS #26235, MS #26274, MS #26277, and MS #26311, at the facility from 9/3/24 through 9/5/24. The investigations covered resident rights, quality of care, resident safety, staffing, grooming, safety, physical environment, nursing, infection control, neglect, and dietary services.
Complaint Details
Complaint Investigation (CI) MS #26083, MS #26172, MS #26184, 26199, MS #26230, MS #26231, MS #26233, MS #26235, MS #26274, MS #26277, and MS #26311 were investigated covering multiple allegations including resident rights, quality of care, resident safety, staffing, grooming, safety, physical environment, nursing, infection control, neglect, and dietary services. No deficiencies were cited during this complaint investigation.
Findings
Although there were no deficiencies cited during the complaint investigation, the facility remains out of compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement due to deficiencies cited on the 08/01/24 survey.
Report Facts
Complaint investigations: 11
Inspection Report — Sep 5, 2024
Complaint Investigation
Date: Sep 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26083, MS #26172, MS #26184, MS #26199, MS #26230, MS #26231, MS #26233, MS #26235, MS #26274, MS #26277, and MS #26311, at the facility from 9/3/24 through 9/5/24. The investigations covered resident rights, quality of care, resident safety, staffing, grooming, physical environment, nursing, infection control, neglect, dietary services, and infection control.
Complaint Details
Complaint Investigation (CI) MS #26083, MS #26172, MS #26184, MS #26199, MS #26230, MS #26231, MS #26233, MS #26235, MS #26274, MS #26277, and MS #26311 were investigated for various allegations including resident rights, quality of care, resident safety, staffing, grooming, physical environment, nursing, infection control, neglect, and dietary services. No deficiencies were cited during this complaint investigation.
Findings
Although there were no deficiencies cited during the complaint investigation, the facility remains out of compliance with the requirements for participation in Medicare and Medicaid due to deficiencies cited on the 08/01/24 survey.
Report Facts
Complaints investigated: 11
Inspection Report — Aug 1, 2024
Annual Inspection
Date: Aug 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey and thirteen (13) Complaint Investigations at the facility from 7/29/24 through 8/1/24.
Complaint Details
Thirteen complaint investigations were conducted for issues including accidents and hazards related to injury, not following the plan of care, not treating pain, not notifying physician and resident representative, resident safety and potential elopement, resident rights and nursing services, staffing, neglect, maintenance of equipment, verbal abuse, and medications not given per physician orders.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies related to resident rights, restraints, respiratory care, food safety, and quality assurance.
Deficiencies (5)
F0561 - Self-determination. The facility failed to accommodate the needs of a resident dependent on staff for eating by leaving her unassisted and unfed during a meal.
F0604 - Right to be Free from Physical Restraints. The facility failed to ensure a resident was free from physical restraints by not completing an assessment and evaluation for an upper body harness vest and not ensuring it was the least restrictive device.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to ensure proper storage of respiratory equipment as tubing was not dated or bagged when not in use.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to store food and use sanitary practices properly, including unlabeled food items, exposed foods, overly ripe produce, improperly stored foods, and contaminated dry bin items.
F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt. The facility failed to sustain an effective Quality Assurance and Performance Improvement (QAPI) committee as evidenced by a re-cited deficiency related to restraints.
Report Facts
Deficiencies cited: 13
Inspection Report — Aug 1, 2024
Annual Inspection
Date: Aug 1, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility on 08/01/2024.
Findings
The facility was found to have multiple deficiencies related to resident care including failure to accommodate resident self-determination, failure to notify changes in condition, failure to implement comprehensive care plans, failure to prevent accidents during transfers, and failure to provide adequate pain management.
Deficiencies (5)
F0561 - Self-Determination. The facility failed to accommodate the needs of a resident dependent on staff for eating by interrupting feeding and leaving the resident unfed during a meal.
F0580 - Notify of Changes (Injury/Decline/Room, etc.). The facility failed to notify the physician and resident representative when a resident experienced pain after a transfer that resulted in a femoral fracture.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement care plan interventions related to pain for a resident who complained of pain after a transfer.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to ensure a resident was free of accident hazards when staff manually transferred a resident without a mechanical lift, resulting in a femur fracture.
F0697 - Pain Management. The facility failed to provide pain management to a resident who complained of pain after a manual transfer and was diagnosed with a femoral fracture.
Report Facts
Deficiencies cited: 5
Inspection Report — Jul 30, 2024
Life Safety
Date: Jul 30, 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 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 — Jul 18, 2024
Follow-Up
Date: Jul 18, 2024
Visit Reason
The State Agency conducted a follow-up revisit survey at the facility on 07/18/24 related to a complaint survey that was conducted 06/24/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommended the facility be placed back in compliance effective 07/17/24.
Inspection Report — Jun 24, 2024
Complaint Investigation
Date: Jun 24, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility from 6/14/24 through 6/24/24. Multiple complaints were investigated including Nursing Services and Accidents, Quality of Care/Treatment, Resident Abuse, and Misappropriation of Property.
Complaint Details
Complaint Investigations CI MS #25376, #25377, #25448, #25477, and #25547 were investigated. Deficiencies were cited for Nursing Services and Accidents (F656, F689), Quality of Care/Treatment (F580), and Resident Abuse reporting (F609). Some complaints had no deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified related to failure to secure medication carts and failure to implement care plans. Additional deficiencies were cited for failure to notify resident representatives of changes, failure to report alleged violations, and failure to provide adequate supervision and accident hazard prevention.
Deficiencies (4)
F0656 - The facility failed to implement a comprehensive care plan to prevent Resident #1 from accessing an unlocked medication cart and ingesting medication, placing the resident and others at risk of serious harm.
F0689 - The facility failed to ensure the resident environment was free from accident hazards and failed to provide adequate supervision, as evidenced by leaving a medication cart unlocked and unattended, allowing Resident #1 to ingest medication.
F0580 - The facility failed to notify the resident representative of a severely cognitively impaired resident's change in condition related to scratches found on the resident's chest.
F0609 - The facility failed to report an allegation of resident-to-resident non-consensual sexual contact to the State Agency for Residents #3 and #4.
Report Facts
Deficiencies cited: 4
Inspection Report — Jun 24, 2024
Complaint Investigation
Date: Jun 24, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility from 6/14/24 through 6/24/24. Multiple complaints were investigated including Nursing Services and Accidents, Quality of Care/Treatment, Resident Abuse, and Misappropriation of Property.
Complaint Details
CI MS #25376 was investigated for Nursing Services and Accidents and cited M640 at a Level IV. Other complaints investigated included Quality of Care/Treatment, Resident Abuse, and Misappropriation of Property with no deficiencies cited. Immediate Jeopardy and Substandard Quality of Care were identified related to the unlocked medication cart incident.
Findings
M0640 - The facility failed to provide a safe environment free from accident hazards by leaving a medication cart unlocked and unattended, allowing Resident #1 to access and ingest medication. Immediate Jeopardy was identified but removed after corrective actions were implemented.
Deficiencies (1)
M640 - The facility failed to provide an environment free from accident hazards and adequate supervision, as evidenced by leaving a medication cart unlocked and unattended, allowing Resident #1 to remove and ingest medication, placing the resident and others at risk of serious injury or death.
Report Facts
Deficiencies cited: 1
Complaint investigations: 5
Inspection Report — May 29, 2024
Follow-Up
Date: May 29, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/29/24 related to a complaint survey that was conducted from 4/22/24 through 4/23/24.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 5/22/24.
Inspection Report — May 29, 2024
Follow-Up
Date: May 29, 2024
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 5/29/24 related to a complaint survey that was conducted from 4/22/24 through 4/23/24.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 5/22/24.
Inspection Report — May 28, 2024
Complaint Investigation
Date: May 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24943) at the facility on 5/28/24 related to a fall.
Complaint Details
CI MS #24943 was investigated related to a fall. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation. However, the facility remains out of compliance due to deficiencies cited on the 4/23/2024 survey.
Report Facts
Deficiencies cited: 0
Inspection Report — May 28, 2024
Complaint Investigation
Date: May 28, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24943 at the facility on 5/28/24 related to a fall.
Complaint Details
CI MS#24943 was investigated related to a fall. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm; no deficiencies were cited during this investigation.
Inspection Report — Apr 23, 2024
Complaint Investigation
Date: Apr 23, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #24808 and CI MS #24809) at the facility from 4/22/24 through 4/23/24. CI MS #24808 was related to provision of a safe environment and CI MS #24809 was related to services not performed according to plan of care and physician orders.
Complaint Details
Two complaint investigations were conducted: CI MS #24808 related to provision of a safe environment, which resulted in a deficiency citation; and CI MS #24809 related to services not performed according to plan of care and physician orders, which resulted in no citations.
Findings
The facility was found not in compliance due to failure to ensure the environment was free from accident hazards and residents received adequate supervision to prevent a resident from ingesting a cleaning solution retrieved from an unsecured housekeeping cart.
Deficiencies (1)
F0689 - The facility failed to ensure the environment was free from accident hazards and residents received adequate supervision to prevent a resident with wandering behaviors from ingesting a cleaning solution retrieved from an unsecured housekeeping cart.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 23, 2024
Complaint Investigation
Date: Apr 23, 2024
Visit Reason
The State Agency conducted Complaint Investigations (CI) MS #24808 and CI MS #24809 at the facility from 4/22/24 through 4/23/24. CI MS #24808 was related to provision of a safe environment, and CI MS #24809 was related to services not performed according to plan or care and physician orders.
Complaint Details
Complaint Investigations (CI) MS #24808 and CI MS #24809 were conducted. CI MS #24808 related to safe environment resulted in a deficiency cited (M640). CI MS #24809 related to services not performed according to plan or care and physician orders had no citations.
Findings
The facility was found not in compliance with state licensure requirements and cited for M640 due to failure to ensure the environment was free from accident hazards and provide adequate supervision to prevent a resident from ingesting a cleaning solution from an unsecured housekeeping cart.
Deficiencies (1)
M640 - The facility failed to ensure the environment was free from accident hazards and residents received adequate supervision to prevent a resident with wandering behaviors from ingesting a cleaning solution retrieved from an unsecured housekeeping cart.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 11, 2024
Complaint Investigation
Date: Apr 11, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24704 and CI MS #24751) related to allegations of resident to resident abuse and resident to resident sexual abuse from 4/09/24 through 4/11/24.
Complaint Details
Complaint Investigation CI MS #24704 was related to an allegation of resident to resident abuse and CI MS #24751 was related to an allegation of resident to resident sexual abuse. Both complaints were investigated and no deficiencies were cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this investigation. The facility remains out of compliance due to deficiencies cited on the 4/3/2024 survey.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 11, 2024
Complaint Investigation
Date: Apr 11, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24704 and MS #24751 at the facility from 4/09/24 through 4/11/24. MS #24704 was investigated related to an allegation of resident to resident abuse. MS #24751 was investigated related to an allegation of resident to resident sexual abuse.
Complaint Details
Complaint Investigation MS #24704 and MS #24751 involved allegations of resident to resident abuse and sexual abuse. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited during this complaint investigation.
Inspection Report — Apr 3, 2024
Complaint Investigation
Date: Apr 3, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #24635 and CI MS #24461) related to residents not receiving their pain medication as ordered, nurse scheduling, and missing medications.
Complaint Details
Complaint Investigation (CI MS #24635 and CI MS #24461) investigated residents not receiving pain medication as ordered and missing medications. Deficiency F0697 was cited related to CI MS #24635.
Findings
The facility was found not in compliance due to failure to timely manage and treat complaints of pain for two residents when no licensed nurse was present on the unit for over six hours. Residents reported pain that was not assessed or treated timely, and staff communication failures contributed to the issue.
Deficiencies (1)
F0697 - Pain Management. The facility failed to timely manage and treat complaints of pain for two residents when no licensed nurse was present on the unit from approximately 7:00 PM on 3/22/24 until 1:47 AM on 3/23/24, resulting in untreated pain and delayed medication administration.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 3, 2024
Complaint Investigation
Date: Apr 3, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24635 and CI MS #24461, at the facility from 4/01/24 through 4/03/24. CI MS #24635 was investigated related to residents not receiving their pain medication as ordered and nurse scheduling. CI MS #24461 was investigated related to missing medications.
Complaint Details
Complaint Investigation MS #24635 was related to residents not receiving their pain medication as ordered and nurse scheduling. Complaint Investigation MS #24461 was related to missing medications. Both complaints were investigated and the facility was found in compliance with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. There were no deficiencies cited.
Inspection Report — Mar 5, 2024
Complaint Investigation
Date: Mar 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24351 at the facility from 3/04/24 through 3/05/24 regarding the allegation of verbal and physical abuse.
Complaint Details
Complaint MS #24351 investigated allegations of verbal and physical abuse. The facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Report Facts
Complaint investigations: 1
Inspection Report — Mar 5, 2024
Complaint Investigation
Date: Mar 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI) MS #24351 at the facility from 3/04/24 through 3/05/24 regarding the allegation of verbal and physical abuse.
Complaint Details
CI MS #24351 was investigated regarding the allegation of verbal and physical abuse. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements, and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
Visit Reason
The State Agency conducted complaint investigations for CI MS#23800 and CI MS#23876 related to misappropriation of resident funds at the facility from 2/5/24 to 2/6/24.
Complaint Details
Complaint investigations CI MS#23800 and CI MS#23876 were related to misappropriation of resident funds. The deficiency was substantiated as Past Non-Compliance and corrected prior to the survey.
Findings
The facility was found to be in compliance with Minimum Standards but cited for a Past Non-Compliance (PNC) under M500 for failure to protect a resident from misappropriation of funds. The Social Service Director misappropriated resident funds, falsified signatures, and was terminated. The facility implemented corrective actions prior to the survey.
Deficiencies (1)
M500 - Residents' Rights. The facility failed to protect a resident from misappropriation of funds by a Social Service Director who did not provide requested money, falsified signatures on Trust Fund Cash Request forms, and was subsequently terminated.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 6, 2024
Complaint Investigation
Date: Feb 6, 2024
Visit Reason
The State Agency conducted two complaint investigations (CI MS#23800 and CI MS#23876) related to misappropriation of resident funds at the facility from 2/5/24 to 2/6/24.
Complaint Details
CI MS#23800 and CI MS#23876 were investigated related to misappropriation of resident funds. Deficiency F0602 was cited as Past Non-Compliance and corrected prior to the survey.
Findings
F0602 - The facility failed to protect a resident from misappropriation of funds when the Social Service Director misappropriated money requested by Resident #1 on two occasions in December 2023. The facility investigated, terminated the responsible staff, implemented corrective actions, and was found in compliance at the time of the survey.
Deficiencies (1)
F0602 - The facility failed to protect a resident from misappropriation of funds when the Social Service Director misappropriated money requested by Resident #1 on two occasions in December 2023. The facility investigated, terminated the responsible staff, and implemented corrective actions.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 12, 2023
Follow-Up
Date: Sep 12, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 9/12/23 related to an annual recertification survey that was conducted 7/24/23 through 7/27/23.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement and recommends the facility be placed back in compliance effective 9/8/23.
Inspection Report — Sep 12, 2023
Follow-Up
Date: Sep 12, 2023
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 9/12/23 related to an annual recertification survey that was conducted from 7/24/23 through 7/27/23.
Findings
The SA found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 9/8/23.
Inspection Report — Sep 12, 2023
Annual Inspection
Date: Sep 12, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 7/24/23 through 7/27/23.
Findings
The facility was found in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and no deficiencies were cited.
Inspection Report — Aug 7, 2023
Routine
Date: Aug 7, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as specified by CMS and CDC.
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, which has the potential to cause 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 — Jul 31, 2023
Life Safety
Date: Jul 31, 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 — Jul 27, 2023
Annual Inspection
Date: Jul 27, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility on 7/24/2023 through 7/27/2023. During the survey, the facility was not in compliance with the Mississippi Regulation for Minimum Standards for Institutions for the Aged or Infirm and cited M640 and M1570.
Findings
The facility was found not in compliance with Mississippi minimum standards, citing two deficiencies related to accident prevention and infection control.
Deficiencies (2)
M640 - The facility failed to provide care to protect vulnerable residents from falls resulting in injury for one resident who slid out of bed during peri care without the required two-person assist.
M1570 - The facility failed to consistently implement infection control measures, including improper hand hygiene, contamination of linens and medications, and incomplete bathing, affecting two residents.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 27, 2023
Annual Inspection
Date: Jul 27, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility on 7/24/23 through 7/27/23. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid.
Findings
The facility was found not in compliance with multiple requirements including resident privacy, restraint use, assessment accuracy, care planning, fall prevention, incontinent care, bedrail use, psychotropic medication management, infection control, and immunization education and documentation.
Deficiencies (10)
F0583 - Personal privacy/confidentiality of records. The facility failed to ensure a resident's privacy by posting clinical care signage on the resident's wall for one of 22 residents reviewed.
F0604 - Right to be free from physical restraints. The facility failed to obtain a physician order for the use of a restraint for one of three residents reviewed for restraints.
F0641 - Accuracy of assessments. The facility failed to accurately code the discharge Minimum Data Set assessment for one of two sampled closed records.
F0657 - Care plan timing and revision. The facility failed to revise a comprehensive care plan regarding interventions to prevent a dependent resident from falling for one of three residents reviewed for falls.
F0689 - Free of accident hazards/supervision/devices. The facility failed to provide care to protect a vulnerable resident from falls resulting in injury for one of three residents reviewed for falls.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to provide appropriate care and services to a resident who was incontinent to prevent urinary tract infections for one of three residents reviewed for incontinent care.
F0700 - Bedrails. The facility failed to ensure residents and/or family were educated on the risk of bedrails and failed to evaluate and document alternatives prior to the application and use of bed rails for one of 22 sampled residents.
F0758 - Free from unnecessary psychotropic meds/PRN use. The facility failed to ensure as needed psychotropic medications were limited to 14 days unless a longer timeframe was documented appropriate by the attending physician for one of 22 residents reviewed.
F0880 - Infection prevention & control. The facility failed to ensure infection control measures were consistently implemented to prevent infection transmission for two of 22 sampled residents.
F0883 - Influenza and pneumococcal immunizations. The facility failed to ensure that the resident or the resident's representative received education regarding influenza and pneumococcal immunizations and were given the opportunity to receive or refuse the immunizations for 20 of 25 residents reviewed.
Report Facts
Deficiencies cited: 10
Inspection Report — May 30, 2023
Complaint Investigation
Date: May 30, 2023
Visit Reason
On 05/30/23 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 04/05/23. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
Complaint CI MS#26995 was investigated through a desk review; the facility was found in compliance and no deficiencies were cited.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 05/19/23. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — May 26, 2023
Complaint Investigation
Date: May 26, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints, MS #21577 and MS #21541 from 5/25/23 through 5/26/23. The investigation related to abuse by facility staff and abuse by another resident.
Complaint Details
Complaint investigation MS #21577 and MS #21541 related to abuse by facility staff and abuse by another resident; no deficiencies were cited during this investigation.
Findings
No deficiencies were cited during this complaint investigation. The facility remains out of compliance due to deficiencies cited on a prior complaint investigation dated 4/5/23.
Inspection Report — May 26, 2023
Complaint Investigation
Date: May 26, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints, MS #21577 and MS #21541 from 5/25/23 through 5/26/23. The SA investigated MS #21577 related to abuse by facility staff and MS #21541 for abuse related to abuse by another resident.
Complaint Details
Complaint numbers MS #21577 and MS #21541 were investigated; no deficiencies were cited and the complaints were not substantiated during this investigation.
Findings
No deficiencies were cited during this complaint investigation. The facility remains out of compliance due to deficiencies cited on the 4/5/23 complaint investigation.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 5, 2023
Complaint Investigation
Date: Apr 5, 2023
Visit Reason
The State Agency conducted Complaint Investigations at the facility for three complaints, CI MS #20667, CI MS #21059, and CI MS #21136 from 3/30/23 through 4/05/23. The SA investigated CI MS #20667 for Injury of Unknown Origin and did not cite any deficiencies. The SA investigated CI MS #21059 for Resident Rights, Assessment/Monitoring and Quality of Care/Treatment and cited M500. The SA investigated CI MS #21136 for Personnel screening for employment eligibility and cited M460 Criminal History Record Checks.
Complaint Details
Complaint investigations CI MS #20667, CI MS #21059, and CI MS #21136 were conducted. CI MS #20667 for Injury of Unknown Origin was not substantiated with deficiencies. CI MS #21059 for Resident Rights, Assessment/Monitoring and Quality of Care/Treatment was substantiated with deficiency M500 cited. CI MS #21136 for Personnel screening for employment eligibility was substantiated with deficiency M460 cited.
Findings
The facility was found not in compliance with state licensure requirements. Deficiency M460 was cited for failure to perform a thorough investigation of a Certified Nursing Assistant's criminal history record check, resulting in continued employment despite disqualifying events. Deficiency M500 was cited for failure to ensure a resident's right to reasonable accommodation of needs and preferences, including inappropriate room transfer causing disorientation and decreased mobility for Resident #1.
Deficiencies (2)
M460 - Criminal History Record Checks. The facility failed to thoroughly investigate the criminal history of a Certified Nursing Assistant after notification from the state licensure board, resulting in continued employment despite disqualifying events.
M500 - Residents' Rights. The facility failed to ensure a resident's right to reasonable accommodation of needs and preferences by transferring Resident #1 from a private to a semi-private room without proper care plan review or consideration of the resident's cognitive, visual, and hearing impairments, causing disorientation and decreased mobility.
Report Facts
Deficiencies cited: 2
Complaints investigated: 3
Inspection Report — Apr 5, 2023
Complaint Investigation
Date: Apr 5, 2023
Visit Reason
The State Agency conducted Complaint Investigations (CI) at the facility for three complaints, CI MS #20667, CI MS #21059, and CI MS #21136 from 3/30/23 through 4/05/23. The SA investigated CI MS #20667 for Injury of Unknown Origin and did not cite any deficiencies. The SA investigated CI MS #21059 for Resident Rights, Assessment/Monitoring and Quality of Care/Treatment and cited F656 and F558. The SA investigated CI MS #21136 for Administration/Personnel related to Personnel Screening for Employment Eligibility and cited F606.
Complaint Details
Complaint investigations were conducted for CI MS #20667 (no deficiencies cited), CI MS #21059 (deficiencies cited for Resident Rights, Assessment/Monitoring, and Quality of Care/Treatment), and CI MS #21136 (deficiency cited for Personnel Screening).
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies included failure to accommodate resident needs and preferences related to room assignment and care planning for Resident #1, failure to develop and implement a comprehensive care plan consistent with resident needs, and failure to properly investigate and act on a staff member's disqualifying criminal history.
Deficiencies (3)
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to ensure a resident's right to reside and receive services with reasonable accommodation of needs and preferences, moving Resident #1 from a private to a semi-private room without proper care plan review or consent, resulting in disorientation and decreased mobility.
F0606 - Not Employ/Engage Staff w/ Adverse Actions. The facility failed to perform a thorough investigation of a Certified Nurse Assistant's criminal history after notification from the state licensure board, resulting in continued employment despite disqualifying events until termination on 3/28/2023.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to provide interventions identified in the comprehensive care plan for Resident #1, including failure to review the care plan prior to room transfer and failure to accommodate the resident's cognitive, visual, and mobility needs.
Report Facts
Deficiencies cited: 3
Complaints investigated: 3
Inspection Report — Jan 5, 2023
Complaint Investigation
Date: Jan 5, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation, CI #19867 at the facility on 01/05/23.
Complaint Details
Complaint Investigation CI #19867 was not substantiated for misappropriation of property and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Inspection Report — Jan 5, 2023
Complaint Investigation
Date: Jan 5, 2023
Visit Reason
The State Agency (SA) conducted a Complaint Investigation, CI #19867 at the facility on 01/05/23.
Complaint Details
Complaint CI #19867 involved an allegation of misappropriation of property which was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Nov 15, 2022
Complaint Investigation
Date: Nov 15, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19762, MS #19557, and MS #19445 at the facility from 11/14/22 through 11/15/22.
Complaint Details
Complaint Investigation MS #19762, MS #19557, and MS #19445 regarding Quality of Care related to physician orders, incontinent care, following orders, and answering call bells were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited.
Inspection Report — Nov 15, 2022
Complaint Investigation
Date: Nov 15, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19762, MS #19557, and MS #19445 at the facility from 11/14/22 through 11/15/22.
Complaint Details
Complaint numbers MS #19762, MS #19557, and MS #19445 were investigated regarding quality of care issues related to physician orders, incontinent care, following orders, and answering call bells. The complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited related to the complaints investigated.
Report Facts
Complaints investigated: 3
Inspection Report — Jul 15, 2022
Complaint Investigation
Date: Jul 15, 2022
Visit Reason
The State Agency conducted three Complaint Investigations (CI), MS #18771, MS #18663, and MS #18662 at the facility from 7/14/22 to 7/15/22.
Complaint Details
Three complaint investigations were conducted: MS #18771 for neglect, resident safety, and resident with weight loss was not substantiated; MS #18663 for resident rights and abuse was not substantiated; MS #18662 for pressure sores, responsible party notification, resident assessment, care per physician's order, and resident left soiled/wet was not substantiated.
Findings
During the survey, the State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements and there were no deficiencies cited.
Report Facts
Complaint Investigations: 3
Inspection Report — Jul 15, 2022
Complaint Investigation
Date: Jul 15, 2022
Visit Reason
The State Agency conducted three Complaint Investigations (CI), MS #18771, MS #18663, and MS #18662 at the facility from 7/14/22 to 7/15/22.
Complaint Details
Three complaint investigations were conducted: MS #18771 was not substantiated for neglect, resident safety, and resident with weight loss; MS #18663 was not substantiated for resident rights and abuse; MS #18662 was not substantiated for pressure sores, responsible party notification, resident assessment, care per physician's order, and resident left soiled/wet for extended periods.
Findings
The facility was found in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.
Report Facts
Complaint Investigations: 3
Inspection Report — Jul 15, 2021
Complaint Investigation
Date: Jul 15, 2021
Visit Reason
The State Agency conducted the Complaint Investigation (CI) #17887 from 7/15/21 through 7/15/21.
Complaint Details
Complaint Investigation CI #17887 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The State Agency determined the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, State Licensure requirements.
Report Facts
Complaint count: 1
Inspection Report — Jul 15, 2021
Complaint Investigation
Date: Jul 15, 2021
Visit Reason
The State Agency (SA) conducted a complaint survey for Complaint Investigation (CI) #17887 from 7/15/21 through 7/15/21.
Complaint Details
Complaint Investigation (CI) #17887 was not substantiated; no deficiencies were cited.
Findings
During the survey, the SA did not substantiate the complaint and found the facility in compliance.
Report Facts
Complaint Investigations: 1
Inspection Report — Dec 21, 2020
Routine
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/21/20.
Findings
The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Dec 21, 2020
Routine
Date: Dec 21, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/21/20.
Findings
The facility was found to be in compliance with Medicaid and Medicare requirements related to E-0024 (b)(6).
Inspection Report — Nov 30, 2020
Routine
Date: Nov 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 11/30/20.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Nov 30, 2020
Routine
Date: Nov 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 11/30/20. The facility was found to be in compliance with infection control regulations and has implemented the Centers for Medicare and Medicaid (CMS) and the Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Jun 2, 2020
Routine
Date: Jun 2, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/2/20. 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.
Findings
The facility was found to be in compliance with infection control regulations and no deficiencies were cited.
Inspection Report — Jan 16, 2020
Date: Jan 16, 2020
Visit Reason
The State Agency (SA) conducted a licensure survey from 1/13/2020 through 1/16/2020. During the survey, the SA determined the facility was not in compliance with the Minimum Standards of the Institutions for the Aged and Infirmed. The SA cited deficiencies at M715 and M945.
Findings
Two deficiencies were cited related to medication labeling and food storage. The facility failed to date opened insulin pens and failed to label and remove expired food items in the kitchen.
Deficiencies (2)
M715 - The facility failed to date Resident #37's insulin pen at the time it was opened as required by policy, risking medication errors.
M945 - The facility failed to label opened food items, remove expired food, and prevent contamination by leaving a scoop in the sugar bin during kitchen inspections.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 16, 2020
Annual Inspection
Date: Jan 16, 2020
Visit Reason
The State Agency (SA) conducted an annual survey from 1/13/2020 through 1/16/2020. During the survey, the SA determined the facility was not in compliance with the Medicare and Medicaid Requirements for participation.
Findings
The survey identified deficiencies related to Medicare Non-Coverage notices, accuracy of Minimum Data Set assessments, medication labeling and storage, and food safety practices. The facility failed to provide required Medicare Non-Coverage notices to three residents, inaccurately coded assessments for two residents, failed to date an opened insulin pen, and failed to properly label and store food items in the kitchen.
Deficiencies (4)
F0582 - Medicaid/Medicare Coverage/Liability Notice. The facility failed to provide a Notice of Medicare Non-Coverage at discharge for three residents receiving Medicare skilled services.
F0641 - Accuracy of Assessments. The facility failed to accurately code Minimum Data Set assessments for two residents regarding mental illness and antipsychotic medication use.
F0761 - Label/Store Drugs and Biologicals. The facility failed to date an opened insulin pen for one resident.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to label opened food items, remove expired food, and remove a scoop left in the sugar container in the kitchen.
Report Facts
Deficiencies cited: 4
Inspection Report — Sep 1, 2019
Complaint Investigation
Date: Sep 1, 2019
Visit Reason
A complaint investigation was conducted on September 10, 2019 in the facility.
Complaint Details
Complaint investigation CI MS#15727 & CI MS#15849 was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Mar 7, 2019
Annual Inspection
Date: Mar 7, 2019
Visit Reason
A standard survey was conducted at Edgewood Health and Rehab from March 4, 2019 through March 7, 2019. The standard survey revealed that the facility was not in substantial compliance with Medicare/Medicaid requirements of participation.
Findings
The facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed, potentially affecting 106 of 117 residents who received meals in the facility.
Deficiencies (1)
F0801 - Qualified Dietary Staff. The facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed, potentially affecting 106 of 117 residents who received meals in the facility.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 7, 2019
Annual Inspection
Date: Mar 7, 2019
Visit Reason
The State Agency conducted an annual licensure survey at the facility.
Findings
The facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed, potentially affecting 106 of 117 residents who received meals.
Deficiencies (1)
M810 - The facility failed to ensure a Certified Dietary Manager with appropriate credentials was employed, which could affect the nutritional services provided to residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Mar 1, 2019
Complaint Investigation
Date: Mar 1, 2019
Visit Reason
A complaint investigation was conducted on March 1, 2019 in the facility.
Complaint Details
CI MS#15685: A complaint investigation was conducted and was unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
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