Inspection Reports for
Grenada Rehabilitation and Healthcare Center
1966 Hill Drive, Grenada, MS, 38901
Back to Facility Profile58 Reports
Inspection Report — Apr 29, 2026
Follow-Up
Date: Apr 29, 2026
Visit Reason
On 4/29/26 the State Agency (SA) conducted an onsite revisit for the complaint survey completed on 4/6/26. The information reviewed confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with requirements of the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Complaint Details
Complaint survey completed on 4/6/26; the facility was found to be in compliance upon revisit.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm as of 4/23/26.
Report Facts
Deficiencies cited: 0
Inspection Report — Apr 6, 2026
Complaint Investigation
Date: Apr 6, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS #2962512, CI MS #2969216, and CI MS #2969871) at the facility on 04/06/26. The facility was found not in compliance with deficiencies cited for CI MS #2962512 related to failure to provide timely Activities of Living (ADL) care. No deficiencies were cited for the other two complaints related to verbal abuse.
Complaint Details
CI MS #2962512 involved failure to provide timely Activities of Living (ADL) care to Resident #2. The complaint was substantiated with deficiencies cited. CI MS #2969216 and CI MS #2969871 related to verbal abuse were not substantiated and no deficiencies were cited.
Findings
The facility failed to ensure a resident's right to be treated with dignity and respect by not responding timely to Resident #2's requests for assistance, leaving him in a soiled brief for over an hour. This failure caused embarrassment and humiliation and put the resident at risk for skin breakdown and pressure ulcers.
Deficiencies (2)
F0550 - Resident Rights/Exercise of Rights. The facility failed to respond timely to Resident #2's requests for assistance, leaving him in a soiled brief for over an hour, causing embarrassment and humiliation.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide timely incontinence care for Resident #2, leaving him in a soiled brief for over an hour, which caused embarrassment, humiliation, and risk for skin impairment.
Report Facts
Deficiencies cited: 2
Complaint investigations: 3
Inspection Report — Mar 2, 2026
Complaint Investigation
Date: Mar 2, 2026
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS# 2679910) at the facility on 3/2/26.
Complaint Details
Complaint number CI MS# 2679910 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Feb 3, 2026
Complaint Investigation
Date: Feb 3, 2026
Visit Reason
The State Agency (SA) conducted a Complaint Investigation (CI MS #2732430) at the facility on 2/3/26 for nursing services and admission, transfer & discharge rights.
Complaint Details
CI MS #2732430 was investigated for nursing services and admission, transfer & discharge rights. The complaint was not substantiated as no deficiencies were cited.
Findings
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 — Nov 25, 2025
Follow-Up
Date: Nov 25, 2025
Visit Reason
The State Agency (SA) conducted a Follow-up Survey at the facility on 11/25/25. The SA determined the facility was in compliance with Medicare and Medicaid regulations for participation.
Findings
The facility was found in compliance with Medicare and Medicaid regulations during the follow-up survey.
Inspection Report — Nov 25, 2025
Follow-Up
Date: Nov 25, 2025
Visit Reason
The State Agency (SA) conducted a Follow-up Survey at the facility on 11/25/25.
Findings
The SA determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm and recommended the facility be placed back in compliance effective 11/19/25.
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
The inspection was conducted following complaints regarding physical abuse by a Certified Nurse Assistant and concerns about insufficient nursing staff leading to delayed care and response times.
Complaint Details
The complaint investigation substantiated physical abuse by CNA #4 against Resident #7. Numerous complaints from residents and families about staffing shortages and delayed care were confirmed by interviews and record reviews.
Findings
The facility substantiated physical abuse by a CNA who pushed a resident onto a bed causing potential harm. Additionally, the facility failed to maintain sufficient nursing staff to meet residents' needs, resulting in prolonged call-light response times and delays in care affecting all 94 residents.
Deficiencies (2)
F 0600: The facility failed to protect a resident from physical abuse by a CNA who forcefully pushed the resident onto the bed, confirmed by interviews and investigation.
F 0725: The facility failed to provide enough nursing staff daily to meet residents' needs, causing delays in call-light responses and care for all 101 residents.
Report Facts
Residents affected by abuse: 1
Residents affected by staffing issues: 101
Residents per CNA ratio: 15
Staffing shifts and resident counts: 95
Staffing shifts and resident counts: 91
Staffing shifts and resident counts: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #4 | Certified Nurse Assistant | Named in physical abuse finding and terminated after investigation. |
| CNA #1 | Certified Nurse Assistant | Witnessed abuse and reported it to administration. |
| Administrator | Administrator (ADM) | Conducted investigation and confirmed abuse and staffing issues. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding abuse and staffing concerns. |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Handled scheduling and confirmed staffing problems. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse (LPN) | Interviewed about staffing shortages and care delays. |
| Respiratory Therapist | Respiratory Therapist | Reported staffing shortages affecting care for residents with tracheostomies. |
Inspection Report — Oct 29, 2025
Complaint Investigation
Date: Oct 29, 2025
Visit Reason
The State Agency conducted four complaint investigations (CI MS# 2623645, CI MS# 2626262, CI MS# 2639198 and CI MS# 2628498) at the facility on 10/28/25-10/29/25. The facility was found not in compliance with Medicare and Medicaid requirements for all four complaints and cited F0725, and additionally cited F0600 for abuse in CI MS# 2639198.
Complaint Details
Four complaint investigations (CI MS# 2623645, CI MS# 2626262, CI MS# 2639198 and CI MS# 2628498) were conducted. The facility was found not in compliance for all four complaints and cited deficiencies. Abuse was substantiated in CI MS# 2639198 with citation of F0600.
Findings
The facility was found to have substantiated physical abuse by a CNA against a resident and insufficient nursing staff to meet residents' needs, resulting in delayed care and prolonged call-light response times affecting all residents.
Deficiencies (2)
F0600 - The facility failed to ensure a resident's right to be free from physical abuse by a Certified Nurse Assistant, resulting in a resident being forcefully pushed down onto the bed causing potential physical and psychological harm.
F0725 - The facility failed to provide sufficient qualified nursing staff at all times to meet residents' needs, resulting in prolonged call-light response times, delays in assistance with care, and potential harm to all residents.
Report Facts
Deficiencies cited: 2
Complaint investigations: 4
Inspection Report — Sep 9, 2025
Complaint Investigation
Date: Sep 9, 2025
Visit Reason
On 09/09/25 the State Agency conducted a desk review of the information provided related to the complaint survey completed on 08/13/25. The facility confirmed measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS#26995 complaint survey completed on 08/13/25; the facility was found in compliance after the desk review.
Findings
The State Agency found the facility in compliance and is recommending the facility be placed back in compliance effective 09/08/25. No deficiencies were cited in this document.
Report Facts
Deficiencies cited: 0
Inspection Report — Aug 13, 2025
Complaint Investigation
Date: Aug 13, 2025
Visit Reason
The inspection was conducted in response to an online complaint alleging that the facility failed to provide written transfer notification to a resident's representative.
Complaint Details
The complaint alleged that the resident's representative was not notified of the resident's transfer to the emergency room on 6/25/25. This was substantiated by record review and staff interview.
Findings
The facility failed to provide written transfer notice to the representative of one resident who was transferred to the emergency room. The Administrator stated no notification was sent because the resident returned within a few hours.
Deficiencies (1)
F 0628: The facility failed to provide required documentation or notification related to a resident's transfer or discharge. Specifically, the resident's representative was not notified in writing of the transfer to the emergency room on 6/25/25.
Report Facts
Residents records reviewed: 9
Residents affected: 1
Inspection Report — Aug 13, 2025
Complaint Investigation
Date: Aug 13, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI# 2570923, CI# 2572006, CI# 2583570, CI# 475360, CI# 475361, CI# 475362, CI# 475363, and CI# 475369) at the facility from 8/11/25 through 8/13/25. During the survey, the SA determined that the facility was not in compliance with the requirements of participation in Medicare and Medicaid Services.
Complaint Details
Complaint investigation involved multiple complaint numbers including CI# 2570923, CI# 2572006, CI# 2583570, CI# 475360, CI# 475361, CI# 475362, CI# 475363, and CI# 475369. Deficiency was cited only for CI# 475363 related to failure to provide proper discharge/transfer notice. Other complaints had no deficiencies cited.
Findings
The facility was found not in compliance due to failure to provide proper discharge/transfer notice for one resident. No deficiencies were cited for the other complaint investigations.
Deficiencies (1)
F0628 - Discharge Process. The facility failed to provide written transfer notice to a resident’s representative for one of nine residents reviewed, specifically Resident #1 who was transferred to the emergency room without written notification to the representative.
Report Facts
Deficiencies cited: 1
Inspection Report — Apr 8, 2025
Complaint Investigation
Date: Apr 8, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS # 27516 and CI MS #27900) at the facility on 4/8/25.
Complaint Details
Complaint Investigation CI MS # 27516 and CI MS #27900 were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. There were no deficiencies cited.
Report Facts
Complaint Investigations: 2
Inspection Report — Aug 28, 2024
Annual Inspection
Date: Aug 28, 2024
Visit Reason
On 08/28/24 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 07/18/24.
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 08/22/24.
Inspection Report — Aug 28, 2024
Date: Aug 28, 2024
Visit Reason
On 08/28/24 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey completed on 07/18/24. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 08/22/24. No deficiencies were cited in this desk review.
Inspection Report — Jul 18, 2024
Annual Inspection
Date: Jul 18, 2024
Visit Reason
The State Agency conducted an annual re-certification and two complaint investigations (CI MS #25383 and CI MS #25658) survey at the facility from July 15, 2024 to July 18, 2024. No deficiencies were cited related to these complaints.
Complaint Details
Two complaint investigations (CI MS #25383 and CI MS #25658) were conducted during the survey. No deficiencies were cited related to these complaints.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for six deficiencies related to resident assessments, nursing staff competency, payroll-based journal reporting, and infection prevention and control.
Deficiencies (6)
F0609 - Not cited in the text, but listed in Initial Comments as cited.
F0636 - The facility failed to complete an Annual Minimum Data Set (MDS) within 14 days of the Assessment Reference Date for one of 19 assessments reviewed, Resident #24, with late submission confirmed by the MDS Coordinator and Consultant.
F0638 - The facility failed to complete a Quarterly Minimum Data Set (MDS) within 14 days of the Assessment Reference Date for one of 19 assessments reviewed, Resident #49, with late submission confirmed by the MDS Coordinator and Consultant.
F0726 - The facility failed to ensure respiratory therapist staff completed competency skills check-off and Enhanced Barrier Precautions training prior to caring for residents with tracheostomies, as evidenced by RT #1 performing tracheostomy care without proper PPE and hand hygiene.
F0851 - The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for the second quarter of 2024, with direct care hours worked by department managers not correctly reported.
F0880 - The facility failed to prevent the possibility of infection spread by not ensuring Enhanced Barrier Precautions and proper hand hygiene during tracheostomy care for Resident #53, as Respiratory Therapist #1 did not wear a gown or perform appropriate hand hygiene.
Report Facts
Deficiencies cited: 6
Inspection Report — Jul 18, 2024
Complaint Investigation
Date: Jul 18, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of abuse involving Resident #58.
Complaint Details
The complaint investigation found that the facility did not report an allegation of abuse within the required timeframe. The allegation involved Resident #58 and was substantiated by staff interviews and policy review.
Findings
The facility did not report an allegation of abuse to the State Agency within two hours after the incident occurred. Interviews and record reviews confirmed that Nursing Assistant #1 delayed reporting the incident until the next day, contrary to facility policy.
Deficiencies (1)
F 0609: The facility failed to timely report suspected abuse to the State Agency within two hours after the incident involving Resident #58. Nursing Assistant #1 did not report the incident immediately as required by policy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Assistant #1 | Named in failure to report abuse allegation involving Resident #58. | |
| Certified Nursing Assistant #1 | Witnessed the abuse incident involving Resident #58. | |
| Registered Nurse #1 | Interviewed regarding the delayed reporting of the abuse incident. | |
| Director of Nursing | Director of Nursing | Interviewed about the facility's awareness of the abuse incident and disciplinary action. |
Inspection Report — Jul 18, 2024
Life Safety
Date: Jul 18, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. There were no Life Safety Code deficiencies cited during this survey.
Inspection Report — Jul 18, 2024
Date: Jul 18, 2024
Visit Reason
The survey documents an investigation into the facility's failure to report an allegation of abuse within the required timeframe.
Findings
The facility failed to report an allegation of abuse to the State Agency within two hours after the incident occurred, as evidenced by staff interviews and record review.
Deficiencies (1)
F0609 - Reporting of Alleged Violations. The facility did not report an allegation of abuse to the State Agency within two hours after the incident for one of four investigations involving Resident #58.
Report Facts
Deficiencies cited: 1
Inspection Report — Jul 18, 2024
Annual Inspection
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including timely completion of resident assessments, staff competency, infection control, and accurate staffing data submission.
Findings
The facility failed to complete timely Minimum Data Set (MDS) assessments for residents, did not ensure competency training and proper infection control practices for respiratory staff, and submitted inaccurate staffing data to the Payroll-Based Journal (PBJ) system.
Deficiencies (5)
F0636: The facility failed to complete an Annual Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #24.
F0638: The facility failed to complete a Quarterly Minimum Data Set (MDS) assessment within 14 days of the Assessment Reference Date for Resident #49.
F0726: The facility failed to ensure one respiratory therapist completed competency skills check-off and Enhanced Barrier Precautions training prior to providing care for residents with tracheostomies.
F0851: The facility failed to submit accurate direct care staffing data into the Payroll-Based Journal system for the second quarter of 2024.
F0880: The facility failed to prevent infection spread by not ensuring Enhanced Barrier Precautions and proper hand hygiene during tracheostomy care for Resident #53.
Report Facts
Number of assessments reviewed: 19
Number of respiratory staff personnel files reviewed: 4
Number of resident care treatments observed: 4
Number of quarters reviewed: 4
Quarter: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT #1 | Respiratory Therapist | Named in findings for lack of competency training and improper infection control during tracheostomy care |
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding staffing data submission and infection control standards |
| Assistant Director of Nurses | Assistant Director of Nurses (ADON) | Confirmed lack of in-service training for respiratory therapist |
| Respiratory Therapist Director | Respiratory Therapist Director | Interviewed regarding training and infection control standards |
| Human Resources/Payroll Coordinator | Human Resources/Payroll Coordinator | Interviewed regarding Payroll-Based Journal data submission |
| Corporate Consultant | Corporate Consultant | Confirmed errors in Payroll-Based Journal data entry |
| MDS Coordinator | MDS Coordinator | Confirmed late completion of Minimum Data Set assessments |
| MDS Consultant | MDS Consultant | Confirmed ongoing issues with timely MDS completion and submission |
Inspection Report — Apr 17, 2024
Complaint Investigation
Date: Apr 17, 2024
Visit Reason
The State Agency conducted two Complaint Investigations (CI MS #24201 and CI MS# 24338) at the facility from 4/16/24 through 4/17/24, investigating pressure sores, activities of daily living, neglect, call lights, dress, weight loss, contractures, visitation, and environment.
Complaint Details
Two complaint investigations (CI MS #24201 and CI MS# 24338) were conducted, covering multiple allegations including pressure sores and neglect; no deficiencies were cited and the complaints were not substantiated.
Findings
The facility was found to be in compliance with the Minimum Standards of Operation for Institutions of Aged or Infirm, with no deficiencies cited.
Report Facts
Complaint Investigations conducted: 2
Inspection Report — Sep 26, 2023
Complaint Investigation
Date: Sep 26, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI MS #22843, #22753 and #22887) at the facility on 9/25/23 through 9/26/23. The SA investigated verbal abuse, sexual abuse, quality of care/grooming, Therapy Services, call light not accessible, no water access for residents, inappropriate feeding assistance with no deficiencies cited.
Complaint Details
Complaint Investigation CI MS #22843, #22753 and #22887 involved allegations of verbal abuse, sexual abuse, quality of care/grooming, Therapy Services, call light accessibility, water access, and feeding assistance. 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. No deficiencies were cited during this complaint investigation.
Report Facts
Complaints investigated: 3
Inspection Report — Jun 29, 2023
Follow-Up
Date: Jun 29, 2023
Visit Reason
The State Agency conducted a revisit to the annual recertification survey on 6/26/23-6/28/23. During the survey, the SA determined the facility was in compliance with the requirements for participation in Medicare and Medicaid as of 6/15/2023.
Findings
The facility was found to be in compliance with all requirements during this revisit.
Inspection Report — May 15, 2023
Annual Inspection
Date: May 15, 2023
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 4/30/2023 to 5/15/2023. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements of participation. The SA identified non-compliance and cited multiple F-tags during the annual survey. The SA re-entered the facility on 5/15/23 for a Complaint Investigation (CI MS # 21504) related to neglect, pressure sores and staffing and determined the facility was in compliance with Medicare and Medicaid requirements of participation related to CI MS # 21504.
Complaint Details
CI MS # 21504 related to neglect, pressure sores and staffing was investigated during a re-entry on 5/15/23 and the facility was determined to be in compliance with Medicare and Medicaid requirements related to this complaint.
Findings
The facility was found not in compliance with multiple federal requirements including resident rights, care planning, medication administration, infection control, food safety, and quality of care. Deficiencies included failure to respect resident rights, incomplete care plans, medication errors, improper storage of medications and food, and inadequate infection prevention practices.
Deficiencies (11)
F0550 - Resident Rights/Exercise of Rights. The facility failed to respect the right of a cognitively intact resident by applying a lap tray against her wishes without proper consent and notification to the resident's representative.
F0578 - Request/Refuse/Discontinue Treatment; Formulate Advance Directives. The facility failed to review and gain consent on a cognitively intact resident's advance directives and failed to obtain a physician's order and formulate a Do Not Resuscitate status in the medical record for another resident.
F0604 - Right to be Free from Physical Restraints. The facility failed to ensure a resident was assessed for the need of physical restraint prior to applying a lap tray and failed to obtain timely consent prior to application.
F0655 - Baseline Care Plan. The facility failed to complete a baseline care plan within 48 hours of admission for a new resident, leaving the social services section incomplete.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop and implement a comprehensive care plan for a resident's splints and for monitoring side effects and behaviors related to psychotropic medication for another resident.
F0657 - Care Plan Timing and Revision. The facility failed to include a resident in the development of their plan of care and failed to document resident participation in care plan meetings.
F0658 - Services Provided Meet Professional Standards. The facility failed to ensure medications were administered according to professional standards, including failure to sign off medications as administered and failure to check the five rights of medication prior to administration.
F0759 - Free of Medication Error Rate 5% or More. The facility's medication error rate was 6.9% during observation due to failure to administer medications as ordered and signing off medications not given.
F0761 - Label/Store Drugs and Biologicals. The facility failed to store drugs and biologicals in locked compartments as required, leaving a medication storage room open and unattended with medications accessible.
F0812 - Food Procurement, Store, Prepare, Serve Sanitary. The facility failed to properly label and store food items in kitchen and resident nourishment refrigerators, failed to maintain temperature logs and cleaning schedules, and stored expired food items.
F0880 - Infection Prevention and Control. The facility failed to prevent the possible spread of infection by failing to remove gloves and perform hand hygiene after administering eye drops and prior to oral medication administration, and failed to sanitize an eye drop box before returning it to the medication cart.
Report Facts
Deficiencies cited: 14
Medication error rate: 6.9
Inspection Report — May 15, 2023
Routine
Date: May 15, 2023
Visit Reason
Routine inspection of Grenada Rehabilitation and Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to respect resident rights, incomplete or missing care plans, medication administration errors, improper storage and labeling of food, inadequate infection control practices, and failure to maintain proper documentation and assessments related to restraints and advance directives.
Deficiencies (13)
F 0550: The facility failed to respect the right of a cognitively intact resident by applying a lap tray against her wishes without proper consent.
F 0578: The facility failed to review and gain consent on cognitively intact residents' advance directives and failed to obtain a physician's order for Do Not Resuscitate status for two residents.
F 0604: The facility failed to ensure a resident was assessed for the need of physical restraint prior to applying a lap tray and did not obtain timely consent.
F 0655: The facility failed to complete a baseline care plan within 48 hours for a new admit resident.
F 0656: The facility failed to develop and implement comprehensive care plans for a resident's orthopedic devices and psychotropic medication monitoring.
F 0657: The facility failed to include a resident in the development of their plan of care.
F 0658: The facility failed to meet professional standards of quality in medication administration, including failure to sign off medications and failure to check the five rights of medication.
F 0684: The facility failed to provide appropriate treatment and care according to orders and resident preferences related to orthopedic devices for a resident.
F 0758: The facility failed to monitor for side effects and behaviors related to psychotropic medications for a resident.
F 0759: The facility's medication error rate was 6.9%, exceeding the acceptable threshold of 5%, due to errors in medication administration for a resident.
F 0761: The facility failed to ensure drugs and biologicals were stored securely, as a medication storage room was left open and unattended with medications accessible.
F 0812: The facility failed to properly label and store food items, maintain temperature logs, and clean resident nourishment refrigerators, risking foodborne illness.
F 0880: The facility failed to prevent possible spread of infection by not removing gloves and performing hand hygiene after administering eye drops and before oral medications, and not sanitizing an eye drop box.
Report Facts
Medication error rate: 6.9
Residents reviewed for restraint assessment: 18
Residents sampled: 29
Residents care plans reviewed: 20
Residents reviewed for unnecessary medications: 6
Medication error opportunities observed: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Failed to remove gloves and perform hand hygiene after eye drops and before oral meds; failed to sanitize eye drop box |
| LPN #3 | Licensed Practical Nurse | Medication administration errors including wrong medication form and missed medication |
| Director of Nursing | Director of Nursing | Confirmed multiple deficiencies including consent, medication administration, and storage issues |
| Assistant Director of Nursing | Assistant Director of Nursing | Administered IV medication without checking five rights |
| Infection Control Nurse | Infection Control Nurse | Provided education on medication administration and infection control practices |
| Dietary Manager | Dietary Manager | Confirmed expired food items and lack of proper labeling and cleaning schedules |
| Occupational Therapist | Occupational Therapist | Failed to document splint application for Resident #17 |
| Physical Therapist | Physical Therapist | Confirmed lack of documentation for splint application |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed Resident #17 not wearing ordered orthopedic devices |
| LPN #4 | Licensed Practical Nurse | Confirmed failure to follow psychotropic medication care plan |
Inspection Report — May 4, 2023
Life Safety
Date: May 4, 2023
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility met the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Apr 10, 2023
Follow-Up
Date: Apr 10, 2023
Visit Reason
The State Agency (SA) conducted a follow-up survey at the facility on 4/10/23, after a complaint survey with deficiencies on 2/27/23 through 3/3/23.
Findings
The SA recommends putting the facility back into compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirmed.
Inspection Report — Apr 10, 2023
Follow-Up
Date: Apr 10, 2023
Visit Reason
The State Agency conducted a follow-up survey at the facility on 4/10/23, after a complaint survey with deficiencies from 2/27/23 through 3/3/23. The SA recommends putting the facility back into compliance with the requirements for participation in Medicare and Medicaid effective 3/31/23.
Findings
This follow-up survey was conducted to verify the facility's compliance with previously cited deficiencies. The document does not list any new deficiencies, indicating the facility was found in compliance at the time of this follow-up.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 3, 2023
Complaint Investigation
Date: Mar 3, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and develop a care plan for a resident at risk of wandering and elopement.
Complaint Details
The complaint investigation substantiated that the facility failed to prevent elopement of Resident #1, who was cognitively intact but exhibited wandering and exit seeking behaviors. The resident left the facility unnoticed and was found injured in the community. The facility was notified by the local hospital emergency room. Immediate Jeopardy was identified and removed after corrective actions.
Findings
The facility failed to develop and implement a comprehensive care plan and provide supervision to prevent elopement of Resident #1, who exhibited exit seeking behaviors and left the facility unnoticed and unsupervised. This failure placed the resident and others at risk of serious harm. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan with measurable actions for Resident #1 exhibiting exit seeking behaviors and wandering risk. Supervision was inadequate, allowing the resident to elope unnoticed and sustain injuries.
F 0689: The facility failed to provide adequate supervision and accident hazard prevention to stop Resident #1 from eloping through a window, resulting in injury and risk of serious harm.
Report Facts
Resident wandering risk score: 28
Resident last seen time: 21
Resident found time: 21.53
Distance from facility: 236.22
Number of residents audited: 88
Number of residents at high risk for wandering: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | On duty charge nurse who responded to Resident #1's elopement and assessed injuries. |
| LPN #1 | Licensed Practical Nurse | Witnessed Resident #1's exit seeking behavior and last saw resident before elopement. |
| CNA #1 | Certified Nursing Assistant | Assigned to Resident #1, monitored wandering behavior and provided observations. |
| CNA #2 | Certified Nursing Assistant | Assisted in monitoring Resident #1 and responded to elopement event. |
| Administrator | Nursing Home Administrator | Notified of Immediate Jeopardy and participated in corrective action plan. |
| ADON | Assistant Director of Nursing | Conducted resident audits, investigations, and staff in-services related to elopement. |
| DON | Director of Nursing | Conducted audits and interviews regarding wandering residents and care plans. |
| RDCS | Regional Director of Clinical Services | Conducted audits and staff in-services on care plans and wandering interventions. |
| SDC | Staff Development Nurse | Conducted nursing staff in-service on care plans for wandering and elopement risk. |
| Maintenance Supervisor | Maintenance Supervisor | Inspected elopement site and window, described physical environment of elopement. |
Inspection Report — Mar 3, 2023
Complaint Investigation
Date: Mar 3, 2023
Visit Reason
The State Agency conducted three Complaint Investigations from 2/27/2023 to 3/3/2023 for CI MS #20856, CI MS #20857, and CI MS #20895. Non-compliance was identified for CI MS #20856 related to failure to develop and implement a comprehensive care plan and failure to provide supervision to prevent elopement. No deficiencies were cited for the other two complaints.
Complaint Details
CI MS #20856 cited for failure to develop and implement a comprehensive care plan and failure to provide supervision to prevent elopement. Immediate Jeopardy was identified and later removed after corrective actions.
Findings
The facility failed to develop and implement care plan interventions and failed to provide supervision to prevent elopement for Resident #1, a wandering risk who left the facility unnoticed and unsupervised on 2/23/2023, resulting in injuries. Immediate Jeopardy was identified and removed after corrective actions were implemented.
Deficiencies (2)
F0656 - The facility failed to develop and implement a comprehensive care plan for Resident #1 who displayed exit seeking behaviors and eloped from the facility. Care plan interventions were delayed and supervision was inadequate, placing the resident and others at risk of serious harm.
F0689 - The facility failed to provide adequate supervision and accident prevention devices to prevent Resident #1 from leaving the facility unsupervised through a broken window, resulting in injury and risk of harm.
Report Facts
Deficiencies cited: 2
Inspection Report — Jan 25, 2023
Complaint Investigation
Date: Jan 25, 2023
Visit Reason
The State Agency conducted a desk review of information related to the complaint survey completed on 11/30/22. 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 - The complaint survey completed on 11/30/22 was reviewed and the facility was found to have corrected the deficient practice and sustained compliance.
Findings
The facility was found to be in compliance as of 01/13/23 with no deficiencies cited during this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Jan 25, 2023
Routine
Date: Jan 25, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) from 11/28/22 to 11/30/22.
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 — Nov 30, 2022
Routine
Date: Nov 30, 2022
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 11/28/22 to 11/30/22.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report — Nov 30, 2022
Complaint Investigation
Date: Nov 30, 2022
Visit Reason
The State Agency (SA) conducted a complaint survey, MS CI #19742 at the facility from 11/28/22 to 11/30/22. The SA substantiated the complaint for Dietary Services: Residents Not Offered Snack At Night and cited F809. The SA also cited F812 and F925 during the survey.
Complaint Details
Complaint investigation MS CI #19742 substantiated for Dietary Services: Residents Not Offered Snack At Night with deficiencies cited.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements. Deficiencies were cited for failure to provide snacks between meals, unsanitary food preparation and storage conditions, and ineffective pest control resulting in insect infestations in the kitchen and dry storage areas.
Deficiencies (3)
F0809 - Frequency of Meals/Snacks at Bedtime. The facility failed to provide snacks between meals for residents, as evidenced by a prepared resident snack cart remaining in the dining room past snack time for 4 of 5 residents interviewed, and lack of assigned staff to ensure snack delivery.
F0812 - Food Procurement/Store/Prepare/Serve Sanitary. The facility failed to maintain a clean and sanitary kitchen environment, including buildup of food residue and rust on equipment, unclean food preparation and drying equipment, and unsanitary floors and surfaces, posing a risk of fire and contamination.
F0925 - Maintains Effective Pest Control Program. The facility failed to maintain an effective pest control program, as evidenced by multiple insect/rodent sticky traps containing numerous dead insects and pests in the kitchen and dry storage room, and failure to promptly replace traps or notify maintenance.
Report Facts
Deficiencies cited: 3
Inspection Report — Sep 22, 2022
Complaint Investigation
Date: Sep 22, 2022
Visit Reason
The State Agency (SA) conducted a complaint survey MS #19561 and MS #19597 on 9/21/22-9/22/22. The SA did not substantiate the complaints regarding Quality of Care/treatment inappropriate feeding assist for weight loss residents and Dietary Services (MS #19561) and Quality of Care/Treatment pressure sore precautions, call bells not answered timely, residents not groomed adequately and services not performed per MD orders (MS #19597).
Complaint Details
Complaint MS #19561 alleged inappropriate feeding assist for weight loss residents and Dietary Services; complaint MS #19597 alleged pressure sore precautions, call bells not answered timely, residents not groomed adequately and services not performed per MD orders. Both complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Report Facts
Complaints investigated: 2
Inspection Report — Aug 4, 2022
Complaint Investigation
Date: Aug 4, 2022
Visit Reason
The State Agency conducted a complaint survey MS #19387 and MS #19384 from 8/3/22-8/4/22. The SA did not substantiate the complaint of MS #19387 with an allegation of Quality of Care/Treatment/left wet and soiled, Pressure Sore Precautions, Activities of Daily Living, Medical Doctor Orders not followed and MS #19384 with an allegation of Accidents/falls.
Complaint Details
Complaint MS #19387 alleged Quality of Care/Treatment issues and MS #19384 alleged Accidents/falls; both complaints were not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm with no deficiencies cited.
Inspection Report — Aug 3, 2022
Complaint Investigation
Date: Aug 3, 2022
Visit Reason
The State Agency (SA) 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, neglect, safety/falls, and services not performed per Medical Doctor orders. The complaint was not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the complaint and found the facility in compliance with Medicare and Medicaid requirements. No deficiencies were cited.
Report Facts
Complaint count: 1
Inspection Report — Jun 30, 2022
Complaint Investigation
Date: Jun 30, 2022
Visit Reason
The State Agency conducted a complaint survey MS #18679, MS #19330, and MS #19329 from 6/29/22-6/30/22.
Complaint Details
Complaint survey MS #18679, MS #19330, and MS #19329 were investigated with allegations of Quality of Care, Neglect, Physicians Services, Dietary Services. None of the complaints were substantiated.
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
Complaints investigated: 3
Inspection Report — Dec 16, 2021
Complaint Investigation
Date: Dec 16, 2021
Visit Reason
The State Agency conducted a facility reported incident complaint survey, MS # 18246 at the facility from 12/16/2021 to 12/16/2021.
Complaint Details
Complaint MS #18246 related to quality of care and safety/falls was investigated and not substantiated; no deficiencies were cited.
Findings
The survey determined that the facility followed the requirements for participation in Medicare and Medicaid and cited no deficiencies.
Report Facts
Complaint count: 1
Inspection Report — Jul 15, 2021
Complaint Investigation
Date: Jul 15, 2021
Visit Reason
A Complaint Investigation (CI) was conducted 7/12/21-7/15/21 by the State Agency (SA). Complaints investigated were #17840, #17578, #17507, #17524, #17023 and #17001. The allegations were neglect, resident rights, Quality of Care, Pressure sore prevention, Following MD orders, Misappropriation of property, staffing, Injury of unknown origin, RP notifications.
Complaint Details
Complaints investigated were #17840, #17578, #17507, #17524, #17023 and #17001. The facility was found to be in compliance with no deficiencies cited.
Findings
The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. No deficiencies were cited.
Report Facts
Complaints investigated: 6
Inspection Report — Jul 15, 2021
Complaint Investigation
Date: Jul 15, 2021
Visit Reason
A Complaint Investigation (CI) was conducted 7/12/21-7/15/21 by the State Agency (SA). Complaints investigated were #17840, #17578, #17507, #17524, #17023 and #17001. The allegations were neglect, resident rights, Quality of Care, Pressure sore prevention, Following MD orders, Misappropriation of property, staffing, Injury of unknown origin, RP notifications.
Complaint Details
Complaint Investigation numbers #17840, #17578, #17507, #17524, #17023 and #17001 were investigated. The facility was found in compliance and no deficiencies were cited.
Findings
The facility was found to be in compliance with Centers for Medicare and Medicaid (CMS) regulations. No deficiencies were cited.
Report Facts
Complaints investigated: 6
Inspection Report — Jan 12, 2021
Routine
Date: Jan 12, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 1/12/21.
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 — Jan 12, 2021
Routine
Date: Jan 12, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 1/12/21.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024(b)(6).
Inspection Report — Aug 5, 2020
Routine
Date: Aug 5, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 8/5/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Aug 5, 2020
Routine
Date: Aug 5, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 8/5/2020.
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 — Jul 9, 2020
Routine
Date: Jul 9, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/9/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jul 9, 2020
Routine
Date: Jul 9, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/9/20.
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 — Jun 24, 2020
Routine
Date: Jun 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/24/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — Jun 24, 2020
Routine
Date: Jun 24, 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 — 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 — Feb 20, 2020
Annual Inspection
Date: Feb 20, 2020
Visit Reason
The State Agency (SA) conducted an annual recertification survey from 02/17/2020 to 02/20/2020. The SA determined the facility was not in compliance with requirements of participation in Medicare and Medicaid.
Findings
The facility was found not in compliance with deficiencies cited at F584, F641, F656, F761, and F812. Deficiencies included failure to maintain a safe, clean, homelike environment, inaccurate MDS assessments, failure to implement care plans, improper labeling and disposal of medications, and unsanitary food storage and preparation areas.
Deficiencies (5)
F0584 - Safe/clean/homelike environment. The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, homelike environment on three of four halls, with issues including dirt and debris on floors and baseboards, broken trim, burn holes in tile, peeling baseboards, cracked tiles, leaking faucets, and sharp edges.
F0641 - Accuracy of Assessments. The facility failed to accurately code a Minimum Data Set (MDS) discharge status for one resident, coding discharge to an acute hospital instead of home with home health services.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement the care plan related to a diet order for one resident who did not receive meals as ordered due to swallowing issues.
F0761 - Label/Store Drugs and Biologicals. The facility failed to properly label opened medications and discard expired medications within the manufacturer's recommended time frame for two medication carts and one medication storage room, including expired creams and insulin vials beyond 28 days of opening.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to maintain a clean and sanitary environment and store food properly to prevent foodborne illnesses, with expired and undated food items in refrigerators, freezers, and dry storage, and unclean kitchen equipment including ovens, ice machines, and buffet tables.
Report Facts
Deficiencies cited: 5
Inspection Report — Feb 18, 2020
Routine
Date: Feb 18, 2020
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to facility environment, resident assessments, care planning, medication management, and food safety.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment due to housekeeping and maintenance issues. There were inaccuracies in resident assessments, failure to implement care plans, improper medication labeling and storage, and unsanitary food storage and kitchen conditions.
Deficiencies (5)
F 0584: The facility failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable, homelike environment for three of four halls observed, including dirt accumulation, broken trim, cracked tiles, leaking faucets, and missing end caps exposing sharp edges.
F 0641: The facility failed to accurately code a Minimum Data Set (MDS) related to discharge status for one of 22 MDS assessments reviewed, resulting in incorrect discharge coding for Resident #90.
F 0656: The facility failed to implement the care plan related to a diet order for one of 22 residents reviewed, Resident #89, who did not receive meal trays as ordered due to swallowing issues.
F 0761: The facility failed to properly label opened medications and discard expired medications within the manufacturer's recommended time frame for two of three medication carts and one of four medication storage rooms, including expired creams and insulin past discard dates.
F 0812: The facility failed to maintain a clean and sanitary kitchen environment and store food properly, with observations of undated opened food items, carbon buildup on oven, food debris on ice machine, and unsanitary conditions in food preparation and storage areas.
Report Facts
MDS assessments reviewed: 22
Residents affected: 1
Residents affected: 1
Medication carts observed: 3
Medication storage rooms observed: 4
Expired tubes of barrier cream: 4
Expired tubes of skin repair cream: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding inaccurate coding of Resident #90's MDS assessment |
| LPN #2 | Licensed Practical Nurse / Wound Nurse | Interviewed about responsibility for removing expired wound or skin supplies |
| LPN #1 | Licensed Practical Nurse | Interviewed about insulin labeling and expiration practices |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding insulin vial labeling and discard dates |
| Director of Nursing | Director of Nursing | Provided statements on medication policies and responsibilities |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about care plan implementation for Resident #89 |
| Dietary Services Manager | Dietary Services Manager | Interviewed about kitchen cleaning schedules and food storage practices |
| Administrator | Facility Administrator | Interviewed regarding environmental concerns and kitchen sanitation |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed about Resident #89 not receiving meal trays |
Inspection Report — Dec 6, 2019
Complaint Investigation
Date: Dec 6, 2019
Visit Reason
The State Agency (SA) conducted a complaint survey, MS #16398, from 12/05/19 - 12/06/19. During the survey, the SA substantiated the complaint related to food services and determined the facility was not in compliance with State Licensure Regulations for the Aged or Infirm, and cited State Statutes at M815 and M970.
Complaint Details
Complaint survey MS #16398 was substantiated related to food services with deficiencies cited at M815 and M970.
Findings
The facility was found not in compliance with state regulations due to unsafe food handling procedures and pest control issues in the kitchen. Black ants were observed in the kitchen area and food temperatures were not consistently maintained at safe levels during meal service.
Deficiencies (2)
M815 - Safe Food Handling Procedures. The facility failed to serve food at safe temperatures during the dinner meal service on 12/5/19, affecting 85 of 98 residents, and dietary staff lacked proper training on checking and recording food temperatures.
M970 - Control of insects, rodents, etc. The facility failed to maintain a pest-free kitchen as black ants were observed crawling on food preparation surfaces and cabinets during the evening meal tray set up on 12/5/19.
Report Facts
Deficiencies cited: 2
Inspection Report — Dec 6, 2019
Complaint Investigation
Date: Dec 6, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation, MS #16398, from 12/5/19 to 12/6/19. The investigation was substantiated for food services, with deficiencies cited at F802, F804, F812, and F925. The facility was found not in compliance with Medicare and Medicaid requirements.
Complaint Details
CI MS #16398: The complaint investigation substantiated deficiencies related to food services, including insufficient dietary staffing, unsafe food temperatures, improper food service safety, and pest control issues.
Findings
The facility failed to employ sufficient dietary staff trained to check food temperatures, resulting in food served at unsafe and unappetizing temperatures to 85 of 98 residents. Additionally, the facility failed to maintain an effective pest control program evidenced by black ants observed in the kitchen area.
Deficiencies (4)
F0802 - The facility failed to employ sufficient dietary staff with appropriate competencies and skills to carry out food and nutrition service functions, as evidenced by untrained kitchen staff unable to check food temperatures affecting all residents.
F0804 - The facility failed to ensure food was served at a safe and appetizing temperature, with residents reporting cold food and observations confirming food temperatures below safe levels.
F0812 - The facility failed to serve food in accordance with professional food safety standards, with multiple food items served below safe temperatures during dinner service affecting all residents.
F0925 - The facility failed to maintain an effective pest control program, as black ants were observed crawling on kitchen surfaces and food preparation areas during meal service.
Report Facts
Deficiencies cited: 4
Residents assessed: 85
Total residents: 98
Inspection Report — Oct 21, 2019
Complaint Investigation
Date: Oct 21, 2019
Visit Reason
The State Survey Agency conducted a complaint investigation on 10/21/19.
Complaint Details
Complaint investigation CI MS #16241, CI MS #16255, CI MS #16294, CI MS #16305 & CI MS #16318 were substantiated with no deficiencies cited.
Findings
The investigation was substantiated with no deficiencies cited. The facility was found in compliance with Medicare and Medicaid requirements for participation.
Report Facts
Complaints investigated: 5
Inspection Report — Aug 22, 2019
Complaint Investigation
Date: Aug 22, 2019
Visit Reason
A complaint investigation was conducted on August 22, 2019 in the facility. The result of the investigation was substantiated with no deficiencies cited.
Complaint Details
CI MS #15885: A complaint investigation was conducted and substantiated with no deficiencies cited.
Findings
The complaint investigation was substantiated but no deficiencies were cited, indicating the facility was found in compliance.
Inspection Report — Apr 23, 2019
Complaint Investigation
Date: Apr 23, 2019
Visit Reason
A complaint investigation was conducted on April 23, 2019 in the facility.
Complaint Details
CI MS#15839: A complaint investigation was conducted on April 23, 2019. The complaint was unsubstantiated with no deficiencies cited.
Findings
The result of the investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Apr 11, 2019
Annual Inspection
Date: Apr 11, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey from 4/8/19 to 4/11/19. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid Requirements of Participation.
Findings
The facility was found to have deficiencies related to resident rights to communication, comprehensive care plan implementation, activities of daily living, and catheter care. The facility also had a life safety code deficiency related to exit discharge egress.
Deficiencies (5)
F0576 - Right to forms of communication with privacy. The facility failed to provide postal mail services on Saturdays for residents, potentially affecting all residents who receive mail.
F0656 - Develop and implement comprehensive care plan. The facility failed to implement comprehensive care plans for three residents, including failure to provide nail care, oral care, shaving, proper catheter bag positioning, and sterile catheter irrigation.
F0676 - Activities of daily living (ADLs) maintenance. The facility failed to ensure ADL care was provided for two residents, evidenced by long, dirty, or jagged fingernails and toenails, and failure to provide shaving and oral care.
F0690 - Bowel/bladder incontinence, catheter, UTI. The facility failed to ensure Foley catheter bags were positioned properly to allow urine flow by gravity and failed to use sterile technique during catheter irrigation, risking infection for two residents.
K0271 - Discharge from exits. The facility failed to maintain an all-weather surface at the rear exit of the therapy building, potentially blocking egress.
Report Facts
Deficiencies cited: 5
Inspection Report — Apr 3, 2019
Complaint Investigation
Date: Apr 3, 2019
Visit Reason
A complaint investigation was conducted on April 3, 2019 in the facility.
Complaint Details
Complaint investigations CI MS #15755, CI MS #15757 and CI MS #15769 were conducted; the results were unsubstantiated or substantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated or substantiated with no deficiencies cited.
Report Facts
Complaint investigations: 3
7 CMS Surveys
CMS Survey — Mar 3, 2023
Mar 3, 2023
CMS Survey — Jul 18, 2024
Jul 18, 2024
CMS Survey — Aug 13, 2025
Aug 13, 2025
CMS Survey — Oct 29, 2025
Oct 29, 2025
CMS Survey — Feb 20, 2020
Feb 20, 2020
CMS Survey — May 15, 2023
May 15, 2023
CMS Survey — Jul 18, 2024
Jul 18, 2024
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