Inspection Report
Annual Inspection
Census: 145
Capacity: 184
Deficiencies: 3
Dec 11, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 12/8/2025 through 12/11/2025 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with several requirements including safe and comfortable living environment, discharge process documentation, and PASARR screening accuracy. Deficiencies included failure to maintain comfortable room and water temperatures, incomplete and untimely written transfer notices for hospitalizations, and inaccurate identification of a resident's major mental illness on PASRR screening.
Severity Breakdown
SS = E: 1
SS = D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to ensure residents’ rights to a comfortable living environment by not maintaining comfortable room and water temperatures across three halls. | SS = E |
| Failure to provide complete and timely written transfer notices for six residents hospitalized, including lack of clear, resident-specific reasons and late or missing notifications. | SS = D |
| Failure to accurately identify a resident’s diagnosis of a major mental illness on the Pre-Admission Screening and Resident Review (PASRR) at admission. | SS = D |
Report Facts
Census: 145
Total Capacity: 184
Number of residents reviewed for hospitalizations: 6
Number of sampled residents for PASRR review: 29
Inspection Report
Annual Inspection
Deficiencies: 1
Dec 11, 2025
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 12/8/2025 to 12/11/2025 to assess compliance with Minimum Standards of Operations and state licensure requirements.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, specifically failing to ensure residents' rights to a comfortable living environment by not maintaining comfortable room and water temperatures in three of four halls. Multiple residents reported cold room temperatures and uncomfortable water temperatures, which were confirmed by maintenance measurements.
Deficiencies (1)
| Description |
|---|
| Failure to ensure residents’ rights to a comfortable living environment by not ensuring comfortable room and water temperatures across three of four halls in the facility. |
Report Facts
Room temperature: 65
Room temperature: 85
Water temperature: 68
Water temperature: 100
Number of halls with temperature issues: 3
Survey period: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Reported receiving resident concerns and submitting maintenance work orders | |
| Maintenance Director | Conducted temperature measurements and reported on water temperature delays | |
| Administrator | Acknowledged facility operates a tankless hot water system and expects consistent, comfortable living environment |
Inspection Report
Life Safety
Deficiencies: 0
Dec 11, 2025
Visit Reason
The survey was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) and emergency preparedness requirements.
Findings
The facility met all applicable provisions of the 2012 Life Safety Code and emergency preparedness requirements. No deficiencies were cited during the survey.
Inspection Report
Complaint Investigation
Census: 141
Capacity: 184
Deficiencies: 0
Jul 23, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to quality of care, neglect, misappropriation of property, and resident rights at the facility from 7/22/2025 through 7/23/2025.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited during the investigation.
Complaint Details
Complaint Investigation MS #473276 and MS #473277 were conducted regarding quality of care, neglect, misappropriation of property, and resident rights. The complaints were not substantiated as no deficiencies were cited.
Report Facts
Licensed beds: 184
Census: 141
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 23, 2025
Visit Reason
The State Agency conducted a Complaint Investigation related to quality of care, neglect, misappropriation of property, and resident rights at the facility from 7/22/25 through 7/23/25.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #473276 and MS #473277 regarding quality of care, neglect, misappropriation of property, and resident rights. No deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 13, 2025
Visit Reason
The State Agency conducted a complaint investigation (CI), MS #27821, at the facility on 02/13/25. The investigation was for pressure sores, resident left soiled for extended periods, services not performed per plan of care, and quality of life.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and Minimum Standards for Institutions for the Aged or Infirm, with no deficiencies cited.
Complaint Details
Complaint investigation MS #27821 was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Census: 149
Capacity: 184
Deficiencies: 0
Feb 13, 2025
Visit Reason
The State Agency conducted a complaint investigation (MS #27821) at the facility on 02/13/2025 regarding pressure sores, resident left soiled for extended periods, services not performed per plan of care, and quality of life.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint investigation MS #27821 was substantiated with no deficiencies cited.
Report Facts
Census: 149
Total licensed capacity: 184
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 1, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-09-26 to verify corrective measures taken by the facility.
Findings
The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-10-27.
Report Facts
Annual survey completion date: Sep 26, 2024
Compliance effective date: Oct 27, 2024
Inspection Report
Plan of Correction
Deficiencies: 0
Nov 1, 2024
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2024-09-26 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2024-10-27.
Report Facts
Annual survey completion date: Sep 26, 2024
Desk review date: Nov 1, 2024
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 29, 2024
Visit Reason
The State Agency conducted a complaint investigation related to an injury of unknown origin and neglect at the facility.
Findings
No deficiencies were cited during the survey; however, the facility remains out of compliance due to deficiencies cited in a prior survey on 2024-09-24.
Complaint Details
Complaint investigation MS #26763 related to injury of unknown origin and neglect; no deficiencies cited during this survey.
Inspection Report
Complaint Investigation
Census: 141
Capacity: 184
Deficiencies: 0
Oct 29, 2024
Visit Reason
The State Agency conducted a complaint investigation related to an injury of unknown origin and resident neglect at the facility.
Findings
No deficiencies were cited during this complaint investigation survey; however, the facility remains out of compliance due to deficiencies cited in a prior survey dated 09/26/24.
Complaint Details
Complaint investigation MS #26763 related to an injury of unknown origin and resident neglect. No deficiencies cited during this survey.
Report Facts
Licensed beds: 184
Census: 141
Inspection Report
Annual Inspection
Census: 21
Capacity: 42
Deficiencies: 0
Sep 26, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 09/23/2024 through 09/26/2024 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit and there were no citations.
Inspection Report
Annual Inspection
Census: 137
Capacity: 184
Deficiencies: 3
Sep 26, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 09/23/2024 through 09/26/2024 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies in timely transmission of Minimum Data Set (MDS) assessments, accuracy of assessments regarding hospice services, and food safety practices related to food storage and labeling.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to transmit MDS assessments within 14 days of completion for 10 of 52 sampled residents. | SS=D |
| Facility failed to ensure the MDS assessment accurately reflected the resident's status regarding hospice services for one of 52 sampled residents. | SS=D |
| Facility failed to store food in accordance with professional standards for food safety related to unlabeled food item, scoop stored in dry bin container, food item not refrigerated, and opened food item not discarded after 'Best Before' date. | SS=D |
Report Facts
Residents sampled: 52
Residents with late MDS transmission: 10
Residents in facility census: 137
Total licensed capacity: 184
Residents affected by deficient MDS accuracy: 1
Residents utilizing dietary services: 112
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Minimum Data Set Nurse | Responsible for transmitting MDS assessments and correcting deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding MDS transmission responsibilities and expectations |
| Administrator | Administrator | Interviewed regarding MDS transmission and accuracy responsibilities |
| Dietary Manager | Dietary Manager | Responsible for food safety, removed expired and unlabeled food items, and conducted staff in-service |
| Registered Nurse #1 | MDS Nurse | Confirmed inaccuracy of hospice status on Resident #99's MDS |
| Registered Dietician | Registered Dietician | Conducts bi-weekly inspections for food safety concerns |
Inspection Report
Annual Inspection
Census: 112
Deficiencies: 1
Sep 26, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 09/23/2024 through 09/26/2024 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found not in compliance due to unsafe food handling procedures, including unlabeled food items, improper storage of a scoop in a dry bin, unrefrigerated food items, and failure to discard opened food items after the 'Best Before' date during kitchen observations.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to store food in accordance with professional standards for food safety related to a food item not labeled, a scoop stored in a dry bin container, a food item not refrigerated, and an opened food item not discarded after the 'Best Before' date. | Level II |
Report Facts
Residents affected: 112
Survey duration days: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food safety deficiencies and corrective actions; responsible for removing expired items and in-servicing staff. | |
| Registered Dietician | In-serviced dietary staff on food receiving and storing policy and involved in ongoing inspections. | |
| Administrator | Interviewed about awareness of food safety issues related to lime juice storage and scoop placement. |
Inspection Report
Deficiencies: 0
Sep 24, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies noted.
Inspection Report
Life Safety
Census: 86
Deficiencies: 1
Sep 24, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA), specifically regarding smoke barrier construction in the facility.
Findings
The facility failed to provide the required half-hour fire resistance rating in two of eleven smoke compartments due to unsealed holes and inadequate smoke barrier walls. Immediate repairs were made by adding fire caulk, and audits confirmed no other deficiencies.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide half-hour fire resistance rating in smoke barrier walls on A station and B station, including unsealed holes around blue data cables near the Conference Room. | SS=D |
Report Facts
Smoke compartments affected: 2
Residents potentially affected: 86
Smoke barrier wall monitoring frequency: 3
Monitoring duration (months): 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Supervisor | Performed repairs, completed audit, verified observations, and was in-serviced regarding smoke barrier walls. | |
| Administrator | Acknowledged the finding during the exit interview. |
Inspection Report
Routine
Deficiencies: 0
Sep 24, 2024
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable emergency preparedness requirements with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 24, 2024
Visit Reason
The State Agency conducted a desk review on 10/17/2024 of information related to the annual survey conducted on 09/24/2024 to verify correction of deficient practices.
Findings
The facility provided information confirming that measures were put in place to correct the deficient practice and sustain compliance with the 2012 Edition of the Life Safety Code. The State Agency recommended the facility be placed back in compliance effective 09/30/2024.
Inspection Report
Complaint Investigation
Census: 141
Capacity: 184
Deficiencies: 0
Apr 11, 2024
Visit Reason
The State Agency conducted a complaint investigation related to an injury of unknown origin at the facility.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #24617) related to an injury of unknown origin; no deficiencies cited.
Report Facts
Licensed beds: 184
Census: 141
Inspection Report
Complaint Investigation
Deficiencies: 1
Jan 5, 2024
Visit Reason
The State Agency conducted a Complaint Investigation from 2024-01-02 through 2024-01-05 related to a complaint of sexual abuse involving two residents at the facility.
Findings
The facility failed to provide adequate supervision and monitoring, allowing Resident #2 to be in his room with his pants unzipped and penis exposed with Resident #1, a cognitively impaired and vulnerable resident, in his bed with her clothing pulled down exposing her genital area. This created an Immediate Jeopardy situation beginning on 2023-12-21 due to Resident #2's inappropriate sexual behaviors and lack of supervision.
Complaint Details
The complaint was substantiated as the facility failed to protect Resident #1 from sexual abuse by Resident #2. Immediate Jeopardy was identified and later removed after corrective actions were implemented.
Severity Breakdown
Level 4: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a resident from sexual abuse by another resident due to inadequate supervision and monitoring. | Level 4 |
Report Facts
Duration Resident #1 was in Resident #2's room: 7.5
Date Immediate Jeopardy began: Dec 21, 2023
Date Immediate Jeopardy removed: Dec 23, 2023
Date of survey: Jan 5, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses #2 | Assistant Director of Nurses | Observed the sexual abuse incident on 12/22/23 and confirmed Resident #2's hypersexual behavior. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed Resident #1 in Resident #2's room during the incident and notified nurse immediately. |
| Registered Nurse #1 | Registered Nurse | Observed Resident #2's inappropriate behavior on 12/21/23 and called for assistance. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #2 masturbating and notified physician on 12/21/23. |
| Medical Director | Medical Director | Prescribed medication for Resident #2's hypersexual behavior and was notified of the incident. |
| Director of Nurses | Director of Nurses | Assessed residents after incident, initiated body audits, notified authorities, and conducted staff in-service. |
Inspection Report
Complaint Investigation
Census: 145
Capacity: 184
Deficiencies: 1
Jan 5, 2024
Visit Reason
The State Agency conducted a complaint investigation and facility reported incident related to sexual abuse allegations involving two residents, from January 2, 2024 through January 5, 2024.
Findings
The facility failed to provide adequate supervision and monitoring, allowing Resident #2 to engage in inappropriate sexual behavior with Resident #1, a cognitively impaired and vulnerable resident. This resulted in an Immediate Jeopardy that began on December 21, 2023, which was corrected by December 23, 2023 prior to the surveyor's entrance.
Complaint Details
The complaint investigation was triggered by allegations of sexual abuse involving Resident #1 and Resident #2. The facility was found to have failed in supervision and monitoring, leading to an Immediate Jeopardy situation beginning 12/21/23. The Immediate Jeopardy was removed on 12/23/23 after corrective actions were implemented.
Severity Breakdown
Scope/Severity "J": 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to protect a resident from sexual abuse by another resident due to inadequate supervision and monitoring. | Scope/Severity "J" |
Report Facts
Census: 145
Total Capacity: 184
Duration Resident #1 in Resident #2's room: 7.5
Medication Dosage: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nurses #2 | Assistant Director of Nurses | Observed and separated residents during the incident and confirmed hypersexual behavior of Resident #2 |
| Registered Nurse #1 | Registered Nurse | Observed Resident #2's inappropriate behavior and called for assistance |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed Resident #2 masturbating and notified Director of Nurses |
| Certified Nurse Aide #1 | Certified Nurse Aide | Observed the incident and notified nurse to separate residents |
| Certified Nurse Aide #2 | Certified Nurse Aide | Reported Resident #2's inappropriate behavior to ADON #2 |
| Director of Nurses | Director of Nurses | Notified of the incident, assessed residents, initiated corrective actions and staff in-service |
| Medical Director | Medical Director | Prescribed medication for Resident #2 and was notified of the incident |
Inspection Report
Complaint Investigation
Census: 148
Capacity: 184
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted two complaint investigations at the facility from 10/23/23 through 10/24/23. One investigation was related to abuse and the other related to administration/personnel records involving a staff member with child neglect on background with an active certification.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Two complaint investigations were conducted: CI MS #23054 related to abuse and CI MS #23086 related to administration/personnel records involving a staff member with child neglect on background with an active certification. No deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 24, 2023
Visit Reason
The State Agency conducted two complaint investigations at the facility from 10/23/23 through 10/24/23. One investigation was related to abuse and the other related to administration/personnel records involving a staff member with child neglect on background with an active certification.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.
Complaint Details
Two complaint investigations (CI MS #23054 and CI MS #23086) were conducted related to abuse and personnel records involving a staff member with child neglect background. The complaints were not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22258, related to the facility allowing unqualified Nurse Aides to work.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #22258 was related to the facility allowing unqualified Nurse Aides to work. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 150
Capacity: 184
Deficiencies: 0
Sep 7, 2023
Visit Reason
The State Agency conducted a complaint investigation related to pest control at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited.
Complaint Details
Complaint MS #22617 related to pest control was investigated and found to be unsubstantiated with no deficiencies cited.
Report Facts
Licensed beds: 184
Census: 150
Inspection Report
Complaint Investigation
Census: 150
Capacity: 184
Deficiencies: 0
Sep 7, 2023
Visit Reason
The State Agency conducted a complaint investigation related to pest control at the facility on 09/07/2023.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited during the survey.
Complaint Details
Complaint MS #22617 related to pest control was investigated and found to be unsubstantiated as no deficiencies were cited.
Report Facts
Licensed beds: 184
Census: 150
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 24, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #22385, related to family not being contacted about resident developing wounds and resident not receiving pain medications.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirement. There were no deficiencies cited.
Complaint Details
Complaint Investigation MS #22385 was related to family not being contacted about resident developing wounds and resident not receiving pain medications. The complaint was not substantiated as no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 147
Capacity: 184
Deficiencies: 0
Aug 24, 2023
Visit Reason
The State Agency conducted a complaint investigation related to family not being contacted about residents developing wounds and resident not receiving pain medications.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
Complaint MS #22385 was investigated concerning family notification about wounds and pain medication administration; no deficiencies were found.
Report Facts
Licensed beds: 184
Census: 147
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 9, 2023
Visit Reason
The State Agency conducted Complaint Investigations at the facility from 8/7/23 through 8/9/23 for quality of care, facility staffing, equipment, no hot water, and care not received per Physician's Orders.
Findings
The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and no deficiencies were cited.
Complaint Details
Complaint Investigations MS #21922 and MS #22261 were conducted; MS #21922 involved quality of care, staffing, equipment, and no hot water; MS #22261 involved care not received per Physician's Orders. No deficiencies were found.
Inspection Report
Complaint Investigation
Census: 147
Capacity: 184
Deficiencies: 0
Aug 9, 2023
Visit Reason
The State Agency conducted complaint investigations at the facility from 08/07/2023 through 08/09/2023 related to quality of care, facility staffing, equipment, no hot water, and care not received per Physician's Orders.
Findings
During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Complaint Details
The investigations MS #21922 and MS #22261 were conducted for quality of care, staffing, equipment, no hot water, and care not received per Physician's Orders. No deficiencies were found.
Report Facts
Licensed beds: 184
Census: 147
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #21334 at the facility on 4/20/23 for resident abuse.
Findings
The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies.
Complaint Details
The complaint investigation MS #21334 for resident abuse was not substantiated; no deficiencies were cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 20, 2023
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #21334 at the facility on 4/20/23 related to resident abuse allegations.
Findings
The survey determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm and cited no deficiencies.
Complaint Details
The complaint investigation MS #21334 for resident abuse was not substantiated and no deficiencies were cited.
Inspection Report
Complaint Investigation
Census: 142
Capacity: 150
Deficiencies: 0
Apr 20, 2023
Visit Reason
The State Agency conducted a complaint investigation regarding resident abuse at the facility.
Findings
The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.
Complaint Details
Complaint investigation MS #21334 regarding resident abuse; no deficiencies cited.
Report Facts
Licensed beds: 150
Census: 142
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-10-13 to confirm compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.
Findings
The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2022-10-13 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were taken to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2022-11-25.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2022-10-13 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming corrective actions were taken to address deficient practices, and the State Agency recommended the facility be placed back in compliance effective 2022-11-25.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-10-13 to confirm compliance with Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit, and the agency recommended the facility be placed back in compliance effective 2022-11-25.
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 29, 2022
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2022-10-13 to assess compliance with Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was confirmed to be in compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit, and the State Agency recommended the facility be placed back in compliance effective 2022-11-25.
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 13, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/10/2022 to 10/13/2022 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with all applicable standards and state licensure requirements, with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 13, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/10/2022 to 10/13/2022 to determine compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with all applicable standards and state licensure requirements, with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Oct 13, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/10/2022 to 10/13/2022 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found to be in compliance with all applicable standards and state licensure requirements, with no deficiencies cited during the survey.
Inspection Report
Annual Inspection
Census: 143
Capacity: 184
Deficiencies: 2
Oct 13, 2022
Visit Reason
The State Agency conducted an annual survey at the facility from 10/10/22 through 10/13/22 to determine compliance with Medicare and Medicaid Requirements for Participation.
Findings
The facility was found not in compliance with requirements related to transfer/discharge notifications and bed-hold policy notifications for residents transferred to hospitals. Specifically, the facility failed to provide and retain written documentation of transfer and bed-hold notifications for two residents.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to provide written documentation of transfer/discharge notification for two residents transferred to hospital. | SS=D |
| Failed to provide written documentation of bed-hold notification upon resident transfer to hospital for two residents. | SS=D |
Report Facts
Licensed beds: 184
Resident census: 143
Residents reviewed for hospitalizations: 4
Residents with deficient notifications: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding transfer/discharge and bed-hold notification practices; responsible for mailing notifications | |
| Director of Nursing (DON) | Interviewed regarding resident transfers and hospitalizations | |
| Administrator | Interviewed regarding facility notification practices and staff statements | |
| Business Office Director | Participated in in-service training regarding notification procedures |
Inspection Report
Annual Inspection
Census: 29
Capacity: 42
Deficiencies: 1
Oct 13, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 10/10/22 through 10/13/22 to assess compliance with the Minimum Standards of Operations for Alzheimer's Disease/Dementia Care Unit.
Findings
The facility was found not in compliance with the ambulation requirements for the Alzheimer's/Dementia Care Unit, as 15 of 29 residents required staff assistance for transfers and could not self-propel their wheelchairs, exceeding the allowed 10% limit. The facility took corrective actions including moving 8 residents off the unit and conducting staff in-service training.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure residents on the locked Alzheimer's/Dementia unit could perform transfers without staff assistance and self-propel their wheelchairs, affecting 15 of 29 residents. |
Report Facts
Resident census: 29
Total bed capacity: 42
Residents requiring assistance: 15
Residents moved off unit: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Conducted in-service training and reviewed residents for ambulation | |
| Registered Nurse #1 | Registered Nurse | Confirmed residents' ambulation status and lack of familiarity with Alzheimer's regulations |
| Administrator | Acknowledged knowledge of ambulation non-compliance and resident placement issues |
Inspection Report
Life Safety
Deficiencies: 0
Oct 12, 2022
Visit Reason
The survey was conducted to assess 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. No LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Oct 12, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 4, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 3/3/22 to 3/4/22 related to MS #18500 and MS #17818.
Findings
The facility was found to be in compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. The complaints regarding pressure injury prevention and treatment, staffing, and resident rights were not substantiated, and no deficiencies were cited.
Complaint Details
The complaint investigation did not substantiate MS #18500 related to pressure injury prevention and treatment, staffing, and resident rights. The complaint MS #17818 for insufficient staffing was also not substantiated.
Inspection Report
Complaint Investigation
Census: 184
Capacity: 141
Deficiencies: 0
Mar 4, 2022
Visit Reason
The State Agency conducted a Complaint Investigation at the facility from 3/3/22 to 3/4/22 related to pressure injury prevention and treatment, staffing, and resident rights.
Findings
The facility was found to be in compliance with Medicare and Medicaid requirements. The complaints regarding pressure injury prevention, treatment, and staffing were not substantiated, and no deficiencies were cited.
Complaint Details
The complaint investigation included MS #18500 and MS #17818. MS #18500 related to pressure injury prevention and treatment, staffing, and resident rights was not substantiated. MS #17818 related to insufficient staffing was also not substantiated.
Report Facts
Beds in abatement: 20
Inspection Report
Complaint Investigation
Deficiencies: 0
Apr 13, 2021
Visit Reason
The inspection was conducted as a complaint investigation (CI MS #17601) from 04/12/21 to 04/13/21.
Findings
The facility was found to be in compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Complaint Details
Complaint investigation CI MS #17601 was conducted and the facility was found compliant.
Inspection Report
Complaint Investigation
Census: 142
Capacity: 164
Deficiencies: 0
Apr 13, 2021
Visit Reason
The State Agency conducted a partial extended survey for the Complaint Investigation (CI MS #17601) for Quality of Care from 04/12/21 through 04/13/21.
Findings
During the survey, the State Agency did not substantiate the complaints and no deficiencies were cited.
Complaint Details
Complaint Investigation (CI MS #17601) for Quality of Care; complaints were not substantiated.
Report Facts
Licensed beds: 164
Census: 142
Inspection Report
Complaint Investigation
Census: 69
Capacity: 98
Deficiencies: 0
Sep 1, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16786) was conducted by the State Agency on 9/1/2020.
Findings
The complaint investigation was unsubstantiated for Physical Environment related to Facility Not Clean and Resident Abuse related to Verbal Abuse. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint investigation (CI MS #16786) was unsubstantiated for Physical Environment related to Facility Not Clean and Resident Abuse related to Verbal Abuse.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 9/1/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Deficiencies: 0
Sep 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 9/1/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Complaint Investigation
Census: 69
Capacity: 98
Deficiencies: 0
Sep 1, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey along with a complaint investigation (CI MS #16786) was conducted by the State Agency on 9/1/2020.
Findings
The complaint investigation was unsubstantiated for Physical Environment related to Facility Not Clean and Resident Abuse related to Verbal Abuse. The facility was found to be in compliance with infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Complaint Details
Complaint investigation (CI MS #16786) was unsubstantiated for Physical Environment related to Facility Not Clean and Resident Abuse related to Verbal Abuse.
Report Facts
Census: 69
Total licensed capacity: 98
Inspection Report
Abbreviated Survey
Census: 146
Capacity: 184
Deficiencies: 0
Aug 11, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/11/2020 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 146
Capacity: 184
Deficiencies: 0
Aug 11, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 8/11/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jul 14, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 156
Capacity: 184
Deficiencies: 0
Jul 14, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices for COVID-19 preparation.
Inspection Report
Abbreviated Survey
Census: 161
Capacity: 184
Deficiencies: 0
Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency on 6/24/20 to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 161
Capacity: 184
Deficiencies: 0
Jun 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Census: 161
Total licensed capacity: 184
Inspection Report
Complaint Investigation
Census: 169
Capacity: 184
Deficiencies: 2
Dec 2, 2019
Visit Reason
The State Agency conducted a Complaint Investigation from 11/12/2019 to 12/02/2019 related to allegations of Quality of Care and Abuse issues.
Findings
The investigation substantiated misappropriation of money for Resident #9 and physical abuse for Resident #16. The facility was found not in compliance with State Licensure Regulations for the Aged or Infirm.
Complaint Details
The complaint investigation substantiated misappropriation of money for Resident #9 and physical abuse for Resident #16. Resident #9 gave $10 to CNA #1, who initially accepted it but later returned it. Resident #16 was physically abused by Resident #15, who was placed on 1:1 monitoring and transported to a behavioral health unit. The facility conducted staff in-services and implemented monitoring and corrective actions.
Severity Breakdown
Level II: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from misappropriation for one of six residents reviewed; CNA accepted money from Resident #9. | Level II |
| Facility failed to protect Resident #16 from resident to resident abuse involving Resident #15 hitting Resident #16. | Level II |
Report Facts
Residents at risk: 172
Census: 169
Total licensed capacity: 184
Money accepted: 10
BIMS score: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Accepted money from Resident #9 and was placed on administrative suspension. |
| Administrator | Disciplinary actions and investigation oversight related to CNA #1's acceptance of money. | |
| Director of Nursing | Director of Nursing | Oversaw investigation of money misappropriation and resident altercation; implemented monitoring and staff in-service. |
| Social Services Director | Social Services Director | Provided information on Resident #15's behavioral history. |
| Physician Assistant | Physician Assistant | Assessed injuries of Resident #16 and Resident #15 after altercation. |
| RN #1 | Registered Nurse | Documented resident altercation and assessments. |
Inspection Report
Complaint Investigation
Census: 169
Capacity: 184
Deficiencies: 2
Dec 2, 2019
Visit Reason
The State Agency conducted a Complaint Investigation from 11/12/19 to 12/02/19 related to allegations of Quality of Care and Abuse issues.
Findings
The facility was found to have substantiated misappropriation of money for Resident #9 and physical abuse for Resident #16. The facility failed to ensure residents were free from misappropriation and resident-to-resident abuse.
Complaint Details
The complaint investigation was substantiated for misappropriation of money by CNA #1 from Resident #9 and physical abuse by Resident #15 against Resident #16. The facility reimbursed the resident and suspended the CNA. Resident #16 was injured and placed on 1:1 monitoring. The facility conducted staff in-services and reported the incidents to the State Department of Health and Attorney General's office.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to ensure residents were free from misappropriation for Resident #9, where a CNA accepted $10 from the resident, violating facility policy. | SS=D |
| Facility failed to protect Resident #16 from resident-to-resident physical abuse by Resident #15, resulting in injury and need for 1:1 supervision. | SS=D |
Report Facts
Facility census: 169
Total licensed capacity: 184
Residents at risk: 172
Monitored residents: 2
Monitored residents: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nursing Assistant | Accepted money from Resident #9, placed on administrative suspension |
| Administrator | Disciplinary actions and interviews related to CNA #1 misappropriation case | |
| Director of Nursing | Director of Nursing | Conducted investigation and staff in-service, monitored resident altercations |
| Social Services Director | Social Services Director | Provided information on Resident #15's prior behavioral history |
| RN #1 | Registered Nurse | Documented resident abuse incident involving Resident #15 and Resident #16 |
| Licensed Practical Nurse | Staff Development Nurse | Conducted in-service on policy and procedure related to accepted gifts |
Inspection Report
Annual Inspection
Census: 173
Capacity: 184
Deficiencies: 3
Jul 12, 2019
Visit Reason
The State Agency conducted a recertification survey from 7/9/2019 through 7/12/2019 to determine compliance with the Minimum Standards for the Aged & Infirmed.
Findings
The facility was found not in compliance with standards related to urinary incontinence catheter care, tracheostomy care, and nebulizer treatment administration. Deficiencies included improper catheter care techniques risking infection, failure to maintain sterile technique during tracheostomy care, and failure to supervise nebulizer treatments as required by policy.
Severity Breakdown
Level II: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to provide catheter/perineal care in a manner to prevent possible spread of infection for four of six catheter care observations. | Level II |
| Failed to provide tracheostomy care in a manner to prevent cross contamination for two of three residents observed. | Level II |
| Failed to provide nebulizer treatment under staff supervision for one of two resident nebulizer treatment observations. | Level II |
Report Facts
Census: 173
Total Capacity: 184
Residents with Foley catheters: 11
Tracheostomy residents: 10
Residents receiving nebulizer treatments: 26
Deficiency monitoring period: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in catheter care deficiency for failing to reposition catheter tubing. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in catheter care deficiency for failing to clean head of penis and improper barrier use. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in catheter care deficiency for failing to rotate wipes during catheter care. |
| Registered Nurse #1 | Infection Control Nurse | Provided infection control oversight and confirmed catheter care deficiencies. |
| Registered Nurse #3 | Staff Development Nurse | Provided staff training and confirmed catheter care deficiencies. |
| Director of Nursing | Director of Nursing | Oversaw corrective actions and confirmed deficiencies in catheter and tracheostomy care. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in tracheostomy care deficiency for improper sterile technique. |
| Respiratory Therapist | Respiratory Therapist | Named in tracheostomy care deficiency for improper glove use and cleaning technique. |
| Licensed Practical Nurse #2 | Transitional Care Nurse | Named in nebulizer treatment deficiency for leaving resident unattended. |
Inspection Report
Annual Inspection
Census: 173
Capacity: 184
Deficiencies: 1
Jul 12, 2019
Visit Reason
The State Agency conducted a recertification survey from 7/9/2019 through 7/12/2019 to determine compliance with the Minimum Standards for the Aged & Infirmed.
Findings
The facility was found not in compliance due to failure to provide catheter and perineal care in a manner to prevent the possible spread of infection during catheter care observations for four residents. Staff failed to follow proper catheter care procedures, including improper handling of catheter tubing and wipes, which could lead to urinary tract infections.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to provide catheter/perineal care in a manner to prevent the possible spread of infection for four of six catheter care observations. | Level II |
Report Facts
Census: 173
Total Capacity: 184
Residents with Foley catheters assessed: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Named in relation to failure to properly position catheter tubing. |
| Registered Nurse #1 | Infection Control Officer | Confirmed catheter tubing should not be positioned above bladder level and commented on staff knowledge. |
| Registered Nurse #3 | Staff Development Nurse | Provided information on staff training and catheter care procedures. |
| Director of Nursing | Director of Nursing | Provided information on staff training and confirmed deficiencies. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #139. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #7. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #88. |
| Certified Nursing Assistant #4 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #88. |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #88. |
| Certified Nursing Assistant #6 | Certified Nursing Assistant | Named in relation to improper catheter care for Resident #88. |
| Registered Nurse #4 | Unit Manager | Provided interview regarding proper catheter care techniques. |
Inspection Report
Annual Inspection
Census: 173
Capacity: 184
Deficiencies: 8
Jul 12, 2019
Visit Reason
The State Agency conducted an annual recertification survey and complaint survey from 07/09/2019 to 07/12/2019 to assess compliance with Medicare and Medicaid participation requirements and investigate complaints related to quality of care and pest control.
Findings
The facility was found not in substantial compliance with Medicare and Medicaid requirements, with deficiencies cited in comprehensive assessment after significant change, PASARR screening, care plan development and implementation, catheter care, respiratory and tracheostomy care, and food safety. Complaint allegations were not substantiated. The facility also had a life safety code deficiency related to an exit door malfunction.
Complaint Details
Complaints related to quality of care and pest control were investigated and not substantiated.
Severity Breakdown
Level I: 4
Level D: 3
Level E: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to code a Significant Change in Status Assessment (SCSA) for Resident #157 related to mental health diagnosis and Level II PASARR screening. | Level I |
| Failed to provide accurate PASARR screening for Resident #76 with mental disorder diagnosis. | Level I |
| Failed to notify state mental health authority promptly after significant change for Resident #157. | Level I |
| Failed to develop and implement comprehensive care plans consistent with assessments for tracheostomy care, nebulizer treatments, and catheter care for multiple residents. | Level E |
| Failed to revise Resident #89's comprehensive care plan timely after Foley catheter insertion. | Level I |
| Failed to provide catheter/perineal care in a manner to prevent infection for multiple residents. | Level D |
| Failed to maintain exit door release mechanism for fire safety on B hall exit door near room B13. | Level D |
| Failed to clean kitchen stove drip pan in a timely manner to prevent fire hazard. | Level D |
Report Facts
Census: 173
Total Capacity: 184
Deficiencies cited: 8
Residents with tracheostomy: 10
Residents receiving respiratory treatments: 26
Residents with indwelling or external catheters: 11
Residents with Foley catheters: 10
Exit doors: 8
Residents potentially affected by exit door malfunction: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Quality Assurance Nurse | Named in failure to code Significant Change in Status Assessment and Level II PASARR screening |
| Licensed Practical Nurse #3 | Minimum Data Set Coordinator | Named in failure to code Significant Change in Status Assessment and care plan compliance |
| Director of Nursing | Director of Nursing | Named in multiple findings including failure to code assessments, care plan compliance, and staff in-service |
| Registered Nurse #1 | Infection Control Nurse | Named in catheter care deficiencies and infection control |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Named in catheter care deficiencies |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Named in tracheostomy care deficiencies |
| Respiratory Therapist | Respiratory Therapist | Named in tracheostomy care deficiencies |
| Dietary Manager | Dietary Manager | Named in kitchen cleaning and food safety deficiencies |
Inspection Report
Annual Inspection
Census: 173
Capacity: 184
Deficiencies: 1
Jul 12, 2019
Visit Reason
The State Agency conducted an annual recertification survey from 07/09/2019 to 07/12/2019. Complaints MS #00015937 and MS #00015956 were also investigated in conjunction with this annual survey.
Findings
The complaints were not substantiated and resulted in no citations related to the complaint. The annual survey revealed that the facility was not in substantial compliance with Medicare/Medicaid participation requirements, with deficiencies related to the standard survey.
Complaint Details
Complaints MS #00015937 and MS #00015956 were investigated and found not substantiated, resulting in no citations related to the complaint.
Deficiencies (1)
| Description |
|---|
| Noncompliance related to the standard survey including deficiencies F637, F645, F646, F656, F657, F690, F695, and F812 |
Report Facts
Deficiencies cited: 8
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 19, 2018
Visit Reason
A complaint investigation was conducted at the facility on October 19, 2018.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 30, 2018
Visit Reason
A complaint investigation was conducted at Hattiesburg Health & Rehab Center on August 30, 2018.
Findings
The investigation was substantiated with no deficiencies cited.
Complaint Details
The complaint investigation was substantiated with no deficiencies cited.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 5, 2018
Visit Reason
A complaint investigation was conducted at the facility on July 5, 2018.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Complaint Details
The complaint investigation was unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Census: 171
Capacity: 184
Deficiencies: 3
May 24, 2018
Visit Reason
The State Agency conducted an annual recertification survey and complaint survey from 5/15/18 through 5/24/18. The complaint regarding an injury during transfer with a lift was substantiated, and the facility was found not in compliance with Medicare and Medicaid participation requirements.
Findings
The facility failed to revise the pressure wound care plan to address reporting missing, soiled, or dislodged wound dressings for one resident. The facility also failed to promote healing of pressure ulcers consistent with professional standards for one resident with a stage three sacral pressure ulcer. Additionally, one exit door failed to release upon fire alarm activation, obstructing egress.
Complaint Details
The complaint regarding an injury during transfer with a lift was substantiated with no deficiencies cited related to the complaint.
Severity Breakdown
SS=D: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to revise pressure wound care plan to address reporting missing, soiled, or dislodged wound dressings for Resident #89. | SS=D |
| Failed to promote healing of pressure ulcers consistent with professional standards for Resident #89 with a stage three sacral pressure ulcer. | SS=D |
| Exit door located across from 'B' Wing Nurse Station did not release and open upon activation of the fire alarm and sprinkler system, obstructing means of egress. | SS=D |
Report Facts
Residents with wound dressing care plans: 19
Wound care plans audited: 33
Wound care plans revised: 12
Residents potentially affected by exit door malfunction: 55
Number of exit doors inspected: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Treatment Nurse | Provided wound care to Resident #89 and confirmed missing dressing. |
| RN #4 | Dementia Care Unit Manager | Confirmed dressing issues and CNA reporting expectations. |
| CNA #3 | Noticed dressing was dislodged during bathing and failed to report immediately. | |
| RN #6 | Minimum Data Set Coordinator | Confirmed reporting of missing, dislodged, or soiled dressing should be part of care plan. |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations for reporting missing, dislodged, or soiled wound dressings and facility policy updates. |
| CNA #4 | Stated CNAs should report missing, soiled, or coming off dressings immediately. | |
| LPN #1 | Licensed Practical Nurse | Confirmed expectation to report missing, soiled, or dislodged dressings immediately. |
| Maintenance Supervisor | Acknowledged and repaired exit door malfunction. |
Inspection Report
Routine
Deficiencies: 1
May 24, 2018
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to pressure sore treatment and wound care at Hattiesburg Health & Rehab Center.
Findings
The facility failed to promote the healing of pressure ulcers for one resident with a stage three sacral pressure ulcer due to missing wound dressings that were not reported promptly by staff. The facility lacked a policy addressing reporting of dislodged, missing, or soiled wound dressings, which was later revised following the inspection.
Severity Breakdown
Level II: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to promote healing of pressure ulcers evidenced by missing wound dressing on a stage three sacral pressure ulcer for Resident #89. | Level II |
Report Facts
Residents reviewed with pressure ulcers: 5
Residents with wound dressings potentially affected: 19
Date of pressure ulcer onset: Apr 20, 2017
Date of inspection: May 24, 2018
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Treatment Nurse | Observed missing wound dressing and completed physician ordered treatment |
| RN #4 | Dementia Care Unit Manager | Confirmed missing dressing and discussed staff reporting expectations |
| CNA #3 | Noted dressing came off during bathing but failed to report immediately | |
| CNA #4 | Stated CNAs should report missing or soiled dressings immediately | |
| LPN #1 | Licensed Practical Nurse | Confirmed expectation to report missing or soiled dressings promptly |
| Director of Nursing | DON | Confirmed reporting expectations and lack of facility policy on missing dressings |
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