Inspection Reports for
Heritage House Nursing Center
3103 Wisconsin Avenue Community Care Center of, Vicksburg, MS, 39180
Back to Facility Profile22 Reports
Inspection Report — Apr 6, 2026
Annual Inspection
Date: Apr 6, 2026
Visit Reason
On 04/06/26 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 02/26/26. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 03/31/26. No deficiencies were cited in this document.
Inspection Report — Feb 26, 2026
Annual Inspection
Date: Feb 26, 2026
Visit Reason
The State Agency conducted an Annual Recertification Survey along with two Complaint Investigations (CI MS #2740450 and CI MS #2601556) at the facility from 2/23/26 through 2/26/26. CI MS #2740450 was investigated related to call lights not answered and CI MS #2601556 was investigated related to meal menus not followed, medications not administered timely, grievance response and unaddressed nutritional concerns. There were no citations related to the complaint investigations.
Complaint Details
Two complaint investigations (CI MS #2740450 and CI MS #2601556) were conducted related to call lights not answered, meal menus not followed, medications not administered timely, grievance response, and unaddressed nutritional concerns. No citations were related to these complaint investigations.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements with seven deficiencies cited. Deficiencies included failure to provide reasonable accommodations, failure to evaluate psychotropic medication use timely, inaccurate resident assessments, incomplete care plan implementation, insufficient dietary support personnel, improper food safety and sanitation practices, and failure to implement infection control precautions during wound care.
Deficiencies (7)
F0558 - Reasonable Accommodations Needs/Preferences. The facility failed to ensure Resident #5’s right to reasonable accommodation of her physical limitations by not maintaining a call light within reach and not providing a call light she could independently activate to request assistance.
F0605 - Right to be Free from Chemical Restraints. The facility failed to ensure Resident #9 was evaluated for continued need of a PRN psychotropic medication after fourteen days as required.
F0641 - Accuracy of Assessments. The facility failed to ensure a Minimum Data Set (MDS) assessment was coded accurately to reflect Resident #46’s tobacco use.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to implement a comprehensive care plan intervention for Resident #5 related to ensuring the call light was within reach.
F0802 - Sufficient Dietary Support Personnel. The facility failed to ensure staff maintained competency in food safety practices by failing to properly calibrate a food thermometer prior to checking food temperatures.
F0812 - Food Procurement, Store/Prepare/Serve-Sanitary. The facility failed to ensure sanitary food handling practices by failing to sanitize a food thermometer between checking temperatures of multiple food items on the steam table.
F0880 - Infection Prevention & Control. The facility failed to implement Enhanced Barrier Precautions during wound care for Resident #18 by not wearing gowns as required.
Report Facts
Deficiencies cited: 7
Inspection Report — Feb 26, 2026
Annual Inspection
Date: Feb 26, 2026
Visit Reason
The State Agency conducted an Annual Recertification Survey along with two Complaint Investigations (CI MS #2740450 and CI MS #2601556) at the facility from 2/23/26 through 2/26/26. CI MS #2740450 was related to call lights not answered and CI MS #2601556 was related to meal menus not followed, medications not administered timely, grievance response and unaddressed nutritional concerns. There were no citations related to the Complaint Investigations.
Complaint Details
Two complaint investigations (CI MS #2740450 and CI MS #2601556) were conducted related to call lights not answered, meal menus not followed, medications not administered timely, grievance response, and unaddressed nutritional concerns. No citations were issued related to these complaints.
Findings
The facility was found not in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, citing deficiencies M500, M815, and M1570. Deficiencies involved residents' rights related to call light accessibility, unsafe food handling practices, and failure to implement enhanced barrier precautions during wound care.
Deficiencies (3)
M500 - Residents' rights were not ensured as Resident #5 did not have a call light within reach and could not independently activate it to request assistance.
M815 - The facility failed to maintain sanitary food handling practices by not sanitizing a food thermometer between checking temperatures of multiple food items on the steam table.
M1570 - The facility failed to implement Enhanced Barrier Precautions during wound care for Resident #18, as staff did not wear gowns as required.
Report Facts
Deficiencies cited: 3
Inspection Report — Feb 24, 2026
Life Safety
Date: Feb 24, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements on 02/24/2026.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Apr 15, 2025
Complaint Investigation
Date: Apr 15, 2025
Visit Reason
On 04/15/25 the State Agency (SA) conducted an onsite complaint investigation (CI) MS #28139 for alleged sanitation concerns in the dietary department.
Complaint Details
CI MS #28139 for alleged sanitation concerns in the dietary department. The complaint was not substantiated and no deficiencies were cited.
Findings
The SA determined that the facility was in compliance with the Standards for Participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Sep 25, 2024
Complaint Investigation
Date: Sep 25, 2024
Visit Reason
On September 25, 2024 the State Agency conducted an onsite complaint investigation, CI MS #25959, which alleged that the facility had neglected to use proper infection control procedures while a resident with an infection was in isolation. The complaint alleged that the neglect of the staff to follow proper infection control procedures had hastened the death of the resident.
Complaint Details
CI MS #25959 alleged neglect of proper infection control procedures hastening a resident's death; the complaint was not substantiated and no deficiencies were cited.
Findings
The State Agency determined that the facility was in compliance with the Rules and Regulations for "The Aged and Infirmed" and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Apr 15, 2024
Annual Inspection
Date: Apr 15, 2024
Visit Reason
On 04/15/24 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 03/14/24. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The SA is recommending that the facility be placed back in compliance effective 04/11/24. No deficiencies were cited in this desk review.
Report Facts
Deficiencies cited: 0
Inspection Report — Mar 14, 2024
Annual Inspection
Date: Mar 14, 2024
Visit Reason
The State Agency (SA) conducted an annual re-certification survey at the facility from 03/11/24 through 03/14/24. During the survey, the SA determined that the facility was not in compliance with Medicare and Medicaid requirements of participation related to F583, F584, F640, F656, F658, F677, F759 and F921.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements related to personal privacy, safe environment, resident assessments, care planning, medication administration, ADL care, medication error rates, and fire door safety.
Deficiencies (8)
F0583 - Personal Privacy/Confidentiality of Records. The facility failed to secure electronic health records as an Electronic Medication Record (EMAR) was visible on an unattended medication cart on the 200 hall for one resident.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to provide resident rooms in good repair as evidenced by broken blinds, missing base molding, and peeling sheetrock in two resident rooms.
F0640 - Encoding/Transmitting Resident Assessments. The facility failed to transmit a discharge Minimum Data Set (MDS) Assessment for one resident reviewed for discharge MDS assessments.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop care plans related to resident facial hair for two residents and failed to implement a care plan for one resident related to administering medications one at a time with flushes through a PEG tube.
F0658 - Services Provided Meet Professional Standards. The facility failed to follow professional standards of practice for a feeding tube by crushing and administering multiple medications at once without using gravity and failing to follow physician orders for water flushes for one resident.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide personal hygiene to residents as evidenced by unshaven facial hair for two residents.
F0759 - Free of Medication Error Rts 5 Prcnt or More. The facility failed to ensure the medication error rate was not 5 percent or greater; the medication error rate was 17.24% for one resident.
F0921 - Safe/Functional/Sanitary/Comfortable Environment. The facility failed to ensure linen barrels did not block fire doors on one of two halls, posing a potential fire hazard affecting all residents.
Report Facts
Deficiencies cited: 8
Medication error rate: 17.24
Medication opportunities: 29
Residents sampled: 18
Residents: 56
Beds licensed: 60
Inspection Report — Mar 12, 2024
Life Safety
Date: Mar 12, 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 was found to meet 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 — Dec 20, 2022
Annual Inspection
Date: Dec 20, 2022
Visit Reason
On 12/20/22 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 11/9/22.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation. The SA is recommending that your facility be placed back in compliance effective 12/15/22.
Inspection Report — Dec 19, 2022
Life Safety
Date: Dec 19, 2022
Visit Reason
On 12/19/22 the State Agency conducted a desk review of the information provided related to the annual survey conducted on 11/09/22. The facility had put measures in place to correct the deficient practice and sustain compliance with the Life Safety Code.
Findings
The facility was found to be in compliance with the Life Safety Code based on the desk review and corrective measures provided.
Inspection Report — Nov 9, 2022
Annual Inspection
Date: Nov 9, 2022
Visit Reason
The State Agency (SA) conducted an annual recertification survey at the facility from 11/7/22 through 11/9/22. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation.
Findings
Two deficiencies were cited related to medication administration and infection control. The facility failed to instruct a resident to rinse and spit after inhaler use and failed to use a spacer as ordered. The facility also failed to clean a pulse oximeter and blood pressure cuff between resident uses, increasing the risk of infection spread.
Deficiencies (2)
F0658 - Services provided did not meet professional standards as the facility failed to instruct a resident to rinse and spit after inhaler use and failed to use a spacer during inhaler administration for one resident observed during medication pass.
F0880 - Infection prevention and control was inadequate as the facility failed to clean a pulse oximeter and blood pressure cuff between use for one resident observed during medication pass.
Report Facts
Deficiencies cited: 2
Inspection Report — Nov 9, 2022
Life Safety
Date: Nov 9, 2022
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility failed to provide the required half-hour fire resistance rating in the smoke barrier wall on the 100 Hall, where smoke barrier doors between rooms 103 and 104 did not close to a positive latching position to prevent the spread of smoke throughout the facility.
Deficiencies (1)
K0372 - The facility failed to provide half hour rating in the smoke barrier wall in accordance with NFPA 101 sections 19.3.7.3 and 8.5. Smoke barrier doors between rooms 103 and 104 on the 100 Hall did not close to a positive latching position to prevent the spread of smoke.
Report Facts
Deficiencies cited: 1
Inspection Report — Nov 9, 2022
Life Safety
Date: Nov 9, 2022
Visit Reason
Survey conducted on 11/09/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements. No deficiencies were cited.
Inspection Report — Aug 22, 2022
Routine
Date: Aug 22, 2022
Visit Reason
The survey was conducted to assess the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network.
Findings
The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Deficiencies (1)
F0884 - The facility failed to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Deficiencies cited: 1
Inspection Report — May 25, 2022
Routine
Date: May 25, 2022
Visit Reason
The State Agency conducted an onsite infection control survey on 05/25/2022.
Findings
The facility was found to be in substantial compliance with the Standards for Infection Control and for participation with Medicare and Medicaid. No deficiencies were cited in the area of infection control.
Inspection Report — May 25, 2022
Routine
Date: May 25, 2022
Visit Reason
A Covid-19 Focused Emergency Preparedness Survey was conducted by the State Agency (SA) on 5/25/22.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report — Sep 2, 2021
Complaint Investigation
Date: Sep 2, 2021
Visit Reason
The State Agency conducted a Complaint Investigation (CI) for #18019 on 9/2/21 regarding an allegation of physical abuse.
Complaint Details
Complaint #18019 involved an allegation of physical abuse which was unsubstantiated and no deficiencies were cited.
Findings
The allegation of physical abuse was unsubstantiated and no deficiencies were cited. The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Report Facts
Complaint investigations: 1
Inspection Report — Jul 7, 2021
Complaint Investigation
Date: Jul 7, 2021
Visit Reason
The State Agency conducted a complaint survey, MS #16801 and MS# 17623, at the facility from 07/06/2021 to 07/07/2021.
Complaint Details
Complaint MS #16801 involved quality of care treatment, grooming, assessment and monitoring, hydration, and pressure sores; complaint MS #17623 involved quality of care assessment/monitoring and facility staffing. Both complaints were not substantiated and no deficiencies were cited.
Findings
The surveyor determined that the facility was in compliance with participation in Medicare and Medicaid. No deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Jun 2, 2020
Routine
Date: Jun 2, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 6/2/20.
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 — Dec 11, 2019
Complaint Investigation
Date: Dec 11, 2019
Visit Reason
The State Agency conducted an abbreviated/partial extended survey investigating CI MS #16128 from 12/10/19 through 12/11/19. Concerns identified in the complaint were Infection Control.
Complaint Details
CI MS #16128 - Infection Control concerns were investigated and found not substantiated; no deficiencies were cited.
Findings
The concerns identified in the complaint were not substantiated and no deficiencies were cited. The facility was found to be in substantial compliance with Medicare and Medicaid requirements.
Report Facts
Complaint investigations: 1
Inspection Report — Jul 2, 2019
Annual Inspection
Date: Jul 2, 2019
Visit Reason
The State Survey Agency (SA) conducted an annual recertification survey along with a complaint survey for CI MS #15795, at the facility from 06/30/19 to 07/02/19.
Complaint Details
Complaint investigation CI MS #15795 was substantiated for quality of care, with no citations related to the complaint.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements and cited for deficiencies related to resident self-administration of medications and infection prevention and control. The complaint was substantiated for quality of care but no citations were related to the complaint.
Deficiencies (2)
F0554 - Resident Self-Admin Meds-Clinically Appropriate. The facility failed to assess Resident #32 for self-administration of medication and left medications at the bedside without physician order or proper evaluation.
F0880 - Infection Prevention and Control. The facility failed to prevent the possible spread of infection as evidenced by a nurse's hair contaminating medication cart surfaces, failure to perform hand hygiene and clean feeding syringes during medication administration for Residents #5 and #30, and failure to properly label feeding syringes and formula bags for Resident #20.
Report Facts
Deficiencies cited: 2
3 CMS Surveys
Inspection Report — Mar 14, 2024
Annual Inspection
Date: Mar 14, 2024
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/11/2024 through 03/14/2024.
Findings
The facility was found to have multiple deficiencies including failure to secure electronic health records, maintain resident rooms in good repair, timely transmit discharge assessments, develop and implement complete care plans, follow professional standards for feeding tube medication administration, provide personal hygiene care, ensure medication error rates below 5%, and maintain clear fire doors.
Deficiencies (8)
F0583 - Keep residents' personal and medical records private and confidential. The facility failed to secure electronic health records as an unattended medication cart had an open computer screen displaying a resident's electronic medication record visible to passersby.
F0584 - Honor the resident's right to a safe, clean, comfortable and homelike environment. The facility failed to provide resident rooms in good repair as evidenced by broken blinds, missing base molding, and peeling sheetrock in two resident rooms.
F0640 - Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. The facility failed to transmit a discharge Minimum Data Set (MDS) assessment for one resident reviewed for discharge MDS assessments.
F0656 - Develop and implement a complete care plan that meets all the resident's needs. The facility failed to develop or implement care plans related to facial hair for two residents and medication administration through a PEG tube for another resident.
F0658 - Ensure services provided by the nursing facility meet professional standards of quality. The facility failed to follow professional standards for feeding tube medication administration by crushing and administering multiple medications at once without using gravity and not following physician orders for water flushes.
F0677 - Provide care and assistance to perform activities of daily living for any resident who is unable. The facility failed to provide personal hygiene to residents as evidenced by unshaven facial hair for two sampled residents.
F0759 - Ensure medication error rates are not 5 percent or greater. The facility failed to ensure the medication error rate was below 5 percent, with a rate of 17.24% for one resident.
F0921 - Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. The facility failed to ensure linen barrels did not block fire doors on one hall, creating a potential fire hazard.
Report Facts
Deficiencies cited: 8
Inspection Report — Nov 9, 2022
Annual Inspection
Date: Nov 9, 2022
Visit Reason
The State Agency conducted an annual recertification survey at the facility on 11/09/2022.
Findings
Two deficiencies were cited related to medication administration and infection control. The facility failed to properly instruct a resident to rinse and spit after inhaler use and failed to clean medical equipment between resident uses.
Deficiencies (2)
F0658 - The facility failed to instruct a resident to rinse and spit after inhaler use and failed to use a spacer as ordered during medication administration for one resident.
F0880 - The facility failed to prevent the spread of infection by not cleaning a pulse oximeter and blood pressure cuff between resident uses during medication pass for one resident.
Report Facts
Deficiencies cited: 2
Inspection Report — Jul 2, 2019
Annual Inspection
Date: Jul 2, 2019
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 06/30/2019 through 07/02/2019.
Findings
The facility was found to have deficiencies related to medication self-administration assessment and infection prevention and control practices. The facility failed to assess a resident for self-administration of medication and failed to prevent possible spread of infection during medication administration and enteral feeding procedures.
Deficiencies (2)
F0554 - The facility failed to assess a resident for self-administration of medication, allowing medications to be left at the bedside without physician order or interdisciplinary team assessment.
F0880 - The facility failed to provide and implement an infection prevention and control program, evidenced by a nurse's hair contaminating medication areas, improper cleaning of feeding syringes, failure to perform hand hygiene during medication administration, and failure to properly label enteral feeding supplies.
Report Facts
Deficiencies cited: 2
Viewing
Loading inspection reports...
