Inspection Reports for
Grenada Living Center
1950 Grandview Drive, Grenada, MS, 38901
Back to Facility Profile36 Reports
Inspection Report — Jun 9, 2026
Complaint Investigation
Date: Jun 9, 2026
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI MS #2980281) at the facility on 06/09/26.
Complaint Details
Complaint Investigation CI MS #2980281 was conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm, state licensure requirements and there were no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — May 19, 2025
Annual Inspection
Date: May 19, 2025
Visit Reason
On 05/19/25 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 04/10/25.
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 05/13/25.
Inspection Report — May 13, 2025
Life Safety
Date: May 13, 2025
Visit Reason
On 05/08/25 the State Agency conducted a desk review of information related to the annual survey conducted on 04/08/25. 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 all applicable emergency preparedness and Life Safety Code requirements. No deficiencies were cited.
Inspection Report — Apr 23, 2025
Complaint Investigation
Date: Apr 23, 2025
Visit Reason
The State Agency conducted a complaint investigation, CI MS #28668 at the facility from 4/22/25 through 4/23/25.
Complaint Details
CI MS #28668 complaint investigation found the facility in compliance with no deficiencies cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements and no deficiencies were cited during this complaint investigation. However, the facility remains out of compliance due to deficiencies cited on the 4/10/25 survey.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 10, 2025
Routine
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including call light accessibility, resident food preferences, PASARR screening, care plan implementation, fluid restriction monitoring, and pain management.
Findings
The facility was found deficient in ensuring call light accessibility for a resident, honoring resident food preferences, accurately completing PASARR screening, implementing care plans for fluid restriction, documenting fluid intake accurately, and following physician orders for pain management referrals.
Deficiencies (6)
F 0558: The facility failed to ensure a call light was accessible for one of 17 residents reviewed. Resident #45's call light was wrapped around the bed rail and unreachable.
F 0561: The facility failed to honor a resident's food preferences for one of two residents reviewed. Resident #61 was served rice and mustard greens despite these being listed as dislikes.
F 0645: The facility failed to accurately submit a resident's PASARR information for Level II evaluation for one of three residents reviewed. Resident #43's psychiatric diagnoses and psychotropic medications were omitted.
F 0656: The facility failed to implement a care plan related to fluid restriction for one of 17 residents reviewed. Resident #20's fluid intake documentation was incomplete and inconsistent with prescribed restrictions.
F 0692: The facility failed to ensure accurate monitoring and documentation of fluid intake for a resident on fluid restriction for one of four residents reviewed. Resident #20's fluid intake was not properly reported or documented.
F 0697: The facility failed to follow a physician's order for a referral to a pain management clinic for one of three residents reviewed. Resident #23's referral was never made or scheduled.
Report Facts
Residents reviewed for call lights: 17
Residents reviewed for food preferences: 2
Residents reviewed for PASARR: 3
Resident care plans reviewed: 17
Residents reviewed for fluid restrictions: 4
Residents reviewed for pain management: 3
Fluid restriction order: 1000
Fluid restriction shift limits: 450
Fluid restriction shift limit: 100
Medication doses: 300
Medication doses: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed call light accessibility issue for Resident #45 and medication administration for Resident #23 |
| CNA #4 | Certified Nurse Aide | Confirmed call light inaccessibility for Resident #45 |
| RN #1 | Registered Nurse | Confirmed meal ticket process and resident food preferences for Resident #61 |
| Dietary Manager | Dietary Manager | Confirmed food preferences not honored for Resident #61 |
| Administrator | Administrator | Acknowledged food preference deficiencies for Resident #61 |
| Accounts Manager | Accounts Manager | Completed PASARR screening incorrectly for Resident #43 |
| Director of Nursing | Director of Nursing | Confirmed PASARR screening error for Resident #43, care plan and fluid restriction deficiencies for Resident #20, and pain management referral issue for Resident #23 |
| Social Worker | Social Worker | Confirmed PASARR screening error for Resident #43 |
| CNA #2 | Certified Nurse Assistant | Acknowledged failure to report fluid intake for Resident #20 |
| LPN #4 | Licensed Practical Nurse | Confirmed fluid restriction awareness but incomplete fluid intake documentation for Resident #20 |
| Nurse Practitioner | Nurse Practitioner | Discussed pain management and medication allergies for Resident #23 |
| Medical Doctor | Medical Doctor | Discussed Resident #23's complex pain management needs and referral |
| Medical Records Nurse | Medical Records Nurse | Reported Social Services did not schedule pain management appointment for Resident #23 |
| Social Services | Social Services | Unaware of pain management referral order for Resident #23 |
Inspection Report — Apr 10, 2025
Annual Inspection
Date: Apr 10, 2025
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 04/07/25 through 04/10/25. During the survey the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited regulatory deficiencies at F558, F561, F645, F656, F692, and F697.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies related to call light accessibility, honoring resident food preferences, PASARR screening, care plan implementation for fluid restriction, fluid intake monitoring, and pain management referral.
Deficiencies (6)
F0558 - The facility failed to ensure a call light was accessible for one resident, Resident #45, who had the call light wrapped around the bed rail and was unable to use it to call for help.
F0561 - The facility failed to honor a resident's food preferences for Resident #61, who was served foods she had listed as dislikes despite documented preferences.
F0645 - The facility failed to accurately submit a resident's information for PASARR Level II evaluation for Resident #43, omitting psychiatric diagnoses and psychotropic medication use.
F0656 - The facility failed to implement a care plan related to fluid restriction for Resident #20 and did not accurately monitor and document fluid intake.
F0692 - The facility failed to ensure accurate monitoring and documentation of fluid intake for Resident #20 on fluid restriction, with incomplete intake and output records and lack of communication between CNAs and nurses.
F0697 - The facility failed to follow a physician's order for a referral to a pain management clinic for Resident #23, resulting in a delay in appropriate pain management.
Report Facts
Deficiencies cited: 6
Inspection Report — Apr 8, 2025
Life Safety
Date: Apr 8, 2025
Visit Reason
The survey conducted on 4/8/25 revealed the above facility meets all applicable Federal, State and local emergency preparedness requirements. The facility must meet the applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
K0321 - Hazardous areas were not properly protected by fire barriers as the Laundry Room on the Service Hall lacked a door, allowing smoke to pass through the facility. This deficiency affected one of six smoke compartments in the building.
Deficiencies (1)
K0321 - Hazardous areas were not properly protected by fire barriers as the Laundry Room on the Service Hall lacked a door, allowing smoke to pass through the facility.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 13, 2023
Annual Inspection
Date: Nov 13, 2023
Visit Reason
On 11/13/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 10/5/23.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 11/1/23.
Inspection Report — Nov 1, 2023
Life Safety
Date: Nov 1, 2023
Visit Reason
On 11/01/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 10/03/23.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 Edition of the Life Safety Code. The SA is recommending that your facility be placed back in compliance effective 11/01/23.
Inspection Report — Oct 24, 2023
Complaint Investigation
Date: Oct 24, 2023
Visit Reason
The State Agency conducted a Complaint Investigation CI MS #23032 at the facility on 10/24/23 regarding Quality of Care/Treatment/Responsible Party not notified of changes in resident condition, Neglect/Pressure Ulcers, Quality of Care/Treatment/services not provided per Plan of Care and MD orders.
Complaint Details
Complaint CI MS #23032 involved allegations of Quality of Care/Treatment, Responsible Party not notified of changes in resident condition, Neglect/Pressure Ulcers, and services not provided per Plan of Care and MD orders. The complaint was investigated with no deficiencies cited.
Findings
The SA investigated the complaint and found no deficiencies cited; however, the facility remains out of compliance due to deficiencies cited on the 10/05/23 annual licensure survey.
Report Facts
Complaint investigations: 1
Inspection Report — Oct 5, 2023
Annual Inspection
Date: Oct 5, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 10/2/23 through 10/5/23. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation and cited F583, F699 and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements. Deficiencies were cited related to personal privacy during treatments, trauma-informed care planning, and infection prevention and control practices.
Deficiencies (3)
F0583 - Personal privacy/confidentiality of records. The facility failed to provide privacy during one of seven treatment observations when the Treatment Nurse did not close the door, pull the privacy curtain, or close the blinds while treating Resident #6.
F0699 - Trauma informed care. The facility failed to identify triggers and develop individualized trauma-informed care plans for Resident #15 with a diagnosis of PTSD.
F0880 - Infection prevention and control. The facility failed to perform hand hygiene during wound care and medication administration, failed to use a clean barrier during medication pass, and failed to properly sanitize a glucometer after use for Residents #6, #36, #39, and #78.
Report Facts
Deficiencies cited: 3
Inspection Report — Oct 5, 2023
Routine
Date: Oct 5, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with federal and state regulations regarding resident privacy, trauma-informed care, infection prevention and control, and medication administration practices.
Findings
The facility was found deficient in maintaining resident privacy during treatment, failing to develop individualized trauma-informed care plans for residents with PTSD, and not adhering to infection control protocols including hand hygiene, use of barriers during medication pass, and proper sanitization of equipment.
Deficiencies (3)
F 0583: The facility failed to provide privacy during treatment for Resident #6 as the nurse did not close the door, pull the privacy curtain, or close blinds while care was provided.
F 0699: The facility failed to identify trauma triggers and develop individualized trauma-informed care plans for Resident #15 diagnosed with PTSD.
F 0880: The facility failed to prevent infection spread by not performing hand hygiene during wound care and medication administration, not using a clean barrier during medication pass, and not properly sanitizing a glucometer after use.
Report Facts
Residents reviewed for trauma-informed care: 4
Treatment observations: 7
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Named in privacy deficiency for Resident #6 | |
| Director of Nursing (DON) | Confirmed expectations for privacy, trauma-informed care, and infection control | |
| Licensed Practical Nurse (LPN) #1 | LPN | Unaware of PTSD diagnosis and lack of care plan for Resident #15 |
| Social Worker (SW) #1 | Social Worker | Completed social assessment and acknowledged lack of trauma-informed care plan for Resident #15 |
| Licensed Practical Nurse (LPN) #3 | LPN | Failed to perform hand hygiene and properly sanitize glucometer during glucose check and insulin administration for Resident #36 |
| LPN #2 | LPN | Failed to use barrier during medication pass for Resident #78 |
| LPN/Infection Control Nurse | Infection Control Nurse | Confirmed infection control expectations and deficiencies |
Inspection Report — Oct 3, 2023
Life Safety
Date: Oct 3, 2023
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found deficient for failing to provide and properly maintain corridor doors to resist the passage of smoke and ensure positive latching in three smoke compartments. The deficiency affected multiple resident rooms and was acknowledged by the Administrator and Maintenance Supervisor.
Deficiencies (1)
K0363 - The facility failed to provide and properly maintain corridor doors to ensure they close to a positive latching position and resist the passage of smoke in three smoke compartments, affecting multiple resident rooms.
Report Facts
Deficiencies cited: 1
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
The State Agency conducted a complaint investigation (CI MS #20523) at the facility from 1/25/23 to 1/25/23.
Complaint Details
Complaint investigation CI MS #20523 found the facility in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for the Institutions for the Aged or Infirm for CI MS #20523. However, the facility remains out of compliance due to deficiencies cited on the 12/9/2022 survey.
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
The State Agency conducted a complaint investigation (MS CI #20523) at the facility from 1/25/23 to 1/25/23.
Complaint Details
Complaint investigation MS CI #20523 found no deficiencies and was determined to be in compliance.
Findings
The survey determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid. There were no deficiencies cited for MS CI #20523 for Physical Environment.
Report Facts
Complaint investigations: 1
Inspection Report — Jan 9, 2023
Routine
Date: Jan 9, 2023
Visit Reason
The facility was surveyed for compliance with COVID-19 reporting requirements as part of routine monitoring.
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 — Dec 9, 2022
Complaint Investigation
Date: Dec 9, 2022
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) from 11/30/22 through 12/9/22 for CI MS#19787. During the survey, the facility was determined not to be in substantial compliance with the requirements of participation for Medicare and Medicaid. An extended survey was completed, and deficiencies were cited: F656, F686, F726, and F865.
Complaint Details
CI MS#19787. The complaint investigation found the facility not in substantial compliance with deficiencies cited including Immediate Jeopardy related to failure to provide competent nursing staff and prevent worsening of a pressure ulcer for Resident #1. The Immediate Jeopardy was removed prior to exit.
Findings
The facility was found not in substantial compliance due to failure to provide competent nursing staff and prevent worsening of a pressure ulcer for Resident #1, resulting in Immediate Jeopardy that was removed prior to exit. The facility failed to develop and implement comprehensive care plans, provide treatment and services to prevent and heal pressure ulcers, ensure competent nursing staff, and maintain an effective QAPI program.
Deficiencies (4)
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop an updated comprehensive care plan for Resident #1 after identifying a deteriorating pressure ulcer, placing the resident at risk of serious harm.
F0686 - Treatment/Services to Prevent/Heal Pressure Ulcer. The facility failed to prevent the worsening of a pressure ulcer and provide necessary treatment for Resident #1, who was hospitalized with wound sepsis.
F0726 - Competent Nursing Staff. The facility failed to provide competent and consistent nursing staff to prevent the worsening of a pressure ulcer for Resident #1, resulting in Immediate Jeopardy that was removed prior to exit.
F0865 - QAPI Prgm/Plan, Disclosure/Good Faith Attmpt. The facility failed to follow the Quality Assurance and Performance Improvement plan related to skin issues, failed to notify the physician of a worsening pressure ulcer, and failed to update interventions in the High-Risk Committee meeting for Resident #1.
Report Facts
Deficiencies cited: 4
Inspection Report — Sep 20, 2022
Complaint Investigation
Date: Sep 20, 2022
Visit Reason
The State Agency conducted a complaint survey MS #19522 on 9/20/22. The SA did not substantiate the complaint of MS #19522 with allegations against Tube Feedings.
Complaint Details
Complaint MS #19522 alleged issues with Tube Feedings but 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 Aged or Infirm with no deficiencies cited.
Report Facts
Complaint count: 1
Inspection Report — Aug 3, 2022
Complaint Investigation
Date: Aug 3, 2022
Visit Reason
The State Agency conducted a complaint survey CI MS #19342 on 8/3/22 regarding allegations of Quality of Care/left wet/left soiled, neglect, safety/falls, and services not performed per Medical Doctor orders.
Complaint Details
Complaint CI MS #19342 alleged Quality of Care/left wet/left soiled, neglect, safety/falls, and services not performed per Medical Doctor orders. The complaint was not substantiated and no deficiencies were cited.
Findings
The State Agency did not substantiate the complaint and found the facility in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Complaints investigated: 1
Inspection Report — Jun 7, 2022
Annual Inspection
Date: Jun 7, 2022
Visit Reason
On 06/07/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 05/05/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 06/01/22.
Inspection Report — May 5, 2022
Annual Inspection
Date: May 5, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 5/2/22 to 5/5/22. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid regulations for participation.
Findings
Two deficiencies were cited related to comprehensive assessments and food safety. The facility failed to accurately code a Minimum Data Set for one resident and failed to discard expired bread in the dietary department.
Deficiencies (2)
F0636 - The facility failed to accurately code a Minimum Data Set for one resident who received hemodialysis, resulting in incorrect coding of special treatments and procedures.
F0812 - The facility failed to discard expired bread as evidenced by observation of 28 packs of buns and rolls with expired use-by dates in the dietary department.
Report Facts
Deficiencies cited: 2
Inspection Report — May 5, 2022
Routine
Date: May 5, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and food safety practices in the nursing home.
Findings
The facility failed to accurately code a Minimum Data Set (MDS) for one resident regarding dialysis treatment and failed to discard expired bread in the dietary department, posing a potential risk of food-borne illness to residents.
Deficiencies (2)
F 0636: The facility failed to accurately code the Minimum Data Set (MDS) for Resident #32 by not marking dialysis treatment, which could affect resident care and financial reimbursement.
F 0812: The facility failed to discard expired bread, with 28 packs of buns and rolls past their use-by date found in the dietary department, risking food-borne illness to residents.
Report Facts
Expired bread packs: 28
MDS reviewed: 19
Dialysis frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS nurse | Confirmed dialysis should be marked on MDS for Resident #32 | |
| Administrator | Confirmed dialysis should be marked on MDS and dietary staff should check bread dates | |
| Dietary Staff Member #1 (Dietary Manager) | Acknowledged failure to check expiration dates on bread and confirmed expired bread presence | |
| Dietary Staff Member #2 | Confirmed process of separating expired bread and presence of expired bread stacked with fresh bread |
Inspection Report — May 4, 2022
Routine
Date: May 4, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — May 4, 2022
Life Safety
Date: May 4, 2022
Visit Reason
Survey conducted on 05/04/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found to be in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Apr 6, 2022
Complaint Investigation
Date: Apr 6, 2022
Visit Reason
The State Agency conducted complaint surveys for MS #18378 and MS# 18502 at the facility from 04/05/2022 to 04/06/2022 along with an Employee Vaccination section of the Infection Control survey.
Complaint Details
Complaint MS #18378 alleged quality of care issues including resident left soiled for extended period, resident dressed improperly, and no pressure sore precautions taken. Complaint MS #18502 alleged quality of care issues including water not offered, resident not groomed adequately, resident not assessed timely for medical condition changes, and client services not performed per plan of care and physician orders. Both complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding quality of care and treatment were not substantiated and no deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Nov 23, 2021
Follow-Up
Date: Nov 23, 2021
Visit Reason
Follow up completed on 11/23/2021 for deficiencies F580, neglect F600, comprehensive care plans F656, quality of care F684 and resident rights M0500.
Findings
The facility was found to be in compliance with the requirements of participation for Medicare and Medicaid. It is recommended to put the facility back into compliance.
Report Facts
Deficiencies cited: 5
Inspection Report — Oct 18, 2021
Complaint Investigation
Date: Oct 18, 2021
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI) from 10/12/21 through 10/18/21 for complaint # MS18163. During the survey, the facility was determined not to be in substantial compliance with the requirements of participation for Medicare and Medicaid. An extended survey was completed, and deficiencies were cited: F580, F600, F656, and F684.
Complaint Details
Complaint # MS18163. The complaint investigation found the facility was not in substantial compliance due to neglect related to failure to notify the physician and obtain treatment orders for a deteriorating surgical wound, resulting in serious harm to Resident #1. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility was found not in substantial compliance due to failure to notify the primary physician and resident representative of a significant change in a resident's acute surgical wound, resulting in worsening of the wound and hospitalization for sepsis. The facility failed to obtain physician orders for removal of staples and appropriate wound care, placing residents at risk of serious harm.
Deficiencies (4)
F0580 - Notification of Changes. The facility failed to notify the primary physician and resident representative of a significant change in Resident #1's acute surgical wound and did not obtain treatment orders, resulting in wound deterioration and hospitalization.
F0600 - Free from Abuse and Neglect. The facility neglected Resident #1 by failing to provide necessary wound care and notify the physician of changes, resulting in wound dehiscence and sepsis.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement Resident #1's care plan by not notifying the physician of a deteriorating surgical wound and not obtaining treatment orders to address the decline.
F0684 - Quality of Care. Resident #1 did not receive treatment and care in accordance with professional standards due to failure to notify the physician of a deteriorating surgical wound and obtain treatment orders, resulting in wound worsening and hospitalization for sepsis.
Report Facts
Deficiencies cited: 4
Residents with acute surgical wounds: 2
Residents audited: 74
Staples on Resident #1's wound: 9
Inspection Report — Dec 20, 2020
Routine
Date: Dec 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 12/20/20.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Dec 3, 2020
Routine
Date: Dec 3, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 12/3/20.
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 — Oct 13, 2020
Routine
Date: Oct 13, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on October 13, 2020.
Findings
No new observations related to infection control were noted during this survey; however, the facility remains out of compliance based on deficiencies cited during the September 14, 2020 COVID-19 Focused Infection Control survey.
Inspection Report — Sep 14, 2020
Routine
Date: Sep 14, 2020
Visit Reason
The State Agency (SA) conducted a COVID 19 Focus Survey from 9/14/20 to 9/14/20. The SA determined the facility was not in compliance with requirements of participation in Medicare and Medicaid and cited the regulatory deficiency F880.
Findings
F0880 - Infection Prevention & Control. The facility failed to maintain an infection control program related to improper mask wearing by one dietary staff and failure to perform hand hygiene by one certified nursing assistant while passing lunch trays, potentially affecting multiple residents.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to maintain an infection control program related to not wearing a face mask properly during serving food on resident's lunch trays for one dietary staff and not performing hand hygiene while passing resident's lunch trays for one certified nursing assistant, potentially affecting multiple residents.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 17, 2020
Routine
Date: Aug 17, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/17/20. 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 — May 29, 2020
Routine
Date: May 29, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/29/20.
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 — May 2, 2019
Annual Inspection
Date: May 2, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 04/29/2019 to 05/02/2019. 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 due to infection prevention and control deficiencies involving sharing of personal care items and use of a single bag to transport resident care supplies between rooms, risking cross contamination.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the potential spread of infection by sharing personal care items and using a single bag to transport resident care supplies from room to room on one of four halls observed.
Report Facts
Deficiencies cited: 1
Inspection Report — Feb 20, 2019
Complaint Investigation
Date: Feb 20, 2019
Visit Reason
A complaint investigation was conducted on February 20, 2019 in the facility.
Complaint Details
CI MS #15593: A complaint investigation was conducted and found unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Mar 30, 2018
Annual Inspection
Date: Mar 30, 2018
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 3/27/18 to 3/30/18. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation.
Findings
The facility was found not in compliance due to failure to coordinate PASARR Level II screenings properly and incomplete sprinkler system coverage in one smoke compartment. Emergency preparedness requirements were met with no deficiencies identified.
Deficiencies (2)
F0644 - The facility failed to ensure Level II PASARR screenings were completed prior to admission and upon significant change in resident status, as evidenced by Resident #45 not receiving a required Level II screening after a new diagnosis of Psychosis.
K0351 - The facility failed to provide complete automatic sprinkler system coverage in the HVAC closet of the Therapy Room, affecting one of five smoke compartments and 21 residents.
Report Facts
Deficiencies cited: 2
3 CMS Surveys
CMS Survey — May 5, 2022
May 5, 2022
CMS Survey — Oct 5, 2023
Oct 5, 2023
CMS Survey — Apr 10, 2025
Apr 10, 2025
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