Inspection Reports for
Grand Trace Health Care and Rehabilitation
555 John R. Junkin Drive, Natchez, MS, 39120
Back to Facility Profile62 Reports
Inspection Report — Jun 29, 2026
Complaint Investigation
Date: Jun 29, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #2994480) related to quality of care.
Complaint Details
CI MS #2994480 was investigated related to quality of care. The SA determined the facility was in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jun 29, 2026
Complaint Investigation
Date: Jun 29, 2026
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI MS #2994480) at the facility on 6/29/26 related to quality of care.
Complaint Details
CI MS #2994480 was investigated related to quality of care. The SA determined the facility was in compliance with no deficiencies cited.
Findings
During the survey, the SA 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: 1
Inspection Report — May 11, 2026
Complaint Investigation
Date: May 11, 2026
Visit Reason
On 05/11/26 the State Agency conducted a desk review of information related to the complaint survey completed on 04/01/26. The facility confirmed corrective measures were implemented and sustained compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS# not explicitly stated. The complaint survey was completed on 04/01/26. 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 05/08/26. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 1, 2026
Complaint Investigation
Date: Apr 1, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #2960853 and CI MS #2787379) at the facility from 3/30/26 through 4/1/26. The survey investigated nursing services, quality of care and accidents.
Complaint Details
Complaint investigations CI MS #2960853 and CI MS #2787379 were conducted. Deficiencies were cited related to CI MS #2787379; no citations were related to CI MS #2960853.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for deficiencies related to pressure ulcer treatment, incontinent care, and infection prevention and control.
Deficiencies (3)
F0686 - Treatment and services to prevent and heal pressure ulcers were inadequate as the facility failed to provide necessary wound care to promote healing and prevent infection for one resident with pressure injuries.
F0690 - The facility failed to ensure proper infection control techniques during incontinent care for one resident, including improper use of wipes leading to potential infection risk.
F0880 - The facility failed to implement Enhanced Barrier Precautions during wound care, as a nurse provided care without wearing a gown, risking spread of infection.
Report Facts
Deficiencies cited: 3
Inspection Report — Apr 1, 2026
Complaint Investigation
Date: Apr 1, 2026
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #2960853 and CI MS #2787379) at the facility from 3/30/26 through 4/1/26, investigating nursing services, quality of care, and accidents.
Complaint Details
Complaint Investigations CI MS #2960853 and CI MS #2787379 were conducted. Deficiencies were cited related to CI MS #2787379; no citations were related to CI MS #2960853.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, citing deficiencies M0615, M0620, and M1570 related to CI MS #2787379. No citations were related to CI MS #2960853.
Deficiencies (3)
M0615 - The facility failed to provide necessary treatment and services to promote healing and prevent infection of pressure ulcers for one of three sampled residents with pressure injuries, as evidenced by improper wound care technique by nursing staff.
M0620 - The facility failed to ensure staff provided incontinent care using proper infection control techniques for one of six sampled residents, including improper wiping technique that could lead to urinary tract infection.
M1570 - The facility failed to prevent the potential spread of infections by not implementing Enhanced Barrier Precautions during wound care for one of three sampled residents with pressure injuries, including failure of nursing staff to wear gowns as required.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 31, 2026
Follow-Up
Date: Mar 31, 2026
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 3/30/26 through 3/31/26 related to the complaint survey that was conducted on 2/17/26.
Complaint Details
Complaint survey conducted on 2/17/26; the follow-up survey found the facility in compliance.
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 3/19/26.
Inspection Report — Mar 31, 2026
Follow-Up
Date: Mar 31, 2026
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 03/30/2026 through 03/31/2026 related to a complaint survey that was conducted on 02/17/2026.
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 into compliance effective 03/19/2026.
Inspection Report — Feb 17, 2026
Complaint Investigation
Date: Feb 17, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2742521, CI MS #2742362, and CI MS #2714479) at the facility on 2/17/26. CI MS #2742521 was related to physical environment and infection control regarding pests and quality of care and neglect. CI MS #2742362 was related to physical environment for facility cleanliness and pests, quality of care and neglect. CI MS #2714479 was related to residents’ rights and neglect.
Complaint Details
Three complaint investigations were conducted: CI MS #2742521 related to physical environment and infection control regarding pests and quality of care and neglect; CI MS #2742362 related to physical environment cleanliness, pests, quality of care and neglect with no citations; and CI MS #2714479 related to residents’ rights and neglect, which resulted in citation of F550.
Findings
The facility was found not in compliance due to failure to ensure a resident's right to receive visitors of her choosing. One deficiency was cited related to resident rights.
Deficiencies (1)
F0550 - Resident Rights/Exercise of Rights. The facility failed to ensure Resident #1's right to receive visitors of her choosing when staff prohibited a friend from visiting in January 2026 and did not notify the resident of the visitor's presence.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 17, 2026
Complaint Investigation
Date: Feb 17, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2742521, CI MS #2742362, and CI MS #2714479) at the facility on 2/17/26. CI MS #2742521 and CI MS #2742362 were investigated related to physical environment and infection control regarding pests and quality of care and neglect, with no citations related to those complaints. CI MS #2714479 was investigated related to residents’ rights and neglect and resulted in citation M500.
Complaint Details
Complaint investigation CI MS #2714479 was related to residents’ rights and neglect and resulted in citation M500. Complaints CI MS #2742521 and CI MS #2742362 related to physical environment and infection control regarding pests and quality of care and neglect were investigated with no citations.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm due to failure to ensure a resident's right to receive visitors of her choosing. Resident #1 was denied visitation by a friend on one occasion in January 2026, contrary to facility policy and resident rights.
Deficiencies (1)
M500 - The facility failed to ensure Resident #1's right to receive visitors of her choosing, as staff prohibited a friend from visiting in January 2026 and did not notify the resident of the visitor's presence.
Report Facts
Complaints investigated: 3
Deficiencies cited: 1
Inspection Report — Nov 14, 2025
Complaint Investigation
Date: Nov 14, 2025
Visit Reason
On 11/14/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/27/25. The facility confirmed it had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint investigation completed on 08/27/25; 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 10/7/25. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 27, 2025
Complaint Investigation
Date: Aug 27, 2025
Visit Reason
The State Agency conducted Complaint Investigations (CIs), MS #499967, CI MS #499969, and CI MS #2568663, and a Facility Reported Incident (FRI), MS #499968, at the facility from 8/25/25 through 8/27/25. CI MS #499967 was investigated for staff allegedly harassing a resident regarding his Social Security income and influencing fund distribution. CI MS #499969 was investigated for alleged fraudulent billing and harassment regarding payment of charges. CI MS #2568663 was investigated for evaluating and diagnosing a resident with dementia and F842 was cited. FRI MS #499968 was investigated for abuse with no deficiencies cited.
Complaint Details
Complaint Investigations MS #499967 and MS #499969 involved allegations of staff harassment and fraudulent billing but resulted in no citations. CI MS #2568663 involved evaluation and diagnosis of a resident with dementia and resulted in citation F842. Facility Reported Incident MS #499968 involved abuse allegations with no deficiencies cited.
Findings
F0842 - The facility failed to maintain accurate medical records for Resident #1, who was admitted with schizoaffective disorder-bipolar type but was documented in error as having dementia. This inaccurate documentation led to concerns about appropriate assessment and diagnosis, although the primary healthcare provider confirmed that treatment would not have changed. Facility leadership acknowledged the documentation errors and the importance of accurate records for patient-centered care.
Deficiencies (1)
F0842 - Resident records were not accurately documented; the facility failed to maintain medical records in accordance with accepted professional standards for one sampled resident, resulting in inaccurate documentation of a dementia diagnosis.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 27, 2025
Complaint Investigation
Date: Aug 27, 2025
Visit Reason
The inspection was conducted due to a complaint alleging that Resident #1 did not receive appropriate assessment, diagnostic tests, or diagnosis while at the facility, resulting in inappropriate care for her actual condition.
Complaint Details
The complaint alleged that Resident #1 did not receive appropriate assessment, diagnostic tests, or diagnosis while at the facility, leading to inappropriate care. The complainant believed Resident #1 also suffered from frontotemporal dementia, which was not diagnosed during the stay. Interviews with staff confirmed inaccurate documentation of dementia and that care was planned based on impaired cognition.
Findings
The facility failed to maintain accurate medical records for Resident #1, specifically regarding the diagnosis of dementia. Documentation inaccurately listed dementia despite the resident being admitted with schizoaffective disorder-bipolar type. Interviews confirmed the inaccurate documentation and that care was provided based on impaired cognition rather than dementia diagnosis.
Deficiencies (1)
Failed to maintain medical records on each resident in accordance with accepted professional standards, specifically inaccurate documentation of dementia diagnosis for Resident #1.
Report Facts
Sampled residents: 8
Residents affected: 1
Dates of Social Service Progress Reviews: 7/07/2023, 2/02/2024, 6/11/2024
Admission diagnosis onset date: 11/02/2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed inaccurate documentation of dementia diagnosis and importance of accurate resident diagnoses |
| Executive Director | Executive Director (ED) | Confirmed inaccurate documentation of dementia diagnosis and importance of accurate resident diagnoses |
| Primary healthcare provider | Physician | Confirmed admission diagnosis and care planning based on impaired cognition; discussed diagnostic imaging and treatment |
| Social Service Director | Former Social Service Director (SSD) | Acknowledged documenting dementia diagnosis in error and lack of review of actual medical records |
Inspection Report — May 2, 2025
Follow-Up
Date: May 2, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 5/1/25 through 5/2/25 related to an annual recertification and complaint survey that was conducted from 3/24/25 through 3/27/25.
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 4/24/25.
Inspection Report — May 2, 2025
Follow-Up
Date: May 2, 2025
Visit Reason
The State Agency conducted a follow-up revisit at the facility from 5/1/25 through 5/2/25 related to an annual recertification and complaint survey that was conducted from 3/24/25 through 3/27/25.
Findings
The State Agency determined the facility was in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 4/24/25.
Inspection Report — Apr 30, 2025
Complaint Investigation
Date: Apr 30, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28653 and CI MS #28552) at the facility on 4/30/25. CI MS #28653 was related to physical environment and quality of care, and CI MS #28552 was regarding quality of care-staffing.
Complaint Details
Two complaint investigations were conducted: CI MS #28653 related to physical environment and quality of care, and CI MS #28552 regarding quality of care-staffing. The facility was found in compliance with no deficiencies cited during this survey.
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. However, the facility remains out of compliance due to deficiencies cited on the 03/27/2025 survey.
Inspection Report — Apr 30, 2025
Complaint Investigation
Date: Apr 30, 2025
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #28653 and CI MS #28552) at the facility on 4/30/25. CI MS #28653 was related to physical environment and quality of care, and CI MS #28552 was regarding quality of care-staffing.
Complaint Details
Two complaint investigations were conducted: CI MS #28653 concerning physical environment and quality of care, and CI MS #28552 regarding quality of care-staffing. Both complaints were investigated and no deficiencies were 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 survey.
Report Facts
Complaint Investigations: 2
Inspection Report — Mar 27, 2025
Annual Inspection
Date: Mar 27, 2025
Visit Reason
The State Agency (SA) conducted an Annual Recertification Survey along with three (3) Complaint Investigations (CI MS #28232, CI MS #28176, and CI MS #28146), at the facility from 3/24/25 through 3/27/25.
Complaint Details
The survey included three complaint investigations: CI MS #28232 for physical environment, misappropriation of property, and client rights; CI MS #28176 for quality of care, client neglect, physical environment; and CI MS #28146 for quality care treatment and physical environment. Deficiencies were cited in all complaint investigations.
Findings
The facility was found not in compliance with multiple requirements including safe environment, comprehensive assessments, care planning, quality of care, infection control, and staffing. Deficiencies were cited related to cleanliness, missing personal belongings, incomplete assessments, inaccurate MDS coding, inadequate wound care, supply shortages, pain management, and infection prevention.
Deficiencies (12)
F0584 - Safe/clean/homelike environment. The facility failed to ensure residents' rights to a clean, safe, homelike environment for three residents as evidenced by unclean floors and bathrooms and improper handling of personal belongings.
F0637 - Comprehensive Assessment After Significant Change. The facility failed to complete a Significant Change in Status Assessment after a resident returned from the hospital with a newly inserted PEG tube and a Stage IV sacral pressure ulcer.
F0641 - Accuracy of Assessments. The facility failed to accurately complete the Minimum Data Set resident assessment, including incorrect coding of enteral feeding and omission of schizophrenia diagnosis for two residents.
F0645 - PASARR Screening for MD & ID. The facility failed to complete an accurate Pre-Admission Screening and Resident Review (PASRR) Level II for a resident with schizophrenia and failed to submit a status change after the resident was admitted to an inpatient behavioral health unit.
F0646 - MD/ID Significant Change Notification. The facility failed to notify the state mental health authority promptly after a significant change in the mental or physical condition of a resident with mental illness.
F0655 - Baseline Care Plan. The facility failed to implement the baseline care plan related to pain medications for a resident, resulting in unaddressed pain and lack of adequate symptom control.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement comprehensive, resident-centered care plan interventions for a resident with pressure ulcers, including failure to follow wound care orders and manage pain during treatment.
F0684 - Quality of Care. The facility failed to ensure adequate supplies for residents, including briefs, gloves, and wipes, resulting in residents wearing ill-fitting briefs and experiencing delays in care.
F0695 - Respiratory/Tracheostomy Care and Suctioning. The facility failed to adhere to accepted standards for timely replacement of oxygen tubing and failed to post oxygen-in-use signage for a resident on oxygen.
F0697 - Pain Management. The facility failed to manage pain for residents by not administering pain medication prior to wound care and not ensuring ordered pain medication was available, resulting in unaddressed pain for two residents.
F0865 - QAPI Program/Plan, Disclosure/Good Faith Attempt. The facility failed to sustain an effective Quality Assurance and Performance Improvement program, as evidenced by repeat deficiencies cited during the current recertification survey.
F0880 - Infection Prevention & Control. The facility failed to implement appropriate infection prevention and control practices during medication administration, including handling medications with ungloved hands and lack of hand hygiene.
Report Facts
Deficiencies cited: 17
Beds licensed: 96
Complaint investigations: 3
Inspection Report — Mar 27, 2025
Annual Inspection
Date: Mar 27, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigations (CIs), CI MS #28232, CI MS #28176, and CI MS #28146, at the facility from 3/24/25 through 3/27/25.
Complaint Details
Complaint Investigations (CIs) CI MS #28232 for physical environment, CI MS #28176 for quality of care, client neglect, physical environment, and CI MS #28146 for quality care treatment and physical environment were investigated. Deficiencies were cited related to these complaints.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, citing deficiencies in staffing, residents' rights, activities of daily living, pressure sores, and infection control.
Deficiencies (5)
M225 - The facility failed to provide sufficient nursing staff including RN coverage for at least 8 hours per day on 8 of 19 days reviewed, affecting Resident #67 and potentially all residents.
M500 - The facility failed to ensure residents' rights to a clean, safe, homelike environment for three residents, evidenced by unclean floors and bathrooms in Resident #11 and #44's rooms and improper handling of personal belongings for Resident #60.
M610 - The facility failed to provide necessary assistance with activities of daily living, including grooming and personal hygiene, for Resident #67 who required total assistance.
M615 - The facility failed to follow physician orders and professional standards for wound care for Resident #33, resulting in inadequate wound care and unmanaged pain during treatment.
M1570 - The facility failed to implement appropriate infection control practices during medication administration for Resident #169, including failure to wear gloves and perform hand hygiene, risking infection transmission.
Report Facts
Deficiencies cited: 5
Days without RN coverage: 8
Residents sampled for ADL care audit: 10
Residents sampled for environment audit: 10
Residents sampled for wound care monitoring: 3
Medication passes monitored: 3
Inspection Report — Mar 27, 2025
Annual Inspection
Date: Mar 27, 2025
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigations (CIs), CI MS #28232, CI MS #28176, and CI MS #28146, at the facility from 3/24/25 through 3/27/27.
Complaint Details
Complaint Investigations CI MS #28232, CI MS #28176, and CI MS #28146 were investigated for physical environment, misappropriation of property, client rights, quality of care, client neglect, and quality care treatment. Deficiencies were cited in all three complaints.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, with deficiencies cited for M225, M500, M610, M615, and M1570.
Deficiencies (5)
M225 - The facility failed to meet quality of care and client neglect standards as cited in complaint investigations.
M500 - The facility was cited for misappropriation of property, client rights violations, and physical environment issues.
M610 - The facility did not comply with certain state licensure requirements.
M615 - The facility failed to meet additional state licensure standards.
M1570 - The facility was cited for further deficiencies related to state licensure standards.
Report Facts
Deficiencies cited: 5
Inspection Report — Mar 26, 2025
Life Safety
Date: Mar 26, 2025
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 — Mar 24, 2025
Complaint Investigation
Date: Mar 24, 2025
Visit Reason
The inspection was conducted based on complaints regarding resident care, facility cleanliness, staffing shortages, and failure to provide adequate personal care and accessible call light for residents.
Complaint Details
The complaint investigation was substantiated with findings of minimal harm or potential for actual harm affecting some or few residents, including issues with call light accessibility, cleanliness, personal belongings, personal care, and staffing shortages.
Findings
The facility failed to provide an accessible call light for a paralyzed resident, maintain a clean and homelike environment for residents, ensure personal hygiene and grooming assistance, and maintain sufficient nursing and CNA staffing to meet resident needs. Several residents reported missing personal belongings and delays in care due to staffing shortages.
Deficiencies (5)
Failed to ensure a resident's right to dignity and communication by not providing an accessible call light for one resident.
Failed to ensure residents' rights to a clean, safe, homelike environment for three residents, evidenced by unclean floors, bathrooms, and improper handling of personal belongings.
Failed to provide a resident unable to carry out activities of daily living with necessary services to maintain good grooming and personal and oral care.
Failed to provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Failed to have a registered nurse on duty 8 hours a day and select a registered nurse to be the director of nurses on a full time basis.
Report Facts
Residents sampled: 20
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 8
Residents: 67
CNAs assigned: 3
CNAs assigned: 2
CNAs assigned: 3
CNAs assigned: 3
CNAs assigned: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Interviewed regarding call light accessibility for Resident #169 |
| Certified Nurse Aide #3 | CNA | Interviewed regarding call light accessibility for Resident #169 and staffing |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding call light accessibility and staffing |
| Social Services #1 | Social Services | Interviewed regarding Resident #169's room request and call light |
| Registered Nurse #2 | RN Weekend Supervisor for Night Shift | Interviewed regarding call light provided to Resident #169 |
| Laundry and Housekeeping Supervisor | Interviewed regarding cleanliness and missing personal belongings | |
| Laundry Aide | Interviewed regarding missing personal belongings of Resident #60 | |
| Corporate Nurse | Interviewed regarding care concerns for Resident #67 | |
| Certified Nurse Aide #2 | CNA | Interviewed regarding staffing and care |
| Certified Nurse Aide #6 | CNA | Interviewed regarding staffing shortages |
| Certified Nurse Aide #4 | CNA | Interviewed regarding staffing and care |
| Certified Nurse Aide #5 | CNA | Interviewed regarding staffing and care |
| Certified Nurse Aide #7 | CNA and Restorative Aide | Interviewed regarding staffing and care |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding staffing and care |
| Licensed Practical Nurse #5 | LPN | Interviewed regarding staffing and scheduling |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding RN coverage and staffing |
| Nurse Consultant | Interviewed regarding staffing and RN coverage | |
| Interim Administrator | Administrator | Interviewed regarding staffing, facility operations, and regulatory compliance |
Inspection Report — Mar 24, 2025
Annual Inspection
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and facility operations at Grand Trace Health and Rehabilitation.
Findings
The facility was found deficient in multiple areas including failure to maintain a clean and safe environment, incomplete significant change assessments, inaccurate resident assessments, inadequate PASRR screenings and status change notifications, failure to implement baseline care plans timely, inadequate wound care and pain management, supply shortages affecting resident care, improper respiratory care, and failure to maintain an effective QAPI program.
Deficiencies (12)
Failure to ensure residents' rights to a clean, safe, homelike environment as evidenced by unclean floors and bathrooms and improper handling of personal belongings.
Failure to complete a Significant Change in Status Assessment after a resident returned from the hospital with a PEG tube and Stage IV sacral pressure ulcer.
Failure to accurately complete Minimum Data Set (MDS) resident assessments, including incorrect coding of feeding tube and schizophrenia diagnosis.
Failure to complete accurate PASRR screening and failure to submit status change after inpatient behavioral health admissions.
Failure to implement baseline care plan related to pain medications within 48 hours of admission.
Failure to develop and implement a comprehensive, resident-centered care plan for wound care, including failure to follow wound care orders and manage pain.
Failure to ensure adequate supplies such as briefs, gloves, and wipes for residents, causing discomfort and increased risk of infection.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, including failure to follow physician orders and professional standards.
Failure to provide safe and appropriate respiratory care, including timely replacement of oxygen tubing and posting oxygen-in-use signage.
Failure to provide safe, appropriate pain management, including failure to administer pain medication prior to wound care and failure to have pain medication available upon admission.
Failure to implement appropriate infection prevention and control practices during medication administration, including handling medications with ungloved hands.
Failure to sustain an effective Quality Assurance and Performance Improvement (QAPI) program, with repeat deficiencies from prior surveys.
Report Facts
Residents sampled: 20
Residents affected: 3
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Repeat deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse / Wound Care Nurse | Responsible for wound care and infection prevention; acknowledged failure to follow wound care orders and pain medication administration |
| LPN #2 | Licensed Practical Nurse | Observed administering medication without gloves, acknowledged infection control breach |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding MDS accuracy and resident care |
| LPN #4 | Licensed Practical Nurse | Assigned to Resident #13, confirmed supply issues |
| LPN #5 | Licensed Practical Nurse | Reported supply shortages including gloves and briefs |
| RN #1 | Registered Nurse / MDS and Care Plan Nurse | Confirmed MDS errors and emphasized importance of following care plans |
| Laundry and Housekeeping Supervisor | Confirmed unclean resident rooms and missing personal items | |
| Administrator | Interviewed regarding facility cleanliness and missing personal items | |
| Corporate Nurse | Aware of resident pain during wound care and repeat deficiencies | |
| Nurse Consultant | Confirmed diagnosis and MDS coding errors | |
| Central Supply Coordinator | Reported supply shortages and inventory issues | |
| Care Plan Nurse | Confirmed presence of pain care plan but responsibility of staff to follow it | |
| Infection Prevention Nurse | Licensed Practical Nurse | Explained infection control requirements during medication administration |
| Corporate Admissions/Marketing | Confirmed admission paperwork delays affecting pain medication availability | |
| Weekend Night Supervisor / Registered Nurse #2 | Confirmed lack of pain assessment and follow-up on admission | |
| Nurse Practitioner | Confirmed delayed awareness of resident pain medication needs | |
| Social Services | Responsible for PASRR status change referrals; acknowledged oversight | |
| Licensed Practical Nurse #1 | Performed wound care without following orders and without pain medication |
Inspection Report — Oct 3, 2024
Complaint Investigation
Date: Oct 3, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26367, at the facility on 10/3/24. MS #26367 was a facility reported incident related to a fall.
Complaint Details
Complaint Investigation CI MS#26367 was related to a facility reported incident involving a fall. The complaint was determined to be unsubstantiated as no deficiencies were cited.
Findings
The survey 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 count: 1
Inspection Report — Oct 3, 2024
Complaint Investigation
Date: Oct 3, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #26367, at the facility on 10/3/24 related to a facility reported incident involving a fall.
Complaint Details
CI MS#26367 was a facility reported incident 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.
Inspection Report — Jun 4, 2024
Life Safety
Date: Jun 4, 2024
Visit Reason
On June 4, 2024, a Life Safety Code complaint (CI MS# 25265) survey was completed by the Mississippi State Department of Health Bureau of Health Facilities Licensure & Certification: Fire Safety & Construction Division to determine if the facility met the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Complaint Details
Complaint number CI MS# 25265 was investigated as a Life Safety Code complaint survey. The facility was found in compliance with no deficiencies cited.
Findings
This survey found the facility to be In Compliance with the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Inspection Report — May 22, 2024
Complaint Investigation
Date: May 22, 2024
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #24940 and MS #25172, at the facility from 5/21/24 through 5/22/24. MS #24940 was investigated related to Resident Rights. MS #25172 was investigated regarding Resident Abuse.
Complaint Details
Complaint Investigation MS #24940 related to Resident Rights and MS #25172 regarding Resident Abuse were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The surveyor determined the facility was in compliance with the requirements for participation in Medicare and Medicaid and there were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 16, 2024
Annual Inspection
Date: Apr 16, 2024
Visit Reason
On 04/16/24 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 03/07/24.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 04/10/24.
Inspection Report — Apr 16, 2024
Date: Apr 16, 2024
Visit Reason
On 04/16/24 the State Agency conducted a desk review of the information provided related to the annual survey completed on 03/07/24. The facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 04/10/24. No deficiencies were cited in this desk review.
Inspection Report — Mar 7, 2024
Annual Inspection
Date: Mar 7, 2024
Visit Reason
The State Agency (SA) conducted an annual recertification survey and Complaint Investigations (CIs), CI MS #24017, CI MS #24188, CI MS #24187, CI MS #24206, CI MS #24299, CI MS #24298, CI MS #24322, and CI MS #24337, at the facility from 3/4/24 through 3/7/24.
Complaint Details
The survey included complaint investigations CI MS #24017, #24188, #24187, #24206, #24299, #24298, #24322, and #24337. Deficiencies were cited related to CI MS #24206 (verbal abuse, M500 cited), CI MS #24299 and #24298 (insufficient staffing, M225 cited). Other complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, citing deficiencies in staffing, residents' rights, and activities of daily living. Specific issues included insufficient nursing staff affecting care for six sampled residents, disrespectful treatment of a resident by staff, failure to provide a bariatric bed for a resident, failure to deliver mail on Saturdays, and failure to provide grooming services for a resident.
Deficiencies (3)
M225 - The facility failed to provide sufficient nursing staffing resulting in incontinent care, grooming, and baths not being provided for six of 18 sampled residents.
M500 - The facility failed to ensure residents were treated with dignity and respect, failed to provide accommodation for a resident who required a larger bed, and failed to ensure residents received mail delivered on Saturdays for four of 18 sampled residents.
M610 - The facility failed to ensure residents dependent on staff for activities of daily living, including shaving, received those services for one of 18 sampled residents.
Report Facts
Deficiencies cited: 3
Inspection Report — Mar 7, 2024
Annual Inspection
Date: Mar 7, 2024
Visit Reason
The State Agency conducted an annual recertification survey and Complaint Investigations (CIs), CI MS #24017, CI MS #24188, CI MS #24187, CI MS #24206, CI MS #24299, CI MS #24298, CI MS #24322, and CI MS #24337, at the facility from 3/4/24 through 3/7/24.
Complaint Details
The survey included complaint investigations CI MS #24017, #24188, #24187, #24206, #24299, #24298, #24322, and #24337. Deficiencies were cited related to verbal abuse (F550), insufficient staffing (F725), and other cited tags. Several complaints were investigated with no deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, citing multiple deficiencies including failure to accommodate resident needs, communication rights, notification requirements, care planning, sufficient staffing, and trauma-informed care.
Deficiencies (10)
F0550 - The facility failed to prevent verbal abuse as cited in complaint investigation CI MS #24206.
F0558 - Reasonable accommodations needs/preferences. The facility failed to provide a bariatric bed for a resident weighing over 400 pounds until after the survey.
F0576 - Right to forms of communication with privacy. The facility failed to ensure residents received mail delivered on Saturdays, affecting all residents.
F0582 - Medicaid/Medicare coverage/liability notice. The facility failed to provide advanced beneficiary notices for a resident discharged from therapy services.
F0623 - Notice requirements before transfer/discharge. The facility failed to provide written notification to a resident and/or representative for a hospital transfer in a language they understood.
F0641 - Accuracy of assessments. The facility failed to accurately code tobacco use on the Minimum Data Set for a resident who smoked.
F0656 - Develop/implement comprehensive care plan. The facility failed to develop a comprehensive care plan including trauma-informed interventions for a resident with PTSD.
F0677 - ADL care provided for dependent residents. The facility failed to provide shaving and grooming services to a dependent resident.
F0699 - Trauma informed care. The facility failed to ensure trauma-informed care with identification of triggers and interventions for a resident with PTSD.
F0725 - Sufficient nursing staff. The facility failed to provide sufficient nursing staff to meet resident needs, resulting in missed incontinent care, grooming, and baths for six residents.
Report Facts
Deficiencies cited: 10
Total licensed beds: 96
Inspection Report — Mar 7, 2024
Life Safety
Date: Mar 7, 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 — Mar 7, 2024
Complaint Investigation
Date: Mar 7, 2024
Visit Reason
The inspection was conducted based on multiple complaints and concerns regarding resident care, staffing shortages, and compliance with regulatory requirements at Grand Trace Health and Rehabilitation.
Complaint Details
The visit was complaint-related based on multiple anonymous complaints alleging inadequate staffing, failure to provide care such as bathing and incontinent care, and failure to meet residents' needs. Specific complaints included insufficient CNAs on shifts, residents left soiled, and lack of timely assistance.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for bariatric beds, failure to ensure timely mail delivery, failure to provide advanced beneficiary notices, failure to provide written transfer notifications, inaccurate Minimum Data Set (MDS) assessments, incomplete care plans for residents with PTSD, inadequate assistance with activities of daily living, failure to provide trauma-informed care, and insufficient nursing staff leading to unmet resident needs.
Deficiencies (9)
Failed to provide accommodation for a resident who required a larger bariatric bed.
Failed to ensure residents received mail delivered on Saturdays.
Failed to provide advanced beneficiary notices for a resident who had completed therapy services.
Failed to provide written notification to resident and/or representative before transfer to acute hospital.
Failed to accurately code Minimum Data Set related to tobacco use for a resident who smokes.
Failed to develop a comprehensive care plan for a resident with PTSD including triggers and interventions.
Failed to provide care and assistance for activities of daily living including shaving for a dependent resident.
Failed to provide trauma-informed care by identifying and initiating interventions for resident with PTSD.
Failed to provide sufficient nursing staff resulting in unmet resident needs including incontinent care, grooming, and baths.
Report Facts
Resident weight: 452
Resident weight: 434
Staffing levels: 3
Staffing levels: 4.5
Staffing levels: 1
Staffing levels: 2
Staffing levels: 0
Staffing levels: 2
Staffing levels: 2
BIMS score: 15
BIMS score: 15
BIMS score: 15
BIMS score: 15
BIMS score: 14
BIMS score: 1
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #1 | CNA | Notified nurses that Resident #57 needed a bariatric bed |
| Maintenance Director | Interviewed about bariatric bed availability | |
| Human Resources associate | Interviewed about ordering bariatric bed | |
| Business Development Coordinator/ admission | BDCA | Interviewed about admission process and bariatric bed requirements |
| Director of Nursing | DON | Interviewed about responsibility for resident needs and care plans |
| Registered Nurse #2 | RN | Completed notification of transfer form for Resident #66 |
| Registered Nurse #1 | RN/MDS/Care Plan nurse | Interviewed about inaccurate MDS coding and care plan development |
| Business Office Manager | BOM | Interviewed about advanced beneficiary notices |
| Therapy Director | Interviewed about therapy discharge and notification responsibilities | |
| Certified Nurse Aide #2 | CNA | Interviewed about resident shaving and staffing |
| Certified Occupation Therapy Assistant | COTA | Provided perineal care to Resident #59 when staff were unavailable |
| Social Services Designee | Interviewed about care plan and trauma informed care | |
| Administrator | Interviewed about staffing challenges and expectations for care plans | |
| Corporate Nurse Consultant | Completed staffing grid and worked floor to ensure resident needs met |
Inspection Report — Feb 20, 2024
Routine
Date: Feb 20, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period, 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 — Oct 10, 2023
Follow-Up
Date: Oct 10, 2023
Visit Reason
The State Agency (SA) conducted a follow-up revisit at the facility on 10/10/23 related to a complaint survey that was conducted 9/06/23 through 9/07/23.
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 9/22/23.
Inspection Report — Oct 10, 2023
Follow-Up
Date: Oct 10, 2023
Visit Reason
The State Agency conducted a follow-up revisit at the facility on 10/10/23 related to a complaint survey that was conducted from 9/06/23 through 9/07/23.
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 9/22/23.
Inspection Report — Sep 7, 2023
Complaint Investigation
Date: Sep 7, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22306, related to a wheelchair accident that occurred during transportation.
Complaint Details
CI MS #22306 was investigated related to a wheelchair accident during transportation. Deficiency F0689 was cited.
Findings
F0689 - The facility failed to ensure a resident was transported safely in the facility van, resulting in the resident's wheelchair tilting and causing injury during transport.
Deficiencies (1)
F0689 - The facility failed to ensure a resident was transported in the facility van in a safe manner; Resident #1's wheelchair tilted causing a fall and injury during transport.
Report Facts
Deficiencies cited: 1
Inspection Report — Sep 7, 2023
Complaint Investigation
Date: Sep 7, 2023
Visit Reason
The inspection was conducted following a complaint and investigation of an accident involving Resident #1, whose wheelchair tilted during transport in the facility van causing a fall and injury.
Complaint Details
The investigation was triggered by a complaint regarding an accident on 8/04/23 where Resident #1's wheelchair tilted during transport causing injury. The complaint was substantiated with findings of actual harm. The Transportation Aide was terminated for unrelated reasons. The resident was treated at the hospital and discharged home as planned.
Findings
The facility failed to ensure safe transport of Resident #1 in the van, resulting in the wheelchair tilting and the resident sustaining a laceration to the left ear and a skin tear to the left elbow. The Transportation Aide did not secure the wheelchair properly prior to transport, and required safety checklists were not completed before transport.
Deficiencies (1)
Failure to ensure a resident was transported in the facility van in a safe manner, resulting in injury due to wheelchair tilting during transport.
Report Facts
Residents reviewed for accidents: 5
Resident #1 injury dimensions: 0.3
Resident #1 injury dimensions: 0.5
Antibiotic therapy duration: 10
Admission date: Jul 12, 2023
Assessment Reference Date: Jul 19, 2023
BIMS score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding accident and resident assessment |
| Transportation Aide | Involved in transport and securing wheelchair; terminated after incident | |
| Certified Nursing Assistant #1 | Certified Nursing Assistant (CNA) | Assisted in righting wheelchair after accident and interviewed |
| Plant Operations Director | Plant Operations Director (POD) | Inspected wheelchair securement system and demonstrated proper use |
| Administrator | Administrator | Interviewed regarding cause of fall |
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for one complaint, MS #21760, from 6/13/23 through 6/14/23.
Complaint Details
Complaint MS #21760 involved allegations of Accidents/Fall and was investigated by the State Agency. The complaint was 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.
Report Facts
Complaint count: 1
Inspection Report — Jun 14, 2023
Complaint Investigation
Date: Jun 14, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for one complaint, MS #21760, from 6/13/23 through 6/14/23.
Complaint Details
Complaint MS #21760 was investigated for Accidents/Fall and was not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with the requirements for participation in Medicare and Medicaid. No deficiencies were cited during the investigation of complaint MS #21760 regarding Accidents/Fall.
Report Facts
Complaints investigated: 1
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
The State Agency conducted a Complaint Investigation at the facility for two complaints, MS #21679 and MS #21490, from 06/06/23 through 06/07/23.
Complaint Details
Complaint MS #21490 involved accidents related to fall prevention, and complaint MS #21679 involved quality of care related to grooming, incontinent care, resident rights related to visitation, and physical environment related to cleanliness. Both complaints were investigated 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 during the investigation.
Inspection Report — Jun 7, 2023
Complaint Investigation
Date: Jun 7, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI) at the facility for two complaints, MS #21679 and MS #21490, from 06/06/23 through 06/07/23.
Complaint Details
Complaint MS #21490 involved accidents related to fall prevention, and complaint MS #21679 involved quality of care related to grooming, incontinent care, resident rights related to visitation, and physical environment related to cleanliness. Both complaints were investigated and no deficiencies were cited.
Findings
The survey determined the facility was in compliance with Medicare and Medicaid requirements and cited no deficiencies.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 20, 2022
Complaint Investigation
Date: Jul 20, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI), MS #19206 and MS #19213 at the facility on 7/20/22.
Complaint Details
Complaint Investigation MS #19206 and MS #19213 were not substantiated; no deficiencies were cited.
Findings
The SA determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and there were no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jul 20, 2022
Complaint Investigation
Date: Jul 20, 2022
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #19206 and MS #19213 at the facility on 7/20/22.
Complaint Details
Complaint Investigation MS #19206 and MS #19213 were not substantiated; no deficiencies were cited.
Findings
The facility was found in compliance with no deficiencies cited during the survey.
Report Facts
Complaints investigated: 2
Inspection Report — Mar 2, 2022
Annual Inspection
Date: Mar 2, 2022
Visit Reason
On 3/2/22 the State Agency conducted a desk review of the information related to the annual survey conducted on 1/20/22. The information provided by the facility confirmed corrective measures were in place to sustain compliance with Medicare and Medicaid requirements.
Findings
The State Survey Agency determined the scope and severity of F565 and F804 was increased from a D to an E. The facility was recommended to be placed back in compliance effective 02/18/22.
Report Facts
Deficiencies cited: 0
Inspection Report — Feb 17, 2022
Life Safety
Date: Feb 17, 2022
Visit Reason
On 2/17/22 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 1/19/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The facility was found to be in compliance with the applicable provisions of the 2012 Edition of the Life Safety Code. The State Agency is recommending the facility be placed back in compliance effective 02/11/22.
Inspection Report — Feb 17, 2022
Annual Inspection
Date: Feb 17, 2022
Visit Reason
On 2/17/22 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 1/19/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with all applicable Federal, State and local emergency preparedness requirements.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 02/11/22. No deficiencies were cited in this desk review.
Inspection Report — Jan 20, 2022
Annual Inspection
Date: Jan 20, 2022
Visit Reason
The State Agency (SA) determined during an annual recertification survey, conducted from 1/18/2022 to 1/20/2022. The SA determined the facility was not in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, state licensure requirements at M500, M615 and M855.
Findings
The facility was found not in compliance with state licensure requirements related to residents' rights, pressure sore care, and food preparation. Deficiencies included failure to resolve food grievances timely, improper wound care technique, and serving food that was not palatable or at an appetizing temperature.
Deficiencies (3)
M500 - Residents' rights. The facility failed to ensure Resident Council grievances related to food were resolved in a timely manner, affecting eight residents.
M615 - Pressure sores. The facility failed to properly clean a wound for one resident, including improper hand hygiene and cleaning technique that could cause infection.
M855 - Food preparation. The facility failed to serve food that was palatable and at an appetizing temperature to eight residents, despite repeated complaints over several months.
Report Facts
Deficiencies cited: 3
Inspection Report — Jan 20, 2022
Annual Inspection
Date: Jan 20, 2022
Visit Reason
The State Agency (SA) conducted an annual survey from 01/18/22 through 01/20/22. During the survey the SA determined the facility was not in compliance with the Medicare and Medicaid requirements for participation.
Findings
The facility was found not in compliance with multiple requirements including grievance resolution, transfer notice, MDS accuracy, wound care, food palatability, and infection control.
Deficiencies (6)
F0565 - Resident Council grievances related to food were not resolved in a timely manner affecting eight residents.
F0623 - The facility failed to provide written notice of transfer to the resident representative for two residents.
F0641 - The facility failed to maintain accurate Minimum Data Set assessments for four residents regarding serious mental illness and hospice care.
F0686 - The facility failed to properly clean a wound for one resident, not washing or sanitizing hands between glove changes and cleaning from the outer wound inward.
F0804 - The facility failed to serve food that was palatable and at an appetizing temperature to eight residents, with repeated complaints of cold and bland food.
F0880 - The facility failed to ensure staff followed infection control measures during wound care for one resident, including hand hygiene and proper wound cleaning technique.
Report Facts
Deficiencies cited: 6
Inspection Report — Jan 20, 2022
Complaint Investigation
Date: Jan 20, 2022
Visit Reason
The inspection was conducted based on complaints regarding unresolved Resident Council grievances related to food quality, specifically food being cold and bland, and failure to provide timely transfer/discharge notices to resident representatives.
Complaint Details
The visit was complaint-related due to grievances about food quality (cold and bland food) and failure to provide written transfer/discharge notices to resident representatives. The complaints were substantiated as the facility failed to resolve food grievances timely and failed to notify resident representatives in writing of transfers.
Findings
The facility failed to ensure Resident Council grievances about food palatability and temperature were resolved timely, affecting eight residents. Additionally, the facility failed to provide written transfer/discharge notices to resident representatives for two residents. The facility also had inaccurate Minimum Data Set (MDS) assessments for four residents and failed to follow proper wound care and infection control procedures for one resident.
Deficiencies (6)
Failed to ensure Resident Council grievances related to food were resolved in a timely manner.
Failed to provide a written notice of transfer to the Resident Representative for two residents.
Failed to maintain accurate Minimum Data Set (MDS) assessments for four residents.
Failed to properly clean a wound and follow infection control measures during wound care for one resident.
Failed to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature.
Failed to implement an infection prevention and control program ensuring proper hand hygiene during wound care.
Report Facts
Residents affected by food grievance: 8
Residents reviewed for MDS accuracy: 21
Residents affected by inaccurate MDS: 4
Residents affected by wound care deficiency: 1
Residents affected by transfer notice deficiency: 2
Residents affected by food palatability deficiency: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed failing to wash/sanitize hands during wound care and confirmed errors in wound cleaning technique. |
| Dietary Manager | Confirmed attendance at resident council meetings and acknowledged food complaints. | |
| Activity Director | Recorded resident grievances about food and communicated concerns to the Director of Nursing. | |
| Director of Nursing | DON | Acknowledged food complaints and attempted to improve meal delivery timing. |
| Administrator | Unaware of ongoing food complaints despite Quality Assurance meetings discussing meal delivery. | |
| Licensed Practical Nurse #1 | LPN / MDS Nurse | Admitted errors in coding MDS assessments for serious mental illness and hospice care. |
| Social Services | Confirmed no written notification to resident representatives for transfers. |
Inspection Report — Jan 19, 2022
Life Safety
Date: Jan 19, 2022
Visit Reason
Survey conducted on 01/19/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
One deficiency was cited related to the facility's failure to maintain and update the emergency preparedness plan as required. The facility did not provide updated emergency preparedness documentation as of 1/18/22.
Deficiencies (1)
E0004 - The facility failed to maintain and update the emergency preparedness plan annually as required by 42 CFR 483.73(a). Documentation review revealed no emergency preparedness book or documentation in the facility on 1/18/22.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 25, 2021
Complaint Investigation
Date: Oct 25, 2021
Visit Reason
The State Agency conducted a complaint survey MS #18209 and MS #18198 at the facility from 10/22/21 through 10/25/21.
Complaint Details
Complaint MS #18209 and MS #18198 were investigated; neither was substantiated and no deficiencies were cited.
Findings
The facility was found to be in compliance with the regulations for participation in Medicaid and Medicare Services. The State Agency did not substantiate MS #18198 for Resident Rights or Staffing and did not substantiate MS #18209 for Resident Rights, Environment, Nurses Services, Resident Safety, Staffing.
Report Facts
Complaints investigated: 2
Inspection Report — Sep 14, 2021
Follow-Up
Date: Sep 14, 2021
Visit Reason
The State Agency (SA) conducted a follow up/revisit survey for Complaint Survey on 9/14/21.
Findings
The State Agency determined the facility was found to be in compliance with the requirements for participation of The Aged and Infirmed.
Inspection Report — Sep 13, 2021
Complaint Investigation
Date: Sep 13, 2021
Visit Reason
The State Agency conducted one complaint investigation on 09/13/2021.
Complaint Details
Complaint investigation CI MS#26995 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 13, 2021
Complaint Investigation
Date: Sep 13, 2021
Visit Reason
The State Agency conducted a complaint survey for Complaint Investigation (CI) 18039 for Quality of Care (QOC), Administration, and QOC on 9/13/21.
Complaint Details
Complaint Investigation (CI) 18039 for Quality of Care (QOC), Administration, and QOC was not substantiated by the State Agency.
Findings
During the survey, the State Agency did not substantiate the complaint and found the facility in compliance.
Report Facts
Complaints investigated: 1
Inspection Report — Jul 23, 2021
Complaint Investigation
Date: Jul 23, 2021
Visit Reason
The State Agency conducted Complaint Investigations (CIs) for CI MS# 17338, CI MS# 17916, and CI MS# 17919 at the facility from 7/26/21 through 7/30/21. CI MS# 17338 and CI MS# 17916 were not substantiated due to lack of sufficient evidence. The SA substantiated CI MS# 17919 for abuse and cited F600.
Complaint Details
CI MS# 17919 was substantiated for abuse with deficiencies cited. CI MS# 17338 and CI MS# 17916 were not substantiated due to lack of sufficient evidence.
Findings
The facility was found not in compliance due to substantiated abuse of one resident by a Certified Nursing Assistant (CNA #1), who was observed physically abusing Resident #2 by hitting him multiple times. The CNA was removed and terminated, and the facility implemented corrective actions including staff education and quality monitoring.
Deficiencies (1)
F0600 - The facility failed to ensure one of nine residents was free from physical abuse, as CNA #1 was observed hitting Resident #2 multiple times and was subsequently removed and terminated.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 23, 2021
Complaint Investigation
Date: Jul 23, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI) from 7/26/21 through 7/30/21 at Glenburney Health Care and Rehabilitation Center. The investigation was to determine compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Complaint Details
CI MS# 17919 was substantiated with a deficiency cited at M490. CI MS# 17338 and CI MS# 17916 were not substantiated due to lack of sufficient evidence.
Findings
The facility was found not in compliance with Mississippi Minimum Standards due to physical abuse of one resident by a Certified Nursing Assistant. The facility failed to ensure Resident #2 was free from physical abuse when CNA #1 was observed striking the resident with a closed fist during care on 6/25/21.
Deficiencies (1)
M500 - Residents' Rights. The facility failed to ensure one of nine residents was free from physical abuse when CNA #1 was observed striking Resident #2 with a closed fist during care on 6/25/21.
Report Facts
Deficiencies cited: 1
Inspection Report — Jun 23, 2020
Routine
Date: Jun 23, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/23/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 23, 2020
Routine
Date: Jun 23, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/24/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Feb 17, 2020
Complaint Investigation
Date: Feb 17, 2020
Visit Reason
The State Agency conducted a complaint survey, MS #16473 and MS #16557, at the facility from 02/17/2020 to 02/18/2020. The SA substantiated the complaint, MS #16557, for Physical Environment and cited F921. The SA did not substantiate the complaint for MS #16473 related to Quality of Care and cited no deficiencies.
Complaint Details
Complaint MS #16557 was substantiated for Physical Environment with deficiencies cited. Complaint MS #16473 related to Quality of Care was not substantiated and no deficiencies were cited.
Findings
The facility was found not in compliance due to failure to maintain water temperatures at a comfortable and acceptable range when bathing for five of six residents interviewed. The whirlpool tub water temperatures were too low, and corrective actions were initiated including repair of the mixing valve and education of staff.
Deficiencies (1)
F0921 - The facility failed to ensure water temperatures were maintained at a comfortable and acceptable range during bathing for five of six residents interviewed, with whirlpool tub temperatures observed as low as 87 degrees.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 31, 2019
Complaint Investigation
Date: Oct 31, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 10/31/19.
Complaint Details
Complaint investigation CI MS #16022 & CI MS #16070 was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Inspection Report — Jun 28, 2019
Complaint Investigation
Date: Jun 28, 2019
Visit Reason
A complaint investigation was conducted on June 28, 2019 in the facility.
Complaint Details
CI MS#16012: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Report
7 CMS Surveys
CMS Survey — Sep 7, 2023
Sep 7, 2023
CMS Survey — Mar 7, 2024
Mar 7, 2024
CMS Survey — Mar 27, 2025
Mar 27, 2025
CMS Survey — Aug 27, 2025
Aug 27, 2025
CMS Survey — Jan 20, 2022
Jan 20, 2022
CMS Survey — Mar 7, 2024
Mar 7, 2024
CMS Survey — Mar 27, 2025
Mar 27, 2025
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