Inspection Reports for Glen Oaks Nursing Center
55 Suzanne Street, Lucedale, MS 39452, MS, 39452
Back to Facility ProfileDeficiencies per Year
4
3
2
1
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 36
Capacity: 45
Deficiencies: 0
Dec 18, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to resident abuse at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #2653208 was related to resident abuse and was found to be unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 18, 2025
Visit Reason
The State Agency conducted a complaint investigation related to resident abuse at the facility.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Complaint Investigation MS #2653208 was related to resident abuse and was found to be unsubstantiated with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 15, 2025
Visit Reason
The State Agency conducted a desk review on 04/15/25 of information related to the annual survey conducted on 03/25/25 to verify correction of deficient practices.
Findings
The facility provided information confirming measures were put in place to correct deficient practices and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 04/11/25.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 11, 2025
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Census: 44
Capacity: 45
Deficiencies: 0
Mar 27, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/24/2025 through 03/27/2025 to assess compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found to be in compliance with all requirements and no deficiencies were cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 27, 2025
Visit Reason
The State Agency conducted an Annual Recertification Survey at the facility from 3/24/25 to 3/27/25 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with all applicable standards and no deficiencies were cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 25, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no Life Safety Code deficiencies cited during the survey.
Inspection Report
Life Safety
Census: 45
Deficiencies: 1
Mar 25, 2025
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code (LSC) requirements, specifically focusing on the fire alarm system installation and maintenance.
Findings
The facility failed to maintain a complete manual fire alarm system as required by NFPA 101 section 9.6.4, with a hardwired smoke/heat detector removed and not replaced in the North Hall Janitor's Closet. This deficiency affected one of five smoke compartments and 11 of 45 residents.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to maintain a complete manual fire alarm system; a hardwired smoke/heat detector was removed and not replaced in the North Hall Janitor's Closet. | SS=D |
Report Facts
Residents affected: 11
Smoke compartments affected: 1
Total residents present: 45
Total smoke compartments: 5
Inspection Report
Annual Inspection
Census: 39
Capacity: 45
Deficiencies: 2
Nov 8, 2023
Visit Reason
The State Agency conducted an annual recertification survey at Glen Oaks Nursing Center from 11/06/2023 through 11/08/2023 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with requirements related to resident self-determination, specifically regarding smoking policies limiting residents to one cigarette per smoke break and two smoke breaks per day, and food safety violations related to improper labeling and storage of food items in the kitchen.
Severity Breakdown
SS=E: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure residents' right to make choices significant to them by not accommodating smoking preferences beyond one cigarette per break or two smoke breaks per day for three sampled residents. | SS=E |
| Failure to store food in accordance with professional food service safety standards, including food items not dated with use-by dates, lacking identifying labels, and opened/exposed food items improperly handled. | SS=F |
Report Facts
Census: 39
Total licensed capacity: 45
Number of residents who smoke: 5
Number of smoke breaks allowed daily: 2
Number of cigarettes allowed per smoke break: 1
Number of kitchen observations: 3
Number of food safety in-services per month: 3
Number of smoke breaks pre-COVID: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | CNA | Assisted residents during smoke breaks and confirmed smoking policy |
| Certified Nursing Assistant #3 | CNA | Assisted with smoke breaks and confirmed smoking policy |
| Administrator | Confirmed smoking policy decisions and admission paperwork details | |
| Dietary Manager | Dietary Manager | Conducted kitchen inspections and oversaw food labeling and safety |
| Cook #1 | Cook | Responsible for labeling opened food items and received food safety in-service training |
Inspection Report
Annual Inspection
Deficiencies: 2
Nov 8, 2023
Visit Reason
The State Agency conducted an annual recertification survey at Glen Oaks Nursing Center from 11/06/2023 through 11/08/2023 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance with residents' rights related to smoking preferences, limiting residents to one cigarette per smoke break despite requests for more, and food safety violations including improper labeling and dating of food items in the kitchen.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure residents' rights to make choices significant to them, specifically accommodating smoking preferences beyond one cigarette per break for three sampled residents. | Level II |
| Failed to store food in accordance with food safety standards, including food items not dated with use-by dates, unlabeled food items, and opened/exposed food items improperly handled. | Level II |
Report Facts
Number of sampled residents with smoking deficiency: 3
Number of kitchen observations with food labeling deficiencies: 1
Number of residents who currently smoke: 5
Number of smoke breaks allowed daily: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Assisted residents during smoke breaks and confirmed smoking policy |
| CNA #3 | Certified Nursing Assistant | Assisted with smoke breaks and confirmed smoking policy |
| Cook #1 | Cook | Responsible for labeling opened food items and confirmed food safety training |
| Administrator | Confirmed smoking policy decisions and food safety expectations | |
| Dietary Manager | Dietary Manager | Responsible for food storage and labeling oversight |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 8, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 11/08/23 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 12/12/23.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 8, 2023
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 11/08/23 to verify the facility's compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective measures were implemented to address deficiencies, and the State Agency recommended the facility be placed back in compliance effective 12/12/23.
Inspection Report
Life Safety
Deficiencies: 0
Nov 7, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.
Inspection Report
Routine
Deficiencies: 0
Nov 7, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 15, 2021
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements as of the survey date.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 9, 2021
Visit Reason
The State Agency conducted an annual survey with a complaint investigation (CI: 17933) from 2021-12-07 to 2021-12-09.
Findings
The complaint investigation was not substantiated and no deficiencies were cited. The facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Complaint Details
Complaint investigation CI: 17933 was not substantiated for poor quality of care, falls, poor dental care, pain, and lost personal belongings.
Inspection Report
Annual Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Dec 9, 2021
Visit Reason
The State Agency conducted an annual recertification along with a complaint investigation from 12/07/21 to 12/09/21.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements. The complaint was not substantiated and no citations were issued related to the complaint.
Complaint Details
Complaint MS #17933 was investigated and not substantiated for poor quality of care, falls, poor dental care, pain, and lost personal belongings.
Inspection Report
Annual Inspection
Deficiencies: 0
Dec 9, 2021
Visit Reason
The State Agency conducted an annual survey with a complaint investigation (CI: 17933) from 2021-12-07 to 2021-12-09.
Findings
The complaint investigation was not substantiated for poor quality of care, falls, poor dental care, pain, and lost personal belongings. The facility was in compliance with Minimum Standards of Operation and state licensure requirements with no deficiencies cited.
Complaint Details
Complaint investigation CI: 17933 was not substantiated; no citations related to the complaint.
Report Facts
Complaint Investigation ID: 17933
Inspection Report
Annual Inspection
Census: 40
Capacity: 60
Deficiencies: 0
Dec 9, 2021
Visit Reason
The State Agency conducted an annual recertification along with a complaint investigation from 12/07/21 to 12/09/21.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaint was not substantiated and no citations were issued related to the complaint.
Complaint Details
Complaint MS #17933 was investigated and not substantiated for poor quality of care, falls, poor dental care, pain, and loss of personal belongings.
Inspection Report
Life Safety
Deficiencies: 0
Dec 9, 2021
Visit Reason
The facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider to assess compliance with the 2012 Edition of the Life Safety Code (LSC).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA). No LSC deficiencies were cited during this survey.
Inspection Report
Abbreviated Survey
Census: 36
Capacity: 60
Deficiencies: 0
Sep 21, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 9/21/20 to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 36
Capacity: 60
Deficiencies: 0
Sep 21, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Census: 38
Capacity: 60
Deficiencies: 0
Aug 20, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey to assess the facility's compliance with infection control regulations and implementation of recommended practices by CMS and CDC to prepare for COVID-19.
Findings
The facility was found in compliance with infection control regulations and had implemented the recommended practices by CMS and CDC for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 38
Capacity: 60
Deficiencies: 0
Aug 20, 2020
Visit Reason
The State Agency conducted a COVID-19 Focused Infection Control Survey to assess the facility's compliance with infection control regulations and implementation of recommended practices by CMS and CDC to prepare for COVID-19.
Findings
The facility was found in compliance with infection control regulations and has implemented the recommended practices by CMS and CDC for COVID-19 preparation.
Inspection Report
Routine
Census: 47
Capacity: 60
Deficiencies: 0
May 20, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Report Facts
Census: 47
Total licensed capacity: 60
Inspection Report
Routine
Census: 47
Capacity: 60
Deficiencies: 0
May 20, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 47
Capacity: 60
Deficiencies: 0
May 16, 2019
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 5/14/2019 to 5/16/2019 to determine compliance with Medicare and Medicaid requirements.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Census: 47
Capacity: 60
Deficiencies: 0
May 16, 2019
Visit Reason
The State Survey Agency conducted an annual recertification survey at the facility from 2019-05-14 to 2019-05-16 to assess compliance with the Minimum Standards for the Aged or Infirm requirements for participation.
Findings
The facility was found to be in compliance with all applicable standards and no deficiencies were cited during the survey.
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