Inspection Reports for
J. G. Alexander Nursing Center
25112 Highway 15, Union, MS 39365, MS, 39365
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
11.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
205% worse than Mississippi average
Mississippi average: 3.8 deficiencies/yearDeficiencies per year
32
24
16
8
0
Census
Latest occupancy rate
97% occupied
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The State Agency conducted a Complaint Investigation (CI), MS #28654, related to a resident left wet, soiled, and injury of unknown origin.
Complaint Details
Complaint Investigation MS #28654 was substantiated with no deficiencies cited.
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.
Inspection Report
Complaint Investigation
Census: 58
Capacity: 60
Deficiencies: 0
Date: Apr 23, 2025
Visit Reason
The State Agency conducted a complaint investigation related to a resident being left wet, soiled, and an injury of unknown origin.
Complaint Details
Complaint Investigation (CI MS #28654) was substantiated with no deficiencies cited.
Findings
During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid requirements and no deficiencies were cited.
Report Facts
Licensed beds: 60
Resident census: 58
Inspection Report
Follow-Up
Census: 58
Capacity: 60
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
The State Agency conducted a follow-up revisit for Annual Recertification survey with complaint survey that was conducted from 2025-01-27 through 2025-01-30.
Complaint Details
The follow-up revisit was related to a complaint survey conducted from 2025-01-27 through 2025-01-30.
Findings
The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 2025-02-22.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 28, 2025
Visit Reason
The State Agency conducted a follow-up revisit for the Annual Recertification survey with complaint survey (CI MS#26987) that was originally conducted from 2025-01-27 through 2025-01-30.
Complaint Details
The follow-up revisit included a complaint survey identified as CI MS#26987.
Findings
The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements, and recommends the facility be placed back in compliance effective 2025-02-14.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Feb 25, 2025
Visit Reason
The State Agency conducted a desk review of information related to the annual survey conducted on 2025-01-30 to verify corrective measures for emergency preparedness.
Findings
The facility had implemented measures to correct the deficient practice and sustain compliance with all applicable Federal, State, and local emergency preparedness requirements. The State Agency recommended the facility be placed back in compliance effective 2025-02-22.
Inspection Report
Life Safety
Deficiencies: 0
Date: Feb 25, 2025
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).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during this inspection.
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Jan 30, 2025
Visit Reason
The inspection was conducted as part of the annual recertification survey to assess compliance with federal regulations regarding resident rights, behavioral health care, food safety, bed rail use, nursing staffing, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights regarding bed rails and dignity, failure to notify physicians of significant weight loss and implement dietary recommendations, failure to provide adequate behavioral health care and psychotropic medication management including lack of psychiatric follow-up and gradual dose reductions, failure to maintain bed rail maintenance logs, failure to post daily nursing staffing information, failure to properly label and dispose of expired food in the kitchen, and failure of the QAPI committee to sustain corrective actions related to food storage.
Deficiencies (9)
Failed to honor residents' rights and dignity by not honoring requests for a second bed rail and posting personal care signs at the head of the bed.
Failed to notify physician of significant weight loss and delayed medical interventions for Resident #45.
Failed to provide adequate nutrition to Resident #45, including failure to implement dietitian recommendations.
Failed to maintain a record log of bed rail maintenance for residents.
Failed to post daily nursing staffing information in a clean, readable, and accessible format including required details.
Failed to provide necessary behavioral health care and services including psychiatric follow-up for Resident #45.
Failed to implement gradual dose reductions for psychotropic medications for Resident #45.
Failed to label and date food stored in refrigerator and freezer and dispose of expired food.
Failed to sustain corrective actions through QAPI to prevent recurrence of food storage deficiencies.
Report Facts
Residents sampled: 16
Weight loss: 33
Meal intake percentage: 0
Bed rail requests denied: 2
Days without psychiatric follow-up: 300
Survey days with missing staffing posting: 2
Expired food items observed: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Confirmed lack of psychiatric follow-up and GDR for Resident #45 |
| RN #3 | Registered Nurse | Reported overseeing QAPI and noted failure to sustain kitchen corrective actions |
| Director of Nursing | Director of Nursing (DON) | Confirmed lack of psychiatric follow-up, GDR, and staffing posting issues |
| Medical Director | Medical Director | Acknowledged unawareness of weight loss and psychiatric follow-up delays |
| Certified Nurse Aide #2 | Certified Nurse Aide | Confirmed Resident #5's repeated requests for additional bed rail |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed facility policy limiting bed rails to one per resident |
| Maintenance #1 | Maintenance Staff | Explained bed rails installed on admission but no maintenance log kept |
| Administrator | Facility Administrator | Acknowledged lack of staffing posting and kitchen food storage issues |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Confirmed expired food items and training expectations |
| Registered Dietitian | Registered Dietitian (RD) | Authored nutrition notes and confirmed failure to implement supplements |
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 9
Date: Jan 30, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and Complaint Investigation at the facility from 01/27/2025 through 01/30/2025 to investigate resident abuse, quality of treatment, and restraints related to a fracture of unknown origin.
Complaint Details
Complaint Investigation MS #26987 was conducted for resident abuse, quality of treatment, and restraints related to a fracture of unknown origin. No citations were issued related to the complaint.
Findings
No citations were related to the complaint investigation. However, during the annual recertification survey, the facility was found not in compliance with Medicare and Medicaid participation requirements and was cited for multiple deficiencies including F550, F580, F692, F700, F732, F740, F758, F812, and F865.
Deficiencies (9)
Deficiency F550
Deficiency F580
Deficiency F692
Deficiency F700
Deficiency F732
Deficiency F740
Deficiency F758
Deficiency F812
Deficiency F865
Report Facts
Census: 55
Total licensed capacity: 60
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation (CI) MS #26987 related to resident abuse, quality of treatment, and restraints concerning a fracture of unknown origin at the facility from 01/27/2025 through 01/30/2025.
Complaint Details
The complaint investigation MS #26987 involved allegations of resident abuse, quality of treatment, and restraints related to a fracture of unknown origin. No citations were issued related to the complaint investigation.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with citations including M500, M645, and M815. Specifically, the facility failed to ensure a resident (Resident #45) did not experience significant weight loss over 10% in six months and failed to implement Registered Dietitian interventions and medication reviews as ordered.
Deficiencies (1)
Facility failed to ensure Resident #45 did not experience significant weight loss over 10% in six months and did not implement Registered Dietitian interventions or medication reviews as ordered.
Report Facts
Weight loss: 33
Meal intake percentage: 0
Weight loss percentage: 18.8
Weight loss percentage: 13
Weight loss percentage: 5
Weight loss percentage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Notified physician of Resident #45's weight loss, lethargy, Dietitian's interventions, and medication review; implemented corrective actions. |
| Medical Director | Medical Director | Unaware of Resident #45's weight loss and acknowledged weight loss should have been addressed sooner. |
| Registered Nurse #2 | Registered Nurse (RN) | Confirmed psychiatric services were ordered for Resident #45 but no follow-up occurred after discharge from behavioral health hospital. |
| Registered Nurse #3 | Registered Nurse (RN) | Reported Resident #45 had altered sleep patterns and increased drowsiness causing missed meals. |
Inspection Report
Annual Inspection
Census: 55
Capacity: 60
Deficiencies: 9
Date: Jan 30, 2025
Visit Reason
The State Agency conducted an Annual Recertification survey and Complaint Investigation at the facility from 01/27/25 through 01/30/25. The complaint investigation was for resident abuse, quality of treatment, and restraints related to a fracture of unknown origin. The annual recertification survey assessed compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaint Investigation (CI MS #26987) was conducted for resident abuse, quality of treatment, and restraints related to a fracture of unknown origin. There were no citations related to the complaint investigation.
Findings
The facility was found not in compliance with multiple regulatory requirements including resident rights, notification of changes, nutrition and hydration, bedrails, nurse staffing postings, behavioral health services, psychotropic medication management, food safety, and quality assurance. Specific deficiencies included failure to honor resident bedrail requests, failure to notify physicians of significant weight loss and dietary needs, failure to maintain bedrail maintenance logs, failure to post nurse staffing information properly, failure to provide timely psychiatric reassessment and psychotropic medication dose reductions, failure to label and dispose of expired food, and failure to sustain corrective actions in QAPI.
Deficiencies (9)
Failed to honor residents' rights and dignity by not honoring requests for a second bed rail and posting signs at the head of beds for three residents.
Failed to notify physician of significant change in condition related to weight loss, drowsiness, and dietary recommendations for Resident #45.
Failed to maintain acceptable nutritional status and implement dietitian recommendations for Resident #45.
Failed to maintain bedrail maintenance logs and ensure proper bedrail maintenance for two residents.
Failed to post daily nurse staffing information in a clear, readable, and accessible manner including required data.
Failed to provide necessary behavioral health services including timely psychiatric reassessment for Resident #45.
Failed to ensure psychotropic medications received gradual dose reductions for Resident #45.
Failed to label, date, and dispose of expired food items in the kitchen refrigerator and freezer.
Failed to sustain corrective actions in the QAPI program to prevent recurrence of food storage deficiencies.
Report Facts
Census: 55
Total Capacity: 60
Weight Loss: 33
Weight Loss Percentage: 17
Meal Intake: 13
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Confirmed Resident #45 had not received psychiatric follow-up or gradual dose reduction for psychotropic medications |
| RN #3 | Registered Nurse | Reported Resident #45 had altered sleep patterns and worsening drowsiness |
| Director of Nursing | Director of Nursing (DON) | Notified physician of Resident #45's weight loss and psychiatric needs; confirmed failure of psychiatric follow-up and gradual dose reduction; involved in QAPI |
| Administrator | Facility Administrator | Acknowledged staffing posting deficiencies and kitchen food safety issues; involved in QAPI |
| Certified Nurse Aide #2 | Certified Nurse Aide | Confirmed Resident #5 requested additional bed rail |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Confirmed Resident #5 had only one bed rail and management policy |
| Maintenance #1 | Maintenance Staff | Explained bed rail installation and lack of maintenance logs |
| Certified Dietary Manager | Dietary Manager | Identified expired and unlabeled food items; responsible for food safety |
| Registered Dietitian | Registered Dietitian | Authored nutrition notes and dietary recommendations for Resident #45 |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The State Agency conducted an annual recertification survey and a Complaint Investigation (CI) related to resident abuse, quality of treatment, and restraints concerning a fracture of unknown origin at the facility from 01/27/2025 through 01/30/2025.
Complaint Details
Complaint Investigation MS #26987 was conducted for resident abuse, quality of treatment, and restraints related to a fracture of unknown origin. No citations were issued related to the complaint investigation.
Findings
The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, with citations related to residents' rights violations including failure to honor requests for bed rails and posting of signage violating resident dignity, and unsafe food handling practices including failure to label, date, and dispose of expired food items.
Deficiencies (2)
Failed to honor residents' rights and dignity by not honoring requests for a second bed rail as an enabler and by posting signs related to resident care at the head of the bed for three residents.
Failed to label and date food stored in the refrigerator and freezer and failed to dispose of expired food during kitchen observations.
Report Facts
Number of sampled residents with bed rail/signage issues: 3
Number of days kitchen observations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #2 | CNA | Confirmed Resident #5's repeated requests for an additional bed rail |
| Licensed Practical Nurse #1 | LPN | Confirmed Resident #5 had only one bed rail and management's instruction limiting bed rails |
| Therapy Director | Observed Resident #5's transfer and confirmed denial of additional bed rail request | |
| Registered Nurse #5 | RN | Explained facility policy allowing only one bed rail unless deemed necessary |
| Director of Nursing | DON | Confirmed facility limited bed rails to one per resident and was unaware of residents' requests |
| Certified Nurse Aide #5 | CNA | Confirmed signage related to resident care had been posted for an extended period |
| Administrator | Confirmed signage violated resident dignity and expected staff to honor residents' rights | |
| Registered Nurse #2 | RN | Acknowledged signage was a dignity issue and should not be posted |
| Dietary Manager | DM | Disposed of expired and unlabeled food items and confirmed observations |
| Certified Dietary Manager | CDM | Stated expectations for kitchen staff regarding food labeling and handling |
| Registered Dietitian | RD | Stated expectations for kitchen staff regarding food labeling and handling |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jan 28, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with emergency preparedness requirements, specifically reviewing the emergency preparedness plan and related documentation.
Findings
The facility failed to provide updated documentation of the emergency preparedness plan after-action reports for community-based exercises for 2024 and 2025. The facility had a current emergency preparedness plan dated 2025 but lacked updated after-action reports as required.
Deficiencies (1)
Failed to provide updated documentation of the emergency preparedness plan after-action reports for community-based exercises for 2024 and 2025.
Report Facts
Date of survey: Jan 28, 2025
Completion date for plan of correction: Feb 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator-in-Training | Conducted in-service training related to emergency operation plan after-action reports | |
| Physical Plant Manager | Received after-action reports and implemented quarterly EOP Record Review Audit | |
| Maintenance Supervisor | Verified observation during exit interview and received in-service training |
Inspection Report
Life Safety
Deficiencies: 0
Date: Jan 28, 2025
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).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code. No deficiencies were cited during the inspection.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 17, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 10/09/2023 to 10/15/2023 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
The State Agency conducted a desk review of information related to the annual survey completed on 2023-08-03 to verify 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, and the facility was recommended to be placed back in compliance effective 2023-09-07.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
The State Agency conducted a desk review related to the annual survey completed on 2023-08-03 to verify corrective measures and compliance with Medicare and Medicaid requirements.
Findings
The facility provided information confirming that corrective measures were implemented and compliance was sustained. The State Agency recommended the facility be placed back in compliance effective 2023-09-07.
Report Facts
Survey completion date: Sep 12, 2023
Annual survey date: Aug 3, 2023
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 3, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 7/31/2023 to 8/3/2023 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 failure to ensure kitchen refrigerator and freezer items were properly dated, labeled, and discarded by expiration dates, posing a risk of foodborne illness.
Deficiencies (1)
Items in the kitchen refrigerator and freezer were not dated, labeled, or discarded by expiration date, including tomato juice, salads, cream of chicken soup, apple sauce, apples, biscuits, cornbread, pancakes, French toast, tuna fish, pimento cheese, and potato salad.
Report Facts
Dietary observations: 3
Expired food items: 1
Food items without labels or dates: 10
Discard timeframe: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Identified and described unlabeled and expired food items during observations and interviews | |
| Clinical Nutrition Manager | Conducted in-service training related to proper disposal and labeling of refrigerated items | |
| Director of Nursing | Reviewed new food handling policy with Food Service Director and responsible for presenting audit data to Quality Assurance Committee |
Inspection Report
Annual Inspection
Census: 56
Capacity: 60
Deficiencies: 5
Date: Aug 3, 2023
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 7/31/23 to 8/3/23 to determine compliance with Medicare and Medicaid requirements of participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, with deficiencies cited related to comprehensive care plans, drug regimen monitoring, medication storage, food preparation, and food safety. Specific issues included failure to implement care plans for psychotropic and anticoagulant medications, improper medication storage, incorrect diet provision, and inadequate food labeling and disposal.
Deficiencies (5)
Failed to develop and implement comprehensive care plans related to side effects and behavior monitoring for psychotropic medications and anticoagulant medication for four residents.
Failed to ensure residents were free from unnecessary drugs by failing to monitor behaviors and side effects for psychotropic and anticoagulant medications for three residents.
Failed to ensure medication was securely stored; Dermaplast spray was found unsecured in a resident's bathroom.
Failed to provide food prepared in a form designed to meet individual needs; a resident on a mechanical soft, chopped meat diet was served a whole chicken patty.
Failed to ensure food items in kitchen refrigerator/freezer were properly labeled, dated, and discarded by expiration date, risking foodborne illness.
Report Facts
Residents reviewed for care plans: 20
Residents reviewed for medication monitoring: 11
Residents observed for dining: 5
Beds licensed: 60
Residents present: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed and confirmed deficiencies related to care plans, medication monitoring, and medication storage. |
| Certified Nurse Assistant #2 | Certified Nurse Assistant | Interviewed regarding incorrect diet served to Resident #19. |
| Food Service Director | Food Service Director | Interviewed regarding diet tray errors and food storage issues. |
| Minimum Data Set Coordinator | MDS Coordinator | Involved in updating care plans and conducting audits related to medication monitoring. |
| Clinical Nutrition Manager | Clinical Nutrition Manager | Conducted in-service training related to food service and food safety. |
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 3, 2023
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).
Findings
The facility met the applicable provisions of the 2012 Edition of the Life Safety Code (LSC) with no deficiencies cited.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The survey was conducted to assess the facility's compliance with emergency preparedness requirements.
Findings
The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies noted.
Inspection Report
Routine
Deficiencies: 5
Date: Aug 3, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to comprehensive care planning, medication management, drug regimen appropriateness, medication storage, and food service standards.
Findings
The facility failed to develop and implement comprehensive care plans addressing side effects and behavior monitoring for psychotropic and anticoagulant medications for several residents. Additionally, the facility did not ensure proper monitoring of medication side effects, secure storage of medications, correct diet provision, and proper labeling and dating of food items in the kitchen.
Deficiencies (5)
Failed to develop and implement comprehensive care plans related to side effects and behavior monitoring for psychotropic and anticoagulant medications for four residents.
Failed to ensure residents were free from unnecessary medications by failing to monitor resident behaviors and side effects for psychotropic and anticoagulant medications for three residents.
Failed to ensure a medication was securely stored for one resident; Dermoplast first aid spray was found unsecured in a resident's bathroom.
Failed to ensure a mechanical soft, chopped meat diet was provided as ordered for one resident; a whole chicken patty was served instead.
Failed to ensure items in the kitchen refrigerator/freezer were dated and labeled and food items were discarded by the expiration date.
Report Facts
Residents care plans reviewed: 20
Residents reviewed for medications: 11
Residents observed for dining: 5
Sampled residents for medication storage: 17
Food items with missing or expired labels: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Confirmed failures in care plan implementation, medication monitoring, and medication storage. |
| Certified Nurse Aide #2 | Certified Nurse Aide | Reported incorrect meal served to Resident #19. |
| Food Service Director | Food Service Director | Confirmed incorrect meal preparation and food labeling issues. |
| Certified Dietary Manager | Certified Dietary Manager | Confirmed diet order for Resident #19 was not followed. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Verified medication was unsecured in Resident #10's bathroom. |
Inspection Report
Renewal
Deficiencies: 0
Date: Apr 8, 2021
Visit Reason
A desk review was completed on April 8, 2021, to assess all previous deficiencies cited on the March 11, 2021, relicensure survey.
Findings
All deficiencies from the prior relicensure survey have been corrected, and no new noncompliance was found. The facility is in substantial compliance with state licensure requirements.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 8, 2021
Visit Reason
A Desk Review was completed on April 8, 2021, to verify correction of all previous deficiencies cited on the March 11, 2021, recertification survey.
Findings
All deficiencies have been corrected, and no new noncompliance was found. The facility is in substantial compliance with the participation requirements for Medicare and Medicaid.
Inspection Report
Annual Inspection
Census: 50
Deficiencies: 1
Date: Mar 11, 2021
Visit Reason
The inspection was an annual recertification survey conducted from 03/08/2021 through 03/11/2021 to assess compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm and state licensure requirements.
Findings
The facility was found non-compliant due to unresolved resident grievances concerning food quality and failure to complete discharge assessments. Specifically, eight residents attending the resident council meeting reported ongoing unresolved complaints about poor tasting and poor textured food, with no documented resolutions or communication from the dietary manager.
Deficiencies (1)
Failure to promptly resolve resident council grievances related to food for eight residents.
Report Facts
Residents with unresolved grievances: 8
Census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Dietary Manager | Named in relation to failure to respond to resident food grievances and lack of communication with residents | |
| Director of Nursing | Named in relation to ensuring dietary manager access and addressing resident grievances | |
| Activities Director | Named in relation to reporting resident complaints and communication with dietary manager |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Mar 11, 2021
Visit Reason
The inspection was conducted due to unresolved resident council grievances regarding food quality and taste, as well as failure to complete and submit a discharge Minimum Data Set (MDS) for one resident.
Complaint Details
The complaint investigation revealed that eight residents attending the resident council meeting had ongoing unresolved food complaints. The Dietary Manager had not received timely notification of these complaints and had not provided written or verbal responses. The Director of Nursing acknowledged the issue and planned to allow the Dietary Manager to attend resident council meetings. Additionally, the facility failed to complete a discharge MDS for one resident due to staff illness and communication failures.
Findings
The facility failed to promptly resolve resident council grievances about poor tasting and poor textured food reported by eight residents. The Dietary Manager had not been properly notified of these complaints and had not communicated any resolutions. Additionally, the facility failed to complete and submit a discharge MDS for one resident in a timely manner.
Deficiencies (2)
Failed to promptly resolve resident council grievances for eight residents regarding poor tasting and poor textured food.
Failed to complete and submit a discharge Minimum Data Set (MDS) for one resident.
Report Facts
Residents affected: 8
Resident MDS reviewed: 19
Resident MDS not completed: 1
Census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Dietary Manager | Notified late of resident food complaints, did not provide written or verbal responses, had not visited residents since before March 2020 due to COVID-19 restrictions |
| Activities Director | Activities Director | Received resident food complaints, faxed resident council minutes to Dietary Manager, confirmed ample snacks available |
| Director of Nursing | Director of Nursing | Acknowledged failure to have Dietary Manager attend resident council meetings and lack of responses to grievances |
| MDS Coordinator | MDS Coordinator | Failed to complete and submit discharge MDS for one resident due to COVID-19 illness and communication failure |
| MDS Nurse | MDS Nurse | Completes Medicaid assessments except discharge assessments, confirmed discharge assessments are done by MDS Coordinator |
Inspection Report
Annual Inspection
Census: 50
Capacity: 60
Deficiencies: 2
Date: Mar 11, 2021
Visit Reason
The State Agency conducted an annual recertification survey at the facility from 03/08/2021 to 03/11/2021 to determine compliance with Medicare and Medicaid participation requirements.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements, citing deficiencies related to unresolved resident council grievances about food quality and failure to timely complete and submit a discharge Minimum Data Set (MDS) for one resident.
Deficiencies (2)
Failure to promptly resolve resident council grievances regarding food quality for eight residents.
Failure to complete and submit a discharge Minimum Data Set (MDS) for one resident in a timely manner.
Report Facts
Licensed beds: 60
Resident census: 50
Residents with unresolved grievances: 8
Resident MDS reviewed: 19
Discharge MDS not submitted timely: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding allowing Dietary Manager access and MDS submission issues |
| Dietary Manager | Dietary Manager | Interviewed regarding lack of communication and response to resident food complaints |
| MDS Coordinator | MDS Coordinator | Interviewed regarding failure to submit discharge MDS timely |
| MDS Nurse | MDS Nurse | Interviewed regarding MDS assessment responsibilities |
| Activities Director | Activities Director | Interviewed regarding resident food complaints and communication with Dietary Manager |
Inspection Report
Life Safety
Deficiencies: 0
Date: Mar 8, 2021
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, and no LSC deficiencies were cited during this survey.
Inspection Report
Deficiencies: 0
Date: Mar 8, 2021
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
Abbreviated Survey
Census: 53
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency on 12/29/20 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
Census: 53
Deficiencies: 0
Date: Dec 29, 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
Deficiencies: 0
Date: Dec 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on 12/29/20 to assess compliance with emergency preparedness regulations.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness requirements.
Inspection Report
Routine
Census: 56
Capacity: 60
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Date: Sep 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the State Agency on September 15, 2020.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to E-0024 (b)(6).
Inspection Report
Routine
Census: 57
Deficiencies: 0
Date: Sep 15, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency to assess the facility's compliance with infection control guidelines during the COVID-19 pandemic.
Findings
The facility was found to be in substantial compliance with infection control safety practices and guidance recommended by CMS and CDC during the COVID-19 pandemic.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 10, 2020
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 07/27/2020 and 08/09/2020 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Census: 56
Capacity: 60
Deficiencies: 0
Date: May 25, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and implementation of CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 56
Capacity: 60
Deficiencies: 0
Date: May 25, 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: 56
Total Capacity: 60
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Oct 1, 2019
Visit Reason
The State Agency conducted an onsite complaint investigation at the facility on 10/01/19.
Complaint Details
CI MS#16232 was substantiated with no deficiencies cited.
Findings
The complaint investigation (CI MS#16232) was substantiated with no deficiencies cited. The facility was found to be in compliance with Medicare and Medicaid requirements for participation.
Inspection Report
Complaint Investigation
Census: 59
Deficiencies: 0
Date: Oct 1, 2019
Visit Reason
The State Agency conducted an onsite complaint investigation at the facility on 10/01/19.
Complaint Details
Complaint investigation CI MS#16232 was substantiated with no deficiencies cited.
Findings
The complaint investigation (CI MS#16232) was substantiated with no deficiencies cited, and the facility was found to be in compliance with Medicare and Medicaid requirements.
Inspection Report
Annual Inspection
Census: 57
Capacity: 60
Deficiencies: 7
Date: Jan 4, 2019
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 01/02/2019 to 01/04/2019 to determine compliance with Medicare and Medicaid regulations.
Findings
The facility was found not in compliance with Medicare and Medicaid regulations, with deficiencies cited in resident self-determination, resident/family group response, care plan timing and revision, nutritive value and palatability of food, food procurement and sanitation, means of egress, and fire drills.
Deficiencies (7)
Facility failed to honor resident choices related to food preferences for two residents.
Facility failed to resolve grievances related to food concerns in a timely manner for three residents.
Facility failed to revise the comprehensive care plan related to nutrition for one resident.
Facility failed to serve palatable meals to residents as evidenced by resident complaints and observations.
Facility failed to provide a clean and sanitary environment in the kitchen walk-in cooler/freezer.
Facility failed to maintain exit egress properly; staff did not have access to key for gate on egress from 400 Hall.
Facility failed to properly perform fire drills with audible alarms during required hours and lacked documentation for some shifts.
Report Facts
Deficiencies cited: 7
Residents present: 57
Total licensed beds: 60
Fire drills conducted: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Interviewed residents regarding food preferences and grievances; conducted in-services and audits related to food preferences and grievance resolution. | |
| Dietary Manager | Updated resident tray cards, conducted resident satisfaction surveys, and was involved in kitchen sanitation and food palatability improvements. | |
| Dietary Consultant | Communicated food concerns to Dietary Manager and visited residents to determine likes and dislikes. | |
| Diet Clerk Supervisor | Confirmed residents' food preferences were not being honored. | |
| Minimum Data Set Registered Nurse | Confirmed care plan was not updated with dietary orders. | |
| Director of Nursing | Interviewed regarding dietary concerns and grievance resolution. | |
| Social Worker | Referred food concerns to Dietary Manager. | |
| Dietary Supervisor | Observed kitchen sanitation issues. | |
| Dietician | Registered Dietician | Provided oversight on kitchen sanitation and in-serviced dietary staff on food preparation. |
| Maintenance Supervisor | Removed lock on gate to egress and replaced with carabiner; in-serviced on means of egress and fire safety; audits exit egress and fire drills monthly. | |
| Administrator | Interviewed regarding fire drill procedures and staff awareness. | |
| Field Maintenance Supervisor | Provided in-service training to Maintenance Supervisor on fire drills. |
Inspection Report
Annual Inspection
Census: 59
Deficiencies: 2
Date: Jan 4, 2019
Visit Reason
The annual recertification survey was conducted from January 2, 2019 through January 4, 2019 to assess compliance with Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Findings
The facility was found non-compliant with food preparation standards, failing to serve palatable meals to three of 22 residents interviewed. Additionally, the facility failed to properly maintain exit egress as per Life Safety Code, affecting one of six exits and eight of 59 residents.
Deficiencies (2)
Failed to serve palatable meals to residents, with issues including unseasoned, soggy, and overcooked food.
Failed to properly maintain exit egress; staff did not have access to the key for the lock on the gate to the egress from the 400 Hall.
Report Facts
Residents interviewed regarding food: 22
Residents affected by exit egress deficiency: 8
Exits affected by exit egress deficiency: 1
Total exits in facility: 6
Residents in facility on day of survey: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed residents and altered meal tray preparation cards to ensure palatable meals | |
| Director of Nurses | Interviewed residents regarding food palatability | |
| Quality Assurance Nurse | Responsible for auditing test trays and compiling findings related to food palatability | |
| Dietary Consultant | Interviewed and stated food lacks seasoning and received complaints | |
| Facility Maintenance Supervisor | Removed lock on gate to egress and replaced with carabiner | |
| Laird Maintenance Supervisor | Will audit monthly to ensure exit egress is maintained |
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